Impact of chronic obstructive pulmonary disease on mortality: A large national cohort study

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.

The impact of chronic diseases on all-cause mortality in Spain: A population-based cohort study

OBJECTIVE

Our study aimed to assess the association between all-cause mortality and the most prevalent chronic diseases in Spain, including diabetes mellitus.

DESIGN

Population-based retrospective cohort study. SITE: Spanish population (Spanish National Health Survey).

PARTICIPANTS

A population numbering 14,584 respondents of both sexes aged 40 years or older was selected.

MAIN MEASUREMENTS

The outcome variable was all-cause mortality over 6-year follow-up, measured by probabilistic cross-matching with the national death registry. Socioeconomic variables, health indicators, service use, and behavioral factors were collected. The main data source was the National Statistics Institute.

RESULTS

Of the 14584 people included, 1346 (9.2%) died over 6-year follow-up. Regarding the most prevalent chronic diseases, those showing the strongest association with mortality were cancer (HR 1.74, 95% CI 1.40-2.16); chronic lung diseases (chronic obstructive pulmonary disease, bronchitis, or emphysema; HR 1.44, 95% CI 1.19-1.70); acute myocardial infarction (HR 1.33, 95% CI 1.08-1.65); and diabetes (HR 1.23, 95% CI 1.06-1.42). Less prevalent chronic diseases also increased mortality risk, including cirrhosis/liver disease (prevalence 1.5%; HR 1.67, 95% CI 1.22-2.29) and cerebrovascular diseases, including embolism and stroke (prevalence 2%; HR 1.39, 95% CI 1.07-1.81).

CONCLUSIONS

Chronic diseases affect over half the population aged 40 years and older in Spain. Some of the most prevalent conditions are closely associated with all-cause mortality. These include chronic lung diseases, acute myocardial infarction, and diabetes. Given their impact on mortality in the population, more efforts are needed in chronic disease prevention and management.

Risk of acute exacerbation of chronic obstructive pulmonary disease after COVID-19 recovery: a nationwide population-based cohort study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is associated with severe Coronavirus disease 2019 (COVID-19) outcomes. However, it is uncertain whether the risk of acute exacerbation of COPD (AECOPD) increases after recovering from COVID-19.

METHODS

This study included 2,118 individuals with COPD from the Korea National Health Insurance Service database who were also diagnosed with COVID-19. Matched controls were chosen using 1:1 propensity score (PS) matching. We compared the risk of AECOPD after COVID-19 recovery between the COVID-19 cohort and matched controls between October 8, 2020, and December 31, 2021, using PS-matched Cox proportional hazard regression models.

RESULTS

During a median follow-up of 62 days (interquartile range, 29-179 days), including a median of 14 days of recovery time after COVID-19, 68 people (5.6%) in the COVID-19 cohort and 50 (3.9%) in the matched control group experienced AECOPD. Compared to the matched controls, the COVID-19 cohort had a significantly higher risk of overall AECOPD (hazard ratio [HR] = 1.45, 95% confidence interval [CI] = 1.09-1.92). This increased risk was particularly evident for severe AECOPD among individuals who had severe COVID-19 within the first 30days post-recovery (aHR = 8.14, 95% CI = 3.32-19.97). When classified by COVID-19 severity, while severe COVID-19 significantly increased this risk (aHR = 2.97, 95% CI = 2.15-4.11), non-severe COVID did not significantly influence the risk of AECOPD, regardless of time duration or exacerbation severity.

CONCLUSION

Individuals with COPD who had severe COVID-19 have increased risk of AECOPD after COVID-19 recovery, especially within the first 30 days after COVID-19 recovery.

Asthma Increases Long-Term Risk of Death by Suicide: A Nationwide Population-Based Cohort Study

BACKGROUND

Previous studies have identified an increased risk of suicidal behaviors among individuals with asthma.

OBJECTIVE

To evaluate the long-term risk and factors related to suicide in the adult population with asthma.

METHODS

This study used the Korean National Health Insurance Service data. We investigated the risk of suicide concerning the presence or absence of asthma and potential risk factors for suicide among 3,914,041 adults aged 20 years or more.

RESULTS

During a median follow-up of 12.3 years (interquartile range, 12.1-12.6 years), 1383 (0.48%) individuals with asthma died by suicide. Individuals with asthma had an increased risk of suicide compared with controls (adjusted hazard ratio [aHR], 1.26; 95% CI, 1.19-1.33). Suicide risk was especially high in individuals with asthma phenotypes: hospitalization-prone (aHR, 1.61; 95% CI, 1.40-1.84), nonobese (aHR, 1.37; 95% CI, 1.27-1.64), and asthma-chronic obstructive pulmonary disease overlap (aHR, 1.47; 95% CI, 1.22-1.76). Coexisting underweight status (aHR, 2.54; 95% CI, 2.05-3.16), mental health disorders (schizophrenia [aHR, 3.38; 95% CI, 2.28-5.02], depression [aHR, 3.24; 95% CI, 2.85-3.68], and anxiety disorder [aHR, 2.47; 95% CI, 2.00-3.05]), and cancers (aHR, 2.22; 95% CI, 1.73-2.84) further increased the suicide risk.

CONCLUSIONS

Asthma was associated with an increased risk of suicide, particularly in hospitalization-prone, nonobese, and asthma-chronic obstructive pulmonary disease overlap phenotypes. The risk was further increased when asthma coexisted with underweight status, mental health disorders, or cancers.

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.

Exploring the association between socioeconomic inequalities in chronic respiratory disease and all-cause mortality in China: findings from the China Health and Retirement Longitudinal Study

Objective

Research on the inequality of chronic respiratory disease (CRD) is limited, and the association between CRD and all-cause mortality is not well-established. Investigating the distribution of CRD and its associated mortality risks is essential for improving CRD conditions and developing targeted intervention measures. This study aimed to explore the relationship between inequalities in CRD and all-cause mortality in China.

Methods

This study utilized nationally representative baseline data from the China Health and Retirement Longitudinal Study (CHARLS, 2011-2020, wave 1-wave 5), including a total of 14,743 subjects. The concentration index was employed to measure socioeconomic-related inequality in CRD, and the concentration index decomposition method was used to describe its influencing factors. Cox proportional hazards regression model was employed to examine the association between CRD and all-cause mortality.

Results

The prevalence of CRD was 11.79% (95% CI: 10.98, 12.66) in China. The concentration index for CRD was -0.050 (95% CI: -0.075, -0.026), indicating a certain degree of inequality in its prevalence. Chronic lung disease (concentration index = -0.046, 95% CI: -0.073, -0.019), asthma (concentration index = -0.102, 95% CI: -0.148, -0.056), and asthma-chronic obstructive pulmonary disease overlap syndrome (concentration index = -0.114, 95% CI: -0.173, -0.055) also exhibited a pro-poor distribution. The decomposition analysis of the concentration index for CRD revealed that age, education level, and economic status played substantial roles in contributing to the observed inequality. Additionally, Cox regression analysis showed that participants with CRD had an increased risk of all-cause mortality (HR = 1.49, 95% CI: 1.34, 1.65).

Conclusion

Inequalities exists in CRDs in China, with the prevalence of these diseases primarily concentrated among economically disadvantaged groups. Additionally, CRD increases the risk of all-cause mortality. Addressing the root causes of economic inequalities and enhancing the educational attainment of individuals with low socioeconomic status can help improve the situation.

Demographic and geographical trends in chronic lower respiratory diseases mortality in the United States, 1999 to 2020

Chronic lower respiratory disease (CLRD) related mortality has decreased in the United States due to increasing awareness in the general population and advancing preventative efforts, diagnostic measures, and treatment. However, demographic and regional differences still persist throughout the United States. In this study, we analyzed the temporal trends of demographic and geographical differences in CLRD-related mortality. Data was extracted from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database. Using this data, age-adjusted mortality rates per 100,000 people (AAMR), annual percentage change (APC), and average annual percentage changes with 95% confidence intervals (CIs) were assessed. The Joinpoint Regression Program was used to determine mortality trends between 1999 and 2020 based on demographic and regional groups.During this study period, there were 3,064,049 CLRD-related deaths, with most demographics and regional areas showing an overall decreasing trend. However, higher mortality rates were seen in the non-Hispanic White population and rural areas. Interestingly, mortality rates witnessed a decreasing trend for males throughout the study duration compared to females, who only began to show decreases in mortality during the latter half of the 2010s. Using these results, one can target efforts and build policies to improve CLRD-related mortality and reduce disparities in the coming decades.

Influencing factors of good quality of life among chronic obstructive pulmonary disease patients living in Zhejiang Province, China

Chronic obstructive pulmonary disease (COPD) is a chronic, progressive and debilitating disease that affects quality of life (QOL), especially among patients living in poor environments. This study aimed to determine the influencing factors of good QOL among COPD patients living in Zhejiang, China. A cross-sectional study was conducted to collect data from participants in six tertiary hospitals in Zhejiang Province by a simple random sampling method. A validated questionnaire was used to collect general information, environmental factors, and COPD stage. The standardized St. George's Respiratory Questionnaire (SGRQ) was used to assess QOL. Logistic regression was used to determine influencing factors of good QOL among COPD patients at a significance level of α = 0.05. A total of 420 participants were recruited for analysis. The overall prevalence of patients with good QOL was 25.7%. Six variables were found to be associated with good QOL in the multivariable analysis. Patients who were employed had 2.35 times (95% CI 1.03-5.34) greater odds of having good QOL than those who were unemployed. Those whose family income was higher than 100,000 CNY had 2.49 times (95% CI 1.15-5.39) greater odds of having good QOL than those whose family income was lower than 100,000 CNY. Those who had treatment expenses less than 5,000 CNY had 4.57 (95% CI 1.57-13.30) times greater odds of having good QOL than those who had treatment expenses of 5,000 CNY or higher. Those who had mild or moderate airflow limitation were 5.27 times (95% CI 1.61-17.26) more likely to have good QOL than those who were in a severe or very severe stage of COPD. Those who had a duration of illness less than 60 months had 5.57 times (95% CI 1.40-22.12) greater odds of having good QOL than those who had a duration of illness of 120 months or more. Those who were not hospitalized within the past 3 months had 9.39 times (95% CI 1.62-54.43) greater odds of having good QOL than those who were hospitalized more than twice over the past 3 months. Socioeconomic status, disease stage and accessibility were associated with good QOL among COPD patients in Zhejiang Province, China. Increasing family income and implementing measures to improve the accessibility of medical care, including developing a proper system to decrease the cost of treatment for COPD patients, can improve patients' QOL.

Longitudinal BMI change and outcomes in Chronic Obstructive Pulmonary Disease: a nationwide population-based cohort study

BACKGROUND

The association between longitudinal body mass index (BMI) change and clinical outcomes in patients with chronic obstructive pulmonary disease (COPD) has not fully investigated.

METHODS

This retrospective cohort study included 116,463 COPD patients aged ≥ 40, with at least two health examinations, one within 2 years before and another within 3 years after COPD diagnosis (January 1, 2014, to December 31, 2019). Associations between BMI percentage change with all-cause mortality, primary endpoint, and initial severe exacerbation were assessed.

RESULTS

BMI decreased > 5% in 14,728 (12.6%), while maintained in 80,689 (69.2%), and increased > 5% in 21,046 (18.1%) after COPD diagnosis. Compared to maintenance group, adjusted hazard ratio (aHR) for all-cause mortality was 1.70 in BMI decrease group (95% CI:1.61, 1.79) and 1.13 in BMI increase group (95% CI:1.07, 1.20). In subgroup analysis, decrease in BMI showed a stronger effect on mortality as baseline BMI was lower, while an increase in BMI was related to an increase in mortality only in obese COPD patients with aHRs of 1.18 (95% CI: 1.03, 1.36). The aHRs for the risk of severe exacerbation (BMI decrease group and increase group vs. maintenance group) were 1.30 (95% CI:1.24, 1.35) and 1.12 (95% CI:1.07, 1.16), respectively.

CONCLUSIONS

A decrease in BMI was associated with an increased risk of all-cause mortality in a dose-dependent manner in patients with COPD. This was most significant in underweight patients. Regular monitoring for weight loss might be an important component for COPD management.

Impact of smoking reduction on lung cancer risk in patients with COPD who smoked fewer than 30 pack-years: a nationwide population-based cohort study

BACKGROUND

The effects of smoking reduction on the incidence of lung cancer in patients with chronic obstructive pulmonary disease (COPD) are not well known. This study aimed to investigate the effects of changes in smoking habits after COPD diagnosis on lung cancer development in patients who smoked less than 30 pack-years.

METHODS

This nationwide retrospective cohort study included 16,832 patients with COPD who smoked less than 30 pack-years at the time of COPD diagnosis. Based on changes in smoking habits in the health screening examination data, smokers were categorized into three groups: quitters, reducers, and sustainers. The primary outcome was the risk of lung cancer development, which was estimated using the Cox proportional hazards model. We also modelled the amount of smoking reduction as a continuous variable.

RESULTS

During a median follow-up of 4 years, the cumulative incidence of lung cancer was the highest among sustainers, followed by reducers and quitters. Compared with sustainers, reducers (adjusted HR 0.74, 95% CI:0.56-0.98) and quitters (adjusted HR 0.78, 95% CI:0.64-0.96) had a significantly lower risk of lung cancer. Incidence of lung cancer showed a decreasing trend with a decreasing amount of smoking (P for linearity < 0.01).

CONCLUSIONS

In patients with COPD who smoked less than 30 pack-years, smoking reduction and cessation lowered the risk of lung cancer.

Impacts of regular physical activity on hospitalisation in chronic obstructive pulmonary disease: a nationwide population-based study

INTRODUCTION

Studies that comprehensively evaluate the association between physical activity (PA) levels, particularly by quantifying PA intensity, and healthcare use requiring emergency department (ED) visit or hospitalisation in patients with chronic obstructive pulmonary disease (COPD) are limited in Korea.

METHODS

The risk of all-cause and respiratory ED visit or hospitalisation according to the presence or absence of COPD and the level of PA was evaluated in a retrospective nationwide cohort comprising 3308 subjects with COPD (COPD cohort) and 293 358 subjects without COPD (non-COPD cohort) from 2009 to 2017.

RESULTS

The COPD group exhibited a higher relative risk of all-cause and respiratory ED visit or hospitalisation across all levels of PA compared with the highly active control group (≥1500 metabolic equivalents (METs)-min/week). Specifically, the highest risk was observed in the sedentary group (adjusted HR (aHR) (95% CI) = 1.70 (1.59 to 1.81) for all-cause ED visit or hospitalisation, 5.45 (4.86 to 6.12) for respiratory ED visit or hospitalisation). A 500 MET-min/week increase in PA was associated with reductions in all-cause and respiratory ED visit or hospitalisation in the COPD cohort (aHR (95% CI) = 0.92 (0.88 to 0.96) for all-cause, 0.87 (0.82 to 0.93) for respiratory cause).

CONCLUSIONS

Compared with the presumed healthiest cohort, the control group with PA>1500 METs-min/week, the COPD group with reduced PA has a higher risk of ED visit or hospitalisation.

All-cause and cause-specific mortality by spirometric pattern and sex - a population-based cohort study

BACKGROUND

Chronic airway obstruction (CAO) and restrictive spirometry pattern (RSP) are associated with mortality, but sex-specific patterns of all-cause and specific causes of death have hardly been evaluated.

OBJECTIVES

To study the possible sex-dependent differences of all-cause mortality and patterns of cause-specific mortality among men and women with CAO and RSP, respectively, to that of normal lung function (NLF).

DESIGN

Population-based prospective cohort study.

METHODS

Individuals with CAO [FEV1/vital capacity (VC) < 0.70], RSP [FEV1/VC ⩾ 0.70 and forced vital capacity (FVC) < 80% predicted] and NLF (FEV1/VC ⩾ 0.70 and FVC ⩾ 80% predicted) were identified within the Obstructive Lung Disease in Northern Sweden (OLIN) studies in 2002-2004. Mortality data were collected through April 2016, totally covering 19,000 patient-years. Cox regression and Fine-Gray regression accounting for competing risks were utilized to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) adjusted for age, body mass index, sex, smoking habits and pack-years.

RESULTS

The adjusted hazard for all-cause mortality was higher in CAO and RSP than in NLF (HR, 95% CI; 1.69, 1.31-2.02 and 1.24, 1.06-1.71), and the higher hazards were driven by males. CAO had a higher hazard of respiratory and cardiovascular death than NLF (2.68, 1.05-6.82 and 1.40, 1.04-1.90). The hazard of respiratory death was significant in women (3.41, 1.05-11.07) while the hazard of cardiovascular death was significant in men (1.49, 1.01-2.22). In RSP, the higher hazard for respiratory death remained after adjustment (2.68, 1.05-6.82) but not for cardiovascular death (1.11, 0.74-1.66), with a similar pattern in both sexes.

CONCLUSION

The higher hazard for all-cause mortality in CAO and RSP than in NLF was male driven. CAO was associated with respiratory death in women and cardiovascular death in men, while RSP is associated with respiratory death, similarly in both sexes.

Risk of Ischemic Heart Disease in Chronic Obstructive Pulmonary Disease: A Nationwide Cohort Study

BACKGROUND

Subjects with chronic obstructive pulmonary disease (COPD) have a higher risk of ischemic heart disease (IHD) than individuals without COPD; however, longitudinal evidence is lacking. Therefore, we aimed to estimate the risk of IHD between COPD and control cohorts using a longitudinal nationwide database.

METHODS

We used 2009-2017 data from the Korean National Health Insurance Service National Sample Cohort (NHIS-NSC). Adult participants at least 20 years of age who underwent health examinations and without a history of COPD or IHD were included (n = 540,976). Participants were followed from January 1, 2009, until death, development of IHD, or December 31, 2019, whichever came first.

RESULTS

At baseline, there were 3,421 participants with incident COPD and 537,555 participants without COPD. During a median of 8.0 years (5.3-9.1 years) of follow-up, 2.51% of the participants with COPD (n = 86) and 0.77% of the participants without COPD (n = 4,128) developed IHD, with an incidence of 52.24 and 10.91 per 10,000 person-years, respectively. Participants with COPD had a higher risk of IHD (adjusted hazard ratio, 1.55; 95% confidence interval, 1.25-1.93) than subjects without COPD. Demographics such as age, sex, body mass index, and personal health behaviors including smoking status and physical activity did not show significant interaction with the relationship between COPD and IHD (P for interaction > 0.05 for all).

CONCLUSION

The results indicate that COPD is associated with the development of IHD independent of demographic characteristics and health-related behaviors. Based on these results, clinicians should closely monitor the onset of IHD in subjects with COPD.

Effect of Broncho-Vaxom (OM-85) on the frequency of chronic obstructive pulmonary disease (COPD) exacerbations

BACKGROUND

Efforts have been made to reduce the risk of chronic obstructive pulmonary disease (COPD) exacerbations using a variety of measures. Broncho-Vaxom (BV) is an immunomodulating agent that has shown potential benefit by balancing between immune stimulation and regulation in patients with COPD. In this study, we evaluated the clinical efficacy of BV for reducing the risk of COPD exacerbations.

METHODS

This study was based on the Korean National Health Insurance database, which contains reimbursement information for almost the entire population of South Korea. We extracted data from 2016 to 2019 for patients started on BV during 2017-2018. We collected baseline data on demographics, comorbidities, inhaler use, hospital type, and insurance type 1 year before starting BV. We also analyzed exacerbation history, starting from the year before BV initiation.

RESULTS

In total, 238 patients were enrolled in this study. Their mean age was 69.2 ± 9.14 years, 79.8% were male, and 45% experienced at least one exacerbation. BV reduced the risk of moderate (odds ratio [OR] = 0.59, 95% confidence interval [CI]: 0.38-0.91) and moderate-to-severe exacerbations compared to pre- and post-BV (OR = 0.571, 95% CI: 0.37-0.89). BV use also reduced the incidence of moderate and moderate-to-severe exacerbations (incidence rate ratio [IRR] = 0.75, p = 0.03; and IRR = 0.77, p = 0.03, respectively). The use of BV was significantly delayed moderate exacerbations (hazard ratio = 0.68, p = 0.02), but not with moderate-to-severe or severe exacerbations.

CONCLUSION

The use of BV was associated with fewer moderate and moderate-to-severe exacerbations. Additionally, BV was associated with a delay in moderate COPD exacerbations.

Air pollution and mortality in patients with chronic obstructive pulmonary disease: a cohort study in South Korea

Background

Evidence on whether long-term exposure to air pollution increases the mortality risk in patients with chronic obstructive pulmonary disease (COPD) is limited.

Objectives

We aimed to investigate the associations of long-term exposure to particulate matter with diameter <10 µm (PM10) and nitrogen dioxide (NO2) with overall and disease-specific mortality in COPD patients.

Design

We conducted a nationwide retrospective cohort study of 121,423 adults ⩾40 years diagnosed with COPD during 1 January to 31 December 2009.

Methods

Exposure to PM10 and NO2 was estimated for residential location using the ordinary kriging method. We estimated the risk of overall mortality associated with 1-, 3-, and 5-years average concentrations of PM10 and NO2 using Cox proportional hazards models and disease-specific mortality using the Fine and Gray method adjusted for age, sex, income, body mass index, smoking, comorbidities, and exacerbation history.

Results

The adjusted hazard ratios (HRs) for overall mortality associated with a 10 µg/m3 increase in 1-year PM10 and NO2 exposures were 1.004 [95% confidence interval (CI) = 0.985, 1.023] and 0.993 (95% CI = 0.984, 1.002), respectively. The results were similar for 3- and 5-year exposures. For a 10-µg/m3 increase in 1-year PM10 and NO2 exposures, the adjusted HRs for chronic lower airway disease mortality were 1.068 (95% CI = 1.024, 1.113) and 1.029 (95% CI = 1.009, 1.050), respectively. In stratified analyses, exposures to PM10 and NO2 were associated with overall mortality in patients who were underweight and had a history of severe exacerbation.

Conclusion

In this large population-based study of patients with COPD, long-term PM10 and NO2 exposures were not associated with overall mortality but were associated with chronic lower airway disease mortality. PM10 and NO2 exposures were both associated with an increased risk of overall mortality, and with overall mortality in underweight individuals and those with a history of severe exacerbation.

Cigarette smoke extract-induced inflammatory response via inhibition of the TFEB-mediated autophagy in NR8383 cells

Objective: Chronic pulmonary inflammation caused by long-term smoking is the core pathology of COPD. Alveolar macrophages (AMs) are involved in the pulmonary inflammation of COPD. The accumulation of damaged materials caused by impaired autophagy triggers inflammatory response in macrophages. As a key transcription regulator, transcription factor EB (TFEB) activates the transcription of target genes related autophagy and lysosome by binding to promoters, whereas it is unclarified for the relationship between inflammatory response induced by cigarette smoke extract (CSE) and TFEB-mediated autophagy. Thus, we investigated the role of TFEB-mediated autophagy in inflammatory response induced by CSE in NR8383 cells, and to explore its potential mechanism. Methods: Based on cell viability and autophagy, cells treated with 20% concentration of CSE for 24 h were selected for further studies. Cells were divided into control group, chloroquine (CQ, the autophagy inhibitor) group, CSE group, CSE + rapamycin (the autophagy inducer) group and CSE + fisetin (the TFEB inducer) group. The levels of tumor necrosis factor α (TNF-α), interleukin 1β (IL-1β), and IL-6 in supernatant were detected by ELISA kits. The protein expressions were tested by western blot. The intensity of fluorescence of Lysosome-associated membrane protein 1 (LAMP1) and TFEB was detected by immunofluorescence. Lyso-Tracker Red staining was applied to detect the lysosome environment. Results: CSE inhibited the cell viability, increased the contents of TNF-α, IL-1β, IL-6, the ratio of LC3II/I, and the level of P62 protein. Besides, CSE decreased the fluorescence intensity of LAMP1 protein and Lyso-Tracker Red staining, as well as the ratio of nucleus/cytosol of TFEB protein. Activating autophagy with rapamycin alleviated CSE-induced inflammatory response. The activation of TFEB via fisetin alleviated CSE-induced autophagy impairment and lysosomal dysfunction, thus alleviated inflammatory response in NR8383 cells. Conclusion: CSE-induced inflammatory response in NR8383 cells, which may be related to the inhibition of TFEB-mediated autophagy.

Long-term outcome of chronic obstructive pulmonary disease: A review

Chronic obstructive pulmonary disease (COPD) is a chronic airway inflammation characterized by fixed airflow limitation and chronic respiratory symptoms, such as cough, sputum, and dyspnea. COPD is a progressive disease characterized by a decline in lung function. During the natural course of the disease, acute deterioration of symptoms leading to hospital visits can occur and influence further disease progression and subsequent exacerbation. Moreover, COPD is not only restricted to pulmonary manifestations but can present with other systemic diseases as comorbidities or systemic manifestations, including lung cancer, cardiovascular disease, pulmonary hypertension, sarcopenia, and metabolic abnormalities. These pulmonary and extrapulmonary conditions lead to the aggravation of dyspnea, physical inactivity, decreased exercise capacity, functional decline, reduced quality of life, and increased mortality. In addition, pneumonia, which is attributed to both COPD itself and an adverse effect of treatment (especially the use of inhaled and/or systemic steroids), can occur and lead to further deterioration in the prognosis of COPD. This review summarizes the long-term outcomes of patients with COPD. In addition, recent studies on the prediction of adverse outcomes are summarized in the last part of the review.

Long-Term Mortality of Tuberculosis Survivors in Korea: A Population-based Longitudinal Study

BACKGROUND

When assessing long-term tuberculosis (TB) mortality, few studies addressed the impact of behavior habits and socioeconomic status. Therefore, we aimed to evaluate long-term TB mortality and risk factors while accounting for potential confounders.

METHODS

This cohort study included TB survivors (n = 82 098) aged ≥20 years between 2010 and 2017, and 1:1 age- and sex-matched controls (n = 82 098). The participants were followed up for death 1 year after study enrollment until December 2018. Long-term mortality was adjusted for behavior habits (smoking, alcohol consumption, or exercise), income level, body mass index (BMI), and comorbidities.

RESULTS

During a median of 3.7 years of follow-up, the incidence rate of mortality was significantly higher in TB survivors than those in the matched controls (18.2 vs. 8.8 per 1000 person-years, P < .001). Even after adjusting for potential confounders, the mortality risk was 1.62-fold (95% confidence interval [CI], 1.54-1.70) higher in TB survivors than those in the matched controls. In addition, the hazard of mortality in TB survivors relative to matched controls significantly increased in participants aged ≥30 years, with the highest risk in those in their 40s. Male sex (adjusted hazard ratio [HR]: 2.31; 95% CI, 2.16-2.47), smoking pack-years (HR: 1.005; 95% CI, 1.004-1.006), heavy alcohol consumption (HR: 1.12; 95% CI, 1.01-1.23), and lowest income (HR: 1.27; 95% CI, 1.18-1.37) were positively associated with increased hazards for mortality, whereas higher BMI (HR: 0.91; 95% CI, .90-.92) and regular exercise (HR: 0.82; 95% CI, .76-.88) reduced the hazards of long-term mortality in TB survivors.

CONCLUSIONS

The long-term mortality risk was significantly higher in TB survivors than those in the matched controls, even after adjusting for potential confounders.

Increased hospitalizations and economic burden in COPD with bronchiectasis: a nationwide representative study

With the increasing use of computed tomography, bronchiectasis has become a common finding in patients with chronic obstructive pulmonary disease (COPD). However, the clinical aspects and medical utilization of COPD with bronchiectasis (BE) remain unclear. We aimed to investigate the BE effect on prognosis and medical utilization in patients with COPD. Among 263,747 COPD patients, we excluded patients lacking chest X-ray, CT, or pulmonary function test codes and classified 2583 GOLD-C/D patients matched according to age, sex, and medical aid as having COPD-BE (447 [17.3%]) and COPD without BE (2136 [82.7%]). Patients with COPD-BE showed a higher rate of acute exacerbation requiring antibiotics than those without BE. Moreover, multivariable analysis showed that BE co-existence was a crucial factor for moderate-to-severe exacerbation (incidence rate ratio [IRR] 1.071; 95% CI 1.012-1.134; p = 0.019). Patients with COPD-BE had a significantly higher rate of exacerbations requiring antibiotics, as well as treatment cost and duration (meant as number of days using hospitalization plus outpatient appointment), than those with COPD without BE (52.64 ± 65.29 vs. 40.19 ± 50.02 days, p < 0.001; 5984.08 ± 8316.96 vs. 4453.40 ± 7291.03 USD, p < 0.001). Compared with patients with COPD without BE, patients with COPD-BE experienced more exacerbations requiring antibiotics, more hospitalizations, and a higher medical cost.

Pulmonary Tuberculosis and the Incidence of Lung Cancer among Patients with Chronic Obstructive Pulmonary Disease

RATIONALE

While the history of pulmonary tuberculosis (PTB) is a risk factor for developing both chronic obstructive pulmonary disease (COPD) and lung cancer, it remains unclear whether the history of PTB affects lung cancer development in COPD patients.

OBJECTIVES

To investigate whether a history of PTB is associated with an increased risk of lung cancer development in a population with COPD.

METHODS

This cohort study included a nationwide representative sample of 13,165 Korean men and women with COPD, aged between 50-84 years. In addition, to assess whether the relationship between PTB and lung cancer risk differs between participants with and without COPD, a matched cohort without COPD was included. Participants were matched 1:3 for age, sex, smoking history, and PTB status based on the index health screening exam of corresponding participants with COPD. The two cohorts were followed up for 13 years (January 1st, 2003, to December 31st, 2015). PTB was diagnosed based on the results of chest radiography, and incident lung cancer was identified from hospitalization and outpatient visit claims (International Classification of Diseases, Tenth Revision diagnosis code C33 or C34).

RESULTS

During 370,617 person-years (PY) of follow-up (median follow-up, 7.7 years), in the COPD group, we observed 430 incident cases of lung cancer in participants without a history of PTB (incidence rate 524 per 100,000 PY) and 148 cases in those with a history of PTB (incidence rate 931 per 100,000 PY). Compared to participants without a PTB history, the fully adjusted subdistribution hazard ratio (95% confidence interval) for lung cancer in those with a history of PTB was 1.24 (1.03, 1.50). The association of PTB history and lung cancer development was more evident in never-smokers with COPD. In contrast, among participants without COPD, the corresponding hazard ratio (95% confidence interval) was 0.98 (0.78, 1.22). There was no interaction between PTB, smoking status, and COPD.

CONCLUSIONS

The history of PTB was associated with an increased risk of developing lung cancer among COPD patients in our country with an intermediate TB burden. COPD patients with a history of PTB, particularly the never-smokers, might benefit from periodical screening or assessment for lung cancer development.

Increased mortality in patients with non cystic fibrosis bronchiectasis with respiratory comorbidities

There are limited data regarding whether mortality is higher in patients with non cystic fibrosis bronchiectasis (bronchiectasis) than in those without bronchiectasis. Using 2005-2015 data from the Korean National Health Insurance Service, we evaluated hazard ratio (HR) for all-cause mortality in the bronchiectasis cohort relative to the matched cohort. The effect of comorbidities over the study period on the relative mortality was also assessed. All-cause mortality was significantly higher in the bronchiectasis cohort than in the matched cohort (2505/100,000 vs 2142/100,000 person-years, respectively; P < 0.001). Mortality risk was 1.15-fold greater in the bronchiectasis cohort than in the matched cohort (95% confidence interval [CI] 1.09-1.22); mortality was greatest among elderly patients (HR = 1.17, 95% CI 1.10-1.25) and men (HR = 1.19, 95% CI 1.10-1.29). Comorbidities over the study period significantly increased the risk of death in the bronchiectasis cohort relative to the matched cohort: asthma (adjusted HR = 1.20, 95% CI 1.11-1.30), chronic obstructive pulmonary disease (adjusted HR = 1.24, 95% CI 1.15-1.34), pneumonia (adjusted HR = 1.50, 95% CI 1.39-1.63), lung cancer (adjusted HR = 1.85, 95% CI 1.61-2.12), and cardiovascular disease (adjusted HR = 1.34, 95% CI 1.23-1.45). In contrast, there were no significant differences in the risk of death in patients without bronchiectasis-related comorbidities and the matched cohort, except in the case of non-tuberculous mycobacterial infection. In conclusion, all-cause mortality was higher in patients with bronchiectasis cohort than those without bronchiectasis, especially in elderly patients and men. Comorbidities over the study period played a major role in increasing mortality in patients with bronchiectasis relative to those without bronchiectasis.

Association between Exposure to Ambient Air Pollution and Age-Related Cataract: A Nationwide Population-Based Retrospective Cohort Study

This study aimed to investigate the association between ambient air pollutants and cataracts in the general population aged 50 years or older using data from the Korean National Insurance Service-National Sample Cohort. Cataract patients were defined as those diagnosed by a physician and having undergone cataract surgery. After matching the average concentrations of PM2.5, PM10, NO2, CO, SO2, and O3 in residential areas, the association between quartile level of air pollutants and incidence of cataract was analyzed using a multivariate Cox-proportional hazard risk model. Among the 115,728 participants, 16,814 (14.5%) were newly diagnosed with cataract and underwent related surgery between 1 January 2004, and 31 December 2015. Exposure to PM10, NO2, and SO2 was positively associated with cataract incidence, while O3 was negatively associated. The adjusted hazard ratio (HR) with 95% confidence interval was 1.069 (1.025-1.115) in PM10 and 1.080 (1.030-1.133) in NO2. However, the association between cataract and the quartile of PM2.5 measured during one year in 2015 was not clear. The HR of female participants aged 65 or older was significantly increased according to quartile of air pollutants. We identified exposure to PM10, NO2, SO2, and O3 associated with cataract development in Korean adults aged ≥ 50 years. This information may be helpful for policymaking to control air pollution as a risk factor for eye health.

Nationwide quality assessment of treatment for chronic obstructive pulmonary disease

Background

Chronic obstructive pulmonary disease (COPD) requires careful ambulatory care. If treatment is effective, exacerbation and hospitalization can be preventable. Appropriate management is important; the disease prevalence is high, as is the demand on healthcare resources. Here, we have reported the results of nationwide quality assessment performed with the aims of improving patient management, reducing progression to severe status, and minimizing medical care expenses.

Methods

The Health Insurance Review and Assessment Service (HIRA) engaged in quality assessment three times from May 2014 to April 2017. Medical care institutions were evaluated in terms of the pulmonary function test (PFT), patient revisit, and inhaled bronchodilator prescription rates.

Results

The numbers of patients assessed were 141,782, 142,790, and 143,339 in years 1, 2, and 3, respectively; the numbers of medical care institutions assessed were 6,691, 6,722, and 6,470, respectively. The PFT implementation rates were 58.7%, 62.5%, and 67.9% for years 1, 2, and 3, respectively; these rates were highest for tertiary hospitals, followed by general and local hospitals, as well as primary healthcare clinics. The repeat visit rates were 85.5%, 92.1%, and 85.0% for years 1, 2, and 3, respectively; these rates were highest for general hospitals, followed by local and tertiary hospitals, and primary healthcare clinics. The inhaled bronchodilator prescription rates were 67.9%, 71.2%, and 76.9% for years 1, 2, and 3, respectively; these rates increased with increasing hospital grade.

Conclusions

The PFT and inhaled bronchodilator prescription rates improved over the 3-year nationwide quality assessment period.

Non-cytotoxic doses of shikonin inhibit lipopolysaccharide-induced TNF-α expression via activation of the AMP-activated protein kinase signaling pathway

Shikonin has been reported to exhibit a wide variety of medical functions. However, the strong non-selective cytotoxicity of shikonin can restrict its clinical application. The aim of the present study was to investigate the effects of shikonin at non-cytotoxic doses on the pro-inflammation functions of monocytes and macrophages. The present results suggested that the non-cytotoxic doses of shikonin effectively inhibited lipopolysaccharide (LPS)-induced reactive oxygen species production, NF-κB activation and TNF-α expression in RAW 264.7 mouse macrophages via AMP-activated protein kinase (AMPK) signaling pathway. In addition, the non-cytotoxic doses of shikonin downregulated LPS-induced TNF-α expression via AMPK signaling activation in primary murine bone marrow-derived macrophages, and also in monocytes cultured ex vivo from patients with chronic obstructive pulmonary disease (COPD). The present in vivo results indicated that the low-toxic dose of shikonin suppressed LPS-induced endotoxin shock and TNF-α expression in mice. Collectively, the present results may provide clinical and translational relevance for treating COPD and other TNF-α-related inflammatory disorders.

Coexisting COPD Increases Mortality in Patients With Corticosteroid-Dependent Asthma: A Nationwide Population-Based Study

PURPOSE

Chronic corticosteroid (CS) use is a risk factor for long-term mortality in asthmatic patients, and the presence of coexisting chronic obstructive pulmonary disease (COPD) is associated with a severe presentation and poor prognosis. However, the impact of coexisting COPD on long-term mortality in patients with CS-dependent asthma has not been well elucidated. This study aimed to determine the impact of coexisting COPD on long-term mortality in patients with CS-dependent asthma.

METHODS

A retrospective cohort of patients with CS-dependent asthma aged 40 years or older was established using records from the Korean National Health Insurance Service database for 2005 to 2015. We classified the subjects into 2 groups according to the presence of COPD and evaluated the hazard ratio (HR) for all-cause mortality in patients with COPD relative to those without COPD.

RESULTS

Of 8,021 patients with CS-dependent asthma, 3,121 (38.9%) had COPD. All-cause mortality was significantly greater in patients with CS-dependent asthma and COPD than in those without COPD (9,955/100,000 person-years vs. 5,585/100,100 person-years, P < 0.001). The adjusted HRs were 1.29 (95% confidence interval [CI], 1.21-1.38), and the associations were especially significant for chronic lower respiratory diseases (subdistribution HR, 2.30; 95% CI, 2.06-2.57) and lung cancer (subdistribution HR, 1.34; 95% CI, 1.02-1.78).

CONCLUSIONS

In this population-based retrospective cohort study, the presence of physician-recognized COPD was associated with greater all-cause mortality and greater risk of mortality due to chronic lower respiratory diseases and lung cancer in patients with CS-dependent asthma. Early recognition and appropriate management of COPD can improve treatment outcomes in patients with CS-dependent asthma.

Chronic obstructive pulmonary disease and lung cancer incidence in never smokers: a cohort study

There has been limited evidence for the association between chronic obstructive pulmonary disease (COPD) and the incidence of lung cancer among never smokers. We aimed to estimate the risk of lung cancer incidence in never smokers with COPD, and to compare it with the risk associated with smoking. This cohort study involved 338 548 subjects, 40 to 84 years of age with no history of lung cancer at baseline, enrolled in the National Health Insurance Service National Sample Cohort. During 2 355 005 person-years of follow-up (median follow-up 7.0 years), 1834 participants developed lung cancer. Compared with never smokers without COPD, the fully-adjusted hazard ratios (95% CI) for lung cancer in never smokers with COPD, ever smokers without COPD, and ever smokers with COPD were 2.67 (2.09 to 3.40), 1.97 (1.75 to 2.21), and 6.19 (5.04 to 7.61), respectively. In this large national cohort study, COPD was also a strong independent risk factor for lung cancer incidence in never smokers, implying that COPD patients are at high risk of lung cancer, irrespective of smoking status.