COPD as a systemic disease

Screening for comorbidities in COPD

Due to growing recognition of comorbidities, COPD is no longer considered a disease affecting only the respiratory system. Its management now entails the early diagnosis and treatment of comorbidities. However, although many studies have examined the impact of comorbidities on the evolution of COPD and patients' quality of life, very few have explored the means to systematically identify and manage them. The aims of this article are to summarise the state of current knowledge about comorbidities associated with COPD and to propose a possible screening protocol in the outpatient setting, emphasising the areas needing further research.

Cardiovascular surgery complication and the benefits of pulmonary rehabilitation in preventing COPD exacerbation

Introduction. Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality worldwide, and the burden of the disease is constantly increasing. Although COPD is primarily characterized by the presence of airflow obstruction, in many patients, it is associated with systemic manifestations that can result in impaired functional capacity, reduced quality of life, and increased mortality. Pulmonary rehabilitation (PR) consists of a multidisciplinary and comprehensive non-pharmacological intervention that is designed to improve health status in COPD patients, along with pharmacologic treatment. PR has also been shown to improve the diaphragmatic mobility in patients with different conditions that affect the diaphragm. The aim of the paper is to describe the clinical and functional features of a COPD patient with unilateral paralysis of the phrenic nerve and the role of PR as a major component of the case management. Material and method. This paper presents the case of a 66-year-old patient, diagnosed with COPD Gold stage III, which suffered a surgical intervention for an aorta aneurysm and later complicated with phrenic nerve injury and left diaphragmatic paralysis. This condition worsened the respiratory functional status and the patient needed a tailored treatment. Results and discussions. The treatment included besides inhaled dual long acting bronchodilator and corticoid therapy, pulmonary rehabilitation with complex methods, consisting in training of the respiratory musculature and techniques of bronchial drainage using devices with positive inspiratory and expiratory pressure, with good clinical and functional outcomes. A PR program should be included into a personalized management plan, along with pharmacological therapy. Conclusion. Although there is no standard treatment for COPD associated with unilateral paralysis of the phrenic nerve, it is important to diagnose these conditions promptly, and to recommend the adequate pharmacological treatment for controlling the symptoms along with a personalized complex respiratory rehabilitation program, in order to increase functional status and quality of life. Key words: respiratory rehabilitation, COPD, phrenic nerve paralysis

Sarcopenia in COPD: a systematic review and meta-analysis

COPD is associated with a progressive loss of muscle mass and function. However, there is an unmet need to define and standardise methods to estimate the prevalence of sarcopenia in COPD patients.

We performed a systematic review and meta-analysis of the prevalence of this extrapulmonary manifestation in COPD patients. We searched Embase, Medline (Ovid), CINAHL (EBSCO), Web of Science, Scopus and Google Scholar for studies published up to January 17, 2019, assessing sarcopenia in COPD patients based on low muscle mass and decreased muscle function. Interventional studies, in vitro experiments, protocols or reviews and meta-analyses were excluded. We estimated heterogeneity (I²) and assessed significance (Q) using a Chi-squared test for estimates obtained from random-effects models.

4465 articles were initially identified. After removing the duplicates and applying the selection criteria, we reviewed 62 full-text articles. Finally, 10 articles (n=2565 COPD patients) were included in this systematic review and meta-analyses. Overall, the prevalence of sarcopenia in patients with COPD was 21.6% (95% CI 14.6–30.9%, I²=94%), ranging from 8% in population-based to 21% in clinic-based studies, and 63% in COPD patients residing in nursing homes.

Sarcopenia is frequently observed in COPD patients, with varying prevalence across population settings. Sarcopenia in COPD should be assessed using standardised tests and cut-off points from sarcopenia consensus criteria for clinical practice and international comparisons.

We confirmed a high prevalence of sarcopenia in COPD patients, with varying prevalence across population settings. We recommend adhering to the sarcopenia consensus criteria to systematically evaluate the muscle health of COPD patients.http://bit.ly/2KA6weh

Evaluation of diaphragm ultrasound in predicting extubation outcome in mechanically ventilated patients with COPD

Background

To explore the value of the right hemi-diaphragmatic excursion (DE) and its variation in predicting extubation outcome in mechanically ventilated patients with COPD.

Methods

All included patients with COPD received mechanical ventilation (MV) and were ready to wean from MV. After patients passed the 30 min spontaneous breathing trail (SBT), extubation was considered to be feasible, and the right DE measured by ultrasound at 0 min, 5 min, and 30 min of SBT were named as DE₀, DE₅, and DE₃₀, respectively.

Results

Twenty-five patients succeeded extubation; 12 patients failed. The area under receiver operator characteristic curve (AUC_ROC) of DE₃₀ and ΔDE₃₀₋₅ (the variation between 30 and 5 min) were 0.762 and 0.835; a cutoff value of DE₃₀ > 1.72 cm and ΔDE₃₀₋₅ > 0.16 cm were associated with a successful extubation with a sensitivity of 76% and 84%, a specificity of 75% and 83.3%, respectively. The predictive probability equation of the DE₃₀ plus ∆DE₃₀₋₅ was P = 1/[1 + e^{−(−5.625+17.689×∆DE}₃₀₋₅^+1.802×DE₃₀⁾], a cutoff value of P > 0.626 was associated with a successful extubation with the AUC_ROC of 0.867, a sensitivity of 92%, and a specificity of 83.3%.

Conclusion

The combination of DE₃₀ and ∆DE₃₀₋₅ could improve the predictive value and could be used as the predictor of extubation outcome in mechanically ventilated patients with COPD.

Malnutrition and related risk factors in older adults from different health-care settings: an enable study

Objective:

The origin of malnutrition in older age is multifactorial and risk factors may vary according to health and living situation. The present study aimed to identify setting-specific risk profiles of malnutrition in older adults and to investigate the association of the number of individual risk factors with malnutrition.

Design:

Data of four cross-sectional studies were harmonized and uniformly analysed. Malnutrition was defined as BMI < 20 kg/m² and/or weight loss of >3 kg in the previous 3–6 months. Associations between factors of six domains (demographics, health, mental function, physical function, dietary intake-related problems, dietary behaviour), the number of individual risk factors and malnutrition were analysed using logistic regression.

Setting:

Community (CD), geriatric day hospital (GDH), home care (HC), nursing home (NH).

Participants:

CD older adults (n 1073), GDH patients (n 180), HC receivers (n 335) and NH residents (n 197), all ≥65 years.

Results:

Malnutrition prevalence was lower in CD (11 %) than in the other settings (16–19 %). In the CD sample, poor appetite, difficulties with eating, respiratory and gastrointestinal diseases were associated with malnutrition; in GDH patients, poor appetite and respiratory diseases; in HC receivers, younger age, poor appetite and nausea; and in NH residents, older age and mobility limitations. In all settings the likelihood of malnutrition increased with the number of potential individual risk factors.

Conclusions:

The study indicates a varying relevance of certain risk factors of malnutrition in different settings. However, the relationship of the number of individual risk factors with malnutrition in all settings implies comprehensive approaches to identify persons at risk of malnutrition early.

Does chronic obstructive pulmonary disease increase the risk of prostate cancer? A nationwide population-based study

Purpose

Chronic obstructive pulmonary disease (COPD) is a major pulmonary disease. However, few studies have investigated the relationship between COPD and prostate cancer (PCa). This study aimed to investigate the association between COPD severity and PCa risk.

Patients and methods

We conducted a nationwide population-based cohort study utilizing data from 2001 to 2013 from the National Health Insurance Research Database of Taiwan. Cox proportional hazards models with 1:1 propensity score-matched analysis were used to investigate the association between COPD and PCa risk. We further divided the COPD group according to severe complications (including acute respiratory failure, cardiopulmonary arrest, pneumonia, and acute exacerbation) to test for the relationship between COPD severity and PCa risk.

Results

This study included 47,634 patients (23,817 COPD patients and 23,817 matched non-COPD controls). Among them, 756 (1.59%) were diagnosed with PCa during a mean follow-up period of 7.05±4.13 years; 387 (1.62%) were from the COPD group and 369 (1.55%) were from the control group. Compared with the patients without COPD, the adjusted hazard ratio (HR) for PCa in the COPD patients was 1.10 (95% confidence interval [CI] 0.95–1.27), while that in the COPD patients with complications was 2.46 (95% CI 1.96–3.61).

Conclusions

An increased risk for PCa was found among the COPD patients with complications. COPD complications included acute respiratory failure, cardiopulmonary arrest, pneumonia, and acute exacerbation. These findings may help physicians in treating COPD with complications and in remaining alert to the potential development of PCa.

Muscle energy technique for chronic obstructive pulmonary disease: a systematic review

Background

Chronic Obstructive Pulmonary Disease (COPD) is an increasingly prevalent respiratory disease that impacts on daily living. In addition to difficulty breathing, many people experience extrapulmonary comorbidities such as musculoskeletal disorders. Pulmonary rehabilitation can improve fitness and strength but may be difficult for patients with musculoskeletal disorders. Recent research indicates promising benefits of adding manual therapy to standard care to improve clinical outcomes.

Objectives

To evaluate the efficacy and safety of Muscle Energy Technique (MET) for people with COPD.

Methods

Ten databases were searched from inceptions to May 2018. Eligible studies were randomised controlled trials assessing MET compared to any control for COPD. Outcomes included lung function, exercise capacity, health-related quality of life, and adverse events.

Results

Three randomised controlled trials assessing 90 participants were included. The quality of the research was limited by reporting of outcome measures and results, varying treatment protocols, and small sample sizes. Results from one study showed that pulmonary function was not statistically different between groups at end of treatment (FEV1% MD 4.87%; 95% CI - 0.79 to 10.53). Exercise capacity and perceived dyspnoea ratings were improved in single studies. Adverse events were unrelated to the MET intervention.

Conclusions

The use of MET for COPD is an emerging field of research, with few studies evaluating its efficacy and safety. Currently, there is insufficient evidence to support the use of MET in the management of COPD. Rigorously designed studies with larger sample sizes are needed to better understand the role of MET for COPD.

The LEAD (Lung, Heart, Social, Body) Study: Objectives, Methodology, and External Validity of the Population-Based Cohort Study

BACKGROUND

The Lung, hEart, sociAl, boDy (LEAD) Study (ClinicalTrials.gov; NCT01727518; http://clinicaltrials.gov) is a longitudinal, observational, population-based Austrian cohort that aims to investigate the relationship between genetic, environmental, social, developmental and ageing factors influencing respiratory health and comorbidities through life. The general working hypothesis of LEAD is the interaction of these genetic, environmental and socioeconomic factors influences lung development and ageing, the risk of occurrence of several non-communicable diseases (respiratory, cardiovascular, metabolic and neurologic), as well as their phenotypic (ie, clinical) presentation.

METHODS

LEAD invited from 2011-2016 a random sample (stratified by age, gender, residential area) of Vienna inhabitants (urban cohort) and all the inhabitants of six villages from Lower Austria (rural cohort). Participants will be followed-up every four years. A number of investigations and measurements were obtained in each of the four domains of the study (Lung, hEart, sociAl, boDy) including data to screen for lung, cardiovascular and metabolic diseases, osteoporosis, and cognitive function. Blood and urine samples are stored in a biobank for future investigations.

RESULTS

A total of 11.423 males (47.6%) and females (52.4%), aged 6-80 years have been included in the cohort. Compared to governmental statistics, the external validity of LEAD with respect to age, gender, citizenship, and smoking status was high.

CONCLUSIONS

In conclusion, the LEAD cohort has been established following high quality standards; it is representative of the Austrian population and offers a platform to understand lung development and ageing as a key mechanism of human health both in early and late adulthood.

Anthropometric status of individuals with COPD in the city of São Paulo, Brazil, over time - analysis of a population-based study

OBJECTIVE

To evaluate the anthropometric data obtained for residents of the city of São Paulo, Brazil, in a study of Latin America conducted in two phases (baseline, in 2003, and follow-up, in 2012).

METHODS

This was an analysis of data obtained for São Paulo residents in a two-phase population-based study evaluating the prevalence of COPD and its relationship with certain risk factors among individuals ≥ 40 years of age. The anthropometric data included values for weight, height, body mass index (BMI), and waist circumference. In the follow-up phase of that study, the same variables were evaluated in the same population sample as that of the baseline phase.

RESULTS

Of the 1,000 São Paulo residents enrolled in the baseline phase of that study, 587 participated in the follow-up phase, and 80 (13.6%) of those 587 subjects had COPD. Comparing the baseline and follow-up phases, we found increases in all anthropometric measures in both groups (COPD and non-COPD), although the differences were significant only in the non-COPD group. The subjects with mild COPD showed increases in weight and BMI (Δweight = 1.6 ± 5.7 and ΔBMI = 0.7 ± 2.2), whereas those with moderate or severe COPD showed reductions (Δweight = -1.7 ± 8.1 and ΔBMI = -0.4 ± 3.0), as did those with severe or very severe COPD (Δweight = -0.5 ± 5.4 and ΔBMI = -0.8 ± 3.3).

CONCLUSIONS

Between the two phases of the study, the subjects with mild COPD showed increases in weight and BMI, whereas those with a more severe form of the disease showed reductions.

Age and Disease have a Distinct Influence on Postural Balance of Patients with COPD

The postural imbalance is an extra-pulmonary condition, associated with chronic obstructive pulmonary disease (COPD). COPD affects older individuals and it is unclear whether balance abnormalities can be described as pathophysiological mechanism or aging. The present study aimed to evaluate the influence of age or disease on postural balance of patients with COPD. Patients with COPD over 50 years old were compared with age- and sex-matched healthy adults, and with sex-matched younger healthy adults (n = 30 in each group). The Modified Sensory Organization Test (mSOT) was performed in four different conditions fixed or sway-referenced surface both either with full or no vision. It was analyzed the center of pressure (CoP) variables: amplitude, velocity, root-mean-square and load asymmetry. Three-way ANOVA and post hoc analysis were performed been represented of age (older or COPD compared with younger healthy adults) or disease influences (COPD compared with older healthy groups). Main results were as follows: The CoP excursion was faster, with higher amplitude and variability progressively from COPD vs. older healthy vs. younger healthy adults (p < 0.05) showing age and disease influences (p < 0.05). Age and disease influences were also observed in the sway-referenced surface in both vision conditions. Impairment in postural balance was found related to aging and disease in patients with COPD older than 50 years.

The relationship between acrolein and oxidative stress in COPD: in systemic plasma and in local lung tissue

Purpose

Cigarette smoke produces a high level of acrolein, which is thought to be pathogenically involved in the development of chronic obstructive pulmonary disease (COPD). The present study investigated the pathological role of acrolein in the development of COPD.

Patients and methods

Acrolein concentration was measured in plasmas obtained from 47 patients with COPD and 18 current smokers without COPD, and in supernatants of homogenized lung tissues obtained from 10 never-smokers, 8 current smokers, and 8 patients with COPD by high-performance liquid chromatography. Oxidant status and antioxidant activity were measured using derivatives of reactive oxygen metabolite (d-ROM) and bio-antioxidant power (BAP), respectively, in the Free Radical Elective Evaluation FRAS4 system. In addition, immunohistochemistry was used to evaluate the over-presentation of acrolein in lung tissues of patients with COPD.

Results

Plasma concentrations of acrolein were significantly higher in the patients with COPD than the non-COPD smokers (P<0.001), which significantly correlated with the oxidant status in patients with COPD (R=0.69, P<0.05). Similar pathological alterations in acrolein concentrations were found in the lung tissue supernatants of patients with COPD, which significantly correlated with the oxidant status in patients with COPD. Furthermore, acrolein was strongly expressed in the lung tissues of patients with COPD.

Conclusion

The increased acrolein concentrations were highly involved in the pathogenesis of COPD through interference in the balance of oxidative stress versus antioxidant potentiality.

Effects of extracellular Hsp70 and cigarette smoke on differentiated THP-1 cells and human monocyte-derived macrophages

Extracellular Hsp70 (eHsp70) can act as pro-inflammatory mediator and is elevated in blood of chronic obstructive pulmonary disease (COPD) patients. Most of those patients are smokers, and it was suggested previously that cigarette smoke might induce Hsp70 secretion from the circulating cells. Therefore, we aimed to explore inflammation-associated effects of cigarette smoke extract (CSE) and its combinations with eHsp70 in monocyte-derived macrophages (MDMs) and THP-1 cell line, used as systemic component models of COPD. We hypothesized that eHsp70 induces inflammation, but that it can also modulate cigarette smoke extract (CSE)-stimulated inflammatory responses. We assessed IL-8 secretion, TLR2, TLR4 and Hsp70 expressions, MAPKs and NF-κB activation, and cytotoxicity after treating the cells with CSE (2.5 and 5%) and its combinations with low-endotoxin recombinant human (rh) Hsp70, used to mimic eHsp70 effects. CSE induced IL-8 secretion from both cell types, but its combinations with rhHsp70 increased IL-8 release compared to CSE alone only from MDMs. In THP-1, combinations of rhHsp70 with 2.5% CSE induced TLR2 and TLR4 mRNA, while 5% CSE decreased TLR2 expression. In MDMs, CSE alone attenuated TLR2, while rhHsp70 increased TLR2 and lowered TLR4 gene expression. Hsp70 mRNA expression was suppressed in THP-1 with rhHsp70 and CSE; however, the same treatments increased its level in MDMs. CSE had cytotoxic effect only on MDMs, but cytotoxicity was reduced in co-treatments with rhHsp70, which also triggered apoptosis. CSE and rhHsp70 activated p38 and JNK, while ERK was activated only by rhHsp70 in MDMs. In THP-1, 2.5% CSE activated ERK, and 5% CSE activated p38. Inhibition of NF-κB and JNK in MDMs, and ERK and JNK in THP-1 cells, attenuated IL-8 release after rhHsp70 treatment. In conclusion, rhHsp70 provoked pro-inflammatory effects and could also modulate inflammatory response to CSE on protein and gene expression levels in THP-1 cells and MDMs, which suggests that eHsp70 might be implicated in systemic inflammation induced by cigarette smoke.

Genetic landscape of chronic obstructive pulmonary disease identifies heterogeneous cell-type and phenotype associations

Chronic obstructive pulmonary disease (COPD) is the leading cause of respiratory mortality worldwide. Genetic risk loci provide new insights into disease pathogenesis. We performed a genome-wide association study in 35,735 cases and 222,076 controls from the UK Biobank and additional studies from the International COPD Genetics Consortium. We identified 82 loci associated with P < 5 × 10-8; 47 of these were previously described in association with either COPD or population-based measures of lung function. Of the remaining 35 new loci, 13 were associated with lung function in 79,055 individuals from the SpiroMeta consortium. Using gene expression and regulation data, we identified functional enrichment of COPD risk loci in lung tissue, smooth muscle, and several lung cell types. We found 14 COPD loci shared with either asthma or pulmonary fibrosis. COPD genetic risk loci clustered into groups based on associations with quantitative imaging features and comorbidities. Our analyses provide further support for the genetic susceptibility and heterogeneity of COPD.

Trabecular bone score in active or former smokers with and without COPD

BACKGROUND

Smoking is a recognized risk factor for osteoporosis. Trabecular bone score (TBS) is a novel texture parameter to evaluate bone microarchitecture. TBS and their main determinants are unknown in active and former smokers.

OBJECTIVE

To assess TBS in a population of active or former smokers with and without Chronic Obstructive Pulmonary Disease (COPD) and to determine its predictive factors.

METHODS

Active and former smokers from a pulmonary clinic were invited to participate. Clinical features were recorded and bone turnover markers (BTMs) measured. Lung function, low dose chest Computed Tomography scans (LDCT), dual energy absorptiometry (DXA) scans were performed and TBS measured. Logistic regression analysis explored the relationship between measured parameters and TBS.

RESULTS

One hundred and forty five patients were included in the analysis, 97 (67.8%) with COPD. TBS was lower in COPD patients (median 1.323; IQR: 0.13 vs 1.48; IQR: 0.16, p = 0.003). Regression analysis showed that a higher body mass index (BMI), younger age, less number of exacerbations and a higher forced expiratory volume-one second (FEV1%) was associated with better TBS (β = 0.005, 95% CI:0.000-0.011, p = 0.032; β = -0.003, 95% CI:-0.007(-)-0.000, p = 0.008; β = -0.019, 95% CI:-0.034(-)-0.004, p = 0.015; β = 0.001, 95% CI:0.000-0.002, p = 0.012 respectively). The same factors with similar results were found in COPD patients.

CONCLUSIONS

A significant proportion of active and former smokers with and without COPD have an affected TBS. BMI, age, number of exacerbations and the degree of airway obstruction predicts TBS values in smokers with and without COPD. This important information should be considered when evaluating smokers at risk of osteoporosis.

A Comparison between Two Pathophysiologically Different yet Microbiologically Similar Lung Diseases: Cystic Fibrosis and Chronic Obstructive Pulmonary Disease

Cystic fibrosis (CF) and chronic obstructive pulmonary disease (COPD) are chronic pulmonary diseases that affect ~70,000 and 251 million individuals worldwide, respectively. Although these two diseases have distinctly different pathophysiologies, both cause chronic respiratory insufficiency that erodes quality of life and causes significant morbidity and eventually death. In both CF and COPD, the respiratory microbiome plays a major contributing role in disease progression and morbidity. Pulmonary pathogens can differ dramatically during various stages of each disease and frequently cause acute worsening of lung function due to disease exacerbation. Despite some similarities, outcome and timing/type of exacerbation can also be quite different between CF and COPD. Given these clinical distinctions, both patients and physicians should be aware of emerging therapeutic options currently being offered or in development for the treatment of lung infections in individuals with CF and COPD. Although interventions are available that prolong life and mitigate morbidity, neither disorder is curable. Both acute and chronic pulmonary infections contribute to an inexorable downward course and may trigger exacerbations, culminating in loss of lung function or respiratory failure. Knowledge of the pulmonary pathogens causing these infections, their clinical presentation, consequences, and management are, therefore, critical. In this review, we compare and contrast CF and COPD, including underlying causes, general outcomes, features of the lung microbiome, and potential treatment strategies.

Determining the minimally important difference in quadriceps strength in individuals with COPD using a fixed dynamometer

Background

Measurement of quadriceps muscular force is recommended in individuals with COPD, notably during a pulmonary rehabilitation program (PRP). However, the tools used to measure quadriceps maximal voluntary contraction (QMVC) and the clinical relevance of the results, as well as their interpretation for a given patient, remain a matter of debate. The objective of this study was to estimate the minimally important difference (MID) of QMVC using a fixed dynamometer in individuals with COPD undergoing a PRP.

Methods

Individuals with COPD undergoing a PRP were included in this study. QMVC was measured using a dynamometer (MicroFET2) fixed on a rigid support according to a standard-ized methodology. Exercise capacity was measured by 6-minute walk distance (6MWD) and evaluation of quality of life with St George's respiratory questionnaire (SGRQ) and Hospital Anxiety and Depression Scale (HADS) total scores. All measures were obtained at baseline and the end of the PRP. The MID was calculated using distribution-based methods.

Results

A total of 157 individuals with COPD (age 62.9±9.0 years, forced expiratory volume in 1 second 47.3%±18.6% predicted) were included in this study. At the end of the PRP, the patients had improved their quadriceps force significantly by 8.9±15.6 Nm (P<0.001), as well as 6MWD by 42±50 m (P<0.001), SGRQ total score by -9±17 (P<0.001) and HADS total score by -3±6 (P<0.001). MID estimation using distribution-based analysis was 7.5 Nm by empirical rule effect size and 7.8 Nm by Cohen's effect size.

Conclusion

Measurement of QMVC using a fixed dynamometer is a simple and valuable tool capable of assessing improvement in quadriceps muscle force after a PRP. We suggest an MID of 7.5 Nm to identify beneficial changes after a PRP intervention.

The physical, mental, and social impact of COPD in a population-based sample: results from the Longitudinal Aging Study Amsterdam

Chronic obstructive pulmonary disease (COPD) is associated with substantial health impact that may already become apparent in early disease. This study aims to examine the features of subjects with COPD in a Dutch population-based sample and compare their physical status, mental status, and social status to non-COPD subjects. This study made use of Longitudinal Aging Study Amsterdam (LASA) data. Demographics, clinical characteristics, self-reported diseases, post-bronchodilator spirometry, physical, mental, and social status were assessed. A number of 810 subjects (50.5% male, mean age 60.5 ± 2.9 years) were included. Subjects with COPD (n = 68, mean FEV₁ 67.6 [IQR 60.4–80.4] %.) had a slower walking speed than non-COPD subjects, p = 0.033. When compared to non-COPD subjects, COPD subjects gave a lower rating on their health (physical subscale of SF-12: 15 [IQR 16.0–19.0] vs. 18 [IQR 11.0–17.0] points) and life (EQ5D VAS: 75 [IQR 70.0–90.0] vs. 80 points [IQR 65.0–85.5]) surveys. COPD subjects also had a more impaired disease-specific health status (CAT: 9.5 ± 5.9 vs. 6.7 ± 5.2, respectively), were less likely to have a partner (69% vs. 84%, respectively) and received emotional support less often (24% vs. 36%, respectively) compared to non-COPD subjects (All comparisons p < 0.001). In a population-based sample, subjects with COPD had a reduced physical performance, a more impaired disease-specific health status and were more socially deprived compared to non-COPD subjects. These impairments need to be taken into consideration when setting up a management program for patients with mild COPD.

Patients with early-stage chronic lung disease need holistic support to limit the physical, mental and social impacts of the condition. There is more to chronic obstructive pulmonary disease (COPD) than persistent airflow limitation; systemic effects, including loss of muscle strength and higher risk of heart conditions, mental health and social problems can manifest from the early stages. Frits Franssen at CIRO, the Netherlands, and co-workers interviewed 810 participants aged 55–65 from the Longitudinal Aging Study Amsterdam to investigate the physical, mental and social status of COPD sufferers and compare them with healthy controls. Those with COPD were more likely to walk slower, tire easily and perceive themselves as having poor overall health. Socially, COPD patients were less likely to have long-term partners and felt the need for more emotional support than their healthy peers.

Prevalence of osteoarthritis in individuals with COPD: a systematic review

The objective of this review was to examine the prevalence of osteoarthritis (OA) in individuals with COPD. A computer-based literature search of CINAHL, Medline, PsycINFO and Embase databases was performed. Studies reporting the prevalence of OA among a cohort of individuals with COPD were included. The sample size varied across the studies from 27 to 52,643 with a total number of 101,399 individuals with COPD recruited from different countries. The mean age ranged from 59 to 76 years. The prevalence rates of OA among individuals with COPD were calculated as weighted means. A total of 14 studies met the inclusion criteria with a prevalence ranging from 12% to 74% and an overall weighted mean of 35.5%. Our findings suggest that the prevalence of OA is high among individuals with COPD and should be considered when developing and applying interventions in this population.

The systemic nature of mustard lung: Comparison with COPD patients

Sulphur mustard (SM) is a powerful blister-causing alkylating chemical warfare agent used by Iraqi forces against Iran. One of the known complications of mustard gas inhalation is mustard lung which is discussed as a phenotype of chronic obstructive pulmonary disease (COPD). In this complication, there are clinical symptoms close to COPD with common etiologies, such as in smokers. Based on information gradually obtained by conducting the studies on mustard lung patients, systemic symptoms along with pulmonary disorders have attracted the attention of researchers. Changes in serum levels of inflammatory markers, such as C-reactive protein (CRP), tumor necrosis factor alpha (TNF-α), nuclear factor κB (NF-κB), matrix metalloproteinases (MMPs), interleukin (IL), chemokines, selectins, immunoglobulins, and signs of imbalance in oxidant-antioxidant system at serum level, present the systemic changes in these patients. In addition to these, reports of extra-pulmonary complications, such as osteoporosis and cardiovascular disease are also presented. In this study, the chance of developing the systemic nature of this lung disease have been followed on using the comparative study of changes in the mentioned markers in mustard lung and COPD patients at stable phases and the mechanisms of pathogenesis and phenomena, such as airway remodeling in these patients.

From systems biology to P4 medicine: applications in respiratory medicine

Human health and disease are emergent properties of a complex, nonlinear, dynamic multilevel biological system: the human body. Systems biology is a comprehensive research strategy that has the potential to understand these emergent properties holistically. It stems from advancements in medical diagnostics, “omics” data and bioinformatic computing power. It paves the way forward towards “P4 medicine” (predictive, preventive, personalised and participatory), which seeks to better intervene preventively to preserve health or therapeutically to cure diseases. In this review, we: 1) discuss the principles of systems biology; 2) elaborate on how P4 medicine has the potential to shift healthcare from reactive medicine (treatment of illness) to predict and prevent illness, in a revolution that will be personalised in nature, probabilistic in essence and participatory driven; 3) review the current state of the art of network (systems) medicine in three prevalent respiratory diseases (chronic obstructive pulmonary disease, asthma and lung cancer); and 4) outline current challenges and future goals in the field.

Systems biology and network medicine have the potential to transform medical research and practicehttp://ow.ly/r3jR30hf35x

Angiotensin-(1-7)-mediated Mas1 receptor/NF-κB-p65 signaling is involved in a cigarette smoke-induced chronic obstructive pulmonary disease mouse model

Angiotensin-(1-7) [Ang-(1-7)] has been shown to play a significant role in the pathogenesis of lung inflammation via Mas receptor; however, its effect in chronic obstructive pulmonary disease (COPD) remains unknown. To explore the effect of Ang-(1-7) on a cigarette smoke (CS) exposure-induced COPD model, 40 C57BL/6J mice were divided into four groups (n = 10) and exposed to air or CS for 8 weeks. After that, they were treated with saline or Ang-(1-7) at 0.3 mg/kg for 2 weeks by subcutaneous infusion using osmotic pump. The day following drug/vehicle challenge, lung function was examined and bronchoalveolar lavage (BAL) was performed. Chemokine (C-X-C motif) ligand 1, interleukin-6, and tumor necrosis factor-α protein levels in BAL fluid were determined using ELISA; the corresponding mRNA levels in lung tissues were measured using RT-PCR. Mas1 receptor, pIκBα, IκBα, nuclear NF-κB-p65 protein, pERK1/2, ERK2, pp38, and p38 proteins expression in lung tissues were examined by immunohistochemical staining and western blotting. Ang-(1-7) challenge had no effect on the decreased lung function and emphysema induced by CS exposure. However, Ang-(1-7) treatment blocked CS exposure-induced lung inflammatory responses and lung fibrosis, as determined by Masson's Trichrome staining. Exposure to CS for 8 weeks caused irreversible loss of lung function and emphysema, which could not be reversed by Ang-(1-7) treatment. Thus, the beneficial effect of Ang-(1-7) may be confined to pulmonary inflammation and fibrosis.

Predicting treatable traits for long-acting bronchodilators in patients with stable COPD

Purpose

There is currently no measure to predict a treatability of long-acting β-2 agonist (LABA) or long-acting muscarinic antagonist (LAMA) in patients with chronic obstructive pulmonary disease (COPD). We aimed to build prediction models for the treatment response to these bronchodilators, in order to determine the most responsive medication for patients with COPD.

Methods

We performed a prospective open-label crossover study, in which each long-acting bronchodilator was given in a random order to 65 patients with stable COPD for 4 weeks, with a 4-week washout period in between. We analyzed 14 baseline clinical traits, expression profiles of 31,426 gene transcripts, and damaged-gene scores of 6,464 genes acquired from leukocytes. The gene expression profiles were measured by RNA microarray and the damaged-gene scores were obtained after DNA exome sequencing. Linear regression analyses were performed to build prediction models after using factor and correlation analyses.

Results

Using a prediction model for a LABA, traits found associated with the treatment response were post-bronchodilator forced expiratory volume in 1 second, bronchodilator reversibility (BDR) to salbutamol, expression of three genes (CLN8, PCSK5, and SKP2), and damage scores of four genes (EPG5, FNBP4, SCN10A, and SPTBN5) (R²=0.512, p<0.001). Traits associated with the treatment response to a LAMA were COPD assessment test score, BDR, expression of four genes (C1orf115, KIAA1618, PRKX, and RHOQ) and damage scores of three genes (FBN3, FDFT1, and ZBED6) (R²=0.575, p<0.001). The prediction models consisting only of clinical traits appeared too weak to predict the treatment response, with R²=0.231 for the LABA model and R²=0.121 for the LAMA model.

Conclusion

Adding the expressions of genes and damaged-gene scores to the clinical traits may improve the predictability of treatment response to long-acting bronchodilators.

Expression of Toll-like Receptor 2 and 4 in Peripheral Blood Neutrophil Cells from Patients with Chronic Obstructive Pulmonary Disease

Objectives

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality around the world. Preliminary studies have evaluated the association between innate immunity including Toll-like receptors (TLRs) and airway samples of patients with COPD. The role of TLRs in peripheral blood neutrophils is poorly understood. Hence, this study aimed to investigate the role of TLR2 and TLR4 in peripheral blood neutrophils of COPD patients.

Methods

A total of 101 COPD cases and an equal number of healthy controls participated in this case-control study. Peripheral blood neutrophils were isolated from all participants and cultured for 24 hours through lipopolysaccharide (LPS) stimulation. The gene expressions of TLR2 and TLR4 were assessed by real-time polymerase chain reaction. The protein levels of interleukin (IL)-8 and matrix metalloproteinase (MMP)-9 were measured in neutrophils cell culture supernatants using enzyme-linked immunosorbent assay (ELISA).

Results

The levels of IL-8 and MMP-9 were significantly higher in patients with COPD compared to healthy controls. Similarly, the gene expression of TLR2 and TLR4 were increased in LPS stimulated peripheral blood neutrophils of patients with COPD. Smoke pack years was positively correlated with IL-8 levels and negatively correlated with forced expiratory volume in the first second % (r = -0.33; p = 0.023) and FEV1/forced vital capacity (FVC) (r = -0.27; p = 0.011).

Conclusions

The increased expression of TLR2 and TLR4 suggests its role in disease pathogenesis of COPD. Smoke pack years was negatively associated with spirometric parameters in COPD patients. This may help to predict the smokers without COPD who risk developing the condition in the future.

Meta-analysis of peripheral blood gene expression modules for COPD phenotypes

Chronic obstructive pulmonary disease (COPD) occurs typically in current or former smokers, but only a minority of people with smoking history develops the disease. Besides environmental factors, genetics is an important risk factor for COPD. However, the relationship between genetics, environment and phenotypes is not well understood. Sample sizes for genome-wide expression studies based on lung tissue have been small due to the invasive nature of sample collection. Increasing evidence for the systemic nature of the disease makes blood a good alternative source to study the disease, but there have also been few large-scale blood genomic studies in COPD. Due to the complexity and heterogeneity of COPD, examining groups of interacting genes may have more relevance than identifying individual genes. Therefore, we used Weighted Gene Co-expression Network Analysis to find groups of genes (modules) that are highly connected. However, module definitions may vary between individual data sets. To alleviate this problem, we used a consensus module definition based on two cohorts, COPDGene and ECLIPSE. We studied the relationship between the consensus modules and COPD phenotypes airflow obstruction and emphysema. We also used these consensus module definitions on an independent cohort (TESRA) and performed a meta analysis involving all data sets. We found several modules that are associated with COPD phenotypes, are enriched in functional categories and are overrepresented for cell-type specific genes. Of the 14 consensus modules, three were strongly associated with airflow obstruction (meta p ≤ 0.0002), and two had some association with emphysema (meta p ≤ 0.06); some associations were stronger in the case-control cohorts, and others in the cases-only subcohorts. Gene Ontology terms that were overrepresented included “immune response” and “defense response.” The cell types whose type-specific genes were overrepresented in modules (p < 0.05) included natural killer cells, dendritic cells, and neutrophils. Together, this is the largest investigation of gene blood expression in COPD with 469 cases in COPDGene, ECLIPSE and TESRA combined, with 6267 genes common to all data sets. Additional, we have 42 and 83 controls in COPDGene and ECLIPSE, respectively.

Factors associated with pulmonary impairment in HIV-infected South African adults

Background

HIV-infected individuals have increased risk of developing obstructive lung disease (OLD). Studies from developed countries report high viral load, low CD4 counts, and anti-retroviral therapy (ART) to be associated with OLD; but these findings may not be generalizable to populations in resource-limited settings.

Methods

We conducted a prospective cohort study of lung function in 730 HIV-infected black South African adults. Pre-bronchodilator spirometry was performed at enrollment and repeated annually for three years. Logistic regression models were used to identify factors associated with OLD, defined as FEV1/FVC<0.70, at enrollment. Excess annual declines in FEV1 and FVC were modelled as the product-term of follow-up time and exposures using random effects regression.

Results

Median (IQR) age at enrollment was 36 (32–41) years, 85% were female and 30% ever-smoked with a median (IQR) exposure of 3 (1–6) pack-years. Median (IQR) CD4 count and viral load at enrollment were 372 (261–518) cells/mm³ and 2655 (91–13,548) copies/mL respectively. Overall, 25% were receiving ART at enrollment, 16% of whom reported at least 6 months of ART receipt. OLD was found in 35 (5%) at enrollment. Increasing age (aOR = 2.08 per 10-years [95%CI 1.22–3.57], p = 0.007), current smoking (aOR = 3.55 [95%CI 1.20–10.53], p = 0.02), and CRP (aOR = 1.01 per unit-increase [95%CI 1.00–1.03], p = 0.04) were significantly associated with OLD at enrollment; while increasing CD4 count (aOR = 1.02 per-100 cells/mm³ [95%CI 0.85–1.22], p = 0.82), viral load (aOR = 0.67 per log-increase [95%CI 0.43–1.10], p = 0.12) and receipt of ART (aOR = 0.57 [95%CI 0.18–1.75], p = 0.32) were not. The median (IQR) follow-up time was 18 (12–24) months. Participants with a history of tuberculosis (TB) had a 35 mL (95%CI 2–68, p = 0.03) and 57 mL (95%CI 19–96, p = 0.003) per year excess loss of FEV1 and FVC respectively.

Conclusion

Prevalent OLD was associated with older age, current smoking and higher CRP levels, but not CD4 counts and ART, in HIV-infected South African adults. Better understanding of the long-term effects of TB, smoking and inflammation on lung function in HIV-infected populations is urgently needed.

Analysis of the influence of respiratory disorders observed in preoperative spirometry on the dynamics of early inflammatory response in patients undergoing isolated coronary artery bypass grafting

Background

Preoperative spirometry provides measurable information about the occurrence of respiratory disorders. The aim of this study was to assess the association between preoperative spirometry abnormalities and the intensification of early inflammatory responses in patients following coronary artery bypass graft in extracorporeal circulation.

Material and methods

The study involved 810 patients (625 men and 185 women) aged 65.4±7.9 years who were awaiting isolated coronary artery bypass surgery. On the basis of spirometry performed on the day of admittance to the hospital, the patients were divided into three groups. Patients without respiratory problems constituted 78.8% of the entire group. Restricted breathing was revealed by spirometry in 14.9% and obstructive breathing in 6.3% of patients.

Results

Inter-group analysis showed statistically significant differences in C-reactive protein (CRP) between patients with restrictive spirometry abnormalities and patients without any pulmonary dysfunction. CRP concentrations differed before surgery (P=0.006) and on the second (P<0.001), fourth (P=0.005) and sixth days after surgery (P=0.029). There was a negative correlation between CRP levels and FEV₁.

Conclusion

In our study, the most common pulmonary disorders in the coronary artery bypass graft patients were restrictive. Patients with abnormal spirometry results from restrictive respiratory disorders have an elevated level of generalized inflammatory response both before and after the isolated coronary artery bypass surgery. Therefore, this group of patients should be given special postoperative monitoring and, in particular, intensive respiratory rehabilitation immediately after reconstitution.

Building COPD care on shaky ground: a mixed methods study from Swedish primary care professional perspective

Background

Chronic obstructive pulmonary disease (COPD) is a public health problem. Interprofessional collaboration and health promotion interventions such as exercise training, education, and behaviour change are cost effective, have a good effect on health status, and are recommended in COPD treatment guidelines. There is a gap between the guidelines and the healthcare available to people with COPD.

The aim of this study was to increase the understanding of what shapes the provision of primary care services to people with COPD and what healthcare is offered to them from the perspective of healthcare professionals and managers.

Methods

The study was conducted in primary care in a Swedish county council during January to June 2015. A qualitatively driven mixed methods design was applied. Qualitative and quantitative findings were merged into a joint analysis. Interviews for the qualitative component were performed with healthcare professionals (n = 14) from two primary care centres and analysed with qualitative content analysis. Two questionnaires were used for the quantitative component; one was answered by senior managers or COPD nurses at primary care centres (n = 26) in the county council and the other was answered by healthcare professionals (n = 18) at two primary care centres. The questionnaire data were analysed with descriptive statistics.

Results

The analysis gave rise to the overarching theme building COPD care on shaky ground. This represents professionals driven to build a supportive COPD care on ‘shaky’ organisational ground in a fragmented and non-compliant healthcare organisation. The shaky ground is further represented by uninformed patients with a complex disease, which is surrounded with shame. The professionals are autonomous and pragmatic, used to taking responsibility for their work, and with limited involvement of the management. They wish to provide high quality COPD care with interprofessional collaboration, but they lack competence and are hindered by inadequate routines and lack of resources.

Conclusions

There is a gap between COPD treatment guidelines and the healthcare that is provided in primary care. To facilitate implementation of the guidelines several actions are needed, such as further training for professionals, additional resources, and improved organisational structure for interprofessional collaboration and patient education.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2393-y) contains supplementary material, which is available to authorized users.

Association between chronic obstructive pulmonary disease and increased risk of benign prostatic hyperplasia: a retrospective nationwide cohort study

OBJECTIVE

Chronic obstructive pulmonary disease (COPD) and benign prostatic hyperplasia (BPH) are common disorders in ageing male populations. Nevertheless, the relationship between the two diseases has rarely been explored. The objective of this study was to examine whether patients with COPD are at an increased risk of BPH.

DESIGN

Retrospective nationwide cohort study.

SETTING

Data retrieved from the Taiwan National Health Insurance Research Database.

PARTICIPANTS

Overall, 19 959 male patients aged 40 years and over with newly diagnosed COPD between 2000 and 2006 were included as the COPD group, and 19 959 sex-matched and age-matched enrollees without COPD were included as the non-COPD group. Both groups were followed-up until the end of 2011.

OUTCOME MEASURES

A Cox proportional hazards regression model was used to compute the risk of BPH in patients with COPD compared with enrollees without COPD.

RESULTS

The overall incidence rate of BPH was 1.53 times higher in the COPD group than that in the non-COPD group (44.7 vs 25.7 per 1000 person-years, 95% CI 1.46 to 1.60) after adjusting for covariates. An additional stratified analysis revealed that this increased risk of BPH in patients with COPD remained significantly higher than that in enrollees without COPD in all men aged 40 years and over.

CONCLUSION

After adjustment for covariates, male patients with COPD were found to be at a higher risk of BPH. We suggest that clinicians should be cautious about the increased risk of BPH in male patients with COPD.

Exacerbation of Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a disease with high prevalence and substantial associated economical burden. A significant determinant of quality of life, long-term survival, and health care costs is an acute exacerbation of COPD. Acute exacerbations are provoked by respiratory viruses, altered airway microbiome, and environmental factors. The current treatment options are limited. In order to develop specific therapeutic measures, it is important to understand how acute exacerbations evolve. This review focuses on pathophysiology of stable and exacerbated COPD.

Lung function, inflammation and cardiovascular mortality in Africans

BACKGROUND

The link between impaired lung function and cardiovascular outcome is well established in European and American populations. It is possible that this association may be driven by a systemic spillover of inflammation occurring within the lungs. As several studies have found an increased level of inflammatory markers in African populations, we aimed to establish the contribution of lung function in predicting all-cause and cardiovascular mortality in Africans, whilst taking inflammatory markers into account.

DESIGN

We followed 1442 black South Africans from the North West Province participating in the South African leg of the Prospective Urban and Rural Epidemiology (PURE) study, over a five-year period. Spirometry, cardiovascular and metabolic measures were performed, and cardiovascular mortality as well as all-cause mortality used as endpoints.

RESULTS

In univariate Cox regression models, both forced expiratory volume in 1-s (FEV₁ ) and forced vital capacity (FVC) predicted all-cause (P = 0·022; P < 0·001) and cardiovascular mortality (P = 0·004; P < 0·001). In multivariate adjusted standardized Cox regression analyses, only FVC predicted cardiovascular mortality independent of several covariates (hazard ratio, 0·57 [0·35-0·94]), including C-reactive protein (CRP). When CRP was replaced by interleukin-6 in the model, the significance of FVC was lost (hazard ratio, 0·85 [0·55-1·30]).

CONCLUSION

FVC, but not FEV₁ , is a strong predictor of both all-cause and CV mortality in black South Africans, which may be mediated by inflammation.

Red Blood Cell Distribution Width in Patients With Chronic Obstructive Pulmonary Disease and Healthy Subjects

BACKGROUND

Chronic obstructive pulmonary disease (COPD) increases the risk of cardiovascular disease (CVD). Red blood cell distribution width (RDW) is accepted as a powerful predictor of outcomes in patients with CVD.

AIMS

To study RDW in patients with COPD, and to compare the value of this measurement with clinical, echocardiographic, nutritional and laboratory status. Secondly, we aimed to determine the effect of smoking on RDW values in healthy subjects.

METHODS

One hundred and seventy-five patients with stable COPD and 210 healthy controls were enrolled in the study. Demographic, clinical, nutritional status, echocardiographic, and laboratory characteristics, RDW values were recorded and compared.

RESULTS

RDW values were higher in the COPD group than in controls (15±2.3% vs. 13.8±2.5%, p<0.001). In COPD patients, RDW levels positively correlated with CRP levels (r=0.27, P<.001), albumin levels (r=0.23, P=.04), right ventricular dysfunction (RVD) (r=0.24, P=.001), pulmonary hypertension (PAH) (r=0.1, P=.02), and presence of CVD (r=0.24, P=.02). In multivariable logistic regression suggested that presence of CVD (4.3; 95% CI: 1.3 to 11; P=.01), and presence of RVD (3.1; 95% CI: 1.7 to 8.3; P=.02) were independently related to elevated RDW levels in COPD patients. In the healthy population, correlations analysis showed only a significant correlation between RDW and cigarette smoking years (r=0.57, P<.001).

CONCLUSION

RDW is independently associated with CVD and RVD in patients with COPD. In the healthy population, RDW is also associated with smoking status.

Highly absorptive curcumin reduces serum atherosclerotic low-density lipoprotein levels in patients with mild COPD

PURPOSE

COPD is mainly caused by tobacco smoking and is associated with a high frequency of coronary artery disease. There is growing recognition that the inflammation in COPD is not only confined to the lungs but also involves the systemic circulation and can impact nonpulmonary organs, including blood vessels. α1-antitrypsin-low-density lipoprotein (AT-LDL) complex is an oxidatively modified LDL that accelerates atherosclerosis. Curcumin, one of the best-investigated natural products, is a powerful antioxidant. However, the effects of curcumin on AT-LDL remain unknown. We hypothesized that Theracurmin(®), a highly absorptive curcumin with improved bioavailability using a drug delivery system, ameliorates the inflammatory status in subjects with mild COPD.

PATIENTS AND METHODS

This is a randomized, double-blind, parallel-group study. Subjects with stages I-II COPD according to the Japanese Respiratory Society criteria were randomly assigned to receive 90 mg Theracurmin(®) or placebo twice a day for 24 weeks, and changes in inflammatory parameters were evaluated.

RESULTS

There were no differences between the Theracurmin(®) and placebo groups in terms of age, male/female ratio, or body mass index in 39 evaluable subjects. The percent changes in blood pressure and hemoglobin A1c and LDL-cholesterol, triglyceride, or high-density lipoprotein-cholesterol levels after treatment were similar for the two groups. However, the percent change in the AT-LDL level was significantly (P=0.020) lower in the Theracurmin(®) group compared with the placebo group.

CONCLUSION

Theracurmin(®) reduced levels of atherosclerotic AT-LDL, which may lead to the prevention of future cardiovascular events in mild COPD subjects.

Smokers with emphysema and small airway disease on computed tomography have lower bone density

Osteoporosis is more common in patients with COPD and in smokers. The aim of this study was to assess whether measures of emphysema and airway disease on computed tomography (CT) were associated with lower bone density or vertebral fractures in smokers with and without COPD. For this purpose, we included participants from the NELSON lung cancer screening trial. Bone density was measured as Hounsfield Units in the first lumbar vertebra, and vertebral fractures were assessed semiquantitatively. The 15th percentile method (Perc15) was used to assess emphysema, and the airway lumen perimeter (Pi10) was used for airway wall thickness. Expiratory/inspiratory-ratio_{mean lung density} (E/I-ratio_MLD) was used as a measure for air trapping and tracheal index to assess tracheal deformity. Linear regression models and logistic regression models were used to assess associations between CT biomarkers, bone density, and presence of fractures. Exactly 1,093 male participants were eligible for analysis. Lower Perc15 and higher E/I-ratio_MLD were significantly associated with lower bone density (b=−1.27, P=0.02 and b=−0.37, P=0.02, respectively). Pi10 and tracheal index were not associated with bone density changes. CT-derived biomarkers were not associated with fracture prevalence. Bone density is lower with increasing extent of emphysema and small airway disease but is not associated with large airway disease and tracheal deformity. This may indicate the necessity to measure bone density early in smokers with emphysema and air trapping to prevent vertebral fractures.

Time controlled pulsatile transdermal delivery of nicotine: A phase I feasibility trial in male smokers

Nicotine substitution is a mainstay component in smoking cessation schemes. Current products including patches are poorly effective mainly because they do not give smokers the same pharmacokinetic profile of nicotine as cigarette consumption. This work evaluates a new computer operated delivery system for time controlled pulsatile transdermal administration of nicotine in a phase I clinical trial with twelve heavy smoking male volunteers. The device was affixed to the ventral side of the leading lower arm of the subjects and was programmed to deliver two pulses of drug within 16h with three delivery rates in a consecutive dose escalation study. Tolerability of the three increasing doses of nicotine was established. Plasma concentration of nicotine exhibited two peaks and one trough and reached therapeutically effective levels that behaved linearly with the drug load concentration of the device. In vivo input rate, delivered amount and elimination kinetics were deduced by pharmacokinetic modeling to analyze device performance. Timing, dose and duration of delivery were controlled by system operation parameters. Hence, feasibility of controlled pulsatile delivery of nicotine at predetermined intervals was demonstrated. After additional optimization, preprogrammed or on demand administration to meet individualized and circadian replacement needs should improve smoking cessation efficacy.

Systemic inflammation and lung function: A longitudinal analysis

BACKGROUND

Systemic inflammation is associated with impaired lung function in healthy adults as well as in patients with lung disease. The mechanism for this association is unknown and it is unclear if systemic inflammation leads to impaired lung function or if poor lung function leads to inflammation. We explored the temporal associations between blood C-reactive protein (CRP), fibrinogen, and white blood cells, and lung function in young adults.

METHODS

Spirometry, plethysmography, and diffusion capacity were measured in a population-based cohort at ages 32 and 38 years. High-sensitivity CRP, fibrinogen, and white blood cells were measured at the same ages.

RESULTS

Higher levels of CRP and, to a lesser extent, fibrinogen were associated with lower lung volumes in cross-sectional analyses at both ages 32 and 38 years. Higher CRP and fibrinogen at age 32 were associated with higher FEV1 and FEV1/FVC at age 38, but not other measures of lung function. Lower lung volumes (total lung capacity, functional residual capacity, and residual volume) but not airflow obstruction (FEV1/FVC) at age 32 were associated with higher CRP at age 38. Associations between age 32 lung function and fibrinogen at follow-up were weaker, but consistent. There were no longitudinal associations between white blood cells and lung function.

CONCLUSIONS

We found no evidence that systemic inflammation causes a decline in lung function. However, lower lung volumes were associated with higher CRP and fibrinogen at follow-up indicating that pulmonary restriction may be a risk factor for systemic inflammation. The mechanism for this association remains unclear.

The influence of iron deficiency on the functioning of skeletal muscles: experimental evidence and clinical implications

Skeletal and respiratory myopathy not only constitutes an important pathophysiological feature of heart failure and chronic obstructive pulmonary disease, but also contributes to debilitating symptomatology and predicts worse outcomes in these patients. Accumulated evidence from laboratory experiments, animal models, and interventional studies in sports medicine suggests that undisturbed systemic iron homeostasis significantly contributes to the effective functioning of skeletal muscles. In this review, we discuss the role of iron status for the functioning of skeletal muscle tissue, and highlight iron deficiency as an emerging therapeutic target in chronic diseases accompanied by a marked muscle dysfunction.

The chronic obstructive pulmonary disease comorbidity spectrum in Japan differs from that in western countries

Patients with Chronic Obstructive Pulmonary Disease (COPD) frequently suffer from various comorbidities, such as cardiovascular disease, osteoporosis, depression, malnutrition, metabolic syndrome, diabetes, and lung cancer. These comorbidities have a significant impact on disease severity and survival. In fact, guidelines from both the Global Initiative for Chronic Obstructive Lung Disease and the Japanese Respiratory Society recommend that physicians take comorbidities into account when they evaluate COPD severity. These guidelines also emphasize the importance of managing comorbidities alongside airway obstruction in COPD. The mechanisms by which the many COPD-related comorbidities develop are still unclear. Aging and smoking are well-established as major factors. However, systemic inflammation may also contribute to the disease process. Having developed from the classical theory to differentiate COPD patients into "pink puffers" and "blue bloaters", COPD is now generally considered as a heterogeneous condition. On this point, we have noticed that the characteristics of Japanese COPD patients tend to differ from those of Westerners. Specifically, Japanese patients tend to be older, to have lower body mass index, to suffer from emphysema-dominant lung disease, and to experience exacerbations less frequently. The comorbidity spectrum of Japanese COPD patients also seems to differ from that of Westerners. For instance, in Japanese patients, cardiovascular disease and metabolic syndrome are less prevalent, whereas osteoporosis and malnutrition are more frequent. In order to treat Japanese COPD patients optimally, we must pay particular attention to their unique demographics and comorbidity spectrum, which contrast with those of Western COPD patients.

C-reactive protein levels in stable COPD patients: a case-control study

Background

Previous studies have documented that C-reactive protein (CRP) levels are increased in stable COPD patients. However, most studies have also shown that higher CRP levels are observed in patients with comorbidities like diabetes mellitus and cardiovascular disease. We aimed to investigate if CRP levels are increased in stable COPD patients, and if there is an association between CRP levels and pulmonary function tests and clinical characteristics.

Methods

We conducted a case-control study in a tertiary care, university-affiliated hospital. COPD patients and controls were matched for sex and age in a 2:1 matching ratio. We included only those patients who had quit smoking. CRP levels were determined and pulmonary function tests were performed in both the groups.

Results

A total of 60 COPD patients and 30 controls were included in the analysis. The study subjects had a mean age of 64.8±8.5 years in COPD group and 64.3±9.2 years in control group (P=0.214). The median of CRP levels was 3.17 mg/L (interquartile range [IQR]: 1.73–5.99 mg/L) in COPD group and 2.13 mg/L (IQR: 1.18–7.69 mg/L) in control group (P=0.370). There were 34 (56.7%) patients in COPD group and 14 (46.7%) patients in control group with CRP levels greater than 3 mg/dL (P=0.382). Using bivariate correlations, we found significant positive correlations in COPD patients between body mass index (BMI) and CRP (r=0.3, P=0.045), and between CRP and forced vital capacity (FVC, % of predicted) (r=−0.3; P=0.023). In a multivariate model, female sex and FVC (% of predicted) were associated with a CRP value greater than 3 mg/dL in the COPD group.

Conclusion

The levels of CRP in the stable COPD patients were not significantly different when compared to those in the control subjects. Female sex and FVC (% predicted) were associated with CRP levels greater than 3 mg/dL in the COPD group.

Systemic manifestations of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease is a complex multisystem disease with comorbidities and systemic manifestations that affect respiratory symptoms, exacerbation frequency and mortality. This article gives an overview of these systemic manifestations and their importance, and offers strategies for managing them.

Risk of cardiovascular comorbidity in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a systemic inflammatory disorder associated with increased comorbid prevalence of cardiovascular diseases. We aimed to quantify the magnitudes of association between overall and specific types of cardiovascular disease, major cardiovascular risk factors, and COPD.

METHODS

We searched Cochrane, Medline, and Embase databases for studies published between Jan 1, 1980, and April 30, 2015, on the prevalence of cardiovascular disease and its risk factors in patients with COPD versus matched controls or random samples from the general public. We assessed associations with random-effects meta-analyses. We studied heterogeneity and biases with random-effects meta-regressions, jackknife sensitivity analyses, assessment of funnel plots, and Egger tests.

FINDINGS

We identified 18,176 unique references and included 29 datasets in the meta-analyses. Compared with the non-COPD population, patients with COPD were more likely to be diagnosed with cardiovascular disease (odds ratio [OR] 2·46; 95% CI 2·02-3·00; p<0·0001), including a two to five times higher risk of ischaemic heart disease, cardiac dysrhythmia, heart failure, diseases of the pulmonary circulation, and diseases of the arteries. Additionally, patients with COPD reported hypertension more often (OR 1·33, 95% CI 1·13-1·56; p=0·0007), diabetes (1·36, 1·21-1·53; p<0·0001], and ever smoking (4·25, 3·23-5·60; p<0·0001). The associations between COPD and these cardiovascular disease types and cardiovascular disease risk factors were consistent and valid across studies. Enrolment period, age, quality of data, and COPD diagnosis partly explained the heterogeneity.

INTERPRETATION

The coexistence of COPD, cardiovascular disease, and major risk factors for cardiovascular disease highlights the crucial need for the development of strategies to screen for and reduce cardiovascular risks associated with COPD.

FUNDING

Canadian Institutes of Health Research.

Physical activity and fatigue in chronic obstructive pulmonary disease - A population based study

BACKGROUND

In subjects with chronic obstructive pulmonary disease (COPD), symptoms of fatigue, concomitant heart disease and low physical activity levels are more frequently described than in subjects without COPD. However, there are no population-based studies addressing the relationship between physical activity, fatigue and heart disease in COPD. The aim was to compare physical activity levels among subjects with and without COPD in a population based study, and to evaluate if concomitant heart disease and fatigue was associated to physical activity.

METHODS

In this, 470 subjects with COPD and 659 subjects without COPD (non-COPD) participated in examinations including structured interview and spirometry. A ratio of the forced expiratory volume in one second (FEV1)/best of forced vital capacity (FVC) and vital capacity (VC) < 0.7 was used to define COPD. Physical activity was assessed with the International Physical Activity Questionnaire (IPAQ), and fatigue with the Functional Assessment of Chronic Illness Therapy - Fatigue scale (FACIT-F).

RESULTS

The prevalence of low physical activity was higher among subjects with FEV1 < 80% predicted compared to non-COPD subjects (22.4% vs. 14.6%, p = 0.041). The factors most strongly associated with low physical activity in subjects with COPD were older age, OR 1.52, (95% CI 1.12-2.06), a history of heart disease, OR 2.11 (1.10-4.08), and clinically significant fatigue, OR 2.33 (1.31-4.13); while obesity was the only significant factor among non-COPD subjects, OR 2.26 (1.17-4.35).

CONCLUSION

Physical activity levels are reduced when lung function is decreased below 80% of predicted, and the factors associated with low physical activity are different among subject with and without COPD. We propose that the presence of fatigue and heart disease are useful to evaluate when identifying subjects for pulmonary rehabilitation.