The clinical and genetic features of COPD-asthma overlap syndrome

Pharmacological inhibition of GPR4 remediates intestinal inflammation in a mouse colitis model

Inflammatory bowel disease (IBD) is characterized by chronic, recurring inflammation of the digestive tract. Current therapeutic approaches are limited and include biologics and steroids such as anti-TNFα monoclonal antibodies and corticosteroids, respectively. Significant adverse drug effects can occur for chronic usage and include increased risk of infection in some patients. GPR4, a pH-sensing G protein-coupled receptor, has recently emerged as a potential therapeutic target for intestinal inflammation. We have assessed the effects of a GPR4 antagonist, 2-(4-((2-Ethyl-5,7-dimethylpyrazolo[1,5-a]pyrimidin-3-yl)methyl)phenyl)-5-(piperidin-4-yl)-1,3,4-oxadiazole (GPR4 antagonist 13, also known as NE-52-QQ57) in the dextran sulfate sodium (DSS)-induced acute colitis mouse model. The GPR4 antagonist 13 inhibited intestinal inflammation. The clinical parameters such as body weight loss and fecal score were reduced in the GPR4 antagonist 13 treatment group compared to vehicle control. Macroscopic disease indicators such as colon shortening, splenic expansion, and mesenteric lymph node enlargement were all reduced in severity in the GPR4 antagonist 13 treated mice. Histopathological features of active colitis were alleviated in GPR4 antagonist 13 treatment groups compared to vehicle control. Finally, inflammatory gene expression in the colon tissues and vascular adhesion molecule expression in the intestinal endothelia were attenuated by GPR4 antagonist 13. Our results indicate that GPR4 antagonist 13 provides a protective effect in the DSS-induced acute colitis mouse model, and inhibition of GPR4 can be explored as a novel anti-inflammatory approach.

Longitudinal comparison of outcomes in patients with smoking-related asthma-COPD overlap and in non-smoking asthmatics with incomplete reversibility of airway obstruction

Background

There is a need to characterize the impact of the smoking status on the clinical course of asthmatics with incomplete reversibility of airway obstruction (IRAO).

Objective

To compare longitudinal health care use, symptom control, and medication needs between smoking and non-smoking asthmatics with IRAO.

Materials and methods

This was a 12-month follow-up of a cross-sectional study comparing asthmatics with IRAO according to their tobacco exposure. One group had a tobacco exposure ≥20 pack-years and was considered to have asthma-COPD overlap (ACO) and the second with a past tobacco exposure <5 pack-years was considered as non-smokers with IRAO (NS-IRAO). Study participants were contacted by telephone every 3 months to document exacerbation events and symptom control.

Results

A total of 111 patients completed all follow-up telephone calls: 71 ACO and 40 NS-IRAO. The number of exacerbations per patient over the 12-month follow-up was similar in both groups. However, ACO reported worse symptom control throughout the follow-up as compared to NS-IRAO, although no significant variations within a group were observed over the study period.

Conclusion

Although asthma control scores were poorer in ACO patients over 1 year compared to NS-IRAO, exacerbation rate was similar and low in both groups of asthmatics. These observations suggest that poorer asthma control in ACO was not driven by the number of exacerbations but may reflect the influence of chronic airway changes related to the COPD component.

Longitudinal analysis to better characterize Asthma-COPD overlap syndrome: Findings from an adult asthma cohort in Korea (COREA)

BACKGROUND

Asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS), which has received much attention, has not been unanimously defined.

OBJECTIVE

In this study, we tried to demonstrate that longitudinally defined ACOS is more useful in the real world than blending patients with asthma and COPD.

METHODS

The study patients had undergone two consecutive pulmonary function tests measured at least 3 months apart (n = 1889). We selected the patients who had positive bronchodilator response or methacholine provocation tests (n = 959). Next, we defined ACOS as a patient with a persistent airflow obstruction [forced expiratory volume in 1 second (FEV1)/forced vital capacity <0.7] that was identified twice consecutively by an interval of at least 3 months (n = 228).

RESULTS

The proportions of patients who were older, male and smokers were significantly higher, and baseline lung function was lower in patients with ACOS. In the longitudinal analysis, the mean change in lung function was high, and a greater decline in FEV1 was observed in patients with ACOS. In addition, we compared ACOS and severe asthma, and we also performed a cluster analysis and compared the results with our definition of ACOS. According to our definition, ACOS is an independent subtype with distinctive characteristics. Finally, a genome-wide association study (GWAS) was performed to identify genetic variations associated with ACOS, but no significant single nucleotide polymorphisms were identified.

CONCLUSION

Our findings suggest that ACOS should be defined longitudinally and considered as an independent subgroup distinguished by inherited environmental factors rather than as a genetically distinct independent group.

Gene fingerprint model for literature based detection of the associations among complex diseases: a case study of COPD

BACKGROUND

Disease comorbidity is very common and has significant impact on disease treatment. Revealing the associations among diseases may help to understand the mechanisms of diseases, improve the prevention and treatment of diseases, and support the discovery of new drugs or new uses of existing drugs.

METHODS

In this paper, we introduced a mathematical model to represent gene related diseases with a series of associated genes based on the overrepresentation of genes and diseases in PubMed literature. We also illustrated an efficient way to reveal the implicit connections between COPD and other diseases based on this model.

RESULTS

We applied this approach to analyze the relationships between Chronic Obstructive Pulmonary Disease (COPD) and other diseases under the Lung diseases branch in the Medical subject heading index system and detected 4 novel diseases relevant to COPD. As judged by domain experts, the F score of our approach is up to 77.6%.

CONCLUSIONS

The results demonstrate the effectiveness of the gene fingerprint model for diseases on the basis of medical literature.

Prevalence and features of asthma-COPD overlap in the United States 2007-2012

BACKGROUND

Perceived to be distinct, asthma and chronic obstructive pulmonary disease (COPD) can co-exist and potentially have a worse prognosis than the separate diseases. Yet, little is known about the exact prevalence and the characteristics of the Asthma-COPD overlap (ACO) in the US population.

AIMS

To determine ACO prevalence in the United States, identify ACO predictors, examine ACO association with asthma and COPD severity, and describe distinctive spirometry and laboratory features of ACO.

METHODS

Data on adult participants to the National Health and Nutrition Examination Surveys conducted from 2007 to 2012 was analyzed. ACO was defined as current asthma and post-bronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) <0.7.

RESULTS

Overall, 7,570 participants representing 98.58 million Americans were included in our study. From 2007 to 2012, the crude and age-standardized ACO prevalence were, respectively, 0.96% (95% CI: 0.65%-1.26%) and 1.05% (0.74%-1.37%). In asthma, ACO predictors included older age, male gender, and smoking. In COPD, ACO predictors were non-Hispanic Black race/ethnicity and obesity. ACO was associated with increased ER visits for asthma (OR = 3.46, 95% CI: 1.48-8.06]) and oxygen therapy in COPD (OR = 11.17, 95% CI: 5.17-24.12]). In spirometry, FEV1 and peak expiratory flow were lower in ACO than in asthma or COPD alone.

CONCLUSION

Age-adjusted prevalence of ACO in the United States was 1.05% in 2007-2012, representing 0.94 (95% CI: 0.62-1.26) million Americans. It is much lower than previously reported. The overlap was associated with higher asthma and COPD severity as well as decreased lung function compared with COPD or asthma alone.

Genetic polymorphisms of G protein-coupled receptor 65 gene are associated with ankylosing spondylitis in a Chinese Han population: A case-control study

OBJECTIVE

This study aimed to assess the association between two tag single nucleotide polymorphisms (SNPs) (rs68177277 and rs11624293) of G protein-coupled receptor 65 (GPR65) gene and ankylosing spondylitis (AS) susceptibility in a Chinese Han population.

METHODS

673 patients with AS diagnosed according to the modified New York criteria and 679 age- and gender-matched healthy controls were recruited. SNP genotyping for rs68177277 and rs11624293 polymorphisms were performed using the SNPscan technique. Disease activity was assessed by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI).

RESULTS

Genotype and allele distribution of rs11624293 but not rs68177277 were significantly different between AS and controls (p = 0.004 and p = 0.002). Compared to the wild-type T/T genotype and T allele at rs11624293, the frequencies of C/T genotype and C allele were significantly higher in AS than controls after adjusting for age and gender (OR = 1.527, 95%CIs: 1.190-1.958; OR = 1.515, 95%CIs: 1.183-1.942, respectively). Dominant and co-dominant model of rs11624293 were predictive of AS susceptibility. In AS patients, the genotype of rs11624293 was significantly associated with BASFI scores in those with low disease activity (BASDAI < 4, p = 0.007).

CONCLUSIONS

The results of our study suggest that rs11624293 polymorphism of GPR65 gene is associated with the susceptibility and severity of AS in Chinese Han population.

Epidemiology and risk factors of asthma-chronic obstructive pulmonary disease overlap in low- and middle-income countries

BACKGROUND

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) represents the confluence of bronchial airway hyperreactivity and chronic airflow limitation and has been described as leading to worse lung function and quality of life than found with either singular disease process.

OBJECTIVE

We aimed to describe the prevalence and risk factors for ACO among adults across 6 low- and middle-income countries (LMICs).

METHODS

We compiled cross-sectional data for 11,923 participants aged 35 to 92 years from 4 population-based studies in 12 settings. We defined COPD as postbronchodilator FEV₁/forced vital capacity ratio below the lower limit of normal, asthma as wheeze or medication use in 12 months or self-reported physician diagnosis, and ACO as having both.

RESULTS

The prevalence of ACO was 3.8% (0% in rural Puno, Peru, to 7.8% in Matlab, Bangladesh). The odds of having ACO were higher with household exposure to biomass fuel smoke (odds ratio [OR], 1.48; 95% CI, 0.98-2.23), smoking tobacco (OR, 1.28 per 10 pack-years; 95% CI, 1.22-1.34), and having primary or less education (OR, 1.35; 95% CI, 1.07-1.70) as compared to nonobstructed nonasthma individuals. ACO was associated with severe obstruction (FEV₁ %, <50; 31.6% of ACO vs 10.9% of COPD alone) and severe spirometric deficits compared with participants with asthma (-1.61 z scores FEV₁; 95% CI, -1.48 to -1.75) or COPD alone (-0.94 z scores; 95% CI, -0.78 to -1.10).

CONCLUSIONS

ACO may be as prevalent and more severe in LMICs than has been reported in high-income settings. Exposure to biomass fuel smoke may be an overlooked risk factor, and we favor diagnostic criteria for ACO that include environmental exposures common to LMICs.

Determinants of incident asthma-COPD overlap: a prospective study of 55,110 middle-aged adults

Background and aim

Knowledge of the impact of social determinants driving asthma– chronic obstructive pulmonary disease overlap (ACO) is lacking. Our objective was to identify determinants of incident ACO.

Methods

A total of 55,053 adults (50–64 years) enrolled in the Danish Diet, Cancer, and Health cohort (1993–97) was followed in the National Patient Registry for admissions for asthma (DJ45–46) and chronic obstructive pulmonary disease (COPD; DJ40–44) and vital status. Incident ACO was defined as at least one hospital admission for both asthma and COPD (different time points, one after baseline). Detailed case history was obtained at baseline. Cox proportional hazards model was used to examine associations between possible determinants and incident ACO, in terms of hazard ratio (HR) and 95% confidence interval (CI).

Results

During follow-up, 561 incident cases of ACO were identified. Age (HR 4.4, 95% CI 3.3–5.9, age group 60–65 years), current smoking (HR 3.6, 95% CI 2.8–4.6), unemployment (HR 1.5, 95% CI 1.2–1.8), and being divorced (HR 1.5, 95% CI 1.2–1.9) determined a higher risk of incident ACO, whereas the opposite was found for leisure-time physical activity (HR 0.7, 95% CI 0.6–0.8) and high educational level (HR 0.7, 95% CI 0.5–0.9). In contrast to ACO, preexisting myocardial infarction (MI; HR 1.5, 95% CI 1.2–1.8) and stroke (HR 1.5, 95% CI 1.2–1.9) were associated with a higher risk of COPD.

Conclusion

Incident ACO is to a large extent determined by factors related to lifestyle and socioeconomic status.

Identifying the associated risks of pneumonia in COPD patients: ARCTIC an observational study

Background

Inhaled corticosteroids (ICS) are associated with an increased risk of pneumonia in patients with chronic obstructive pulmonary disease (COPD). Other factors such as severity of airflow limitation and concurrent asthma may further raise the possibility of developing pneumonia. This study assessed the risk of pneumonia associated with ICS in patients with COPD.

Methods

Electronic Medical Record data linked to National Health Registries were collected from COPD patients and matched reference controls in 52 Swedish primary care centers (2000–2014). Levels of ICS treatment (high, low, no ICS) and associated comorbidities were assessed. Patients were categorized by airflow limitation severity.

Results

A total of 6623 patients with COPD and 48,566 controls were analyzed. Patients with COPD had a more than 4-fold increase in pneumonia versus reference controls (hazard ratio [HR] 4.76, 95% confidence interval [CI]: 4.48–5.06). ICS use increased the risk of pneumonia by 20–30% in patients with COPD with forced expiratory volume in 1 s ≥ 50% versus patients not using ICS. Asthma was an independent risk factor for pneumonia in the COPD population. Multivariate analysis identified independent predictors of pneumonia in the overall population. The highest risk of pneumonia was associated with high dose ICS (HR 1.41, 95% CI: 1.23–1.62).

Conclusions

Patients with COPD have a greater risk of pneumonia versus reference controls; ICS use and concurrent asthma increased the risk of pneumonia further.

Blood eosinophils and inhaled corticosteroids in patients with COPD: systematic review and meta-analysis

Background

COPD is a highly heterogeneous disease. Potential biomarkers to identify patients with COPD who will derive the greatest benefit from inhaled corticosteroid (ICS) treatment are needed. Blood eosinophil count can serve as a predictive biomarker for the efficacy of ICS treatment. The aim of this systematic review and meta-analysis was to assess whether a blood eosinophil count of ≥2% in patients undergoing ICS therapy was associated with a greater reduction in COPD exacerbation rate and pneumonia incidence.

Materials and methods

An electronic search was performed using the keywords "COPD", "eosinophil", and "clinical trial" in the PubMed and EMBASE databases to retrieve articles, up to 2017, relevant to our focus. Data were extracted, and a meta-analysis was conducted using RevMan 5 (version 5.3.5).

Results

Five studies comprising 12,496 patients with moderate-to-very severe COPD were included. At baseline, 60% of the patients had ≥2% blood eosinophils. Our meta-analysis showed a 17% reduction in exacerbation of moderate/severe COPD in patients with ≥2% blood eosinophils undergoing ICS therapy compared to the non-ICS/ICS withdrawal/placebo group. The difference between the two types of treatment was significant (risk ratio [RR], 0.816; 95% CI, 0.67-0.99; P=0.03). Furthermore, the risk of pneumonia-related events was significantly increased in the subgroup with eosinophil count ≥2% undergoing ICS-containing treatments (RR, 1.969; 95% CI, 1.369-2.833; P<0.001). There was no significant difference in the subgroup with eosinophil count <2% (RR, 1.29; 95% CI, 0.888-1.879; P<0.181).

Conclusion

The results of our meta-analysis suggest that the 2% threshold for blood eosinophils could accurately predict ICS treatment response in patients with COPD, but increased the risk of pneumonia.

Mortality in Asthma-Chronic Obstructive Pulmonary Disease Overlap in the United States

OBJECTIVES

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is recognized increasingly as a distinct clinical entity and is associated with higher comorbidities compared with patients with asthma and COPD alone. Little is known about the leading causes of death related to ACO in the US general population, however. Our aim was to define the causes of mortality among patients with ACO compared with asthma and COPD in the US population.

METHODS

We examined questions using the National Health and Nutrition Examination Survey III database linked to the National Death Index. The data from 4434 participants were stratified into 4 groups, those with asthma, COPD, ACO, and those without any obstructive lung disease. We examined baseline demographics and used multivariate logistic regression to model the impact of demographics, smoking, and self-reported, physician-diagnosed lung disease on mortality generating odds ratios (ORs) and confidence intervals (CIs).

RESULTS

Among 4434 participants, 120 (2.7%), 340 (7.6%), and 126 (2.8%) participants self-reported diagnoses of asthma, COPD, and ACO syndrome, respectively. Patients with COPD were older (69.7 ± 10.9 years) than other groups. Cardiovascular disease, malignancy, and chronic lower respiratory disease were frequent causes of death. The mortality rates for cardiovascular disease and malignancy were not significantly different among respiratory disease categories. Deaths resulting from chronic respiratory disease were higher in the ACO group (OR 4.9, 95% CI 2.5-9.4) and the COPD group (OR 2.9, 95% CI 1.5-5.4) when compared with those without obstructive lung disease (P < 0.0001).

CONCLUSIONS

Although cardiovascular- and malignancy-related deaths are common, a higher proportion of mortality in ACO and COPD is attributed to chronic lung disease.

Asthma COPD overlap: Impact of associated comorbidities

Asthma and chronic obstructive pulmonary disease (COPD) are common chronic pulmonary conditions worldwide which often coexist. Patients with asthma COPD overlap (ACO) may have worse outcomes than those with either disease alone, for example, more respiratory symptoms and frequent exacerbations, and worse lung function. Additionally, there is a growing interest in factors that affect the disease including comorbid conditions. Indeed, recent studies have demonstrated higher rates of comorbid conditions in the ACO population, but the mechanisms behind these observations remain unclear. The objective of this review is to describe current knowledge and clinical implications of the overlapping features of asthma and COPD, and discuss the prevalence and impact of comorbidities, such as osteoporosis, cardiovascular disease, gastroesophageal reflux disease, and depression, in this subgroup of patients.

Differences in airway structural changes assessed by 3-dimensional computed tomography in asthma and asthma-chronic obstructive pulmonary disease overlap

BACKGROUND

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is a clinical phenotype sharing features of asthma and COPD. Multidetector row computed tomography (MDCT) can be used to evaluate the airway structure; however, differences between asthma and ACO seen on MDCT are poorly understood.

OBJECTIVE

To investigate the difference in airway structural between asthma and ACO, using MDCT in patients with clinical asthma.

METHODS

Sixty-four patients with asthma were allocated to an asthma group (never smokers and ex-smokers with a smoking history of < 10 pack-years) or an ACO group (patients with a ≥10-pack-year smoking history and forced expiratory volume in 1 second [FEV₁]/forced vital capacity [FVC] < 0.7). The asthma group was further divided into patients with airflow limitation (AL; FEV₁/FVC < 0.7) and those without AL. Wall thickness (WT) and airway inner luminal area in the third-generation to fifth-generation bronchi were evaluated using MDCT in both study groups and in 29 healthy controls.

RESULTS

Forty-three patients were included in the asthma group (20 with AL, 23 without AL) and 16 in the ACO group. Patients with asthma and ACO had significantly greater WT than the healthy controls. WT in the third-generation bronchi was significantly greater in the ACO group than in the asthma group. The ACO group and the asthma with AL group were matched for age, disease duration, and FEV₁/FVC. The WT in the third-generation bronchi was still greater in the ACO group than in the asthma with AL group.

CONCLUSION

Patients with ACO have a thicker airway wall than those with asthma, suggesting that airway remodeling is more prominent in ACO than in asthma. UMIN Clinical Trials Registry (UMIN-CTR) system (http://www.umin.ac.jp/ctr/UMIN000028913).

Clinical Approach to the Therapy of Asthma-COPD Overlap

Over the last few years, there has been a renewed interest in patients with characteristics of both asthma and COPD. Although the precise definition of asthma-COPD overlap (ACO) is still controversial, patients with overlapping features are frequently encountered in clinical practice, and may indeed have worse clinical outcomes and increased health-care utilization than those with asthma or COPD. Therefore, there is a critical need to set a framework for the therapeutic approach of such patients. There are key distinctions in the therapy between asthma and COPD, particularly regarding the initial choice of therapy. However, there is considerable overlap in the use of existing medications for both diseases. Furthermore, novel therapies approved for asthma, such as monoclonal antibodies, may have a role in patients with COPD and ACO. The use of biomarkers, such as peripheral blood eosinophils, exhaled nitric oxide, and serum IgE, may help in selecting appropriate therapies for ACO. In this review, we provide an overview of available treatments for both asthma and COPD and explore their potential role in the treatment of patients with ACO.

Blood eosinophil count thresholds and exacerbations in patients with chronic obstructive pulmonary disease

BACKGROUND

Eosinophilic airway inflammation in patients with chronic obstructive pulmonary disease (COPD) is associated with exacerbations and responsivity to steroids, suggesting potential shared mechanisms with eosinophilic asthma. However, there is no consistent blood eosinophil count that has been used to define the increased exacerbation risk.

OBJECTIVE

We sought to investigate blood eosinophil counts associated with exacerbation risk in patients with COPD.

METHODS

Blood eosinophil counts and exacerbation risk were analyzed in patients with moderate-to-severe COPD by using 2 independent studies of former and current smokers with longitudinal data. The Genetic Epidemiology of COPD (COPDGene) study was analyzed for discovery (n = 1,553), and the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) study was analyzed for validation (n = 1,895). A subset of the ECLIPSE study subjects were used to assess the stability of blood eosinophil counts over time.

RESULTS

COPD exacerbation risk increased with higher eosinophil counts. An eosinophil count threshold of 300 cells/μL or greater showed adjusted incidence rate ratios for exacerbations of 1.32 in the COPDGene study (95% CI, 1.10-1.63). The cutoff of 300 cells/μL or greater was validated for prospective risk of exacerbation in the ECLIPSE study, with adjusted incidence rate ratios of 1.22 (95% CI, 1.06-1.41) using 3-year follow-up data. Stratified analysis confirmed that the increased exacerbation risk associated with an eosinophil count of 300 cells/μL or greater was driven by subjects with a history of frequent exacerbations in both the COPDGene and ECLIPSE studies.

CONCLUSIONS

Patients with moderate-to-severe COPD and blood eosinophil counts of 300 cells/μL or greater had an increased risk exacerbations in the COPDGene study, which was prospectively validated in the ECLIPSE study.

Diagnostic value of fractional exhaled nitric oxide for asthma-chronic obstructive pulmonary disease overlap syndrome

To examine the difference in the fractional exhaled nitric oxide (FeNO) between chronic obstructive pulmonary disease (COPD) patients with asthma-COPD overlap syndrome (ACOS) and patients with Non-ACOS COPD (Non-ACOS) and to investigate the correlation between FeNO levels and the differential cell counts of eosinophils in induced sputum, in order to explore the diagnostic value of FeNO in ACOS.A prospective, case-control study was performed on 53 cases of ACOS group and 53 cases of Non-ACOS group in the Respiratory Medicine Outpatient of Zhangzhou Municipal TCM Hospital, Affiliated to Fujian University of Traditional Chinese Medicine. The FeNO levels and induced sputum cell counts were determined and the correlation between FeNO levels and eosinophile percentage was analyzed by Pearson linear correlation analysis.The FeNO levels in patients with ACOS (37[24.5-53.0]) ppb were significantly higher than those of patients with Non-ACOS (20 [15.5-24.5] ppb) (P < .01). Also, the percentage of eosinophils in induced sputum in the ACOS group (5.70 [1.50-17.62]%) were significantly higher than those of the Non-ACOS group (0.50 [0.00-1.00]%) (P < .01). FeNO in both groups correlated positively with the percentage of eosinophils in induced sputum (P < .01), with a correlation coefficient r of 0.521. The area under the receiver operating curve of FeNO for the diagnosis of ACOS phenotype was 0.815 (P < .01), the sensitivity and specificity reach highest when the cut off value was 25.50 ppb.The FeNO in patients from the ACOS group were significantly higher than those in Non-ACOS group and were moderately correlated with the percentage of eosinophils in induced sputum. The results indicated that FeNO may be used as a diagnostic index for ACOS, in addition to the induced sputum.

Sputum proteomics and airway cell transcripts of current and ex-smokers with severe asthma in U-BIOPRED: an exploratory analysis

Severe asthma patients with a significant smoking history have airflow obstruction with reported neutrophilia. We hypothesise that multi-omic analysis will enable the definition of smoking and ex-smoking severe asthma molecular phenotypes.The U-BIOPRED cohort of severe asthma patients, containing current-smokers (CSA), ex-smokers (ESA), nonsmokers and healthy nonsmokers was examined. Blood and sputum cell counts, fractional exhaled nitric oxide and spirometry were obtained. Exploratory proteomic analysis of sputum supernatants and transcriptomic analysis of bronchial brushings, biopsies and sputum cells was performed.Colony-stimulating factor (CSF)2 protein levels were increased in CSA sputum supernatants, with azurocidin 1, neutrophil elastase and CXCL8 upregulated in ESA. Phagocytosis and innate immune pathways were associated with neutrophilic inflammation in ESA. Gene set variation analysis of bronchial epithelial cell transcriptome from CSA showed enrichment of xenobiotic metabolism, oxidative stress and endoplasmic reticulum stress compared to other groups. CXCL5 and matrix metallopeptidase 12 genes were upregulated in ESA and the epithelial protective genes, mucin 2 and cystatin SN, were downregulated.Despite little difference in clinical characteristics, CSA were distinguishable from ESA subjects at the sputum proteomic level, with CSA patients having increased CSF2 expression and ESA patients showing sustained loss of epithelial barrier processes.

Subjective cognitive complaints and neuropsychological performance in former smokers with and without chronic obstructive pulmonary disease

OBJECTIVE

This study examined the association of perceived cognitive difficulties with objective cognitive performance in former smokers. We hypothesized that greater perceived cognitive difficulties would be associated with poorer performance on objective executive and memory tasks.

METHOD

Participants were 95 former smokers recruited from the COPDGene study. They completed questionnaires (including the Cognitive Difficulties Scale [CDS] and the Hospital Anxiety and Depression Scale [HADS]), neuropsychological assessment, and pulmonary function testing. Pearson correlations and t-tests were conducted to examine the bivariate association of the CDS (total score and subscales for attention/concentration, praxis, delayed recall, orientation for persons, temporal orientation, and prospective memory) with each domain of objective cognitive functioning (memory recall, executive functioning/processing speed, visuospatial processing, and language). Simultaneous multiple linear regression was used to further examine all statistically significant bivariate associations. The following covariates were included in all regression models: age, sex, pack-years, premorbid functioning (WRAT-IV Reading), HADS total score, and chronic obstructive pulmonary disease (COPD) status (yes/no based on GOLD criteria).

RESULTS

In regression models, greater perceived cognitive difficulties overall (using CDS total score) were associated with poorer performance on executive functioning/processing speed tasks (b = -0.07, SE = 0.03, p = .037). Greater perceived cognitive difficulties on the CDS praxis subscale were associated with poorer performance on executive functioning/processing speed tasks (b = -3.65, SE = 1.25, p = .005), memory recall tasks (b = -4.60, SE = 1.75, p = .010), and language tasks (b = -3.89, SE = 1.39, p = .006).

CONCLUSIONS

Clinicians should be aware that cognitive complaints may be indicative of problems with the executive functioning/processing speed and memory of former smokers with and without COPD.

Of pleiotropy and trajectories: Does the TGF-β pathway link childhood asthma and chronic obstructive pulmonary disease?

The study of developmental trajectories is where epigenetics truly shines. The "epi" in epigenetics captures the fact that although epigenetic processes also preside over the maintenance and termination of gene expression, the unfolding and remodeling of chromatin architecture are especially critical to prepare genes for regulated transcription. These properties imply being on a path, a trajectory to events that will occur later thanks to epigenetic programming. Thus epigenetics is about timed and timely events. In this article we discuss epigenetic and genetic evidence from several independent studies of asthma, chronic obstructive pulmonary disease, and lung function, which converge to highlight a potential role of the TGF-β gene pathway in these processes. These results raise the possibility that at least in a subset of subjects, these conditions might be functionally connected in ways that need to be further defined but that likely reflect the uniquely pleiotropic nature of TGF-β pathway genes, particularly their ability to control both lung development and immune responses essential for regulation and inflammation. Further characterization of this pathway in longitudinally phenotyped populations might unmask novel trajectories to lung disease that begin in utero and unfold into old age.

Heterogeneity of asthma and COPD overlap

Background

Asthma and COPD are heterogeneous diseases. Patients with both disease features (asthma-COPD overlap [ACO]) are common. However, clinical characteristics and socio-economic burden of ACO are still controversial. The aim of this study was to identify the heterogeneity of ACO and to find out the subtypes with clinical impact among ACO subtypes.

Methods

In the Korean National Health and Nutrition Examination Survey (KNHANES) conducted between 2007 and 2012, subjects who were ≥40 years and had prebronchodilator FEV₁/FVC <0.7 and FEV₁ ≥50% predicted were included. The presence or absence of self-reported wheezing was indicated by W+ or W- and used as an index of airway hyper-responsiveness. S+/S- was defined as subjects who were smokers/never smokers. The subjects were divided into the following four groups: W-S-, W-S+, W+S-, and W+S+. W+S- and W+S+ were asthma-predominant ACO and COPD-predominant ACO, respectively. KNHANES and linked National Health Insurance data were analyzed.

Results

The asthma-predominant ACO group showed the lowest socioeconomic status, FEV₁, FVC% predicted, and quality of life (QoL) levels. The COPD-predominant ACO group showed the highest hospitalization rate, outpatient medical cost, and total and outpatient health care utilization. COPD-predominant ACO was associated with exacerbations compared to the W-S- group (adjusted odds ratio [aOR], 1.79; 95% confidence interval [CI], 1.12-2.85; P=0.015) and W-S+ group (OR 2.11; 95% CI 1.43-3.10; P<0.001). COPD-predominant ACO was associated with increased medical cost.

Conclusion

Asthma-predominant ACO individuals displayed poorer socioeconomic status and QoL compared to the COPD-predominant ACO group. The COPD-predominant ACO group displayed more frequent exacerbations and greater medical costs. Considering the heterogeneity of ACO, it is desirable to identify subtypes of ACO patients and appropriately allocate limited medical resources.

Chronic airway obstruction in a population-based adult asthma cohort: Prevalence, incidence and prognostic factors

BACKGROUND

Asthma and COPD may overlap (ACO) but information about incidence and risk factors are lacking. This study aimed to estimate prevalence, incidence and risk factors of chronic airway obstruction (CAO) in a population-based adult asthma cohort.

METHODS

During 1986-2001 a large population-based asthma cohort was identified (n = 2055, 19-72y). Subsamples have participated in clinical follow-ups during the subsequent years. The entire cohort was invited to a clinical follow-up including interview, spirometry, and blood sampling in 2012-2014 when n = 983 subjects performed adequate spirometry. CAO was defined as post-bronchodilator FEV₁/FVC<0.7.

RESULTS

At study entry, asthmatics with prevalent CAO (11.4%) reported more respiratory symptoms, asthma medication use, and ischemic heart disease than asthmatics without CAO (asthma only). Subjects who developed CAO during follow-up (17.6%; incidence rate of 16/1000/year) had a more rapid FEV₁ decline and higher levels of neutrophils than asthma only. Smoking, older age and male sex were independently associated with increased risk for both prevalent and incident CAO, while obesity had a protective effect.

CONCLUSIONS

In this prospective adult asthma cohort, the majority did not develop CAO. Smoking, older age and male sex were risk factors for prevalent and incident CAO, similar to risk factors described for COPD in the general population.

Epidemiology of asthma-chronic obstructive pulmonary disease overlap (ACO)

The term "asthma-COPD overlap" (ACO) has been applied to the condition in which a person has persistent airflow limitation with clinical features of both asthma and COPD. The certain definition and diagnostic criteria for ACO have not yet been established, and ACO prevalence has varied widely in studies: from 0.9% to 11.1% in the general population, from 11.1% to 61.0% in asthma patients, and from 4.2% to 66.0% in COPD patients. Furthermore, the frequency of exacerbations and prognosis in ACO patients have not been clearly demonstrated. Although ACO consists with several subgroups of patients with distinct clinical and pathophysiological features, it would be important to propose a standardized definition of and/or diagnostic criteria for ACO based on biomarkers and objective measures, even if it is tentative. It may lead cohort studies with large population or clinical trials around the world.

Plasma YKL-40 and NGAL are useful in distinguishing ACO from asthma and COPD

BACKGROUND

Asthma-chronic obstructive pulmonary disorder (COPD) overlap (ACO) is characterized by the coexistence of features of both asthma and COPD and is associated with rapid progress and a poor prognosis. Thus, the early recognition of ACO is crucial.

OBJECTIVES

We sought to explore the plasma levels of biomarkers associated with asthma (periostin, TSLP and YKL-40), COPD (NGAL) and their possible correlation with lung function, the bronchodilator response and radiographic imaging in patients with asthma, COPD and with features of ACO.

METHODS

We enrolled 423 subjects from 6 clinical centers. All participants underwent blood collection, lung function measurements, bronchodilator response tests and high-resolution CT. Correlations of the plasma biomarkers with lung function, the bronchodilator response and percentemphysema were calculated by Spearman's rank correlation and multivariate stepwise regressionanalysis.

RESULTS

1) Patients with features of ACO had lower plasma YKL-40 than COPD patients and a moderate elevated plasma level of NGAL compared with asthma patients. 2) Patients with features of ACO had an intermediate degree of airflow obstruction, the bronchodilator response and emphysema between patients with COPD and asthma. 3) Plasma YKL-40 was negatively correlated with lung function and with the bronchodilator response, and plasma NGAL was positively correlated with the extent of emphysema.

CONCLUSIONS

Plasma YKL-40 is a promising candidate for distinguishing between patients with features of ACO and COPD patients, while plasma NGAL may be a valuable biomarker for differentiating between patients with features of ACO and asthma patients.

CLINICAL TRIAL REGISTRATION

ChiCTR-OOC-16009221.

The nutrition-gut microbiome-physiology axis and allergic diseases

Dietary and bacterial metabolites influence immune responses. This raises the question whether the increased incidence of allergies, asthma, some autoimmune diseases, cardiovascular disease, and others might relate to intake of unhealthy foods, and the decreased intake of dietary fiber. In recent years, new knowledge on the molecular mechanisms underpinning a 'diet-gut microbiota-physiology axis' has emerged to substantiate this idea. Fiber is fermented to short chain fatty acids (SCFAs), particularly acetate, butyrate, and propionate. These metabolites bind 'metabolite-sensing' G-protein-coupled receptors such as GPR43, GPR41, and GPR109A. These receptors play fundamental roles in the promotion of gut homeostasis and the regulation of inflammatory responses. For instance, these receptors and their metabolites influence Treg biology, epithelial integrity, gut homeostasis, DC biology, and IgA antibody responses. The SCFAs also influence gene transcription in many cells and tissues, through their inhibition of histone deacetylase expression or function. Contained in this mix is the gut microbiome, as commensal bacteria in the gut have the necessary enzymes to digest dietary fiber to SCFAs, and dysbiosis in the gut may affect the production of SCFAs and their distribution to tissues throughout the body. SCFAs can epigenetically modify DNA, and so may be one mechanism to account for diseases with a 'developmental origin', whereby in utero or post-natal exposure to environmental factors (such as nutrition of the mother) may account for disease later in life. If the nutrition-gut microbiome-physiology axis does underpin at least some of the Western lifestyle influence on asthma and allergies, then there is tremendous scope to correct this with healthy foodstuffs, probiotics, and prebiotics.

Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Current guidelines recommend that patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) should be treated with systemic corticosteroid for seven to 14 days. Intermittent systemic corticosteroid use is cumulatively associated with adverse effects such as osteoporosis, hyperglycaemia and muscle weakness. Shorter treatment could reduce adverse effects.

OBJECTIVES

To compare the efficacy of short-duration (seven or fewer days) and conventional longer-duration (longer than seven days) systemic corticosteroid treatment of adults with acute exacerbations of COPD.

SEARCH METHODS

Searches were carried out using the Cochrane Airways Group Specialised Register of Trials, MEDLINE and CENTRAL (Cochrane Central Register of Controlled Trials) and ongoing trials registers up to March 2017.

SELECTION CRITERIA

Randomised controlled trials comparing different durations of systemic corticosteroid defined as short (i.e. seven or fewer days) or longer (i.e. longer than seven days). Other interventions-bronchodilators and antibiotics-were standardised. Studies with participants requiring assisted ventilation were excluded.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by The Cochrane Collaboration.

MAIN RESULTS

Eight studies with 582 participants met the inclusion criteria, of which five studies conducted in hospitals with 519 participants (range 28 to 296) contributed to the meta-analysis. Mean ages of study participants were 65 to 73 years, the proportion of male participants varied (58% to 84%) and COPD was classified as severe or very severe. Corticosteroid treatment was given at equivalent daily doses for three to seven days for short-duration treatment and for 10 to 15 days for longer-duration treatment. Five studies administered oral prednisolone (30 mg in four, tapered in one), and two studies provided intravenous corticosteroid treatment. Studies contributing to the meta-analysis were at low risk of selection, performance, detection and attrition bias. In four studies we did not find a difference in risk of treatment failure between short-duration and longer-duration systemic corticosteroid treatment (n = 457; odds ratio (OR) 0.72, 95% confidence interval (CI) 0.36 to 1.46)), which was equivalent to 22 fewer per 1000 for short-duration treatment (95% CI 51 fewer to 34 more). No difference in risk of relapse (a new event) was observed between short-duration and longer-duration systemic corticosteroid treatment (n = 457; OR 1.04, 95% CI 0.70 to 1.56), which was equivalent to nine fewer per 1000 for short-duration treatment (95% CI 68 fewer to 100 more). Time to the next COPD exacerbation did not differ in one large study that was powered to detect non-inferiority and compared five days versus 14 days of systemic corticosteroid treatment (n = 311; hazard ratio 0.95, 95% CI 0.66 to 1.37). In five studies no difference in the likelihood of an adverse event was found between short-duration and longer-duration systemic corticosteroid treatment (n = 503; OR 0.89, 95% CI 0.46 to 1.69, or nine fewer per 1000 (95% CI 44 fewer to 51 more)). Length of hospital stay (n = 421; mean difference (MD) -0.61 days, 95% CI -1.51 to 0.28) and lung function at the end of treatment (n = 185; MD FEV1 -0.04 L; 95% CI -0.19 to 0.10) did not differ between short-duration and longer-duration treatment.

AUTHORS' CONCLUSIONS

Information from a new large study has increased our confidence that five days of oral corticosteroids is likely to be sufficient for treatment of adults with acute exacerbations of COPD, and this review suggests that the likelihood is low that shorter courses of systemic corticosteroids (of around five days) lead to worse outcomes than are seen with longer (10 to 14 days) courses. We graded most available evidence as moderate in quality because of imprecision; further research may have an important impact on our confidence in the estimates of effect or may change the estimates. The studies in this review did not include people with mild or moderate COPD; further studies comparing short-duration systemic corticosteroid versus conventional longer-duration systemic corticosteroid for treatment of adults with acute exacerbations of COPD are required.

Prevalence and features of asthma-chronic obstructive pulmonary disease overlap in Northern Italy general population

OBJECTIVE

There is controversy about the diagnostic criteria, prevalence, symptoms, and spirometry characteristics of asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO). Recent data indicate that the fixed method for diagnosing airway obstruction (AO) may overestimate ACO prevalence in the elderly, and a variable method may be more accurate. We aimed at estimating ACO prevalence in a general population sample and comparing patient and clinical features in subjects with ACO, COPD, and asthma.

METHODS

We analyzed data from a cross-sectional study estimating COPD prevalence in randomly selected adults aged 20-79 years in Verona, Italy, and estimated prevalence and analyzed characteristics of asthma, COPD, and ACO. ACO was defined as AO (Forced Expiratory Volume in one second-FEV₁/ Forced Vital Capacity-FVC < Lower Limit of Normal-LLN), highly positive bronchodilator test (≥15% increase in FEV₁ and FVC ≥400 mL), and personal self-reported history of physician diagnosed asthma and atopy.

RESULTS

One thousand two hundred and thirty-six patients were included; 207 (16.7%) had asthma, COPD, or ACO (mean ages: 61.2, 59.7, and 57.2 years, respectively). The 3 groups had similar clinical and demographic variables; however, spirometry revealed differences between ACO and COPD patients, particularly post-bronchodilator FEV₁ reversibility, which was detected in ACO and asthma patients but not in those with COPD.

CONCLUSION

ACO prevalence in Northern Italy was estimated at 2.1%, in the range of values reported by previous studies. Marked differences between ACO and COPD revealed by spirometry may have important clinical implications in terms of treatment for patients with ACO.

Persistently elevated exhaled nitric oxide fraction is associated with increased risk of exacerbation in COPD

Preventing the occurrence of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is a major therapeutic goal. We hypothesise that persistently increased levels of exhaled nitric oxide (F_eNO) during follow-up can identify a group of COPD patients at higher risk of AECOPD.To test this hypothesis, we measured F_eNO levels (HypAir F_eNO®, Medisoft; Sorinnes, Belgium) prospectively in 226 clinically stable COPD outpatients at recruitment and during follow-up (at 6 and 12 months). Patients were stratified according to the number of visits with F_eNO ≥20 ppb.F_eNO was <20 ppb in all three visits in 44.2% of patients, 29.6% in visit 1 and 26.1% in visit 2 or 3. These three groups suffered progressively higher AECOPD rates during follow-up (0.67, 0.91 and 1.42, respectively, p<0.001). After adjusting for potential confounding variables (log-rank test), the hazard ratio for AECOPD was higher in the latter group (1.579 (95% CI 1.049-2.378), p=0.029). Likewise, time to first moderate and severe AECOPD was shorter in these patients. Finally, there was no relationship between F_eNO levels and circulating eosinophils.Persistent F_eNO levels ≥20 ppb in clinically stable COPD outpatients are associated with a significantly higher risk of AECOPD.

An Official American Thoracic Society Workshop Report: Evaluation and Management of Asthma in the Elderly

Asthma in the elderly (>65 yr old) is common and associated with higher morbidity and mortality than asthma in younger patients. The poor outcomes in this group are due, in part, to underdiagnosis and undertreatment. There are a variety of factors related to aging itself that affect the presentation of asthma in the elderly and influence diagnosis and management. Structural changes in the aging lung superimposed on structural changes due to asthma itself can worsen the disease and physiologic function. Changes in the aging immune system influence the cellular composition and function in asthmatic airways. These processes and differences from younger individuals with asthma are not well understood. Phenotypes of asthma in the elderly have not been clearly delineated, but it is likely that age of onset and overlap with chronic obstructive pulmonary disease impact disease characteristics. Physiologic tests and biomarkers used to diagnose and follow asthma in the elderly are generally similar to testing in younger individuals; however, whether they should be modified in aging has not been established. Confounding influences, such as comorbidities (increasing the risk of polypharmacy), impaired cognition and motor skills, psychosocial effects of aging, and age-related adverse effects of medications, impact both diagnosis and treatment of asthma in the elderly. Future efforts to understand asthma in the elderly must include geriatric-specific methodology to diagnose, characterize, monitor, and treat their disease.

Elevated levels of circulating CD4(+) CRTh2(+) T cells characterize severe asthma

BACKGROUND

Chemoattractant receptor-homologous molecule expressed on Th2 cells (CRTh2) is a receptor for PGD2 and expressed by T cells, eosinophils, basophils, and ILC2 cells. CRTh2 expression by CD4(+) T cells identifies the Th2 subset, and these cells have been characterized as allergen-specific central memory Th2 cells. Recently, activation of the PGD2 -CRTh2 pathway in the lungs was associated with severe asthma.

OBJECTIVE

To assess circulating levels of Th2 cells and related mediators in severe asthma and those who experience asthma exacerbations.

METHODS

Peripheral blood cells expressing CRTh2 were characterized by flow cytometry and qRT-PCR. Serum IL-13 and PGD2 were measured by ELISA and compared with asthma severity and tendency to exacerbate.

RESULTS

Severe asthmatics had more circulating CD4(+) CRTh2(+) T cells, CRTh2 and GATA3 mRNA, and a higher level of serum IL-13 compared to mild/moderate asthmatics. The proportion of CD4(+) CRTh2(+) T cells was associated with lower lung function and was highest in severe asthmatics that exacerbated in the last year. Circulating CD4(+) CRTh2(+) T cells, unlike eosinophils, were positively correlated with inhaled steroid dose.

CONCLUSIONS AND CLINICAL RELEVANCE

Elevated levels of circulating CD4(+) CRTh2(+) T cells are a feature of severe asthma, despite high-dose corticosteroids. Tracking the systemic level of these cells may help identify type 2 severe asthmatics at risk of exacerbation.

Asthma Is a Risk Factor for Respiratory Exacerbations Without Increased Rate of Lung Function Decline: Five-Year Follow-up in Adult Smokers From the COPDGene Study

BACKGROUND

Previous investigations in adult smokers from the COPDGene Study have shown that early-life respiratory disease is associated with reduced lung function, COPD, and airway thickening. Using 5-year follow-up data, we assessed disease progression in subjects who had experienced early-life respiratory disease. We hypothesized that there are alternative pathways to reaching reduced FEV₁ and that subjects who had childhood pneumonia, childhood asthma, or asthma-COPD overlap (ACO) would have less lung function decline than subjects without these conditions.

METHODS

Subjects returning for 5-year follow-up were assessed. Childhood pneumonia was defined by self-reported pneumonia at < 16 years. Childhood asthma was defined as self-reported asthma diagnosed by a health professional at < 16 years. ACO was defined as subjects with COPD who self-reported asthma diagnosed by a health-professional at ≤ 40 years. Smokers with and those without these early-life respiratory diseases were compared on measures of disease progression.

RESULTS

Follow-up data from 4,915 subjects were examined, including 407 subjects who had childhood pneumonia, 323 subjects who had childhood asthma, and 242 subjects with ACO. History of childhood asthma or ACO was associated with an increased exacerbation frequency (childhood asthma, P < .001; ACO, P = .006) and odds of severe exacerbations (childhood asthma, OR, 1.41; ACO, OR, 1.42). History of childhood pneumonia was associated with increased exacerbations in subjects with COPD (absolute difference [β], 0.17; P = .04). None of these early-life respiratory diseases were associated with an increased rate of lung function decline or progression on CT scans.

CONCLUSIONS

Subjects who had early-life asthma are at increased risk of developing COPD and of having more active disease with more frequent and severe respiratory exacerbations without an increased rate of lung function decline over a 5-year period.

TRIAL REGISTRY

ClinicalTrials.gov; No. NCT00608764; https://clinicaltrials.gov.

Asthma-chronic obstructive pulmonary disease overlap syndrome: a controversial concept

PURPOSE OF REVIEW

To illustrate the scant evidence and the shortcomings of the concept of 'asthma-COPD overlap syndrome' (ACOS) in terms of clinical utility.

RECENT FINDINGS

Asthma and chronic obstructive pulmonary disease (COPD) are considered as two distinct and heterogeneous diseases. For many years, physicians have been aware that asthma and COPD can coexist in some patients. Recently, the term ACOS has been applied when a person has clinical features of both asthma and COPD. However, the lack of an accurate diagnosis has led to inconsistent data regarding reported prevalence, prognosis and therapeutics. Even today, it has not been possible to establish a phenotypic characterization of ACOS, although it is part of the overall complexity and heterogeneity of COPDs. No high quality data exist on which to base treatment recommendations for ACOS. Consequently, in clinical practice, treatment is extrapolated from the available evidence on asthma and COPD.

SUMMARY

The current concept of ACOS seems clinically irrelevant because it has no influence on the prognosis and treatment of these patients. The authors concluded that the term ACOS should be avoided in the case of patients with features of both asthma and COPD.

Association of Serum Lipids and Obstructive Lung Disease in Hispanic/Latino Adults of Diverse Backgrounds

Rationale

Substantial variation in the prevalences of obstructive lung disease exist between Hispanic/Latino heritage groups. Experimental studies have posited biological mechanisms linking serum lipids and lipid-lowering medications with obstructive lung disease. The aim of this study is to examine the associations of serum lipid levels with the prevalences of asthma and chronic obstructive pulmonary disease in the Hispanic Community Health Study/Study of Latinos and how these associations vary by Hispanic/Latino heritage group.

Methods

The Hispanic Community Health Study/Study of Latinos is a population-based probability sample of 16,415 self-identified Hispanic/Latino persons aged 18–74 years recruited between 2008 and 2011 from randomly selected households in four US field centers. The baseline clinical examination included comprehensive biological testing (fasting serum lipid levels), behavioral and socio-demographic assessments, medication inventory including inhalers, and respiratory data including questionnaires for asthma and standardized spirometry with post-bronchodilator measures for identification of obstructive lung disease.

Measurements and main results

Hispanic/Latinos with current asthma had lower age- and statin-use-adjusted mean serum total cholesterol, low-density lipoprotein cholesterol, and triglyceride levels than their non-asthmatic counterparts. In analysis adjusted for age plus gender, ethnicity, cigarette smoking, alcohol intake, body mass index, lipid/cholesterol-lowering medications, age at immigration, health insurance status, and use of oral corticosteroids, increasing serum levels of total cholesterol and low-density lipoprotein cholesterol were associated with lower odds of current asthma in the estimated population. Unlike asthma, Hispanic/Latinos with chronic obstructive pulmonary disease had lower mean high-density lipoprotein than their non- chronic obstructive pulmonary disease counterparts. In the fully adjusted analysis no significant associations were found between lipid levels and prevalent chronic obstructive pulmonary disease.

Conclusions

We showed a modest inverse relationship between serum lipid levels and current asthma. These results highlight some important differences in Hispanics/Latinos and certain serum lipids may be factors or markers of obstructive lung disease.

A clustering approach to identify and characterize the asthma and chronic obstructive pulmonary disease overlap phenotype

BACKGROUND

Asthma and chronic obstructive pulmonary disease (COPD) are heterogeneous diseases. The phenotypes that have clinical features of both asthma and COPD are still incompletely understood.

OBJECTIVE

To clarify the best discriminators of the asthma-COPD overlap phenotype from asthma and COPD subgroups using a clustering approach.

METHODS

This study assessed pathophysiological parameters, including mRNA expression levels of T helper cell-related transcription factors, namely TBX21 (Th1), GATA3 (Th2), RORC (Th17) and FOXP3 (Treg), in peripheral blood mononuclear cells in asthma patients (n=152) and in COPD patients (n=50). Clusters were determined using k-means clustering. Exacerbations of asthma and COPD were recorded during the 1-year follow-up period.

RESULTS

The cluster analysis revealed four biological clusters: cluster 1, predominantly patients with COPD; cluster 2, patients with an asthma-COPD overlap phenotype; cluster 3, patients with non-atopic and late-onset asthma; and cluster 4, patients with early-onset atopic asthma. Hazard ratios for exacerbation were 2.5 (95% confidence interval [CI], 1.1-5.6) in cluster 1 and 2.3 (95% CI, 1.0-5.0) in cluster 2 compared with patients in other clusters. Cluster 2 was discriminated from other clusters by total serum IgE level ≥310 IU/mL, blood eosinophil counts ≥280 cells/μL, a higher ratio of TBX21/GATA3, FEV₁ /FVC ratio <0.67 and smoking ≥10 pack-years with an area under the curve of 0.94 (95% CI, 0.90-0.98) in the receiver operating characteristic analysis.

CONCLUSIONS AND CLINICAL RELEVANCE

The asthma-COPD overlap phenotype was characterized by peripheral blood eosinophilia and higher levels of IgE despite the Th2-low endotype.

Asthma in the Elderly

The older population has seen the greatest increase in the prevalence of current asthma in recent years. Asthma may begin at any age and when it occurs at an advanced as opposed to a young age, it is often nonatopic, severe, and unremitting. Unfortunately, geriatric-specific guidelines are not available for the diagnosis and treatment of asthma. However, with objective monitoring, avoidance of asthma triggers, appropriate pharmacotherapy, and patient education, the disease can be managed successfully.

Sex and racial/ethnic differences in the reason for 30-day readmission after COPD hospitalization

BACKGROUND

Reduction of 30-day readmissions in patients hospitalized for chronic obstructive pulmonary disease (COPD) is a national objective. However, there is a dearth of research on sex and racial/ethnic differences in the reason for 30-day readmission.

METHODS

We conducted a retrospective cohort study using 2006-2012 data from the State Inpatient Database of eight geographically-diverse US states (Arkansas, California, Florida, Iowa, Nebraska, New York, Utah, and Washington). After identifying all hospitalizations for COPD made by patients aged ≥40 years, we investigated the primary diagnostic code for all-cause readmissions within 30 days after the original COPD hospitalization, among the overall group and by sex and race/ethnicity strata.

RESULTS

Between 2006 and 2012, there was a total of 845,465 COPD hospitalizations at risk for 30-day readmissions in the eight states. COPD was the leading diagnostic for 30-day readmission after COPD hospitalization, both overall (28%) and across all sex and race/ethnicity strata. The proportion of respiratory diseases (COPD, pneumonia, respiratory failure, and asthma) as the readmission diagnosis was higher in non-Hispanic black (55%), compared to non-Hispanic white (52%) and Hispanics (51%) (p < 0.001). The proportion of asthma as the readmission diagnosis differed significantly by sex (6% in men and 9% in women; p < 0.001). Similarly, the proportion of asthma also differed significantly by race/ethnicity (5% in non-Hispanic white, 16% in non-Hispanic black, 15% in Hispanics, 13% in others; p < 0.001).

CONCLUSIONS

In this analysis of all-payer population-based data, we found sex and racial/ethnic differences in the reason for 30-day readmission in patients hospitalized for COPD.

Asthma-like Features and Clinical Course of Chronic Obstructive Pulmonary Disease. An Analysis from the Hokkaido COPD Cohort Study

RATIONALE

Some patients with chronic obstructive pulmonary disease (COPD) have asthma-like features, such as significant bronchodilator reversibility, blood eosinophilia, and/or atopy, even if they are not clinically diagnosed as having asthma. However, the clinical significance of asthma-like features overlapping with COPD remains unclear.

OBJECTIVES

The aim of this study was to assess the effect of asthma-like features on the clinical course of patients with COPD who were adequately treated and followed-up over 10 years.

METHODS

A total of 268 patients with COPD who had been clinically considered as not having asthma by respiratory specialists were included in this study. The asthma-like features included in this study were bronchodilator reversibility (ΔFEV₁, ≥12% and ≥200 ml), blood eosinophilia (≥300 cells/μl), and atopy (positive specific IgE for any inhaled antigen). The annual changes in post-bronchodilator FEV₁ and COPD exacerbations were monitored during the first 5 years, and mortality was followed during the entire 10 years of the study.

MEASUREMENTS AND MAIN RESULTS

Fifty-seven subjects (21%) had bronchodilator reversibility, 52 (19%) had blood eosinophilia, and 67 (25%) had atopy. Subjects with blood eosinophilia had significantly slower annual post-bronchodilator FEV₁ decline; bronchodilator reversibility and atopy did not affect the annual post-bronchodilator FEV₁ decline, and none of the asthma-like features was associated with development of COPD exacerbation. Even if subjects had two or more asthma-like features, they displayed annual post-bronchodilator FEV₁ declines and exacerbation rates similar to those of subjects with one or zero asthma-like features, as well as a lower 10-year mortality rate (P = 0.02).

CONCLUSIONS

The presence of asthma-like features was associated with better clinical course in patients with COPD receiving appropriate treatment.

Management of the Asthma-COPD Overlap Syndrome (ACOS): a Review of the Evidence

PURPOSE OF REVIEW

Examine the definition of the asthma-COPD overlap syndrome (ACOS) and current treatment strategies.

RECENT FINDINGS

Patients with the ACOS have a lower quality of life and suffer from more complications than those affected by either disease alone. Diagnosis of ACOS is difficult because of the clinical similarities between the two diseases and the various phenotypes that comprise the syndrome. Defining treatment strategies for ACOS has been challenging because many clinical trials for asthma therapy have purposefully excluded patients with features of COPD, and COPD clinical trials have not included patients who might have an asthmatic component to their disease. Therefore, there are few randomized treatment trials which have included patients who have ACOS. Smoking cessation and appropriate vaccinations are cornerstone therapies, and pharmacologic therapy has focused on bronchodilators and inhaled corticosteroids. The role of biologics, such as omalizumab and IL-5 antagonists, in ACOS treatment is still being defined. As of now, with the paucity of randomized control trials guiding treatment strategies, the Global Initiative for Asthma (GINA) and Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend treating ACOS according to the dominant phenotype.

Validity of the Asthma Control Test Questionnaire Among Smoking Asthmatics

BACKGROUND

Smoking asthmatics respond worse to existing asthma therapies and have more asthma symptoms and exacerbations.

OBJECTIVE

We evaluated the Asthma Control Test (ACT) for assessing asthma control among smokers.

METHODS

Adults with asthma who smoked were enrolled and followed for 6 weeks. The statistical properties, validity, and responsiveness of the ACT were evaluated. Physician global assessment (GS) of asthma was the "gold standard."

RESULTS

A total of 151 participants were enrolled: 52% female and 48% male. The median (interquartile ranges) was 35 (27, 43) years for age, 11 (7, 18) for pack-years, and 16 (13, 20) for the ACT score. Participants self-identified as African American (49%), non-Hispanic whites (38%), and Hispanic whites (11%). Participants were classified as well controlled (24%), not well controlled (42%), or very poorly controlled (34%) at enrollment. Cronbach's alpha (95% confidence interval [CI]) for the ACT at enrollment was 0.81 (0.76, 0.85). The intraclass correlation coefficient (95% CI) for agreement of scores at enrollment and 6 weeks was 0.68 (0.57, 0.78) in participant with stable asthma (n = 93). ACT scores were associated with GS (P < .001). Area under the receiver operating characteristic (ROC) curve (95% CI) for an ACT cutoff score of ≤19 (not well controlled) was 0.76 (0.67, 0.84). The ACT score with the maximum area under the ROC curve was 18.6.

CONCLUSIONS

The ACT questionnaire was reliable and discriminated between levels of asthma control in smoking asthmatics with similar sensitivity and specificity as nonsmoking asthmatics, which confirms its value as a tool for the management of asthma in this prevalent but understudied subgroup of subjects.

Prevalence and characteristics of asthma-COPD overlap syndrome identified by a stepwise approach

BACKGROUND AND OBJECTIVE

There is increasing recognition of asthma-COPD overlap syndrome (ACOS), which shares some features of both asthma and COPD; however, the prevalence and characteristics of ACOS are not well understood. The aim of this study was to investigate the prevalence of ACOS among patients with COPD and its characteristics using a stepwise approach as stated in the recent report of the Global Initiative for Asthma (GINA) and the Global Initiative for Chronic Obstructive Lung Disease (GOLD).

METHODS

This multicenter, cross-sectional, observational study enrolled outpatients who were receiving medical treatment for COPD. Clinical data, including spirometry results, were retrieved from medical records. For symptom assessment, patients were asked to complete the Clinical COPD questionnaire and the modified British Medical Research Council questionnaire.

RESULTS

Of the 1,008 patients analyzed, 167 (16.6%) had syndromic features of ACOS. Of the total number of patients, 93 and 42 (9.2% and 4.2%) also had a predefined clinical variability of ≥12%/≥200 mL and ≥12%/≥400 mL in forced expiratory volume in 1 second (FEV1), respectively, and therefore were identified as having ACOS. Conversely, the number of patients who had either syndromic or spirometric feature of ACOS was 595 (59.0%, ≥12%/≥200 mL FEV1 clinical variability), and 328 patients (32.5%, ≥12%/≥400 mL FEV1 clinical variability) had both the features. Patients identified as having ACOS were of significantly younger age, had a shorter duration of COPD, lower number of pack-years, better lung function, milder dyspnea symptoms, and higher peripheral blood eosinophil values compared with patients with COPD alone. The rate of exacerbations in the previous year was not significantly different between the ACOS and COPD groups.

CONCLUSION

Using a stepwise approach, as stated in the GINA/GOLD report, the proportions of patients identified as having ACOS were found to be 9.2% and 4.2% (depending on the FEV1 variability cutoff used) among the 1,008 outpatients medically treated for COPD in a real-life clinical setting.

Phenotypes of COPD patients with a smoking history in Central and Eastern Europe: the POPE Study

Chronic obstructive pulmonary disease (COPD) represents a major health problem in Central and Eastern European (CEE) countries; however, there are no data regarding clinical phenotypes of these patients in this region.Participation in the Phenotypes of COPD in Central and Eastern Europe (POPE) study was offered to stable patients with COPD in a real-life setting. The primary aim of this study was to assess the prevalence of phenotypes according to predefined criteria. Secondary aims included analysis of differences in symptom load, comorbidities and pharmacological treatment.3362 patients with COPD were recruited in 10 CEE countries. 63% of the population were nonexacerbators, 20.4% frequent exacerbators with chronic bronchitis, 9.5% frequent exacerbators without chronic bronchitis and 6.9% were classified as asthma-COPD overlap. Differences in the distribution of phenotypes between countries were observed, with the highest heterogeneity observed in the nonexacerbator cohort and the lowest heterogeneity observed in the asthma-COPD cohort. There were statistically significant differences in symptom load, lung function, comorbidities and treatment between these phenotypes.The majority of patients with stable COPD in CEE are nonexacerbators; however, there are distinct differences in surrogates of disease severity and therapy between predefined COPD phenotypes.

Differences between asthma-COPD overlap syndrome and adult-onset asthma

Differences between asthma-COPD overlap syndrome (ACOS) and adult-onset asthma are poorly understood. This study aimed to evaluate these differences in a clinical cohort of patients with adult-onset asthma, as a part of the Seinäjoki Adult Asthma Study (SAAS).188 patients were diagnosed with adult-onset asthma and re-evaluated 12 years after diagnosis. They were divided into three groups based on smoking history and post bronchodilator spirometry values: 1) never- and ex-smokers with <10 smoked pack-years; 2) non-obstructive (forced expiratory volume in 1 s (FEV₁)/forced vital capacity (FVC) ≥0.7) patients with ≥10 pack-years; and 3) ACOS patients with ≥10 pack-years and FEV₁/FVC <0.7.ACOS patients had lower diffusing capacity (D_LCO/V_A 86% predicted versus 98 or 96% predicted; p<0.001), higher blood neutrophil levels (4.50 versus 3.60 or 3.85×10⁹ L^-1; p=0.008), and higher IL-6 levels (2.88 versus 1.52 or 2.10 pg·mL^-1, p<0.001) as compared to never- and ex-smokers with <10 pack-years, or non-obstructive patients with ≥10 pack-years smoking history, respectively. ACOS patients also showed reduced lung function, higher remaining bronchial reversibility and a higher number of comorbidities.This study shows distinct differences in diffusing capacity, blood neutrophil and IL-6 levels, bronchial reversibility, lung function and comorbidities between ACOS and adult-onset asthma. The present findings should be considered in the comprehensive assessment of adult asthma patients.

Radiographic Evidence of Sinonasal Inflammation in Asthma-Chronic Obstructive Pulmonary Disease Overlap Syndrome: An Underrecognized Association

BACKGROUND

Sinonasal inflammation on both clinical examinations and imaging significantly impacts both asthma and chronic obstructive pulmonary disease (COPD).

OBJECTIVE

The objective of this study was to examine the association between sinonasal inflammation and asthma-COPD overlap syndrome (ACOS).

METHODS

A total of 112 patients with a ratio of forced expiratory volume in 1 s to forced vital capacity of less than 70% were enrolled. COPD, asthma, and ACOS were clinically diagnosed according to the 2014 Global Initiative for Asthma and Global Initiative for Chronic Obstructive Lung Disease guidelines. Sinonasal inflammatory condition was evaluated using sinus computed tomography, and its severity was assessed according to the Lund-Mackay staging (LMS) system. Ethmoid sinus-dominant shadow was defined as the presence of greater LMS scores for the anterior and posterior ethmoid sinuses than for the maxillary sinus.

RESULTS

COPD, asthma, and ACOS were diagnosed in 55 (49.1%), 39 (34.8%), and 18 patients (16.1%), respectively. The frequency of radiographic evidence of sinonasal inflammation in patients with COPD, asthma, ACOS was 60.0%, 94.9%, and 72.2%, respectively. Patients with ACOS and COPD had only mild radiographic evidence of sinonasal inflammation (LMS score, 1-7), whereas moderate (LMS score, 8-11) and severe (LMS score, ≥12) radiographic evidence of sinonasal inflammation were detected only in patients with asthma. Furthermore, the frequency of ethmoid sinus-dominant shadow was significantly higher in patients with asthma than in those with COPD and ACOS.

CONCLUSIONS

Radiographic evidence of sinonasal inflammation was a common comorbidity in ACOS. Future studies are required to examine the role of sinonasal inflammation in ACOS.

Clinical characteristics of eosinophilic COPD versus COPD patients with a history of asthma

Eosinophilic COPD appears to be a distinct patient subgroup with an increased corticosteroid response. Eosinophilic COPD has been labelled as part of the asthma COPD overlap syndrome (ACOS). We compared the clinical characteristics of eosinophilic COPD patients (without any clinical history of asthma) and COPD patients with a childhood history of asthma. COPD patients with asthma were characterised by more allergies and more exacerbations, but less eosinophilic inflammation. While terms such as "ACOS" are used to "lump" patients together, we report distinct differences between eosinophilic COPD and COPD patients with asthma, and propose that these groups should be split rather than lumped.

Asthma-COPD overlap syndrome (ACOS) in primary care of four Latin America countries: the PUMA study

BACKGROUND

Asthma-COPD overlap syndrome (ACOS) prevalence varies depending on the studied population and definition criteria. The prevalence and clinical characteristics of ACOS in an at-risk COPD primary care population from Latin America was assessed.

METHODS

Patients ≥40 years, current/ex-smokers and/or exposed to biomass, attending routine primary care visits completed a questionnaire and performed spirometry. COPD was defined as post-bronchodilator forced expiratory volume in 1 s/forced vital capacity (FEV₁/FVC) < 0.70; asthma was defined as either prior asthma diagnosis or wheezing in the last 12 months plus reversibility (increase in post-bronchodilator FEV₁ or FVC ≥200 mL and ≥12%); ACOS was defined using a combination of COPD with the two asthma definitions. Exacerbations in the past year among the subgroups were evaluated.

RESULTS

One thousand seven hundred forty three individuals completed the questionnaire, 1540 performed acceptable spirometry, 309 had COPD, 231 had prior asthma diagnosis, and 78 asthma by wheezing + reversibility. ACOS prevalence in the total population (by post-bronchodilator FEV₁/FVC < 0.70 plus asthma diagnosis) was 5.3 and 2.3% by post-bronchodilator FEV₁/FVC < 0.70 plus wheezing + reversibility. In the obstructive population (asthma or COPD), prevalence rises to 17.9 and 9.9% by each definition, and to 26.5 and 11.3% in the COPD population. ACOS patients defined by post-bronchodilator FEV₁/FVC < 0.7 plus wheezing + reversibility had the lowest lung function measurements. Exacerbations for ACOS showed a prevalence ratio of 2.68 and 2.20 (crude and adjusted, p < 0.05, respectively) (reference COPD).

CONCLUSIONS

ACOS prevalence in primary care varied according to definition used. ACOS by post-bronchodilator FEV₁/FVC < 0.7 plus wheezing + reversibility represents a clinical phenotype with more frequent exacerbations, which is probably associated with a different management approach.