Epidemiology and management of common pulmonary diseases in older persons

Immunotherapeutic targeting of aging-associated isoDGR motif in chronic lung inflammation

Accumulation of damaged biomolecules in body tissues is the primary cause of aging and age-related chronic diseases. Since this damage often occurs spontaneously, it has traditionally been regarded as untreatable, with typical therapeutic strategies targeting genes or enzymes being ineffective in this domain. In this report, we demonstrate that an antibody targeting the isoDGR damage motif in lung tissue can guide immune clearance of harmful damaged proteins in vivo, effectively reducing age-linked lung inflammation. We observed age-dependent accumulation of the isoDGR motif in human lung tissues, as well as an 8-fold increase in isoDGR-damaged proteins in lung fibrotic tissues compared with healthy tissue. This increase was accompanied by marked infiltration of CD68+/CD11b + macrophages, consistent with a role for isoDGR in promoting chronic inflammation. We therefore assessed isoDGR function in mice that were either naturally aged or lacked the isoDGR repair enzyme. IsoDGR-protein accumulation in mouse lung tissue was strongly correlated with chronic inflammation, pulmonary edema, and hypoxemia. This accumulation also induced mitochondrial and ribosomal dysfunction, in addition to features of cellular senescence, thereby contributing to progressive lung damage over time. Importantly, treatment with anti-isoDGR antibody was able to reduce these molecular features of disease and significantly reduced lung pathology in vivo.

Euglena gracilis-derived β-glucan ameliorates particulate matter (PM2.5)-induced airway inflammation by modulating nuclear factor kappa B, mitogen-activated protein kinase, and nuclear factor erythroid 2-related factor 2 signaling pathways in A549 cells and BALB/c mice

This study aimed to investigate the effects of β-glucan derived from Euglena gracilis (EGB), an edible microalga, on particulate matter (PM2.5)-induced airway inflammation in A549 cells and BALB/c mice. EGB effectively suppressed the mRNA and protein levels of inflammatory cytokines (IL-6, IL-1β, TNF-α, IL-8) and mediators (iNOS, COX-2), while inhibiting the NF-κB and MAPK signaling pathways triggered by PM2.5 exposure and reducing nuclear NF-κB levels. Additionally, EGB decreased PM2.5-induced ROS production and increased the protein levels of NRF2 and HO-1, along with genes encoding antioxidant enzymes (catalase, GPx, SOD1), associated with elevated nuclear NRF2 levels. EGB reduced immune cell infiltration and inflammatory cytokine levels in BALF and serum, both of which increased by PM2.5 exposure. EGB also significantly increased alveolar numbers while decreasing the gene expression of MMP1/9/13. Furthermore, EGB suppressed PM2.5-induced bronchial thickening and collagen-1 deposition by downregulating TGF-β1 expression, and alleviated goblet cell hyperplasia and mucin production in lung tissues. These results suggest that EGB effectively reduces PM2.5-induced airway inflammation by suppressing NF-κB and MAPK signaling pathways, lowering pro-inflammatory cytokines, and activating the NRF2-HO-1 signaling pathway to enhance antioxidant enzyme expression. This study highlights the potential of EGB as an edible functional agent for controlling PM-related airway inflammation.

Omega-3 Fatty Acids and Chronic Lung Diseases: A Narrative Review of Impacts from Womb to Tomb

The lungs are a mucosal organ constantly exposed to potentially harmful compounds and pathogens. Beyond their role in gas exchange, they must perform a well-orchestrated protective response against foreign invaders. The lungs identify these foreign compounds, respond to them by eliciting an inflammatory response, and restore tissue homeostasis after inflammation to ensure the lungs continue to function. In addition, lung function can be affected by genetics, environmental exposures, and age, leading to pulmonary diseases that infringe on quality of life. Recent studies indicate that diet can influence pulmonary health including the incidence and/or severity of lung diseases. Specifically, long-chain omega-3 polyunsaturated fatty acids (n-3 PUFAs) have gained attention because of their potential to reduce inflammation and promote resolution of inflammation. Docosahexaenoic acid and eicosapentaenoic acid are 2 potentially beneficial n-3 PUFAs primarily acquired through dietary intake. Here we review current literature examining the role of n-3 PUFAs and the biological mechanisms by which these fatty acids alter the incidence and pathologies of chronic lung diseases including asthma, chronic obstructive pulmonary disease, and interstitial lung disease. We also highlight the role of n-3 PUFAs in vulnerable populations such as pre/postnatal children, those with obesity, and the elderly. Lastly, we review the impact of n-3 PUFA intake and supplementation to evaluate if increasing consumption can mitigate mechanisms driving chronic lung diseases.

Socioeconomic differences in limited lung function: a cross-sectional study of middle-aged and older adults in Germany

BACKGROUND

Limited lung function represents a serious health impairment. However, studies investigating social inequalities in limited lung function are rare. Thus, the current study investigates which socioeconomic groups are the most affected by overall limited lung function and severely limited lung function.

METHODS

Data from the population-based German Aging Survey were used (N = 4472), with participants being 40 + years old. Lung function was assessed by the peak flow test. Education, income, and occupational prestige were used as socioeconomic indicators.

RESULTS

We found that overall limited lung function was highly prevalent across the whole sample, with about 33% (Women: 35%; Men: 30%) having overall limited lung function and 8% (Women: 7%; Men: 8%) having severely limited lung function. Socioeconomic differences in limited lung function emerged for all three indicators, education, income, and occupational prestige, in both men and women in single effect analyses. These differences persisted for occupational prestige and income when controlling for all indicators simultaneously.

CONCLUSIONS

Thus, overall and severely limited lung function are highly prevalent health conditions. Men and women with a low occupational position and those with low income are the most affected. Socioeconomic indicators cannot be used interchangeably when studying health inequalities in lung functioning. Occupational hazards and physical working conditions are likely to constitute major risks of health inequalities in limited lung functioning and should be investigated as such by future studies.

Time trends in limited lung function among German middle-aged and older adults

Limited lung function represents a serious health impairment. However, studies investigating changes in limited lung function over time are rare. Thus, the current study investigates time-related changes in limited lung function and potential social inequalities. Data from the 2008 and 2017 waves of the population-based German Aging Survey were used in a repeated cross-sectional study design (N = 8778), including participants aged 40 years and older. Lung function was assessed by the peak flow test. Socio-economic indicators included educational attainment, income and occupational group. Additionally, smoking history, occupational exposure to fumes and gases, and physical exercise were used as potentially explanatory variables for the observed changes. We found that the prevalence of limited lung function decreased strongly over time on a descriptive level from 9.0 to 5.4%. In line with these results, a decreasing trend emerged (OR = 0.48) when controlling for age and gender differences. When additionally controlling for changes in socio-economic indicators and explanatory variables there were still significant decreases over time, but the decline was slightly reduced (OR = 0.57). Moreover, similar significant relative decreases over time occurred for middle-aged and older participants, female and male participants, and those belonging to the different socio-economic groups. Thus, limited lung function generally decreased over time. This decrease could partially be explained by beneficial developments in socio-economic indicators, smoking, occupational exposures, and physical exercise. Future studies might investigate how changes in medicinal treatment and prevention efforts have contributed to the observed beneficial trends in lung health.

Comparison of the Effects of Diaphragmatic Breathing and Pursed-lip Breathing Exercises on the Sleep Quality of Elderly Patients with Chronic Obstructive Pulmonary Disease (COPD): A Clinical Trial Study

Background

Sleep-related disorders are common among older adults with chronic obstructive pulmonary disease (COPD). Breathing exercises, a key component of pulmonary rehabilitation programs, may improve sleep quality. However, there is a paucity of research on the impact of breathing exercises on sleep quality in elderly patients with COPD.

Objective

This study aimed to compare the effects of diaphragmatic breathing (DB) and pursed-lip breathing (PLB) exercises on sleep quality in elderly patients with COPD.

Design

Crossover clinical trial.

Methods

In this study, 60 elderly patients with COPD were randomly assigned to two groups: DB followed by PLB (Group 1) and PLB followed by DB (Group 2). Each exercise was performed for 4 weeks. Participants completed the Pittsburgh Sleep Quality Index (PSQI), Abbreviated Mental Test Score (AMTS), and COPD Assessment Test (CAT) questionnaires before training. Data were analyzed using descriptive and inferential statistics in SPSS version 21, with a significance level of 0.05.

Results

Both DB and PLB exercises significantly improved sleep quality in elderly patients with COPD (P < 0.05). No significant difference was found between the two exercises. However, the sequence of exercises in Group 1 (DB followed by PLB) resulted in greater improvement in average sleep quality compared to Group 2.

Conclusion

This study demonstrates that DB and PLB exercises enhance sleep quality in elderly patients with COPD. These exercises are recommended as an effective non-pharmacological approach to improve sleep quality in this population.

Barriers and Facilitators to Exercise Compliance for Community Elders with COPD: A Cross-Sectional Study

Background and Aim

Exercise compliance was known as important to improve long-term health conditions for Chronic obstructive pulmonary disease (COPD) patients, however, little was known about the determinants which affect their exercise compliance. This study aimed to investigate factors related to exercise compliance of COPD elderly patients.

Methods

This cross-sectional study included elderly patients with stable COPD participants. Random cluster sampling and a survey, including the Exercise Compliance Scale, mMRC Dyspnea Index Scale, Social Support Scale, Anxiety Self-Assessment Scale, and Self-rating Depression Scale, were used. Data were analyzed using Spearman correlation and backward logistic regression.

Results

124 participants (45.90%) had poor exercise compliance while 146 had good compliance (54.10%). The backward logistic regression showed household monthly income (¥501-¥1500: OR=21.54, P<0.05; ¥3001-¥5000: OR=32.76, P<0.05), two chronic comorbidities (OR=17.13, P<0.05), and the moderate dyspnea (OR=16.87, P<0.05) might help to improve exercise compliance. While female COPD patients (OR=0.11, P<0.01) who had server dyspnea (OR=0.02, P<0.05) and depression (OR=0.84, P<0.05) might have more difficulties adhering to exercise.

Conclusion

Low exercise compliance in community-dwelling elderly COPD patients could be affected by sex, monthly income level, number of chronic comorbidities, dyspnea, and depression.

The economic burden of idiopathic pulmonary fibrosis in Australia: a cost of illness study

PURPOSE

Idiopathic pulmonary fibrosis (IPF) is a type of interstitial lung disease found mostly in elderly persons, characterized by a high symptom burden and frequent encounters with health services. This study aimed to quantify the economic burden of IPF in Australia with a focus on resource utilization and associated direct costs.

METHODS

Participants were recruited from the Australian IPF Registry (AIPFR) between August 2018 and December 2019. Data on resource utilization and costs were collected via cost diaries and linked administrative data. Clinical data were collected from the AIPFR. A "bottom up" costing methodology was utilized, and the costing was performed from a partial societal perspective focusing primarily on direct medical and non-medical costs. Costs were standardized to 2021 Australian dollars ($).

RESULTS

The average annual total direct costs per person with IPF was $31,655 (95% confidence interval (95% CI): $27,723-$35,757). Extrapolating costs based on prevalence estimates, the total annual costs in Australia are projected to be $299 million (95% CI: $262 million-$338 million). Costs were mainly driven by antifibrotic medication, hospital admissions and medications for comorbidities. Disease severity, comorbidities and antifibrotic medication all had varying impacts on resource utilization and costs.

CONCLUSION

This cost-of-illness study provides the first comprehensive assessment of IPF-related direct costs in Australia, identifies the key cost drivers and provides a framework for future health economic analyses. Additionally, it provided insight into the major cost drivers which include antifibrotic medication, hospital admissions and medications related to comorbidities. Our findings emphasize the importance of the appropriate management of comorbidities in the care of people with IPF as this was one of the main reasons for hospitalizations.

A Comprehensive Landscape of De Novo Malignancy After Double Lung Transplantation

Although the association between post-transplant malignancy (PTM) and immunosuppressive therapy after organ transplantation has been studied, an integrated review of PTM after lung transplantation is lacking. We investigated the incidence and types of de novo PTM and its impact on survival following double lung transplantation (DLT). The incidence and type of PTM as well as the annual and cumulative risks of each malignancy after DLT were analyzed. The overall survival (OS) of recipients with or without PTM was compared by the Kaplan-Meier survival method and landmark analysis. There were 5,629 cases (23.52%) with 27 types of PTMs and incidences and OS varied according to the types of PTMs. The recipients with PTM showed a significantly longer OS than those without PTM (p < 0.001). However, while the recipients with PTM showed significantly better OS at 3, and 5 years (p < 0.001, p = 0.007), it was worse at the 10-year landmark time (p = 0.013). And the single PTM group showed a worse OS rate than the multiple PTM group (p < 0.001). This comprehensive report on PTM following DLT can help understand the risks and timing of PTM to improve the implementation of screening and treatment.

Increasing the accuracy of the asthma diagnosis using an operational definition for asthma and a machine learning method

INTRODUCTION

Analysis of the National Health Insurance data has been actively carried out for the purpose of academic research and establishing scientific evidences for health care service policy in asthma. However, there has been a limitation for the accuracy of the data extracted through conventional operational definition. In this study, we verified the accuracy of conventional operational definition of asthma, by applying it to a real hospital setting. And by using a machine learning technique, we established an appropriate operational definition that predicts asthma more accurately.

METHODS

We extracted asthma patients using the conventional operational definition of asthma at Seoul St. Mary's hospital and St. Paul's hospital at the Catholic University of Korea between January 2017 and January 2018. Among these extracted patients of asthma, 10% of patients were randomly sampled. We verified the accuracy of the conventional operational definition for asthma by matching actual diagnosis through medical chart review. And then we operated machine learning approaches to predict asthma more accurately.

RESULTS

A total of 4,235 patients with asthma were identified using a conventional asthma definition during the study period. Of these, 353 patients were collected. The patients of asthma were 56% of study population, 44% of patients were not asthma. The use of machine learning techniques improved the overall accuracy. The XGBoost prediction model for asthma diagnosis showed an accuracy of 87.1%, an AUC of 93.0%, sensitivity of 82.5%, and specificity of 97.9%. Major explanatory variable were ICS/LABA,LAMA and LTRA for proper diagnosis of asthma.

CONCLUSIONS

The conventional operational definition of asthma has limitation to extract true asthma patients in real world. Therefore, it is necessary to establish an accurate standardized operational definition of asthma. In this study, machine learning approach could be a good option for building a relevant operational definition in research using claims data.

Cognitive decline and risk of dementia in older adults after diagnosis of chronic obstructive pulmonary disease

Cognitive screening has been proposed for older adults diagnosed with chronic obstructive pulmonary disease (COPD). Therefore, we examined the change over time in cognitive function and the risk of incident dementia in older adults after COPD diagnosis. A sample of 3,982 participants from the population-based cohort study Good Aging in Skåne was followed for 19 years, and 317 incident COPD cases were identified. The cognitive domains of episodic memory, executive function, and language were assessed using neuropsychological tests. Mixed models for repeated measures and a Cox model were implemented. Participants performed, on average, worse over time on all neuropsychological tests after COPD diagnosis in comparison to those without COPD, although statistical significance differences were only observed for episodic memory and language. The groups had a comparable risk of developing dementia. In conclusion, our results indicate that cognitive screening in the early stages of COPD may be of limited clinical relevance.

Assessment of health-related quality of life in Australian patients with idiopathic pulmonary fibrosis: a comparison of the EQ-5D-5L and the AQoL-8D

PURPOSE

Idiopathic pulmonary fibrosis (IPF) is a progressive and debilitating chronic lung disease with a high symptom burden, which has a substantial impact on health-related quality of life (HRQoL). Our study aimed to assess the suitability of the EuroQol five-dimension (EQ-5D-5L) and the Assessment of Quality of Life- eight-dimension (AQoL-8D) questionnaires in measuring HRQoL as health state utility values (HSUVs) in an Australian IPF cohort.

METHODS

Data for estimation of health state utility values (HSUVs) were collected from participants of the Australian IPF Registry (AIPFR) using self-administered surveys which included the EQ-5D-5L and the AQoL-8D. Data on lung function and disease specific HRQoL instruments were collected from the AIPFR. Performance of the two instruments was evaluated based on questionnaire practicality, agreement between the two instruments and test performance (internal and construct validity).

RESULTS

Overall completion rates for the EQ-5D-5L and AQoL-8D were 96% and 85%, respectively. Mean (median) HSUVs were 0.65 (0.70) and 0.69 (0.72) for the EQ-5D-5L and AQoL-8D, respectively. There was reasonable agreement between the two instruments based on the Bland-Altman plot mean difference (-0.04) and intraclass correlation coefficient (0.84), however there were some fundamental differences. A larger range of values was observed with the EQ-5D-5L (-0.57-1.00 vs 0.16-1.00). The EQ-5D-5L had a greater divergent sensitivity and efficacy in relation to assessing HSUVs between clinical groupings. The AQoL-8D ,however, had a higher sensitivity to measure psychosocial aspects of HRQoL in IPF.

CONCLUSION

The EQ-5D-5L demonstrated superior performance when compared to AQoL-8D in persons with IPF. This may be attributable to the high symptom burden which is physically debilitating to which the EQ-5D-5L may be more sensitive.

The influence of immortal time bias in observational studies examining associations of antifibrotic therapy with survival in idiopathic pulmonary fibrosis: A simulation study

Background

Immortal time bias (ITB) has been overlooked in idiopathic pulmonary fibrosis (IPF). We aimed to identify the presence of ITB in observational studies examining associations between antifibrotic therapy and survival in patients with IPF and illustrate how ITB may affect effect size estimates of those associations.

Methods

Immortal time bias was identified in observational studies using the ITB Study Assessment Checklist. We used a simulation study to illustrate how ITB may affect effect size estimates of antifibrotic therapy on survival in patients with IPF based on four statistical techniques including time-fixed, exclusion, time-dependent and landmark methods.

Results

Of the 16 included IPF studies, ITB was detected in 14 studies, while there were insufficient data for assessment in two others. Our simulation study showed that use of time-fixed [hazard ratio (HR) 0.55, 95% confidence interval (CI) 0.47-0.64] and exclusion methods (HR 0.79, 95% CI 0.67-0.92) overestimated the effectiveness of antifibrotic therapy on survival in simulated subjects with IPF, in comparison of the time-dependent method (HR 0.93, 95% CI 0.79-1.09). The influence of ITB was mitigated using the 1 year landmark method (HR 0.69, 95% CI 0.58-0.81), compared to the time-fixed method.

Conclusion

The effectiveness of antifibrotic therapy on survival in IPF can be overestimated in observational studies, if ITB is mishandled. This study adds to the evidence for addressing the influence of ITB in IPF and provides several recommendations to minimize ITB. Identifying the presence of ITB should be routinely considered in future IPF studies, with the time-dependent method being an optimal approach to minimize ITB.

Tuberculosis in elderly population: A cross-sectional comparative study

BACKGROUND

Tuberculosis (TB) is a common but neglected infectious disease of global significance. It has a varied presentation in the elderly compared to adults. The present study was conceived to study the resemblances and differences shared in terms of clinical profile, comorbidities, and laboratory investigations by TB in adults and the elderly population.

METHODS

In this cross-sectional study, 68 adults and 72 elderly patients of both genders were enrolled. We collected information on demographics, comorbidities, clinical presentations, and laboratory investigations. The comparison of data between groups was done using the unpaired t-test for continuous variables and the Chi-square test for frequency distribution analysis.

RESULTS

The mean age of the adults and elderly population was 42.13 ± 10.7 years and 68.78 ± 7.62 years, respectively. The elderly TB group demonstrated loss of weight, appetite, the prevalence of comorbid conditions (coronary artery disease, hypertension, and malnutrition), bilateral, predominantly lower lobe, and diffuse involvement of lungs.

CONCLUSION

As the elderly population increases, nonspecific clinical manifestations or laboratory results in this population mandate awareness of these atypical features for effective management of TB in this group.

Incidence, prevalence and mortality of idiopathic pulmonary fibrosis in Australia

BACKGROUND AND OBJECTIVE

Idiopathic pulmonary fibrosis (IPF) is one of the most common forms of interstitial lung diseases. While studies have been conducted in other countries to determine the epidemiological burden of IPF, there is limited information in Australia. Our study aimed to address this gap and generate the first estimates for the mortality, incidence and prevalence of IPF in Australia.

METHODS

Estimates were generated by utilizing the novel Mortality Incidence Analysis Model (MIAMOD) method and software based on the illness-death model. Data inputs included population estimates and mortality data from the Australian Bureau of Statistics (ABS) for the period 1997-2015 and participant data from the Australian IPF Registry (AIPFR). Projections were estimated for a 10-year period up to 2025.

RESULTS

Overall crude and age-standardized estimates for mortality were 5.9 and 6.3 per 100,000 population; incidence, 10.4 and 11.2 per 100,000 population; and prevalence, 32.6 and 35.1 per 100,000 population. Crude and age-standardized mortality, incidence and prevalence increased over the study period; however, they demonstrated a decreasing trend over the projected period. Persons older than 70 years constituted 9% of the population; however, they accounted for approximately 82%-83% of all deaths, incident and prevalent cases. All estimates were higher in males than in females.

CONCLUSION

Our study provides the first estimates for incidence, prevalence and mortality of IPF in Australia. By reporting national estimates for IPF, our study addresses an information gap important for policy, planning and to help optimize the allocation of resources for the management of patients with IPF.

Tuberculosis in the Elderly

The tuberculosis (TB) epidemic is most prevalent in the elderly, and there is a progressive increase in the notification rate with age. Most cases of TB in the elderly are linked to the reactivation of lesions that have remained dormant. The awakening of these lesions is attributable to changes in the immune system related to senescence. The mortality rate from tuberculosis remains higher in elderly patients. Symptoms of active TB are nonspecific and less pronounced in the elderly. Diagnostic difficulties in the elderly are common in many diseases but it is important to use all possible techniques to make a microbiological diagnosis. Recognising frailty to prevent loss of independence is a major challenge in dealing with the therapeutic aspects of elderly patients. Several studies report contrasting data about poorer tolerance of TB drugs in this population. Adherence to antituberculosis treatment is a fundamental issue for the outcome of treatment. Decreased completeness of treatment was shown in older people as well as a higher risk of treatment failure.

Residential Proximity to Biorefinery Sources of Air Pollution and Respiratory Diseases in New York State

Understanding potential health risks associated with biofuel production is critical to sustainably combating energy insecurity and climate change. However, the specific health impacts associated with biorefinery-related emissions are not yet well characterized. We evaluated the relationship between respiratory emergency department (ED) visits (2011-2015) and residential exposure to biorefineries by comparing 15 biorefinery sites to 15 control areas across New York (NY) State. We further examined these associations by biorefinery types (e.g., corn, wood, or soybean), seasons, and lower respiratory disease subtypes. We measured biorefinery exposure using residential proximity in a cross-sectional study and estimation of biorefinery emission via AERMOD-simulated modeling. After controlling for multiple confounders, we consistently found that respiratory ED visit rates among residents living within 10 km of biorefineries were significantly higher (rate ratios (RRs) range from 1.03 to 3.64) than those in control areas across our two types of exposure indices. This relationship held across biorefinery types (higher in corn and soybean biorefineries), seasons (higher in spring and winter), air pollutant types (highest for NO₂), and respiratory subtypes (highest for emphysema). Further research is needed to confirm our findings.

Daily Activities: The Impact of COPD and Cognitive Dysfunction

OBJECTIVE

Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation; however, pulmonary function does not fully account for patients' functional difficulties. The primary aim of the study was to determine the association between several domains of cognition and daily activity among those with COPD.

METHOD

Eighty-nine former smokers completed a neuropsychological battery including measures across multiple domains of cognition, pulmonary function measures, and daily activity questionnaires. Using a cross-sectional design, we compared daily activity between former smokers with and without COPD using two measures (St. George's Respiratory Questionnaire [SGRQ] Activity Subscale and Lawton Instrumental Activities of Daily Living [IADL] Scale) and examined the association between cognition and daily activity among those with COPD.

RESULTS

As expected, former smokers with COPD reported more difficulty than those without COPD on both activity measures (SGRQ Activity Subscale p < .001; Lawton IADL Scale p = .040). Among former smokers with COPD, poorer delayed recall was associated with more difficulty with daily activities (SGRQ Activity Subscale) (p = .038) while adjusting for severity of airflow limitation, exercise tolerance, oxygen use, dyspnea, and symptoms of anxiety and depression.

CONCLUSION

The findings suggest that cognition is associated with daily activity in patients with COPD. Future research should examine whether cognitive interventions may help to maximize patients' engagement in daily activities.

The impact of idiopathic pulmonary fibrosis on health state utility values: evidence from Australia

PURPOSE

Idiopathic pulmonary fibrosis (IPF) is a progressive and universally fatal lung disease, characterised by increasing fibrosis of the lung parenchyma. In this study, we aimed to quantify the health state utility values (HSUVs) for Australians with IPF and to identify the factors affecting these HSUVs.

METHODS

Participants of the Australian IPF Registry (AIPFR), with data on EuroQoL five dimension-five level (EQ-5D-5L) profiles were included. Pulmonary function tests (PFTs) were used to assess disease severity using three IPF -based classification systems. Stepwise multivariable linear regression models assessed the relationship between HSUVs and important demographic and clinical parameters.Query RESULTS: A total of 155 participants provided data for the analysis of HSUVs. For our base case, HSUVs ranged from - 0.57 to 1.00. Mean HSUVs for all participants was 0.65 (95% CI 0.61-0.70). In general, HSUVs decreased with increasing disease severity under all disease severity classification systems. Multivariable linear regression demonstrated a negative association between HSUVs, disease severity and having more than 2 comorbidities.

CONCLUSIONS

Our study has shown that EQ-5D-5L has exhibited discriminatory sensitivity for the study population. We have demonstrated that disease severity and having more than two comorbidities was associated with lower HSUVs in Australians with IPF. Our findings support early diagnosis and appropriate evidence-based treatment to slow or prevent IPF progression; and identification and treatment of associated comorbidities to potentially improve health-related quality of life in people with IPF.

Dysbiosis, malnutrition and enhanced gut-lung axis contribute to age-related respiratory diseases

Older people are at an increased risk of developing respiratory diseases such as chronic obstructive pulmonary diseases, asthma, idiopathic pulmonary fibrosis or lung infections. Susceptibility to these diseases is partly due to the intrinsic ageing process, characterized by genomic, cellular and metabolic hallmarks and immunosenescence, and is associated with changes in the intestinal microbiota. Importantly, in the lungs, ageing is also associated with a dysbiosis and loss of resilience of the resident microbiota and alterations of the gut-lung axis. Notably, as malnutrition is often observed in the elderly, nutrition is one of the most accessible modifiable factors affecting both senescence and microbiota. This article reviews the changes affecting the lung and its resident microbiota during ageing, as well as the interconnections between malnutrition, senescence, microbiota, gut-lung axis and respiratory health. As the communication along the gut-lung axis becomes more permissive with ageing, this review also explores the evidence that the gut and lung microbiota are key players in the maintenance of healthy lungs, and as such, are potential targets for nutrition-based preventive strategies against lung disease in elderly populations.

Drought effects on specific-cause mortality in Lisbon from 1983 to 2016: Risks assessment by gender and age groups

Portugal (Southwestern Europe) experiences a high incidence of dry hazards such as drought, a phenomenon that entails a notable burden of morbidity and mortality worldwide. For the first time in the Lisbon district, a time-series study was conducted to evaluate the impact of drought measured by the Standardised Precipitation Index (SPI) and Standardised Precipitation-Evapotranspiration Index (SPEI) on the daily natural, circulatory, and respiratory mortality from 1983 to 2016. An assessment by gender and adult age population groups (45-64, 65-74, ≥75 years old) was included. To estimate the relative risks and attributable risks, generalised linear models with a Poisson link were used. Additionally, the influence of heatwaves and atmospheric pollution for the period from 2007 to 2016 (available period for pollution data) was considered. The main findings indicate statistically significant associations between drought conditions and all analysed causes of mortality. Moreover, SPEI shows an improved capability to reflect the different risks. People in the 45-64 year-old group did not indicate any significant influence in any of the cases, whereas the oldest groups had the highest risk. The drought effects on mortality among the population varied across the different study periods, and in general, the men population was affected more than the women population (except for the SPEI and circulatory mortality during the long study period). The short-term influence of droughts on mortality could be explained primarily by the effect of heatwaves and pollution; however, when both gender and age were considered in the Poisson models, the effect of drought also remained statistically significant when all climatic phenomena were included for specific groups of the total population and men. This type of study facilitates a better understanding of the population at risk and allows the development of more effective measures to mitigate the drought effects on the population.

Health-related quality of life of patients with idiopathic pulmonary fibrosis: a systematic review and meta-analysis

Idiopathic pulmonary fibrosis (IPF) is one of the most common forms of interstitial lung disease presenting in persons 50 years and older. Through a comprehensive review of available studies, we aimed to assess health-related quality of life (HRQoL) of people living with IPF and the instruments used in this assessment.Searches were conducted up to May, 2020. Quality appraisal and data extraction were performed using pre-designed forms. Narrative synthesis approach was used to report results of the systematic review and a random effects model was used for the meta-analysis. A leave-one-out sensitivity analysis was performed, and a trim and fill method was used to assess publication bias.The review included 134 studies. The most used instruments to measure HRQoL were St George's Respiratory Questionnaire (SGRQ), Short Form 36 (SF36) and EuroQoL (EQ5D). Standardised mean scores (95% confidence interval) for these instruments were as follows: SGRQ total score: 44.72 (42.21-47.22); SF36 physical component score (PCS): 37.00 (34.74-39.26) SF36 mental component score (MCS): 50.18 (48.41-51.95); King's Brief Interstitial Lung Disease questionnaire total score: 58.38 (55.26-61.51); and EQ5D utility: 0.73 (0.68-0.79). Analysis of standardised means for both SGRQ and SF36 demonstrated worse scores in physical health domains as compared to mental health domains.This systematic review confirms that IPF negatively affected HRQoL, mostly impacting the physical health domains. This study also demonstrated that a diverse number of instruments are used to evaluate HRQoL. In view of this diversity, a standardised approach to measurement of HRQoL for IPF is important to ensure that comparisons made are reliable.

Long-term safety of tiotropium/olodaterol in older patients with moderate-to-very-severe COPD in the TONADO® studies

Older patients with chronic obstructive pulmonary disease (COPD) may be at increased risk of adverse events (AEs) due to decreased protective organ function and increased comorbidities. TONADO® 1 + 2 were replicate, randomized, double-blind, parallel-group, 52-week, Phase III trials comparing the efficacy and safety of tiotropium/olodaterol (5/5 µg) versus the monocomponents via the Respimat® inhaler in patients with moderate-to-very-severe COPD. In this prespecified safety analysis, patients were grouped by age. Of 3100 patients, 1585 (51.1%) were aged <65 years, 1198 (38.7%) 65-<75 years, 309 (10.0%) 75-<85 years, and eight (0.3%) ≥85 years. At baseline, 23.4% had a pre-existing cardiac disorder, 45.6% had hypertension, and 13.3% had glucose metabolism disorders, including diagnosed diabetes. Overall, there was no increase in major adverse cardiac events, other AEs, or serious AEs with tiotropium/olodaterol versus the monocomponents in any age group, supporting the safety of tiotropium/olodaterol in older patients with COPD.

Effects of a Comprehensive Care Program on the Readmission Rate and Adherence to Treatment in Elderly Patients with Chronic Obstructive Pulmonary Disease

BACKGROUND

The low treatment adherence of patients with chronic obstructive pulmonary disease (COPD) leads to the exacerbation of their symptoms and readmission. Comprehensive care programs are among interventions that can improve the patients' adherence to treatment and prevent readmission. The present study aimed to evaluate the effects of a comprehensive care program on the adherence to treatment and readmission of COPD patients.

MATERIALS AND METHODS

This randomized clinical trial was performed in a hospital in Rafsanjan, Iran, in 2017. Sixty elderly patients with COPD were randomly enrolled in this study by pair-matching. The intervention group participated in a comprehensive care program, whereas the control group received routine care. The readmission rate and adherence to treatment were measured at one-, three-, and six-month intervals. To evaluate the patients' adherence to treatment, an adherence-to-treatment questionnaire for chronic diseases was used. Data were analyzed using Chi-square test, independent t-test, and repeated measures ANOVA at a significance level of 0.05.

RESULTS

A significant difference was observed between the two groups in terms of readmission at the end of the study (P=0.03). In the intervention group, the mean level of adherence to treatment and its subscales improved as compared to the control group, and there was a significant difference between the two groups.

CONCLUSION

Although most of the patients in this study were old, with a rather low educational level and socioeconomic status, the care program could improve their treatment adherence and reduce the readmission rate.

Why COVID-19 Transmission Is More Efficient and Aggressive Than Viral Transmission in Previous Coronavirus Epidemics?

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is causing a pandemic of coronavirus disease 2019 (COVID-19). The worldwide transmission of COVID-19 from human to human is spreading like wildfire, affecting almost every country in the world. In the past 100 years, the globe did not face a microbial pandemic similar in scale to COVID-19. Taken together, both previous outbreaks of other members of the coronavirus family (severe acute respiratory syndrome (SARS-CoV) and middle east respiratory syndrome (MERS-CoV)) did not produce even 1% of the global harm already inflicted by COVID-19. There are also four other CoVs capable of infecting humans (HCoVs), which circulate continuously in the human population, but their phenotypes are generally mild, and these HCoVs received relatively little attention. These dramatic differences between infection with HCoVs, SARS-CoV, MERS-CoV, and SARS-CoV-2 raise many questions, such as: Why is COVID-19 transmitted so quickly? Is it due to some specific features of the viral structure? Are there some specific human (host) factors? Are there some environmental factors? The aim of this review is to collect and concisely summarize the possible and logical answers to these questions.

National trends in palliative care use among older adults with cardiopulmonary and malignant conditions

BACKGROUND

Palliative care consultation (PCC) is recommended for older adults hospitalized with cardiopulmonary conditions, but frequently is reserved for patients with malignant conditions and those with advanced age.

OBJECTIVES

To compare age-adjusted PCC trends and the relationship between increasing age and PCC among older adults with cardiopulmonary and malignant conditions.

METHODS

Observational analysis of patients age ≥ 65 years, stratified by age and cardiopulmonary (heart failure, chronic obstructive pulmonary disease) vs. malignant (lung and gastrointestinal) conditions. Age-adjusted PCC trends over time and compound annual growth rates (CAGR) were compared.

RESULTS

Discharges with cardiopulmonary vs. malignant conditions were older, more likely to be female, and white. Relative to malignant conditions, discharges with cardiopulmonary conditions had lower age-adjusted PCC rates but higher CAGRS. Increasing age was associated with PCC in both groups but had a stronger effect among cardiopulmonary conditions.

CONCLUSIONS

Older adults with cardiopulmonary conditions experienced lower rates of PCC, but higher rates of growth over time relative to those with malignant conditions.

Vascular Niche in Lung Alveolar Development, Homeostasis, and Regeneration

Endothelial cells (ECs) constitute small capillary blood vessels and contribute to delivery of nutrients, oxygen and cellular components to the local tissues, as well as to removal of carbon dioxide and waste products from the tissues. Besides these fundamental functions, accumulating evidence indicates that capillary ECs form the vascular niche. In the vascular niche, ECs reciprocally crosstalk with resident cells such as epithelial cells, mesenchymal cells, and immune cells to regulate development, homeostasis, and regeneration in various organs. Capillary ECs supply paracrine factors, called angiocrine factors, to the adjacent cells in the niche and orchestrate these processes. Although the vascular niche is anatomically and functionally well-characterized in several organs such as bone marrow and neurons, the effects of endothelial signals on other resident cells and anatomy of the vascular niche in the lung have not been well-explored. This review discusses the role of alveolar capillary ECs in the vascular niche during development, homeostasis and regeneration.

Neutrophil phenotypes in chronic lung disease

Introduction: Neutrophils are the most abundant inflammatory cells in the lungs of patients with chronic lung diseases, especially COPD, yet despite this, patients often experience repeated chest infections. Neutrophil function may be altered in disease, but the reasons are unclear. In chronic disease, sequential pro-inflammatory and pro-repair responses appear distorted. As understanding of neutrophil heterogeneity has expanded, it is suggested that different neutrophil phenotypes may impact on health and disease. Areas covered: In this review, the definition of cellular phenotype, the implication of neutrophil surface markers and functions in chronic lung disease and the complex influences of external, local and genetic factors on these changes are discussed. Literature was accessed up to the 19 July 2019 using: PubMed, US National Library of Medicine National Institutes of Health and the National Centre for Biotechnology Information. Expert opinion: As more is learned about neutrophils, the further we step from the classical view of neutrophils being unrefined killing machines to highly complex and finely tuned cells. Future therapeutics may aim to normalize neutrophil function, but to achieve this, knowledge of phenotypes in humans and how these relate to observed pathology and disease processes is required.

Pharmacokinetics of salvianolic acid B, rosmarinic acid and Danshensu in rat after pulmonary administration of Salvia miltiorrhiza polyphenolic acid solution

A sensitive and accurate LC-MS/MS method was established for quantifying salvianolic acid B (Sal B), rosmarinic acid (Ros A) and Danshensu (DA) in rat plasma. Salvia miltiorrhiza polyphenolic acid (SMPA), active water-soluble ingredients isolated and purified from Salvia miltiorrhiza Bge included Sal B, Ros A and DA. The pharmacokinetic analysis of Sal B, Ros A and DA after pulmonary administration of SMPA solution to rat was performed by LC-MS/MS. Results from the pharmacokinetic studies showed that the peak concentration of DA was 21.85 ± 6.43 and 65.39 ± 3.83 ng/mL after pulmonary and intravenous administration, respectively. DA was not detected at 2 h after administration. The absolute bioavailabilities of Sal B and Ros A were respectively 50.37 ± 27.04 and 89.63 ± 12.16% after pulmonary administration of 10 mg/kg SMPA solution in rats. The absolute bioavailability of Sal B increased at least 10-fold after pulmonary administration, compared with oral administration. It was concluded that the newly established LC-MS/MS method was suitable for describing the pharmacokinetic characteristics of Sal B, Ros A and DA in rat after pulmonary administration of SMPA solution. The data from this study will provide a preclinical insight into the feasibility of pulmonary administration of SMPA.

Evaluating the extremely elderly at a pulmonary function clinic for the diagnosis of respiratory disease: frequency and technical quality of spirometry

OBJECTIVE

To determine the frequency of spirometry in elderly people, by age group, at a pulmonary function clinic, to assess the quality of spirometry in the extremely elderly, and to determine whether chronological age influences the quality of spirometry.

METHODS

This was a cross-sectional retrospective study evaluating information (spirometry findings and respiratory questionnaire results) obtained from the database of a pulmonary function clinic in the city of Aracaju, Brazil, for the period from January of 2012 to April of 2017. In the sample as a whole, we determined the total number of spirometry tests performed, and the frequency of the tests in individuals ≥ 60 years of age, ≥ 65 years of age, and by decade of age, from age 60 onward. In the extremely elderly, we evaluated the quality of spirometry using criteria of acceptability and reproducibility, as well as examining the variables that can influence that quality, such a cognitive deficit.

RESULTS

The sample comprised a total of 4,126 spirometry tests. Of those, 961 (23.30%), 864 (20.94%), 102 (2.47%), and 26 (0.63%) were performed in individuals ≥ 60, ≥ 65, ≥ 86, and ≥ 90 years of age (defined as extreme old age), respectively. In the extremely elderly, the criteria for acceptability and reproducibility were met in 88% and 60% of the spirometry tests (95% CI: 75.26-100.00 and 40.80-79.20), respectively. The cognitive deficit had a negative effect on acceptability and reproducibility (p ≤ 0.015 and p ≤ 0.007, respectively).

CONCLUSIONS

A significant number of elderly individuals undergo spirometry, especially at ≥ 85 years of age, and the majority of such individuals are able to perform the test in a satisfactory manner, despite their advanced age. However, a cognitive deficit could have a negative effect on the quality of spirometry.

Is aging a "comorbidity" of asthma?

The aging population is growing at an unparalleled rate. Asthma is common in the elderly (age over 65 years) and can be more severe with little chance for remission. Asthma in older individuals is often under-diagnosed, misdiagnosed and frequently under-treated. Concomitant medical and psychosocial conditions are more prevalent in the elderly and can obfuscate the presentation of asthma and make it more difficult to assess and manage. While these comorbidities are important in understanding elderly asthma, aging itself can be considered a "comorbidity" since it impacts structural and functional changes in the lung. Structural changes of the aging lung may worsen physiologic function in asthma. The immune system also changes with age, with increased vulnerability to pathogens and differences in airway inflammation, leading to variability in how asthma manifests and responds to treatment. The fact that aging can influence the severity and presentation of asthma along with its diagnosis and management is important for the treating physician to understand. This article will discuss the multitude of factors that justify considering aging as a comorbidity of asthma.

Efficacy of Umeclidinium/Vilanterol in Elderly Patients with COPD: A Pooled Analysis of Randomized Controlled Trials

OBJECTIVE

The aim of this pooled analysis was to assess the efficacy and safety of umeclidinium/vilanterol (UMEC/VI) 62.5/25 µg dual bronchodilation versus placebo in elderly symptomatic patients with chronic obstructive pulmonary disease (COPD).

METHODS

We conducted a post hoc pooled analysis of data from 10 randomized controlled trials (RCTs). Change from baseline (CFB) in trough forced expiratory volume in 1 s (FEV1), proportion of FEV1 responders (≥ 100-mL increase from baseline), and safety were analyzed in patients aged < 65, ≥ 65, and ≥ 75 years on Days 28, 56, and 84 (12-week analysis of parallel-group design studies), Days 28, 56, 84, 112, 140, 168, and 169 (24-week analysis of parallel-group design studies), and Days 2, 42, and 84 (12-week analysis of crossover design studies).

RESULTS

The UMEC/VI intent-to-treat (ITT) populations comprised 2246, 1296, and 472 patients in the 12-week parallel-group, 24-week parallel-group, and 12-week crossover analysis, respectively (≥ 65 years: 36-44%; ≥ 75 years: 7-11%). The placebo ITT populations comprised 528, 280, and 505 patients, respectively (≥ 65 years: 37-41%; ≥ 75 years: 5-11%). Significant improvements in trough FEV1 and significantly greater proportions of FEV1 responders were seen with UMEC/VI compared with placebo in all analyses regardless of patient age or timepoint considered (p ≤ 0.023), except Day 84 trough FEV1 CFB in the 12-week crossover analysis in patients aged ≥ 75 years (p = 0.064). UMEC/VI safety profile was similar to placebo in all age groups.

CONCLUSIONS

In this pooled analysis of RCT data, once-daily UMEC/VI was well tolerated and provided clinically significant lung function benefits compared with placebo in younger and older patients with COPD.

FUNDING

GlaxoSmithKline (study 208125).

Tuberculosis in the elderly: Why inflammation matters

Growing old is associated with an increase in the basal inflammatory state of an individual and susceptibility to many diseases, including infectious diseases. Evidence is growing to support the concept that inflammation and disease susceptibility in the elderly is linked. Our studies focus on the infectious disease tuberculosis (TB), which is caused by Mycobacterium tuberculosis (M.tb), a pathogen that infects approximately one fourth of the world's population. Aging is a major risk factor for developing TB, and inflammation has been strongly implicated. In this review we will discuss the relationship between inflammation in the lung and susceptibility to develop and succumb to TB in old age. Further understanding of the relationship between inflammation, age, and M.tb will lead to informed decisions about TB prevention and treatment strategies that are uniquely designed for the elderly.

PARP-1 inhibition ameliorates elastase induced lung inflammation and emphysema in mice

COPD is associated with high morbidity and mortality and no effective treatment is available till date. We have previously reported that PARP-1 plays an important role in the establishment of airway inflammation associated with asthma and ALI. In the present work, we have evaluated the beneficial effects of PARP-1 inhibition on COPD pathogenesis utilizing elastase induced mouse model of the disease. Our data show that PARP-1 inhibition by olaparib significantly reduced the elastase-induced recruitment of inflammatory cells particularly neutrophils in the lungs of mice when administered at a dose of 5 mg/kg b.wt (i.p.). Reduction in the lung inflammation was associated with suppressed myeloperoxidase activity. Further, the drug restored the redox status in the lung tissues towards normal as reflected by the levels of ROS, GSH and MDA. Olaparib administration prior to elastase instillation blunted the phosphorylation of P65-NF-κB at Ser 536 without altering phosphorylation of its inhibitor IκBα in the lungs. Furthermore, olaparib down regulated the elastase-induced expression of NF-κB dependent pro-inflammatory cytokines (TNF-A, IL-6), chemokine (MIP-2) and growth factor (GCSF) severely both at the mRNA and protein levels. Additionally, PARP-1 heterozygosity suppressed the recruitment of inflammatory cells and production of TNF-A, IL-6, MIP-2 and GCSF in the BALF to the similar extent as exhibited by olaparib administration. Finally, PARP-1 inhibition by olaparib or gene deletion protected against elastase-induced emphysema markedly. Overall, our data strongly suggest that PARP-1 plays a critical role in elastase induced lung inflammation and emphysema, and thus may be a new drug target candidate in COPD.

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.

Palliative and End-of-Life Care for Patients with Malignancy

Patients with cancer continue to have unmet palliative care needs. Concurrent palliative care is tailored to the needs of patients as well as their families to relieve suffering. Specialty palliative care referral is associated with improved symptom management, improved end-of-life quality, and higher family-rated satisfaction. Optimal timing for palliative care referral has not been determined. Barriers to palliative care referral include workforce limitations, provider attitudes and perceptions, and potential ethnic and racial disparities in access to palliative care. Future work should focus on novel, patient-centered approaches to identify and address unmet palliative care needs for patients living with cancer.

Unfavorable clinical implications of peripheral blood CD44+ and CD54+ lymphocytes in patients with lung cancer undergoing chemotherapy

BACKGROUND

There is an unmet need for identification of additional prognostic markers for lung cancer. The aim of this study was to identify novel clinical and immunological predictors of prognosis in lung cancer patients.

METHODS

Lymphocyte subsets CD3+, CD4+, CD8+, CD4+/8+, CD25+, CD69+, CD44+ and CD54+ were quantified in peripheral blood using flow cytometry, for 203 newly diagnosed lung cancer patients and 120 healthy controls.

RESULTS

The levels of CD3+, CD4+, CD8+, CD4+/CD8+ and CD69+ lymphocytes were significantly lower in patients with lung cancer compared with the healthy control group, while CD54+ and CD44+ lymphocytes were significantly higher. In stage III/IV patients with lymph node metastasis or distant metastasis, the levels of CD44+ and CD54+ lymphocytes were significantly increased compared with patients with stage I/II disease (p<0.05). The levels of CD44+ and CD54+ lymphocytes markedly reduced after chemotherapy, and follow-up analysis indicated that patients found without increase of CD44+ and CD54+ lymphocytes after chemotherapy had survival advantages. Independent predictors of survival in lung cancer patients included clinical stage (hazard ratio [HR] = 2.791; 95% confidence interval [95% CI], 1.42-3.54, p<0.001), CD44+ lymphocytes (HR = 1.282; 95% CI, 1.02-1.49, p = 0.002) and CD54+ lymphocytes (HR = 1.475; 95% CI, 1.22-1.73, p = 0.003). Elevated levels of CD44+ and CD54+ lymphocytes correlated with poor prognosis in lung cancer patients.

CONCLUSIONS

Peripheral blood lymphocyte subsets in patients with lung cancer are different from those in healthy people, and circulating CD44+ and CD54+ lymphocytes seem to be a promising criterion to predict survival in lung cancer patients undergoing chemotherapy.

Association of anxiety sensitivity-physical concerns and FVC with dyspnea severity in sarcoidosis

OBJECTIVE

The purpose of the study was to evaluate the relationship of an objective functional lung parameter (FVC) and a subjective psychological factor (physical symptom concerns) with dyspnea in sarcoidosis. Dyspnea constitutes one of the most common and burdensome symptoms in sarcoidosis, yet little is known about its mechanisms and, in particular, psychological.

METHOD

A total of 107 hospitalized sarcoidosis patients (Female=50, M_age=45.3years) volunteered to take part in the correlational research study. Participants underwent spirometry and completed the MRC Dyspnea Scale and the Anxiety Sensitivity Index-3 (ASI) questionnaire. Linear hierarchical regression analysis was used to determine the relationship between the studied predictors and dyspnea severity.

RESULTS

The best fitting model predicted 18% of variance in dyspnea severity. Physical symptom concerns subscale of ASI (β=0.24) and FVC (β=-0.23) were significantly related to dyspnea MRC severity, but only physical concerns remained significantly related to dyspnea when both predictors were in the model.

CONCLUSIONS

The current results suggest that both psychological and physiological factors should be taken into account when explaining subjective dyspnea severity in sarcoidosis. More specifically, these findings call for including cognitive vulnerability factors related to anxiety (physical symptom concerns) into the diagnostic procedures and management of dyspnea in sarcoidosis.

Phenotypes of comorbidity in OSAS patients: combining categorical principal component analysis with cluster analysis

Phenotyping obstructive sleep apnea syndrome's comorbidity has been attempted for the first time only recently. The aim of our study was to determine phenotypes of comorbidity in obstructive sleep apnea syndrome patients employing a data-driven approach. Data from 1472 consecutive patient records were recovered from our hospital's database. Categorical principal component analysis and two-step clustering were employed to detect distinct clusters in the data. Univariate comparisons between clusters included one-way analysis of variance with Bonferroni correction and chi-square tests. Predictors of pairwise cluster membership were determined via a binary logistic regression model. The analyses revealed six distinct clusters: A, 'healthy, reporting sleeping related symptoms'; B, 'mild obstructive sleep apnea syndrome without significant comorbidities'; C1: 'moderate obstructive sleep apnea syndrome, obesity, without significant comorbidities'; C2: 'moderate obstructive sleep apnea syndrome with severe comorbidity, obesity and the exclusive inclusion of stroke'; D1: 'severe obstructive sleep apnea syndrome and obesity without comorbidity and a 33.8% prevalence of hypertension'; and D2: 'severe obstructive sleep apnea syndrome with severe comorbidities, along with the highest Epworth Sleepiness Scale score and highest body mass index'. Clusters differed significantly in apnea-hypopnea index, oxygen desaturation index; arousal index; age, body mass index, minimum oxygen saturation and daytime oxygen saturation (one-way analysis of variance P < 0.0001). Binary logistic regression indicated that older age, greater body mass index, lower daytime oxygen saturation and hypertension were associated independently with an increased risk of belonging in a comorbid cluster. Six distinct phenotypes of obstructive sleep apnea syndrome and its comorbidities were identified. Mapping the heterogeneity of the obstructive sleep apnea syndrome may help the early identification of at-risk groups. Finally, determining predictors of comorbidity for the moderate and severe strata of these phenotypes implies a need to take these factors into account when considering obstructive sleep apnea syndrome treatment options.

DNA methylation age of blood predicts future onset of lung cancer in the women's health initiative

Lung cancer is considered an age-associated disease, whose progression is in part due to accumulation of genomic instability as well as age-related decline in system integrity and function. Thus even among individuals exposed to high levels of genotoxic carcinogens, such as those found in cigarette smoke, lung cancer susceptibility may vary as a function of individual differences in the rate of biological aging. We recently developed a highly accurate candidate biomarker of aging based on DNA methylation (DNAm) levels, which may prove useful in assessing risk of aging-related diseases, such as lung cancer. Using data on 2,029 females from the Women's Health Initiative, we examined whether baseline measures of “intrinsic epigenetic age acceleration” (IEAA) predicted subsequent lung cancer incidence. We observed 43 lung cancer cases over the nearly twenty years of follow-up. Results showed that standardized measures of IEAA were significantly associated with lung cancer incidence (HR: 1.50, P = 3.4×10⁻³). Furthermore, stratified Cox proportional hazard models suggested that the association may be even stronger among older individuals (70 years or above) or those who are current smokers. Overall, our results suggest that IEAA may be a useful biomarker for evaluating lung cancer susceptibility from a biological aging perspective.

The role of respiratory viruses in the etiology of bacterial pneumonia: An ecological perspective

Pneumonia is the leading cause of death among children less than 5 years old worldwide. A wide range of viral, bacterial and fungal agents can cause pneumonia: although viruses are the most common etiologic agent, the severity of clinical symptoms associated with bacterial pneumonia and increasing antibiotic resistance makes bacterial pneumonia a major public health concern. Bacterial pneumonia can follow upper respiratory viral infection and complicate lower respiratory viral infection. Secondary bacterial pneumonia is a major cause of influenza-related deaths. In this review, we evaluate the following hypotheses: (i) respiratory viruses influence the etiology of pneumonia by altering bacterial community structure in the upper respiratory tract (URT) and (ii) respiratory viruses promote or inhibit colonization of the lower respiratory tract (LRT) by certain bacterial species residing in the URT. We conducted a systematic review of the literature to examine temporal associations between respiratory viruses and bacteria and a targeted review to identify potential mechanisms of interactions. We conclude that viruses both alter the bacterial community in the URT and promote bacterial colonization of the LRT. However, it is uncertain whether changes in the URT bacterial community play a substantial role in pneumonia etiology. The exception is Streptococcus pneumoniae where a strong link between viral co-infection, increased carriage and pneumococcal pneumonia has been established.

New Swallowing Evaluation Using Piezoelectricity in Normal Individuals

This study aimed to elucidate the relationship between the piezoelectric waveform latency, hyoid bone movement, surface electromyogram (sEMG), and the pharyngeal transit time (PTT) during swallowing. Forty-one healthy subjects were divided into three age groups: younger (20-39 years, n = 8), middle-aged (40-59 years, n = 9), and older (60-79 years, n = 24). Motion analysis of the hyoid bone using videofluorography (VF), waveform analysis of the front neck using piezoelectric films, and sEMG of the suprahyoid muscle group were performed simultaneously. Latencies of the three movement phases were defined as upward (VFS1), forward (VFS2), and returning to starting position (VFS3). The three phases of the piezoelectric waveform-from wave initiation of the negative wave to the start of the second deep negative wave; from the start of the second deep negative wave to the start of the last positive wave (SLPW); and from the SLPW to the end of the last positive wave-were defined as PS1, PS2, and PS3, respectively. VFS1-3 and PS1-3 were significantly correlated. VFS1 and PS1 latencies were significantly longer with thick liquid than with thin liquid. VFS2, PS1, and PS2 latencies were longer in the older group than in the other two groups. The start of PS1 was nearly equal to those of sEMG and VFS1. Bolus arrival time in the valleculae was statistically equal to the end of the PS1 with both thin and thick liquids. To establish the swallowing screening using Piezoelectric film, further investigation is necessary in the dysphagia patients.

Risk of Frailty in Elderly With COPD: A Population-Based Study

BACKGROUND

Despite frailty being an important geriatric syndrome, its prevalence and associated mortality risk in older patients with chronic obstructive pulmonary disease (COPD) are unknown.

METHODS

We examined the relationship between COPD confirmed by spirometry, COPD severity, and frailty defined by the Fried criteria within 2,142 participants (aged 74.7 ± 5.6 years) of the Rotterdam Study, a prospective population-based cohort study.

RESULTS

The frailty prevalence was significantly higher (p < .001) in participants with COPD (10.2%, 95% CI: 7.6%-13.5%) compared with participants without COPD (3.4%, 95% CI: 2.6%-4.4%). Adjusted for age, sex, smoking, corticosteroids, and other confounders, participants with COPD had a more than twofold increased prevalence of frailty (odds ratio 2.2, 95% CI: 1.34-3.54, p = .002). The prevalence was highest when severe airflow limitation, dyspnea, and frequent exacerbations were present. Participants with mild airflow limitation were more frequently prefrail. COPD elderly who were frail had significant worse survival.

CONCLUSIONS

This population-based cohort study in elderly demonstrates that COPD is associated with frailty even after adjusting for shared risk factors. Our findings suggest that frailty-in addition to COPD severity and comorbidities-identifies those COPD participants at high risk of mortality.

CCNB2 overexpression is a poor prognostic biomarker in Chinese NSCLC patients

Cyclin B2 (CCNB2), a member of cyclin family proteins, serves a key role in progression of G2/M transition. The clinical value of CCNB2 in non-small cell lung cancer is still unknown. The aim of our study is to identify the role of CCNB2 in NSCLC patients. The status of CCNB2 in NSCLC tissues and normal lung tissues was observed in Gene Expression Omnibus (GEO: GSE19804). CCNB2 mRNA and protein expressions were detected in NSCLC and normal lung tissues by using Real-time PCR and immunohistochemistry. The association of CCNB protein expression with clinical characteristics of 186 NSCLC patients was analyzed by immunohistochemistry. Based on microarray data (GEO: GSE19804), we observed that CCNB2 was significantly overexpressed in NSCLC tissues compared with paired adjacent normal lung tissue. Furthermore, we verified mRNA and protein levels of CCNB2 expression were both increased in NSCLC tissues. We found high levels of CCNB2 protein were positively associated with the status of differentiated degree, tumor size, lymph node metastasis, distant metastasis, and clinical stage. Meanwhile, CCNB2 protein overexpression was an independent unfavorable prognostic factor for the overall survival of patients with NSCLC. In conclusion, overexpression of CCNB2 protein is associated with clinical progression and poor prognosis in NSCLC.

Bronchoscopy-Guided Cooled Radiofrequency Ablation as a Novel Intervention Therapy for Peripheral Lung Cancer

BACKGROUND

Our previous animal and preliminary human studies indicated that bronchoscopy-guided cooled radiofrequency ablation (RFA) for the lung is a safe and feasible procedure without major complications.

OBJECTIVES

The present study was performed to evaluate the safety, effectiveness and feasibility of computed tomography (CT)-guided bronchoscopy cooled RFA in patients with medically inoperable non-small-cell lung cancer (NSCLC).

METHODS

Patients with pathologically diagnosed NSCLC, who had no lymph node involvement or distant metastases (T1-2aN0M0) but were not surgical candidates because of comorbidities (e.g., synchronous multiple nodules, advanced age, cardiovascular disease, poor pulmonary function, etc.) were enrolled in the present study. The diagnosis and location between the nearest bronchus and target tumor were made by CT-guided bronchoscopy before the treatment. A total of 28 bronchoscopy-guided cooled RFA procedures were performed in 20 patients. After treatment, serial CT imaging was performed as follow-up.

RESULTS

Eleven lesions showed significant reductions in tumor size and 8 lesions showed stability, resulting in a local control rate of 82.6%. The median progression-free survival was 35 months (95% confidence interval: 22-45 months), and the 5-year overall survival was 61.5% (95% confidence interval: 36-87%). Three patients developed an acute ablation-related reaction (fever, chest pain) and required hospitalization but improved with conservative treatment. There were no other adverse events in the present study.

CONCLUSIONS

CT-guided bronchoscopy cooled RFA is applicable for only highly selected subjects; however, our trial may be an alternative strategy, especially for disease local control in medically inoperable patients with stage I NSCLC.

Asthma control and cognitive function in a cohort of elderly adults

OBJECTIVES

To determine whether poor asthma control is associated with cognitive impairment in a cohort of older, inner-city adults with asthma.

DESIGN

Prospective observational cohort study.

SETTING

Outpatient practices in New York City and Chicago.

PARTICIPANTS

Individuals aged 60 and older with a physician diagnosis of asthma and without chronic obstructive pulmonary disease or a smoking history of 10 pack-years or more (N = 452).

MEASUREMENTS

Cognitive assessments that included processing speed (pattern comparison, Trail-Making Test Part A), executive function (Trail-Making Test Part B), attention and working memory (letter number sequencing), immediate and delayed recall (Wechsler Memory Scale Story A), word fluency (animal naming), and global cognitive function (Mini-Mental State Examination) were administered. Asthma control was measured using the Asthma Control Questionnaire (ACQ) and airway obstruction using spirometry as the predicted forced expiratory volume at 1 second (FEV1) of less than 70%. Cognitive measures were modeled in linear and logistic regression models controlling for age, race, education, English proficiency, and income.

RESULTS

Participants had a mean age of 68; 41% had poor asthma control according to the ACQ, and 35% had FEV1 of less than 70%. Poor asthma control and FEV1 less than 70% were significantly associated with all measures of cognitive function in univariate analyses, although these associations lost their statistical significance after adjusting for age, education, English proficiency, and other covariates. The same pattern was observed when the outcomes were below-normal performance on the cognitive measures based on normative data.

CONCLUSION

Poor asthma control and airway obstruction are not associated with poor performance on various measures of cognitive function in older adults with asthma.

Multiple logistic regression analysis of risk factors in elderly pneumonia patients: QTc interval prolongation as a prognostic factor

Background

Acute pneumonia is a serious problem in the elderly and various risk factors have already been reported, but the involvement of QTc interval prolongation remains uncertain. The aim of this study was to elucidate the prognostic factors for the development of pneumonia in elderly patients and to study the possible involvement of QTc interval prolongation.

Methods

The subjects were 249 hospitalized pneumonia patients more than 65 years old in Aki-Ohta Hospital from January 2010 to December 2013. Community-acquired pneumonia patients and nursing care and healthcare-associated pneumonia patients were included in the study. The pneumonia severity index, vital signs, blood chemistry data and ECG findings were retrospectively compared using multiple logistic regression analysis.

Results

39 patients died within 30 days from onset. The clinical features related to poor prognosis were: advanced age, past history of cerebral vascular disease and/or diabetes mellitus, decreased serum albumin level, higher CURB-65 or PORT index scores and QTc interval prolongation. Patients showing a prolonged QTc interval had a higher mortality than those with a normal QTc interval. A prolonged QTc interval was not related to serum calcium concentration and/or treatment with QTc prolongation drug, clarithromycin or azithromycin, but related to age, lower albumin concentration and past history of diabetes mellitus.

Conclusions

These findings suggest potential prognostic factors for pneumonia in elderly patients, including a prolonged QTc interval (> 0.44 seconds).

The burden of disease in older people and implications for health policy and practice

23% of the total global burden of disease is attributable to disorders in people aged 60 years and older. Although the proportion of the burden arising from older people (≥60 years) is highest in high-income regions, disability-adjusted life years (DALYs) per head are 40% higher in low-income and middle-income regions, accounted for by the increased burden per head of population arising from cardiovascular diseases, and sensory, respiratory, and infectious disorders. The leading contributors to disease burden in older people are cardiovascular diseases (30·3% of the total burden in people aged 60 years and older), malignant neoplasms (15·1%), chronic respiratory diseases (9·5%), musculoskeletal diseases (7·5%), and neurological and mental disorders (6·6%). A substantial and increased proportion of morbidity and mortality due to chronic disease occurs in older people. Primary prevention in adults aged younger than 60 years will improve health in successive cohorts of older people, but much of the potential to reduce disease burden will come from more effective primary, secondary, and tertiary prevention targeting older people. Obstacles include misplaced global health priorities, ageism, the poor preparedness of health systems to deliver age-appropriate care for chronic diseases, and the complexity of integrating care for complex multimorbidities. Although population ageing is driving the worldwide epidemic of chronic diseases, substantial untapped potential exists to modify the relation between chronological age and health. This objective is especially important for the most age-dependent disorders (ie, dementia, stroke, chronic obstructive pulmonary disease, and vision impairment), for which the burden of disease arises more from disability than from mortality, and for which long-term care costs outweigh health expenditure. The societal cost of these disorders is enormous.

Depression and risk of hospitalization for pneumonia in a cohort study of older Americans

OBJECTIVE

The aim of this study is to determine if depression is independently associated with risk of hospitalization for pneumonia after adjusting for demographics, medical comorbidity, health-risk behaviors, baseline cognition and functional impairments.

METHODS

This secondary analysis of prospectively collected data examined a population-based sample of 6704 Health and Retirement Study (HRS) (1998-2008) participants>50years old who consented to have their interviews linked to their Medicare claims and were without a dementia diagnosis. The eight-item Center for Epidemiologic Studies Depression Scale and/or International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) depression diagnoses were used to identify baseline depression. ICD-9-CM diagnoses were used to identify hospitalizations for which the principal discharge diagnosis was for bacterial or viral pneumonia. The odds of hospitalization for pneumonia for participants with depression relative to those without depression were estimated using logistic regression models. Population attributable fractions were calculated to determine the extent that hospitalizations for pneumonia could be attributable to depression.

RESULTS

After adjusting for demographic characteristics, clinical factors, and health-risk behaviors, depression was independently associated with increased odds of hospitalization for pneumonia (odds ratio [OR]: 1.28, 95% confidence interval [95%CI]: 1.08, 1.53). This association persisted after adjusting for baseline cognition and functional impairments (OR: 1.24, 95%CI: 1.03, 1.50). In this cohort, 6% (95%CI: 2%, 10%) of hospitalizations for pneumonia were potentially attributable to depression.

CONCLUSION

Depression is independently associated with increased odds of hospitalization for pneumonia. This study provides additional rationale for integrating mental health care into medical settings in order to improve outcomes for older adults.