Gastroesophageal Reflux Disease Increases Susceptibility to Nontuberculous Mycobacterial Pulmonary Disease

Increased risk of suicide among individuals with chronic obstructive pulmonary disease: A nationwide cohort study in Korea

BACKGROUND

Previous studies have established that individuals with chronic obstructive pulmonary disease (COPD) have an increased risk of suicidal behaviors. However, it is uncertain which subgroups of individuals with COPD are at higher risk of suicide.

METHOD

We analyzed data from the Korean National Health Insurance Service. The exposure was COPD, and the outcome was death by suicide. Participants were followed until their date of death by suicide, the censoring date, or December 31, 2021, whichever came first. A Fine-Gray proportional hazards model for subdistribution was used to determine the associations between COPD and death by suicide.

RESULTS

During a median follow-up of 11.3 years (interquartile range, 11.1-11.6 years), individuals with COPD had an increased risk of death by suicide compared to those without (adjusted subdistribution hazard ratio [aSHR] = 1.20, 95 % confidence interval [CI] = 1.08-1.32). When stratified by the presence or absence of potential risk factors and COPD, the risk of suicide was highest in the COPD population with current smoking habits ≥20 PY (aSHR = 1.71, 95 % CI = 1.39-2.12), depression (aSHR = 2.46, 95 % CI = 1.97-3.08), and anxiety (aSHR = 2.71, 95 % CI = 1.87-3.92) compared to their corresponding reference groups (non-COPD population without the corresponding potential risk factors).

CONCLUSIONS

COPD increased the risk of death by suicide. This risk was particularly pronounced when current heavy smoking habits, depression, and anxiety coexisted with COPD.

Gastroesophageal Reflux Disease and Related Conditions Are Associated With Increased Risk for Nontuberculous Mycobacterium Infection

GOALS

We aimed to assess the relationship between nontuberculous mycobacterium (NTM) and gastroesophageal reflux disease (GERD) and associated conditions using a large international database.

BACKGROUND

Several studies suggest increased incidence of NTM pulmonary disease in patients with GERD.

STUDY

Within TriNetX database of over 130 million patients from 16 countries, a test cohort of patients with ICD-10 codes for GERD after esophagogastroduodenoscopy (EGD) was compared with controls without a GERD diagnosis who underwent screening colonoscopy. Five additional test cohorts were created: GERD without esophagitis (NERD), GERD with esophagitis (ERD), esophageal stricture, Barrett's without dysplasia (BWOD), and Barrett's with dysplasia (BWD). Sequential diagnoses were allowed in the test cohorts. One-to-one propensity score matching was performed between the control group and each test group based on age, gender, ethnicity, BMI, comorbidities, use of oral contraceptives, NSAIDs, bisphosphonate, ferrous sulfate, or immunosuppressant agents. Kaplan-Meier and Cox proportional hazards models (HR) were utilized for time-to-event analysis in matched cohorts with the outcome of de novo NTM diagnosis.

RESULTS

After matching, cohort populations included: GERD 982,194; NERD 772,557; ERD 287,803; esophageal stricture 72,545; BWOD 79,520; BWD 14,401. After analysis, most cohorts displayed increased risk of NTM diagnosis, but no between-group differences: GERD (HR2.024), NERD (HR2.06), ERD (HR1.758), esophageal stricture (HR1.875), BWOD (HR1.28), and BWD (HR2.781).

CONCLUSIONS

Our findings suggest a significant association between GERD and its complications with NTM. There was an increased risk of NTM in GERD patients compared with control and no relationship between severity of GERD and likelihood of contracting NTM.

Gastroesophageal reflux disease is not associated with disease severity in patients with Mycobacterium avium complex lung infection

BACKGROUND

Mycobacterium avium complex (MAC) pulmonary infection was previously associated with gastroesophageal reflux disease (GERD), although the effects of GERD on MAC outcomes remains unclear. The goal of this study was to assess the prevalence of GERD in patients with MAC pulmonary infection and its association with clinical outcomes.

METHODS

This was a retrospective study of adult patients with confirmed MAC pulmonary infection who underwent ambulatory pH monitoring. Pathologic acid reflux was defined as a total distal acid exposure time ≥6 %. Adjunctive esophageal tests including esophagogastroduodenoscopy, barium esophagram, and high-resolution manometry were assessed. The primary outcomes were pulmonary function testing and treatment of MAC pulmonary infection.

RESULTS

Of 132 included patients, 35 (26.5 %) had an acid exposure time ≥6 %. There were no differences between patients with and without pathologic acid reflux by AET and pulmonary function tests including FEV1 absolute (1.79 vs. 1.83 L, p = 0.68), FEV1 % predicted (78.6 vs. 78.0 %, p = 0.94), FEV1/FVC % predicted (71.1 vs. 68.0 %, p = 0.38), or DLCO % predicted (66.0 vs. 79.0 %, p = 0.097). Additionally, there were no differences in MAC pulmonary infection outcomes including antimicrobial treatment, duration, or lobectomy. Findings on adjunctive esophageal testing did not associate with outcomes by pulmonary function tests or treatment of MAC pulmonary infection.

CONCLUSIONS

The prevalence of GERD in patients with MAC pulmonary infection based on ambulatory pH monitoring was 26.5 %. MAC pulmonary infection with GERD was not associated with worse outcomes and further study is needed to assess the impacts of GERD on MAC pulmonary infection.

Air Pollution Increases Healthcare Utilization Below Safe Thresholds in Individuals With Asthma

PURPOSE

Safety thresholds for air quality levels have been proposed to protect people from the harmful effects of air pollutants. However, the impacts of air pollutants on asthma, particularly at levels below these safe thresholds, remain unclear.

METHODS

We analyzed the associations between air pollutants (particulate matter of 10 μm or less in diameter [PM₁₀], particulate matter of 2.5 μm or less in diameter, sulfur dioxide [SO₂], carbon monoxide, ozone [O₃], and nitrogen dioxide) and healthcare utilization in 23,498 individuals with asthma in Seoul during the 2015-2017 season. The relative risk for healthcare utilization was assessed based on quantitative comparison (upper quartile vs. lower quartile) and non-linear concentration-response curves. Safety thresholds for air quality levels were determined according to the World Health Organization and Korean standards.

RESULTS

In quantitative analysis, healthcare utilization risk decreased for PM₁₀ and SO₂ but increased for O₃ on lag day 0, with no significant associations observed for other air pollutants. Non-linear analyses revealed significant concentration-response associations for all air pollutants, indicating increased risks of healthcare utilization on lag day 0. Notably, these increased risks occurred below proposed safety thresholds, with a steeper rise observed for asthma-related healthcare utilization within these ranges.

CONCLUSIONS

Exposure to 6 air pollutants was associated with an increased risk of healthcare utilization among individuals with asthma, with no safe exposure levels identified. The impact was more pronounced below current safety thresholds.

Impact of seropositivity and disease-modifying antirheumatic drugs on pulmonary tuberculosis risk in rheumatoid arthritis

Background

It remains unclear whether active pulmonary tuberculosis risk is still high in rheumatoid arthritis patients in settings where tuberculosis infection screening is performed before the use of biologicals. Moreover, the impacts of seropositivity and disease-modifying antirheumatic drugs on active pulmonary tuberculosis risk should be elucidated.

Methods

The incidence of active pulmonary tuberculosis was compared between patients with rheumatoid arthritis (n=59 577; 41 501 seropositive rheumatoid arthritis and 18 076 seronegative rheumatoid arthritis) and 1:5 age- and sex-matched controls without rheumatoid arthritis (n=297 885) enrolled between 2010 and 2017. The participants were followed until December 2019.

Results

During a median follow-up duration of 4.4 years after a 1-year lag period (interquartile range 2.6-6.4 years; maximum 9 years), patients with rheumatoid arthritis showed a 3.2-fold (95% CI 2.91-3.55) higher active pulmonary tuberculosis risk than matched controls, even after adjusting for potential confounders. In an analysis of rheumatoid arthritis serological status, patients with seropositive rheumatoid arthritis and those with seronegative rheumatoid arthritis showed 3.20-fold (95% CI 2.86-3.58) and 2.54-fold (95% CI 2.13-3.04) increased risks, respectively, relative to matched controls. Furthermore, rheumatoid arthritis patients who were exposed to biological or targeted synthetic and disease-modifying antirheumatic drugs and those not exposed to the drugs showed 4.68-fold (95% CI 3.69-5.93) and 2.88-fold (95% CI 2.59-3.20) increased risks, respectively, relative to matched controls. In rheumatoid arthritis patients, active pulmonary tuberculosis risk factors included male sex, underweight and comorbidities such as diabetes mellitus.

Conclusion

Rheumatoid arthritis patients are prone to active pulmonary tuberculosis development, with rates affected by seropositivity and disease-modifying antirheumatic drugs. Focused tuberculosis screenings may need to be carried out in rheumatoid arthritis patients based on our results.

Treatment of nontuberculous mycobacterial pulmonary disease requires a stepwise and multidisciplinary approach

INTRODUCTION

Nontuberculous mycobacterial pulmonary disease (NTM-PD) occurs in people with inborn or acquired susceptibility factors. Current treatment guideline recommendations include a watchful waiting strategy, antimycobacterial and surgical treatment, with a comprehensive assessment of clinical, microbiological, and radiological factors determining which approach is most suitable.

AREAS COVERED

Treatment outcomes in NTM-PD are unsatisfactory with culture conversion rates varying from 30 to 80% and recurrence rates up to 50%. Possible explanations include our insufficient knowledge and management of host susceptibility factors, poor guideline adherence by physicians, frequent adverse drug reactions demanding premature discontinuation, inadequate drug exposures due to both drug-drug interactions and inter-patient variability in pharmacokinetics, and a lack of pharmacokinetics/pharmacodynamics targets.

EXPERT OPINION

We describe a stepwise approach to NTM-PD treatment, complementing existing guidelines, including recommendations for a multidisciplinary assessment, classification of disease severity, personalized supportive care, antimycobacterial treatment, adjuvant surgery, and host-directed therapies. The recommendations are informed by PubMed literature and the authors' clinical expertise. Recognizing that our experience is shaped within a specialized reference clinic, we acknowledge that some of these recommendations may not be applicable in all settings.

Mycobacterium nebraskense Isolated from Patients in Connecticut and Oregon, USA

Mycobacterium nebraskense infection is rarely encountered; only 7 human cases have been reported worldwide since the initial report of 5 cases in Nebraska, USA, in 2004. We report 9 patients from Connecticut and 2 from Oregon, USA, who had M. nebraskense isolated from respiratory secretions; 7 patients met the American Thoracic Society/Infectious Diseases Society of America criteria for nontuberculous mycobacterial pulmonary disease. In 4 cases, the organism was isolated 1 time and caused brief or no symptoms. Most cases in Connecticut were reported after 2017. Antimicrobial drug susceptibility testing of 6 isolates showed clarithromycin susceptibility. In 2 cases, infection was refractory to treatment. The 9 Connecticut patients lived in 8 different towns; thus, a common water supply did not explain the high frequency of M. nebraskense isolation. M. nebraskense is a clinically significant cause of nontuberculous mycobacterial pulmonary disease in Connecticut; continued surveillance will be needed to determine its frequency and optimum treatment.

Impact of physical activity on all-cause mortality in individuals with non-cystic fibrosis bronchiectasis

Background

Little information is available regarding whether active physical activity lowers mortality risk in individuals with bronchiectasis.

Methods

We used the Korean National Health Insurance Service database from 2010 to 2016 to evaluate the association between changes in physical activity and mortality risk in individuals with bronchiectasis. Of 552,510 individuals with newly diagnosed bronchiectasis, we enrolled 165,842 individuals who had two consecutive health examinations before and after bronchiectasis diagnosis, within two years, as the study aimed to measure changes in exercise habits between the two time points. Active physical activity was defined as engaging in moderate- or vigorous-intensity physical activity at least once a week, either before or after bronchiectasis diagnosis. The outcome measure was all-cause mortality.

Results

During a mean follow-up of 6.2 ± 2.1 years, 10,535 (6.4%) individuals with bronchiectasis died. Individuals with bronchiectasis who were physically active exhibited a lower mortality rate than those who were physically inactive. Mortality reduction was particularly evident in the exercise maintainers group (aHR [adjusted hazard ratio] = 0.69, 95% confidence interval [CI] = 0.64-0.74) and individuals with physical activity ≥1,000 metabolic equivalent of task-min per week (aHR = 0.73, 95% CI = 0.70-0.77) compared to those who were physically inactive.

Conclusion

Engaging in active physical activity is associated with a decreased risk of mortality in individuals with bronchiectasis.

COVID-19 and risk of long-term mortality in COPD: a nationwide population-based cohort study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a risk factor for severe COVID-19. However, mortality after COVID-19 recovery in this population remains unclear.

METHODS

We retrospectively enrolled individuals with COPD from the Korean National Health Insurance database. We compared the mortality rate in individuals with COPD who recovered from COVID-19 between 8 October 2020 and 31 December 2021 (COVID-19 cohort, n=2499) with that in 1:1 propensity score-matched controls (n=2499). The study population was followed until either death or 30 September 2022, whichever came first.

RESULTS

The COVID-19 cohort had a 4.8% mortality rate vs 2.7% in matched controls during a median follow-up of 319 days (IQR, 293-422 days), including 14 days of recovery time. The COVID-19 cohort had a higher risk of death than matched controls (adjusted HR (aHR)=1.81, 95% CI=1.35 to 2.45). The risk of mortality was notably higher in individuals with severe COVID-19 (aHR=5.05, 95% CI=3.65 to 6.97), especially during the first 180 days of recovery (highest during the first 30 days (aHR=20.25, 95% CI=7.79 to 52.64)). Non-severe COVID-19 does not increase the risk of mortality compared with controls (aHR=0.85, 95% CI=0.57 to 1.28).

CONCLUSION

Individuals with COPD recovering from COVID-19 showed an increased risk of long-term mortality, particularly within the first 180 days post-recovery, especially those who experienced severe COVID-19.

Association between rheumatoid arthritis and interstitial lung disease and impact of serologic status: a large-scale longitudinal study

Interstitial lung disease (ILD) leads to worse outcomes in subjects with rheumatoid arthritis (RA). Few large-scale longitudinal studies have provided comprehensive data on the incidence and risk of ILD in RA compared with non-RA populations. We compare the risk of incident ILD in subjects with RA and matched controls, while also evaluating the impact of RA serologic status. Using the Korean National Health Insurance Service Data between 2010 and 2017, we identified 52,325 individuals with RA and 261,625 without RA. During a median follow-up period of 4.4 years, 3.7% of the RA cohort and 0.5% of the matched cohort developed ILD, with incidence rates of 8.30 and 1.01 per 1,000 person-years. Compared to controls, the risk of incident ILD was significantly higher in the RA cohort (adjusted hazard ratio [aHR] 7.84 [7.29-8.44]), and seropositive and seronegative RA exhibited aHRs of 9.00 (8.34-9.72) and 4.81 (4.25-5.44). Although the risk of ILD was higher in seropositive RA than seronegative RA, the risk of developing ILD was also higher in subjects with seronegative RA than in matched controls, suggesting that close monitoring for ILD should be performed in this population.

COVID-19 and Long-term Risk of Ischemic Heart Disease in Asthma

Despite the importance of comorbid ischemic heart disease (IHD) in the prognosis of asthma, the long-term impact of coronavirus disease 2019 (COVID-19) on IHD in adults with asthma remains unclear. This study investigated the long-term effects of COVID-19 on the risk of IHD in individuals with asthma, particularly regarding COVID-19 severity. Using the Korean National Health Insurance Service claims database, we identified individuals with asthma who had recovered from COVID-19 between October 8, 2020, and December 31, 2021 (n = 8,011) and 1:1 propensity score-matched controls (n = 8,011). The incidence and risk of IHD were compared between the two groups. Overall, during a median follow-up of 95 days (interquartile range, 34-213 days; range, 1-448 days), which includes a median of 14 lag days, the COVID-19 cohort did not show a higher risk of IHD (hazard ratio [HR], 2.11; 95% confidence interval [CI], 0.99-4.48) compared to matched controls. However, when the severity of COVID-19 was considered, the severe COVID-19 cohort exhibited a higher risk of IHD (HR, 4.89; 95% CI, 1.86-12.84) than matched controls; in contrast, the non-severe COVID-19 cohort showed no significantly increased risk of IHD (HR, 1.64; 95% CI, 0.73-3.70). Severe COVID-19 is associated with an increased long-term risk of IHD in adults with asthma, emphasizing the importance of cardiovascular events monitoring to improve asthma treatment outcomes in the era of COVID-19.

Nonpharmacological Treatment for Nontuberculous Mycobacterial Pulmonary Disease

Nontuberculous mycobacterial pulmonary disease (NTM-PD) results from the exposure of susceptible hosts to a diverse group of environmental mycobacteria. The emphasis on nonpharmacological strategies is motivated by the widespread presence of NTM in various environments, and the inconsistent success rates of pharmacological treatments. Modifiable factors contributing to NTM-PD development include impaired airway clearance, low body mass index, gastroesophageal reflux disease, and exposure to NTM habitats. This suggests that lifestyle and environmental modifications could affect disease development and progression. The review highlights several modalities that can modify the risk factors. Airway clearance techniques, informed by the "gel-on-brush" model of the bronchial epithelium, aim to enhance mucociliary clearance, and have the potential to alleviate symptoms and improve lung function. The impact of nutritional status is also examined, with a lower body mass index linked to an increased risk and progression of NTM-PD, indicating the importance of targeted nutritional support. Additionally, the theoretical and epidemiological links between gastroesophageal reflux disease and NTM-PD advocate careful management of reflux episodes. Understanding the risk of NTM transmission through environmental exposure to contaminated water and soil is also crucial. Strategies to mitigate this risk, including effective water management and minimizing soil contact, are presented as vital preventive measures. The review supports the inclusion of nonpharmacological treatments within a comprehensive NTM-PD management strategy, alongside conventional pharmacological therapies. This integrated approach seeks to improve the overall understanding and handling of NTM-PD.

Patients at risk of nontuberculous mycobacterial pulmonary disease who need testing evaluated using a modified Delphi process by European experts

Background

Identifying patients at risk of nontuberculous mycobacterial pulmonary disease (NTM-PD) is challenging. Delays in NTM-PD identification and management are associated with declining lung function and increased morbidity and mortality.

Study design and methods

European NTM-PD experts (n=12) participated in a three-round modified Delphi process to score symptoms and comorbidities potentially associated with NTM-PD as reasons to test for nontuberculous mycobacteria.

Results

Experts reached a consensus on the symptoms and comorbidities that should and should not prompt testing for nontuberculous mycobacteria. Requirements for testing were scored as high (mean ≥7), medium (mean ≥4-<7) or low (mean <4). Nontuberculous mycobacteria testing should be undertaken when multiple suggestive symptoms are present simultaneously in all patients except those with cancer (7.3-8.8), or when radiology is indicative of NTM-PD (≥8.9). Symptoms of persistent sputum production, recurrent respiratory infection and haemoptysis should prompt testing for nontuberculous mycobacteria, particularly in those with underlying respiratory diseases. Symptomatic patients with bronchiectasis or previous tuberculosis/NTM-PD or those being prescribed or undergoing long-term macrolide therapy for a respiratory condition should also be tested. Testing is not warranted in patients without an underlying respiratory disorder or in those without a history of respiratory disorders unless presenting with multiple symptoms.

Conclusions

Assessing patients' risk of NTM-PD is challenging. This Delphi consensus process provides insight into symptoms and clinical characteristics that should prompt NTM-PD assessment. Timely testing and diagnosis would enable initiation of appropriate management.

Lower respiratory tract microbiota in patients with clinically suspected nontuberculous mycobacterial pulmonary disease according to the presence of gastroesophageal reflux

Although gastroesophageal reflux has been recognized as one of the risk factors of nontuberculous mycobacterial pulmonary disease (NTM-PD) progression, the effect of reflux on the lower respiratory tract microbiota has not been studied in detail. We investigated the composition of the lower respiratory tract microbiota in patients with clinically suspected NTM-PD, comparing them based on the presence of reflux. Forty-seven patients suspected of having NTM-PD were enrolled and assigned according to presence of reflux (n = 22) and non- reflux (n = 25). We performed a pepsin ELISA assay to identify the presence of reflux and 16S ribosomal RNA gene amplicon sequencing to evaluate the microbiota in bronchoalveolar lavage fluid. There were no significant differences in the diversity or composition of the lower respiratory microbiota between the NTM-PD and non-NTM-PD groups. Bacterial richness was observed in the non-reflux group than in the reflux group [P = 0.03] and a cluster in the reflux group was observed. The reflux group showed a predominance for Pseudomonas aeruginosa or Staphylococcus aureus among the NTM-PD group and for P. aeruginosa, Haemophilus influenzae, Klebsiella pneumoniae, or Eikenella species among the non-NTM-PD group. The non-reflux groups presented diverse patterns. A linear discriminant analysis and volcano plot demonstrated that P. aeruginosa, H. haemolyticus, Selenomonas artemidis, and Dolosigranulum pigrum were specifically associated with the NTM-PD reflux group, while P. aeruginosa was specifically associated with the non-NTM-PD reflux group. These observations confirm that the lower respiratory microbiota is consistently altered by reflux but not in NTM-PD.

Epidemiological and clinical characteristics of nontuberculous mycobacterial infections: A retrospective female cohort study in an Italian population

Objectives

This study aims to assess the characteristics and treatment outcomes of patients diagnosed with non-tuberculous mycobacteria (NTM) diseases at the Infectious Diseases Unit of ARNAS Garibaldi Hospital in Catania, Italy, focusing on demographics, clinical features, and treatment effectiveness.

Methods

We conducted a retrospective observational study of 10 patients diagnosed with NTM diseases between 2019 and 2021. Data was collected from electronic medical records, including demographic information, comorbidities, treatment modalities, and outcomes. The study utilized descriptive statistics to analyze continuous and categorical variables. Treatment regimens were based on individual patient needs, incorporating a combination of antibiotics.

Results

The median age of the patients was 55.44 years, all female, predominantly suffering from pulmonary NTM diseases. Mycobacterium intracellulare was the most common pathogen. Common comorbidities included COPD, bronchiectasis, GERD, and hypovitaminosis D. Patients showed symptoms like fever, cough, and asthenia. The treatment regimens were diverse, with macrolides, rifampicin, and ethambutol forming the core. Adverse effects were noted in 40 % of patients, including gastrointestinal and neurological disorders. All patients achieved microbiological cure, with 60 % showing clinical improvement and 36 % radiological improvement.

Conclusion

The study highlights the complexity of diagnosing and treating NTM diseases, emphasizing the need for personalized treatment plans and vigilant monitoring of adverse effects. Despite achieving microbiological cure, challenges remain in achieving complete clinical and radiological resolution. Further research is needed to enhance the understanding and management of NTM diseases, particularly in diverse populations.

Growing from common ground: nontuberculous mycobacteria and bronchiectasis

Bronchiectasis and nontuberculous mycobacteria (NTM) are intricately intertwined, with NTM capable of being both a cause and consequence of bronchiectatic disease. This narrative review focuses on the common ground of bronchiectasis and NTM pulmonary disease (NTM-PD) in terms of diagnostic approach, underlying risk factors and treatment strategies. NTM-PD diagnosis relies on a combination of clinical, radiological and microbiological criteria. Although their epidemiology is complicated by detection and reporting biases, the prevalence and pathogenicity of NTM species vary geographically, with Mycobacterium avium complex and Mycobacterium abscessus subspecies most frequently isolated in bronchiectasis-associated NTM-PD. Diagnosis of nodular bronchiectatic NTM-PD should prompt investigation of host factors, including disorders of mucociliary clearance, connective tissue diseases and immunodeficiencies, either genetic or acquired. Treatment of NTM-PD in bronchiectasis involves a multidisciplinary approach and considers the (sub)species involved, disease severity and comorbidities. Current guideline-based antimicrobial treatment of NTM-PD is considered long, cumbersome and unsatisfying in terms of outcomes. Novel treatment regimens and strategies are being explored, including rifampicin-free regimens and inclusion of clofazimine and inhaled antibiotics. Host-directed therapies, such as immunomodulators and cytokine-based therapies, might enhance antimycobacterial immune responses. Optimising supportive care, as well as pathogen- and host-directed strategies, is crucial, highlighting the need for personalised approaches tailored to individual patient needs. Further research is warranted to elucidate the complex interplay between host and mycobacterial factors, informing more effective management strategies.

Nontuberculous mycobacterial pulmonary disease added burden to COPD and bronchiectasis in Japan

Background and objective

Nontuberculous mycobacterial pulmonary disease (NTM-PD) prevalence in Japan is among the highest worldwide. COPD and bronchiectasis are common comorbidities among patients with NTM-PD, and it is challenging to treat NTM-PD in patients with these conditions. There are limited data on the incremental burden that NTM-PD adds to underlying COPD or bronchiectasis in Japan. Therefore, the objective of this study was to assess the incremental burden associated with NTM-PD in patients with pre-existing COPD and/or bronchiectasis.

Methods

This nested case-control study was based on JMDC, Inc. claims data (2015-2020). Patients with COPD and/or bronchiectasis with NTM-PD (cases) were age and sex matched 1:3 to patients with COPD and/or bronchiectasis without NTM-PD (controls), resulting in three mutually exclusive patient groups (COPD, bronchiectasis or both; with or without NTM-PD). Incremental burden of NTM-PD was assessed within each group by comparing hospitalisations during the 1-year period after NTM-PD diagnosis (index) between cases and controls with both univariate analysis and multivariate analysis adjusting for pre-index comorbidities.

Results

Univariate analyses in the three patient groups consistently demonstrated incremental hospitalisation burden in cases versus controls (e.g. COPD group: 20% of 492 cases versus 13% of 1476 controls had all-cause hospitalisations; 11% versus 5% had respiratory-related hospitalisations; and 6% versus 2% had COPD-related hospitalisations). Subsequent multivariate analysis further confirmed the findings.

Conclusions

The substantial incremental burden of hospitalisation associated with NTM-PD in patients with COPD and/or bronchiectasis highlights the urgent need for appropriate management of NTM-PD in Japan.

Long-Term Impacts of COVID-19 on Severe Exacerbation and Mortality in Adult Asthma: A Nationwide Population-Based Cohort Study

BACKGROUND

In adults with asthma, the long-term impact of previous coronavirus disease 2019 (COVID-19) on severe exacerbations and mortality is unclear.

OBJECTIVE

We evaluated the long-term risk of severe exacerbation and mortality in adults with asthma who recovered from COVID-19.

METHODS

Using the Korean National Health Insurance claim-based database, we compared the risk of severe exacerbations (emergency room visits or hospitalization) and mortality in adults with asthma aged greater than 20 years who had recovered from COVID-19 between October 8, 2020, and December 16, 2021 (COVID-19 cohort, n = 10,739) with 1:1 propensity score-matched controls (n = 10,739).

RESULTS

During a median follow-up of 87 days (range, 15-448 days), the incidence rate of severe exacerbations in the COVID-19 cohort and the matched cohort was 187.3 and 119.3 per 10,000 person-years, respectively. The COVID-19 cohort had a higher risk of severe exacerbation compared with the matched cohort (hazard ratio = 1.57; 95% CI, 1.06-2.32). During a median follow-up of 360 days (range, 15-721 days), the incidence rate of death in the COVID-19 and matched cohorts was 128.3 and 73.5 per 10,000 person-years, respectively. The COVID-19 cohort had a higher risk of death (hazard ratio = 1.76; 95% CI, 1.33-2.30) compared with the matched cohort. When further analyzed by COVID-19 severity, severe COVID-19 was associated with a 5.12-fold (95% CI, 3.27-8.01) and 7.31-fold (95% CI, 5.41-9.88) increased risk of severe exacerbation and death, respectively, but non-severe COVID-19 was not.

CONCLUSIONS

Our study shows that severe COVID-19 is associated with an increased long-term risk of severe exacerbation and mortality among individuals with asthma.

Tuberculosis and osteoporotic fracture risk: development of individualized fracture risk estimation prediction model using a nationwide cohort study

Purpose

Tuberculosis (TB) is linked to sustained inflammation even after treatment, and fracture risk is higher in TB survivors than in the general population. However, no individualized fracture risk prediction model exists for TB survivors. We aimed to estimate fracture risk, identify fracture-related factors, and develop an individualized risk prediction model for TB survivors.

Methods

TB survivors (n = 44,453) between 2010 and 2017 and 1:1 age- and sex-matched controls were enrolled. One year after TB diagnosis, the participants were followed-up until the date of fracture, death, or end of the study period (December 2018). Cox proportional hazard regression analyses were performed to compare the fracture risk between TB survivors and controls and to identify fracture-related factors among TB survivors.

Results

During median 3.4 (interquartile range, 1.6-5.3) follow-up years, the incident fracture rate was significantly higher in TB survivors than in the matched controls (19.3 vs. 14.6 per 1,000 person-years, p < 0.001). Even after adjusting for potential confounders, TB survivors had a higher risk for all fractures (adjusted hazard ratio 1.27 [95% confidence interval 1.20-1.34]), including hip (1.65 [1.39-1.96]) and vertebral (1.35 [1.25-1.46]) fractures, than matched controls. Fracture-related factors included pulmonary TB, female sex, older age, heavy alcohol consumption, reduced exercise, and a higher Charlson Comorbidity Index (p < 0.05). The individualized fracture risk model showed good discrimination (concordance statistic = 0.678).

Conclusion

TB survivors have a higher fracture risk than matched controls. An individualized prediction model may help prevent fractures in TB survivors, especially in high-risk groups.

Increased Risk of Incident Chronic Obstructive Pulmonary Disease and Related Hospitalizations in Tuberculosis Survivors: A Population-Based Matched Cohort Study

BACKGROUND

Tuberculosis (TB) survivors have an increased risk of developing chronic obstructive pulmonary disease (COPD). This study assessed the risk of COPD development and COPD-related hospitalization in TB survivors compared to controls.

METHODS

We conducted a population-based cohort study of TB survivors and 1:1 age- and sex-matched controls using data from the Korean National Health Insurance Service database collected from 2010 to 2017. We compared the risk of COPD development and COPD-related hospitalization between TB survivors and controls.

RESULTS

Of the subjects, 9.6% developed COPD, and 2.8% experienced COPD-related hospitalization. TB survivors had significantly higher COPD incidence rates (36.7/1,000 vs. 18.8/1,000 person-years, P < 0.001) and COPD-related hospitalization (10.7/1,000 vs. 4.3/1,000 person-years, P < 0.001) than controls. Multivariable Cox regression analyses revealed higher risks of COPD development (adjusted hazard ratio [aHR], 1.63; 95% confidence interval [CI], 1.54-1.73) and COPD-related hospitalization (aHR, 2.03; 95% CI, 1.81-2.27) in TB survivors. Among those who developed COPD, the hospitalization rate was higher in individuals with post-TB COPD compared to those with non-TB COPD (10.7/1,000 vs. 4.9/1,000 person-years, P < 0.001), showing an increased risk of COPD-related hospitalization (aHR, 1.84; 95% CI, 1.17-2.92).

CONCLUSION

TB survivors had higher risks of incident COPD and COPD-related hospitalization compared to controls. These results suggest that previous TB is an important COPD etiology associated with COPD-related hospitalization.

Risk of newly diagnosed interstitial lung disease after COVID-19 and impact of vaccination: a nationwide population-based cohort study

Objectives

Previous studies suggested that coronavirus disease 2019 (COVID-19) could lead to pulmonary fibrosis, but the incidence of newly diagnosed interstitial lung disease (ILD) after COVID-19 is unclear. We aimed to determine whether COVID-19 increases the risk of newly diagnosed ILD and whether vaccination against COVID-19 can reduce this risk.

Methods

This retrospective cohort study used data from the Korean National Health Insurance claim-based database. Two study groups and propensity score (PS)-matched control groups were constructed: Study 1: participants diagnosed with COVID-19 (COVID-19 cohort) and their PS-matched controls; Study 2: COVID-19 vaccinated participants (vaccination cohort) and their PS-matched controls.

Results

In Study 1, during a median 6 months of follow-up, 0.50% of the COVID-19 cohort (300/60,518) and 0.04% of controls (27/60,518) developed newly diagnosed ILD, with an incidence of 9.76 and 0.88 per 1,000 person-years, respectively. The COVID-19 cohort had a higher risk of ILD [adjusted hazard ratio (aHR), 11.01; 95% confidence interval (CI), 7.42-16.32] than controls. In Study 2, the vaccination cohort had a lower risk of newly diagnosed ILD than controls (aHR, 0.44; 95% CI, 0.34-0.57).

Conclusion

Using nationwide data, we demonstrated that COVID-19 was associated with a higher incidence rate of newly diagnosed ILD, but that this risk could be mitigated by COVID-19 vaccination.

Treatable traits and challenges in the clinical management of non-tuberculous mycobacteria lung disease in people with cystic fibrosis

INTRODUCTION

Over the last ten years an increasing prevalence and incidence of non-tuberculous mycobacteria (NTM) has been reported among patients with cystic fibrosis (CF) Viviani (J Cyst Fibros, 15(5):619-623, 2016). NTM pulmonary disease has been associated with negative clinical outcomes and often requires pharmacological treatment. Although specific guidelines help clinicians in the process of diagnosis and clinical management, the focus on the multidimensional assessment of concomitant problems is still scarce.

MAIN BODY

This review aims to identify the treatable traits of NTM pulmonary disease in people with CF and discuss the importance of a multidisciplinary approach in order to detect and manage all the clinical and behavioral aspects of the disease. The multidisciplinary complexity of NTM pulmonary disease in CF requires careful management of respiratory and extra-respiratory, including control of comorbidities, drug interactions and behavioral factors as adherence to therapies.

CONCLUSIONS

The treatable trait strategy can help to optimize clinical management through systematic assessment of all the aspects of the disease, providing a holistic treatment for such a multi-systemic and complex condition.

Treatment of the Less Common Nontuberculous Mycobacterial Pulmonary Disease

Nontuberculous mycobacterial pulmonary disease caused by the less common nontuberculous mycobacteria have distinct features depending on the species. Diagnostic evaluation follows the established criteria for all nontuberculous mycobacteria, but with certain qualifications given species-specific and regional differences in pathogenicity. Clinicians should first institute nonpharmacologic management and evaluate clinical, radiologic, and microbiologic factors in the decision regarding antimycobacterial therapy. Treatment is challenging, and evidence-based recommendations are limited for most species. Drug susceptibility testing is used to help with regimen selection; however, this approach is imperfect given the uncertain correlation between in vitro activity and clinical response for most drugs.