Gender difference in airway hyperresponsiveness in smokers with mild COPD. The Lung Health Study

Anticipating undiagnosed asthma in symptomatic adults with normal pre- and post-bronchodilator spirometry: a decision tool for bronchial challenge testing

BACKGROUND

Some patients with asthma demonstrate normal spirometry and remain undiagnosed without further testing.

OBJECTIVE

To determine clinical predictors of asthma in symptomatic adults with normal spirometry, and to generate a tool to help clinicians decide who should undergo bronchial challenge testing (BCT).

METHODS

Using random-digit dialling and population-based case-finding, we recruited adults from the community with respiratory symptoms and no previous history of diagnosed lung disease. Participants with normal pre- and post-bronchodilator spirometry subsequently underwent BCT. Asthma was diagnosed in those with symptoms and a methacholine provocative concentration (PC20) of < 8 mg/ml. Sputum and blood eosinophils, and exhaled nitric oxide were measured. Univariate analyses identified potentially predictive variables, which were then used to construct a multivariable logistic regression model to predict asthma. Model sensitivity, specificity, and area under the receiver operating curve (AUC) were calculated.

RESULTS

Of 132 symptomatic individuals with normal spirometry, 34 (26%) had asthma. Of those ultimately diagnosed with asthma, 33 (97%) answered 'yes' to a question asking whether they experienced cough, chest tightness or wheezing provoked by exercise or cold air. Other univariate predictors of asthma included female sex, pre-bronchodilator FEV1 percentage predicted, and percent positive change in FEV1 post bronchodilator. A multivariable model containing these predictive variables yielded an AUC of 0.82 (95% CI: 0.72-0.91), a sensitivity of 82%, and a specificity of 66%. The model was used to construct a nomogram to advise clinicians which patients should be prioritized for BCT.

CONCLUSIONS

Four readily available patient characteristics demonstrated a high sensitivity and AUC for predicting undiagnosed asthma in symptomatic adults with normal pre- and post-bronchodilator spirometry. These characteristics can potentially help clinicians to decide which individuals with normal spirometry should be investigated with bronchial challenge testing. However, further prospective validation of our decision tool is required.

Associations of the built environment with type 2 diabetes in Asia: a systematic review

OBJECTIVES

Our study aimed to systematically review the literature and synthesise findings on potential associations of built environment characteristics with type 2 diabetes (T2D) in Asia.

DESIGN

Systematic review of the literature.

DATA SOURCES

Online databases Medline, Embase and Global Health were used to identify peer-reviewed journal articles published from inception to 23 January 2023.

ELIGIBILITY CRITERIA

Eligible studies included cohort, cross-sectional and case-control studies that explored associations of built environment characteristics with T2D among adults 18 years and older in Asia.

DATA EXTRACTION AND SYNTHESIS

Covidence online was used to remove duplicates and perform title, abstract and full-text screening. Data extraction was carried out by two independent reviewers using the OVID database and data were imported into MS Excel. Out of 5208 identified studies, 28 studies were included in this systematic review. Due to heterogeneity in study design, built environment and outcome definitions, a semiqualitative analysis was conducted, which synthesised results using weighted z-scores.

RESULTS

Five broad categories of built environment characteristics were associated with T2D in Asia. These included urban green space, walkability, food environment, availability and accessibility of services such as recreational and healthcare facilities and air pollution. We found very strong evidence of a positive association of particulate matter (PM_2.5, PM₁₀), nitrogen dioxide and sulfur dioxide (p<0.001) with T2D risk.

CONCLUSION

Several built environment attributes were significantly related to T2D in Asia. When compared with Western countries, very few studies have been conducted in Asia. Further research is, therefore, warranted to establish the importance of the built environment on T2D. Such evidence is essential for public health and planning policies to (re)design neighbourhoods and help improve public health across Asian countries.

PROSPERO REGISTRATION NUMBER

CRD42020214852.

Sex differences in adult asthma and COPD therapy: a systematic review

Background

Although asthma is more prevalent in women and the prevalence of COPD is increasing in women, the current international recommendations for the management and prevention of asthma and COPD provide no sex-related indication for the treatment of these diseases. Therefore, we systematically reviewed the evidence across literature on the sex-related effectiveness of asthma and COPD therapy.

Methods

This systematic review has been registered in PROSPERO and performed according to PRISMA-P. The PICO framework was applied for the literature search strategy: "patient problem” included adult patients suffering from asthma or COPD, “Intervention” regarded the pharmacological treatments for asthma or COPD, “Comparison” was vs. baseline, active controls, or placebo, “Outcome” was any difference sex-related in the effectiveness of interventions.

Results

In asthma 44% of the evidence reported that men responded better than women to the therapy, whereas this percentage was 28% in COPD. ICS was generally less effective in women than in men to treat asthma, and consistent evidence suggests that in asthmatic patients ICS/LABA/LAMA combination may be equally effective in both men and women. Due to the inconsistent available evidence, it is not possible to identify specific treatments whose effectiveness is related to sex difference in COPD patients.

Conclusions

There is a strong need of investigating the sex-related impact of asthma and COPD treatments. Pre-specified analyses in men and women should be planned in future trial protocols, a necessary condition that should be requested also by the regulatory agencies to overcome the anachronistic “one-size-fits-all” approach to therapeutics associated with suboptimal outcomes for patients.

Asthma with Fixed Airflow Obstruction: From Fixed to Personalized Approach

Asthma is generally characterized by variable symptoms such as dyspnea and wheezing and variable airflow obstruction. This review focuses on a subset of patients suffering from asthma with persistent airflow limitation that is not fully reversible (asthma with fixed airflow obstruction, FAO). The pathophysiology, the risk factors and the clinical outcomes associated with FAO are presented, as well as the distinct clinical entity of severe asthma and its inflammatory subtypes (T2 and non-T2). The current strategies for the treatment of these endotypes and treatment of the distinct Asthma/COPD overlap (ACO) phenotype are described. Management and medical interventions in FAO and/or ACO patients demand a holistic approach, which is not yet clearly established in guidelines worldwide. Finally, a treatment algorithm that includes FAO/ACO management based on pharmacological and non-pharmacological treatment, guideline-based management for specific co-morbidities, and modification of the risk factors is proposed.

Adverse childhood experiences and risk factors associated with asthma among children in the United States: the intersection of sex and race/ethnicity

OBJECTIVE

The objectives of this cross-sectional study were to examine: 1) the association between adverse childhood experiences (ACEs) and asthma among children, and 2) the interaction between sex and race/ethnicity on asthma.

METHODS

Data for this study were obtained from the 2017-2018 National Survey of Children's Health. Binary logistic regression was conducted on an analytic sample of 49,000 children ages 0-17 years with asthma as the outcome variable and ACEs as the main explanatory variable.

RESULTS

Based on parent reports, we found that 11.5% of children had asthma and about 42% had at least one ACE, with 9.7% having ≥3 ACEs. Controlling for other factors, children with ≥3 ACEs had 1.45 times higher odds of having asthma when compared to children with no ACEs. Non-Hispanic Black males and females were more likely to have asthma when compared to non-Hispanic White males.

CONCLUSIONS

The findings of this study demonstrate an association between ACEs and asthma with children exposed to ≥3 ACEs more likely to have asthma underscoring the importance of cumulative effect of ACEs on asthma. Our study also revealed an interaction between sex and race/ethnicity on asthma among children. Additional studies are needed to understand the mechanisms through which ACEs is associated with asthma among children.

Characteristics Associated with Accelerated Lung Function Decline in a Primary Care Population with Chronic Obstructive Pulmonary Disease

Background

Estimates for lung function decline in chronic obstructive pulmonary disease (COPD) have differed by study setting and have not been described in a UK primary care population.

Purpose

To describe rates of FEV₁ and FVC decline in COPD and investigate characteristics associated with accelerated decline.

Patients and Methods

Current/ex-smoking COPD patients (35 years+) who had at least 2 FEV₁ or FVC measurements ≥6 months apart were included using Clinical Practice Research Datalink. Patients were followed up for a maximum of 13 years. Accelerated rate of lung function decline was defined as the fastest quartile of decline using mixed linear regression, and association with baseline characteristics was investigated using logistic regression.

Results

A total of 72,683 and 50,649 COPD patients had at least 2 FEV₁ or FVC measurements, respectively. Median rates of FEV₁ and FVC changes or decline were -18.1mL/year (IQR: -31.6 to -6.0) and -22.7mL/year (IQR: -39.9 to -6.7), respectively. Older age, high socioeconomic status, being underweight, high mMRC dyspnoea and frequent AECOPD or severe AECOPD were associated with an accelerated rate of FEV₁ and FVC decline. Current smoking, mild airflow obstruction and inhaled corticosteroid treatment were additionally associated with accelerated FEV₁ decline whilst women, sputum production and severe airflow obstruction were associated with accelerated FVC decline.

Conclusion

Rate of FEV₁ and FVC decline was similar and showed similar heterogeneity. Whilst FEV₁ and FVC shared associations with baseline characteristics, a few differences highlighted the importance of both lung function measures in COPD progression. We identified important characteristics that should be monitored for disease progression.

Chronic hypoxaemia and gender status modulate adiponectin plasmatic level and its multimer proportion in severe COPD patients: new endotypic presentation?

BACKGROUND

Disease progression in COPD patient is associated to lung function decline, leading to a higher risk of hypoxaemia and associated comorbidities, notably cardiovascular diseases (CVD). Adiponectin (Ad) is an adipokine with cardio-protective properties. In COPD patients, conflicting results were previously reported regarding Ad plasmatic (Adpl) level, probably because COPD is a heterogeneous disease with multifactorial influence. Among these factors, gender and hypoxaemia could interact in a variety of ways with Ad pathway. Therefore, we postulated that these components could influence Adpl level and its multimers in COPD patients and contribute to the appearance of a distinct endotype associated to an altered CVD risk.

METHODS

One hundred COPD patients were recruited: 61 were men and 39 were women. Patients who were not severely hypoxemic were allocated to non-hypoxemic group which included 46 patients: 27 men and 19 women. Hypoxemic group included 54 patients: 34 men and 20 women. For all patients, Adpl level and proportion of its different forms were measured. Differences between groups were evaluated by Rank-Sum tests. The relationship between these measures and BMI, blood gas analysis (PaO2, PaCO2), or lung function (FEV1, FEV1/FVC, TLCO, TLC, RV) were evaluated by Pearson correlation analysis.

RESULTS

Despite similar age, BMI and obstruction severity, women had a higher TLC and RV (median: TLC = 105%; RV = 166%) than men (median: TLC = 87%; RV = 132%). Adpl level was higher in women (median = 11,152 ng/ml) than in men (median = 10,239 ng/ml) and was negatively associated with hyperinflation (R = - 0,43) and hypercapnia (R = - 0,42). The proportion of the most active forms of Ad (HMW) was increased in hypoxemic women (median = 10%) compared with non-hypoxemic women (median = 8%) but was not modulated in men.

CONCLUSION

COPD pathophysiology seemed to be different in hypoxemic women and was associated to Ad modulations. Hyperinflation and air-trapping in association with hypercapnia and hypoxaemia, could contribute to a modulation of Adpl level and of its HMW forms. These results suggest the development of a distinct endotypic presentation, based on gender.

Sex Differences in Veterans Admitted to the Hospital for Chronic Obstructive Pulmonary Disease Exacerbation

Rationale: As chronic obstructive pulmonary disease (COPD) prevalence in women has outpaced that in men, COPD-related hospitalization and mortality are now higher in women. Presentation, evaluation, and treatment of COPD differ between women and men. Despite higher smoking rates in Veterans, little work has characterized differences in Veterans with COPD by sex. Objectives: To determine risk factors for 30-day readmission among Veterans hospitalized for COPD exacerbations and how they differed by sex. Methods: We performed a retrospective observational analysis of Veterans receiving primary care in Veterans Health Affairs facilities. We included Veterans Administration-based hospitalizations for Veterans with a COPD exacerbation (identified by International Classification of Disease, Ninth Revision codes) who survived to discharge between fiscal years 2012 and 2015. Primary outcome was 30-day readmission. Predictors ascertained before hospitalization included smoking status (current, former, never), pulmonary function testing, pulmonary medication prescriptions, and medical and psychiatric comorbidities (identified by International Classification of Disease, ninth revision codes). We created combined and sex-stratified multivariate logistic regression models to identify associations with 30-day readmission. Results: Our sample included 48,888 Veterans (4% women). Compared with men, women Veterans were younger, more likely to be nonwhite, and differed in smoking status. Women were more likely to have asthma, drug use, and several psychiatric comorbidities. Before hospitalization, women were less likely to have pulmonary function testing (76% vs. 78%; P = 0.01) or be treated with antimuscarinic (43% vs. 48%) or combined long-acting bronchodilator/inhaled corticosteroid (61% vs. 64%) inhalers. Women were more likely to receive nicotine-replacement therapy (all P < 0.01). Women had shorter length of stay (median days, 2 vs. 3; P = 0.04) and lower 30-day readmission rate (20% vs. 22%; P = 0.01). In adjusted models including both sexes, age, antimuscarinic use, comorbidities, and diagnosis of drug or alcohol use were associated with readmission; there was no association with sex and readmission risk. In models stratified by sex, associations were similar between women and men. Conclusions: This study suggests differences between women and men hospitalized for COPD regarding presentation, evaluation, and management. Readmission is strongly influenced by comorbidities, suggesting individualized and comprehensive case management may reduce readmission risk for women and men with COPD.

Celebration of the 50-Year Anniversary of the National Heart, Lung, and Blood Institute Division of Lung Diseases: A Half-Century of Landmark Clinical Trials

The National Institutes of Health (NIH)-National Heart, Lung, and Blood Institute's (NHLBI) Division of Lung Diseases is celebrating its 50th anniversary. On this occasion, we are reviewing the major landmark clinical trials that were initiated by the NHLBI's Division of Lung Disease and that have had substantial impact on our understanding of chronic obstructive pulmonary disease (COPD) and how it is best treated. Although some of these trials did not show hypothesized treatment benefits for COPD, they have enabled clinicians to provide care for individuals with COPD relying on the most rigorous evidence. The 5 trials that are reviewed here are: the Intermittent Positive Pressure Breathing Trial, the Nocturnal Oxygen Treatment Trial, the Lung Health Study, the National Emphysema Treatment Trial, and the Long-term Oxygen Treatment Trial. These clinical trials have not only set the standards for COPD care but have served as models for the state-of-the-art conduct of clinical research in COPD.

Factors associated with appendicular skeletal muscle mass among male Chinese patients with stable chronic obstructive pulmonary disease: A hospital-based cross-sectional study

Limbs muscle wasting is a common disorder in patients with chronic obstructive pulmonary disease (COPD) that limits daily activities and exercise intolerance, especially in males. The present study aimed to estimate the prevalence of appendicular skeletal muscle mass (ASM) in male patients with stable COPD. In addition, factors associated with parameters of ASM were also investigated.We recruited 116 male patients with stable COPD from the outpatient clinic between September 2016 and December 2017. For each patient, we obtained demographic characteristics and measured post-bronchodilator forced expiratory volume in 1 second, symptoms, exacerbations history, and ASM. ASM was defined as the sum of the muscle masses of the 4 limbs.Appendicular skeletal muscle mass index (ASMI) in male patients with stable COPD was 8.2 ± 0.9 kg/m, and the prevalence of low skeletal muscle mass was 7.8% (9 of 116 patients). Multiple linear-regression analysis showed that body mass index, occupation, fat-free mass index, and the modified medical research council scale were significantly correlated with ASMI. Compared with nonexercise group, lower limb muscle mass and ASM were significantly improved in physical exercise group.Underweight, retirement, fat-free mass depletion, and severe dyspnea are all risk factors for ASM in male patients with stable COPD. Our findings also justify the importance of exercise training in improving ASM.

Effects of short-term smoking on lung function and airway hyper-responsiveness in young patients with untreated intermittent adult-onset asthma: retrospective cross-sectional study at a primary-tertiary care hospital in Japan

OBJECTIVE

In daily clinical practice, smokers with asthma and with intermittent disease severity are frequently encountered. The effects of short-term smoking on lung function or disease presentation in younger patients with intermittent adult-onset asthma remain unclear. We sought to clarify the effects of short-term smoking (<10 pack-years) on lung function and airway hyper-responsiveness (AHR) in young patients with untreated intermittent adult-onset asthma.

DESIGN

Retrospective, cross-sectional study.

SETTING

A single primary-tertiary medical centre in Japan.

PARTICIPANTS

From patients who underwent bronchodilator reversibility tests between January 2004 and March 2011 (n=7291), 262 consecutive patients (age, 20-34 years) with untreated intermittent adult-onset asthma, including 157 never smokers and 105 current smokers within 10 pack-years, were analysed.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the association of the daily smoking frequency (number of cigarettes per day), smoking duration (years) and cumulative smoking history (pack-years) with postbronchodilator lung function. The secondary outcome was the association of the former three smoking parameters with AHR.

RESULTS

The daily smoking frequency, smoking duration and cumulative smoking history were significantly associated with decreased postbronchodilator lung function. Daily smoking of ≥11 cigarettes per day was also associated with marked AHR (OR 2.23; 95% CI 1.03 to 4.80), even after adjustment for age, sex, disease duration and body mass index.

CONCLUSION

Short-term active smoking in early adulthood may be associated with decreased lung function and AHR, even in patients with intermittent adult-onset asthma. Our findings suggest a benefit of never smoking, even for young patients with intermittent adult-onset asthma.

Relative and absolute lung function change in a general population aged 60-102 years

Data on longitudinal lung function change in the elderly are scarce. Uncertainty remains about whether to use absolute or relative change and how it relates to subject demographics.

We studied absolute and relative forced expiratory volume in 1 s (FEV₁) and forced vital capacity (FVC) change in a population-based geriatric sample using a repeated measurements model adjusted for age, sex, smoking habits, heart failure, hypertension, diabetes, coronary heart disease, educational level, occupation, alcohol consumption, C-reactive protein (CRP) and body mass index. 3736 participants aged 60–102 years completed between one and five spirometries during 13.5 years of follow-up. Lung volumes, FEV₁ quotient (Q) and Global Lung Initiative (GLI)-2012 and National Health and Nutrition Examination Survey (NHANES) III z-scores were presented from 6932 spirometries.

Adjusted absolute change per year (95% CI) was −51.7 (−63.7–−39.9) mL for FEV₁ and −56.2 (−73.6–−38.8) mL for FVC. Adjusted relative change per year was −2.97 (−3.53–−2.40)% for FEV₁ and −2.46 (−3.07–−1.85)% for FVC. Risk factors for increased relative FVC and FEV₁ decline were female sex, higher age, current smoking habits, elevated CRP (nonsignificant for FEV₁, p=0.057) and low educational level. For increased absolute decline the risk factors were male sex and being a current smoker for FEV₁ and low education for FVC.

Relative but not absolute change correlated significantly with clinically relevant markers of functional status and may be superior to absolute change in risk factor analysis. Cross-sectional reduction in terms of FEV₁Q was ∼1 unit per 10 years for both sexes. Proportions of subjects with results below lower limit of normal using NHANES III were close to anticipated, but were two to four times higher than expected using GLI-2012.

Female sex, ageing and inflammation significantly increased relative but not absolute lung function decline in new Swedish study. NHANES III may offer better lung function reference equations than GLI for elderly: findings from a large cohort aged 65–102.http://ow.ly/Szca30n3JDo

Efficacy of aclidinium/formoterol 400/12 µg, analyzed by airflow obstruction severity, age, sex, and exacerbation history: pooled analysis of ACLIFORM and AUGMENT

Background

Aclidinium/formoterol 400/12 µg is a twice-daily maintenance bronchodilator for COPD. This post hoc study evaluated aclidinium/formoterol vs aclidinium 400 µg, formoterol 12 µg, or placebo in patient subgroups.

Patients and methods

Data were pooled from two 24-week Phase III clinical trials (ACLIFORM and AUGMENT). Patients (N=3,394) were analyzed by baseline airflow obstruction severity (moderate/severe), age (<65/≥65 years), sex, and exacerbation history (0/≥1 exacerbation in the previous 12 months). Changes from baseline vs placebo and mono-therapies were evaluated: morning pre-dose (trough) and morning 1-hour post-dose FEV₁, Transition Dyspnea Index (TDI), and moderate/severe exacerbation rates (healthcare resource utilization [HCRU] and EXAcerbations of Chronic pulmonary disease Tool [EXACT] criteria).

Results

Aclidinium/formoterol improved the post-dose FEV₁ vs placebo and monotherapy in all subgroups (all P<0.01) and trough FEV₁ vs placebo (P<0.001) and formoterol (P<0.05) across all subgroups. Improvements in trough FEV₁ were observed vs aclidinium in patients with severe airflow obstruction, patients aged <65 years, males, and patients with exacerbation history (P<0.05). Improvements in TDI were observed vs placebo in all subgroups (all P<0.001), monotherapies for patients with moderate (formoterol P<0.05) or severe airflow obstruction (aclidinium P<0.05), patients aged <65 years (aclidinium P<0.01, formoterol P<0.05), males (formoterol P<0.05), and patients with no exacerbation history (formoterol P<0.05). HCRU exacerbation rates were lower for aclidinium/formoterol vs placebo in patients with no exacerbation history (P<0.01). EXACT exacerbation rates were lower for aclidinium/formoterol in patients with moderate airflow obstruction vs placebo and aclidinium, patients aged <65 years vs placebo and ≥65 years vs formoterol, males vs placebo, and patients with no exacerbation history vs placebo (all P<0.05).

Conclusion

Aclidinium/formoterol significantly improved post-dose FEV₁, trough FEV₁, and TDI vs placebo across all subgroups and vs monotherapy in many subgroups. These findings further support the benefits of aclidinium/formoterol for all patients with COPD.

In Vitro and In Vivo Experimental Studies of PM2.5 on Disease Progression

Air pollution is a very critical issue worldwide, particularly in developing countries. Particulate matter (PM) is a type of air pollution that comprises a heterogeneous mixture of different particle sizes and chemical compositions. There are various sources of fine PM (PM2.5), and the components may also have different effects on people. The pathogenesis of PM2.5 in several diseases remains to be clarified. There is a long history of epidemiological research on PM2.5 in several diseases. Numerous studies show that PM2.5 can induce a variety of chronic diseases, such as respiratory system damage, cardiovascular dysfunction, and diabetes mellitus. However, the epidemiological evidence associated with potential mechanisms in the progression of diseases need to be proved precisely through in vitro and in vivo investigations. Suggested mechanisms of PM2.5 that lead to adverse effects and chronic diseases include increasing oxidative stress, inflammatory responses, and genotoxicity. The aim of this review is to provide a brief overview of in vitro and in vivo experimental studies of PM2.5 in the progression of various diseases from the last decade. The summarized research results could provide clear information about the mechanisms and progression of PM2.5-induced disease.

COPD Care in the 21st Century: A Public Health Priority

COPD is an underdiagnosed, undertreated, and yet largely preventable disease. COPD affects millions of Americans on a daily basis, accounts for tens of thousands of deaths per year, and costs billions to the United States health-care system annually. Further, it impacts the quality of life for patients living with the disease. COPD care is fragmented in the United States, with a high level of responsibility placed on patients and their primary care physicians. Pulmonary specialists care for a minority of patients with COPD in the United States. Unfortunately, tobacco dependence, which is the leading cause of COPD, remains prevalent. Further, women and those with low socioeconomic status continue to share a relatively greater burden of disease. Exacerbations are experienced frequently by patients and contribute to high rates of emergency department visits and in-patient admissions and readmissions as well as high medical costs to the United States economy. Numerous strategies have been proposed to combat these high rates, including the use of discharge bundles, hospital at-home programs, telemedicine, and tele-rehabilitation, but no single best strategy has emerged. The COPD National Action Plan was introduced in 2017 as part of a multi-stakeholder endeavor to encourage collaboration among various patients, caregivers, physicians, researchers, and policymakers to optimize awareness, diagnosis, and treatment of this disease. It is time to make COPD care a public health priority.

Global association between ambient air pollution and blood pressure: A systematic review and meta-analysis

Although numerous studies have investigated the association of ambient air pollution with hypertension and blood pressure (BP), the results were inconsistent. We performed a comprehensive systematic review and meta-analysis of these studies. Seven international and Chinese databases were searched for studies examining the associations of particulate (diameter<2.5 μm (PM_2.5), 2.5-10 μm (PM_2.5-10) or >10 μm (PM₁₀)) and gaseous (sulfur dioxide (SO₂), nitrogen dioxide (NO₂), nitrogen oxides (NO_x), ozone (O₃), carbon monoxide (CO)) air pollutants with hypertension or BP. Odds ratios (OR), regression coefficients (β) and their 95% confidence intervals were calculated to evaluate the strength of the associations. Subgroup analysis, sensitivity analysis, and meta-regression analysis were also conducted. The overall meta-analysis showed significant associations of long-term exposures to PM_2.5 with hypertension (OR = 1.05), and of PM₁₀, PM_2.5, and NO₂ with DBP (β values: 0.47-0.86 mmHg). In addition, short-term exposures to four (PM₁₀, PM_2.5, SO₂, NO₂), two (PM_2.5 and SO₂), and four air pollutants (PM₁₀, PM_2.5, SO₂, and NO₂), were significantly associated with hypertension (ORs: 1.05-1.10), SBP (β values: 0.53-0.75 mmHg) and DBP (β values: 0.15-0.64 mmHg), respectively. Stratified analyses showed a generally stronger relationship among studies of men, Asians, North Americans, and areas with higher air pollutant levels. In conclusion, our study indicates a positive association between ambient air pollution and increased BP and hypertension. Geographical and socio-demographic factors may modify the pro-hypertensive effects of air pollutants.

Long-term exposure to fine particulate matter air pollution and type 2 diabetes mellitus in elderly: A cohort study in Hong Kong

BACKGROUND

Evidence for the link between long-term air pollution exposure and occurrence of diabetes is limited and the results are mixed.

OBJECTIVES

We aimed to assess the association of long-term residential exposure to fine particulate matter (PM_2.5) with the prevalence and incidence of type 2 diabetes mellitus (DM).

METHODS

This is a prospective cohort study. We studied 61,447 participants of the Chinese Elderly Health Services cohort in Hong Kong enrolled 1998-2001 and followed participants without DM at baseline to 31 December 2010 to ascertain the first hospital admissions for type 2 DM. Yearly mean residential PM_2.5 exposure was predicted based on satellite data. Logistic regression and time-varying Cox regression model were used to evaluate the prevalence and incidence risk of DM associated with PM_2.5 while adjusting for potential individual and neighborhood confounders.

RESULTS

There were 61,447 participants included in the study of prevalent DM, and in 53,905 participants without DM at baseline we studied incident type 2 DM. Over a mean follow-up of 9.8 years, we ascertained 806 incident cases of type 2 DM. After adjusting for potential confounders, the odds ratio (OR) for every interquartile range (3.2 μg/m³) increase of PM_2.5 concentration was 1.06 (95% confidence interval (CI): 1.01-1.11) for prevalent DM, while the corresponding hazard ratio (HR) was 1.15 (95% CI: 1.05-1.25) for incident type 2 DM.

CONCLUSIONS

Long-term exposure to high levels of PM_2.5 may increase the risk of both prevalence and incidence of type 2 diabetes mellitus in Hong Kong elderly population.

Clinical and pulmonary functions profiling of patients with chronic obstructive pulmonary disease experiencing frequent acute exacerbations

Purpose:

The present study aimed at clinical and pulmonary functions profiling of patients with chronic obstructive pulmonary disease (COPD) to anticipate future exacerbations.

Methods:

The study included 80 COPD patients; 40 patients had ≥2 acute exacerbations during preceding 1 year (frequent exacerbation [FECOPD] group) and 40 patients had <2 acute exacerbations during preceding 1 year (infrequent exacerbation [I-FECOPD] group). Clinical profile, sputum microbiology, blood gas analysis, spirometric indices, and diffusion capacity (transfer test) variables were assessed. Groups’ comparison was performed using an independent t-test for numeric scale parameters and Chi-square test for nominal parameters. Pearson's and Spearman's correlation coefficients were derived for numeric scale parameters and numeric nominal parameters, respectively. Multinomial logistic regression analysis was done using SPSS software.

Results:

FECOPD group contained younger patients than in I-FECOPD group although the difference was not statistically significant. There was no significant difference between two groups regarding smoking pack-years and duration of illness. FECOPD group had significantly more expectoration score and Modified Medical Research Council dyspnea scores. Cough score and wheeze score did not differ significantly between two groups. More patients in FECOPD group (12/40 vs. 4/40) had lower airway bacterial colonization. Arterial blood gas parameters were more deranged in FECOPD group. Spirometric indices (forced expiratory volume during 1^st s) as well as transfer test (both diffusing capacity for carbon monoxide and transfer coefficient of the lung values) were significantly reduced in FECOPD group.

Conclusions:

The patients in FECOPD group had clinical, spirometric, and transfer test profiling suggestive of a severe COPD phenotype, the recognition will help in predicting future exacerbations and a better management.

Responsiveness to Ipratropium Bromide in Male and Female Patients with Mild to Moderate Chronic Obstructive Pulmonary Disease

Introduction

Although the prevalence of chronic obstructive pulmonary disease (COPD) is similar between men and women, current evidence used to support bronchodilator therapy has been generated in therapeutic trials that have predominately enrolled male patients. Here, we determined whether there is any significant sex-related differences in FEV₁ responses to ipratropium bromide.

Methods

Data from the Lung Health Study (n = 5887; 37% females) were used to determine changes in FEV₁ with ipratropium or placebo in male and female subjects with mild to moderate COPD over 5 years. Lung Expression Quantitative Trait Loci (eQTL) dataset was used to determine whether there were any sex-related differences in gene expression for muscarinic (M2 and M3) receptors in lungs of male and female patients.

Results

After 4 months, ipratropium therapy increased FEV₁ by 6.0% in female and 2.9% in male subjects from baseline values (p = 2.42 × 10^− 16). This effect was modified by body mass index (BMI) such that the biggest improvements in FEV₁ with ipratropium were observed in thin female subjects (p for BMI ∗ sex interaction = 0.044). The sex-related changes in FEV₁ related to ipratropium persisted for 2 years (p = 0.0134). Female compared with male lungs had greater gene expression for M3 relative to M2 receptors (p = 6.86 × 10^− 8).

Conclusion

Ipratropium induces a larger bronchodilator response in female than in male patients and the benefits are particularly notable in non-obese females. Female lungs have greater gene expression for the M3 muscarinic receptor relative to M2 receptors than male lungs. Female patients are thus more likely to benefit from ipratropium than male COPD patients.

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Ipratropium; a muscarinic antagonist bronchodilator is more effective in female COPD patients compared to males.

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The effect was modified by body mass index (BMI) such that thin female subjects respond better.

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Female compared with male lungs had greater gene expression for the M3/M2 ratio of muscarinic receptors.

Most evidence used to support bronchodilator therapy in COPD has been generated in therapeutic trials with predominately male patients. Here, we determined whether there are any significant sex-related differences in lung function responses to the bronchodilator ipratropium bromide. After 4 months, ipratropium therapy increased lung function in females twice as much as males. This effect was modified by body mass index (BMI) such that the biggest improvements in lung function with ipratropium were observed in thin female subjects. Female compared with male lungs had greater gene expression for ipratropium receptors. Female patients are likely to benefit more from ipratropium than male COPD patients.

Sex differences in function and structure of the quadriceps muscle in chronic obstructive pulmonary disease patients

Chronic obstructive pulmonary disease (COPD) is a complex disorder with extrapulmonary manifestations. Even though there is some knowledge regarding sex differences in the lung disease, little is known about extrapulmonary manifestations. Our aim was to analyze the specific profile of muscle dysfunction, structure, and biology in COPD women. Twenty-one women and 19 men with stable COPD as well as 15 controls were included. Nutritional status, physical activity, lung and muscle function, exercise capacity, and quality of life were assessed. In addition, blood, breath condensate, and quadriceps muscle samples were tested for inflammatory markers. Moreover, fiber phenotype, signs of damage-regeneration, and the expression of key genes linked to myogenesis and inflammation were assessed in the muscle. Inflammatory markers were increased in all body compartments but no correlation was found among them. Muscle dysfunction was present in both COPD groups but was more marked in women. The opposite occurred with the increase in the percentage of type II fibers that was lower in women despite a similar level of airway obstruction as in men. Female COPD also showed higher signs of muscle damage than COPD men who, in contrast, exhibited slightly higher signs of regeneration. We conclude that sex influences muscle phenotype and function in COPD.

Obesity Is Associated With Increased Morbidity in Moderate to Severe COPD

BACKGROUND

Obesity is prevalent in the United States; however, the impact of obesity on COPD morbidity is unclear. We hypothesized that obesity is associated with worse outcomes in COPD.

METHODS

We examined 3,631 participants from the multicenter prospective cohort study Genetic Epidemiology of COPD (COPDGene) who had spirometry-confirmed COPD, a postbronchodilator FEV₁ < 80% predicted, and a BMI ≥ 18.5 kg/m². We conducted logistic and linear regression analyses to determine the association between COPD outcomes and obesity class, adjusting for relevant confounders. The referent for obesity classes included normal/overweight individuals (BMI range, 18.5-29.9 kg/m²).

RESULTS

Overall, 35% of participants were obese, with 21% class I (BMI range, 30-34.9 kg/m²), 9% class II (BMI range, 35-39.9 kg/m²), and 5% class III (BMI ≥ 40 kg/m²). The number of comorbidities increased with increasing obesity class (P < .001). Increasing obesity class was independently associated with worse respiratory-specific and general quality of life (QOL) (St. George's Respiratory Questionnaire score and Short Form-36 score version 2, respectively), reduced 6-min walk distance (6MWD), increased dyspnea (Modified Medical Research Council score ≥ 2), and greater odds of severe acute exacerbation of COPD (AECOPD). The associations between obesity and worse outcomes were independent of the presence of comorbidities, except in the case of SF-36 and severe exacerbations.

CONCLUSIONS

Obesity is prevalent among individuals with COPD and associated with worse COPD-related outcomes, ranging from QOL and dyspnea to 6MWD and severe AECOPD. These associations were strengthened when obesity was analyzed as a dose-dependent response. Obesity in patients with COPD may contribute to a worse COPD-related course.

Sex differences of COPD phenotypes in nonsmoking patients

BACKGROUND

There is growing evidence about sex-related phenotypes of COPD. However, the sex differences in COPD mainly result from smokers. This study evaluated the sex differences in nonsmoking patients with COPD, focusing on structural changes in the lungs in airway diseases and emphysema.

METHODS

Ninety-seven nonsmoking patients, defined as having <1 pack-year of lifetime cigarette smoking, diagnosed with COPD were selected from a Korean COPD cohort. Emphysema extent and mean wall area percentage (WA%) on computed tomography were compared between the male and female groups.

RESULTS

The 97 patients with COPD included 62 females and 35 males. Emphysema index was significantly lower (3.5±4.2 vs 6.2±5.7, P<0.01) and mean WA% on computed tomography was significantly higher (71.8%±5% vs 69.4%±5%, P<0.01) in females than in males, after adjusting for age, body mass index, history of biomass exposure, and postbronchodilator forced expiratory volume in 1 second (% of predicted).

CONCLUSION

WA% was higher and emphysema extent was lower in nonsmoking females with COPD than in nonsmoking males with COPD. These findings suggest that males may be predisposed to an emphysema phenotype and females may be predisposed to an airway phenotype of COPD.

Elderly Female Rhesus Macaques Preserve Lung Alveoli With Estrogen/Progesterone Therapy

The aging lung is associated with increased susceptibility to chronic inflammatory diseases such as chronic obstructive pulmonary disease where females have been reported to be more susceptible than males. The changes in reproductive hormones due to aging may directly or indirectly affect lung structure and function and little is known on the mechanism of these changes. Twenty female rhesus macaques were divided into four groups. Ovariectomy (OVX) was performed on eight animals with three receiving estrogen/progesterone therapy (HRT) and five animals given implants containing vehicle. The remaining 12 animals represented control groups of ages 10-14 years (n = 6) and ages 20-24 (n = 6). A design-based stereological method was employed to estimate the number of alveoli in the right middle lung lobe along with hormone analysis for possible correlation. A significant decrease was found in the number of alveoli in the vehicle OVX animals compared to intact younger adult females (P < 0.001). A significant increase in alveoli between OVX vehicle animals and those on HRT was also found (P < 0.0001). There was difference in the number of alveoli between younger adult animals and animals on HRT. The loss of ovaries and hormones had a significant effect on alveolar lung morphology. This result mimics what is seen in the aging process and could contribute to gender differences reported in the elderly. Hormone replacement, as reported here, could possibly slow the loss of alveoli due to the aging process or aid in alveolar regeneration through direct or indirect mechanisms. Anat Rec, 299:973-978, 2016. © 2016 Wiley Periodicals, Inc.

Sex-specific IL-6-associated signaling activation in ozone-induced lung inflammation

Background

Acute ozone (O₃) exposure has known deleterious effects on the respiratory system and has been linked with respiratory disease and infection. Inflammatory lung disease induced by air pollution has demonstrated greater severity and poorer prognosis in women vs. men. Both severe damage to the bronchial-alveolar epithelium and malfunctioning of bronchial-blood barrier have been largely attributed to the pathobiology of O₃-induced inflammatory response, but the associated mechanisms in the male and female lung remain unknown.

Methods

Here, we investigated sex-based differential regulation of lung interleukin-6 (IL-6) and its downstream signaling pathways JAK2/STAT3 and AKT1/NF-κB in response to O₃ exposure in a mouse model. We exposed male and female mice (in different stages of the estrous cycle) to 2 ppm of O₃ or filtered air (FA) for 3 h, and we harvested lung tissue for protein expression analysis by Western blot.

Results

We found significant up-regulation of IL-6 and IL-6R in females and IL-6 in males in response to O₃ vs. FA. Ozone exposure induced a significant increase in STAT3-Y705 phosphorylation in both females and males. Males exposed to O₃ had decreased levels of JAK2, but increased JAK2 (Y1007+Y1008) phosphorylation, while females exposed to O₃ showed significant up-regulation of both proteins. Both NF-κB (p105/p50) and AKT1 protein levels were significantly increased only in females exposed to O₃. In addition, females exposed to O₃ during proestrus displayed increased expression of selected genes when compared to females exposed to O₃ in other estrous cycle stages.

Conclusions

Together, our observations indicate a sex-based and estrous cycle-dependent differential lung inflammatory response to O₃ and involvement of two converging JAK2/STAT3 and AKT1/NF-κB pathways. To our knowledge, this is the first study specifically addressing the impact of the estrous cycle in O₃-associated lung inflammatory pathways.

Electronic supplementary material

The online version of this article (doi:10.1186/s13293-016-0069-7) contains supplementary material, which is available to authorized users.

Effects on pulmonary rehabilitation in patients with COPD or ILD: A retrospective analysis of clinical and functional predictors with particular emphasis on gender

BACKGROUND

The response of patients in a pulmonary rehabilitation (PR) is essentially good. However, not all patients benefit from PR to the same extent. In this analysis we wanted to identify the impact of gender and other factors on PR outcomes in patients with chronic obstructive pulmonary disease (COPD) or interstitial lung disease (ILD).

METHODS

Patients suffering from COPD (n = 1492) or ILD (n = 599), treated during an inpatient PR between 1997 and 2015, were analysed according to the effects of PR on exercise capacity and quality of life with regard to the impact of gender or other predictors by univariate and multivariate analyzes.

RESULTS

In the group of COPD patients, 30% did not achieve the expected physical performance during the 6-min walk test (28% of female and 32% of male patients). However, the non-responders initially have had a higher 6-min walking distance (6-MWD) (p < 0.001) and both male and female showed a significant lower BODE index (p = 0.025) in the multivariate analysis. In the ILD-group, 37% females and 43% males were classified as non-responders with regard to the 6-MWD. Also in this group, the non-responders initially have had a higher 6-MWD (p < 0.001). All other variables (age, BMI, lung function, blood gases, C-reactive Protein, Haemoglobin or rehabilitation duration) had no influence on the outcome.

CONCLUSION

Our study supports the positive effects of PR in COPD and ILD patients. In both groups, patients with the biggest limitations benefit most from PR. However, relevant gender differences or other predictors could not be found.

Incidence of airflow limitation in subjects 65-100 years of age

The true incidence of chronic obstructive pulmonary disease is largely unknown, because the few longitudinal studies performed have used diagnostic criteria no longer recommended by either the European Respiratory Society or the American Thoracic Society (ATS).We studied the incidence and significance of airflow limitation in a population-based geriatric sample using both an age-dependent predicted lower limit of normal (LLN) value and a fixed-ratio spirometric criterion.Out of 2025 subjects with acceptable spirometry at baseline, 984 subjects aged 65-100 years completed a 6-year follow-up visit. Smoking habits were registered at baseline. Exclusion criteria were non-acceptable spirometry performance according to ATS criteria and inability to communicate. Airflow limitation was defined both according to forced expiratory volume in 1 s (FEV1)/forced vital capacity ratio <0.7 and Collapse

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MESH Headings

• Age Factors
• Aged
• Aged, 80 and over
• Cohort Studies
• Female
• Forced Expiratory Volume
• Humans
• Incidence
• Longitudinal Studies
• Male
• Prospective Studies
• Pulmonary Disease, Chronic Obstructive/diagnosis
• Pulmonary Disease, Chronic Obstructive/epidemiology
• Pulmonary Disease, Chronic Obstructive/physiopathology
• Sex Factors
• Smoking/epidemiology
• Spirometry
• Sweden/epidemiology
• Vital Capacity

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Grants Collapse

Affiliation(s)

Johannes A Luoto Dept of Health Sciences, Division of Geriatric Medicine, Scania University Hospital, Lund University, Malmö, Sweden
Sölve Elmståhl Dept of Health Sciences, Division of Geriatric Medicine, Scania University Hospital, Lund University, Malmö, Sweden
Per Wollmer Clinical Physiology and Nuclear Medicine Unit, Dept of Translational Medicine, Scania University Hospital, Lund University, Malmö, Sweden
Mats Pihlsgård Dept of Health Sciences, Division of Geriatric Medicine, Scania University Hospital, Lund University, Malmö, Sweden

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Bronchial hyperresponsiveness

BACKGROUND

Bronchial hyperresponsiveness (BHR) is often regarded as a 'hallmark' of asthma and bronchoprovocation testing is frequently performed to support a diagnosis of asthma. However, BHR is also found in a spectrum of other lung diseases and can be provoked by a variety of specific stimuli.

AIMS

To review the pathophysiology of BHR, discuss various methods of testing for BHR and describe the epidemiology of BHR in a variety of previously studied populations.

METHODS

We performed a systematic review of references identified using Medline and hand searches of identified articles. Because of space limitations, we have included those reports that seem most representative of the overall BHR literature.

RESULTS

BHR can be induced by a variety of stimuli that trigger a number of different but overlapping physiological mechanisms. Bronchoprovocation testing can be performed using a variety of stimuli, various protocols and differing test criteria, yielding results that may be discordant. Elevated rates of BHR have been reported in studies of smokers, chronic obstructive pulmonary disease patients, atopics, athletes, exposed workers and the general population.

CONCLUSIONS

Due to the prevalence of BHR in a spectrum of clinical patients and working populations, clinicians should be aware that BHR is not specific for asthma. When performed correctly, the greatest clinical value of BHR testing is to rule out suspected asthma in patients in whom testing is negative. Assessment of BHR also provides insights into the pathological mechanisms of airway disease.

Inflammatory and repair pathways induced in human bronchoalveolar lavage cells with ozone inhalation

Background

Inhalation of ambient levels of ozone causes airway inflammation and epithelial injury.

Methods

To examine the responses of airway cells to ozone-induced oxidative injury, 19 subjects (7 with asthma) were exposed to clean air (0ppb), medium (100ppb), and high (200ppb) ambient levels of ozone for 4h on three separate occasions in a climate-controlled chamber followed by bronchoscopy with bronchoalveolar lavage (BAL) 24h later. BAL cell mRNA expression was examined using Affymetrix GeneChip Microarray. The role of a differentially expressed gene (DEG) in epithelial injury was evaluated in an in vitro model of injury [16HBE14o- cell line scratch assay].

Results

Ozone exposure caused a dose-dependent up-regulation of several biologic pathways involved in inflammation and repair including chemokine and cytokine secretion, activity, and receptor binding; metalloproteinase and endopeptidase activity; adhesion, locomotion, and migration; and cell growth and tumorigenesis regulation. Asthmatic subjects had 1.7- to 3.8-fold higher expression of many DEGs suggestive of increased proinflammatory and matrix degradation and remodeling signals. The most highly up-regulated gene was osteopontin, the protein level of which in BAL fluid increased in a dose-dependent manner after ozone exposure. Asthmatic subjects had a disproportionate increase in non-polymerized osteopontin with increasing exposure to ozone. Treatment with polymeric, but not monomeric, osteopontin enhanced the migration of epithelial cells and wound closure in an α9β1 integrin-dependent manner.

Conclusions

Expression profiling of BAL cells after ozone exposure reveals potential regulatory genes and pathways activated by oxidative stress. One DEG, osteopontin, promotes epithelial wound healing in an in vitro model of injury.

Exposure to medium and high ambient levels of ozone causes adverse systemic inflammatory and cardiac autonomic effects

Epidemiological evidence suggests that exposure to ozone increases cardiovascular morbidity. However, the specific biological mechanisms mediating ozone-associated cardiovascular effects are unknown. To determine whether short-term exposure to ambient levels of ozone causes changes in biomarkers of cardiovascular disease including heart rate variability (HRV), systemic inflammation, and coagulability, 26 subjects were exposed to 0, 100, and 200 ppb ozone in random order for 4 h with intermittent exercise. HRV was measured and blood samples were obtained immediately before (0 h), immediately after (4 h), and 20 h after (24 h) each exposure. Bronchoscopy with bronchoalveolar lavage (BAL) was performed 20 h after exposure. Regression modeling was used to examine dose-response trends between the endpoints and ozone exposure. Inhalation of ozone induced dose-dependent adverse changes in the frequency domains of HRV across exposures consistent with increased sympathetic tone [increase of (parameter estimate ± SE) 0.4 ± 0.2 and 0.3 ± 0.1 in low- to high-frequency domain HRV ratio per 100 ppb increase in ozone at 4 h and 24 h, respectively (P = 0.02 and P = 0.01)] and a dose-dependent increase in serum C-reactive protein (CRP) across exposures at 24 h [increase of 0.61 ± 0.24 mg/l in CRP per 100 ppb increase in ozone (P = 0.01)]. Changes in HRV and CRP did not correlate with ozone-induced local lung inflammatory responses (BAL granulocytes, IL-6, or IL-8), but changes in HRV and CRP were associated with each other after adjustment for age and ozone level. Inhalation of ozone causes adverse systemic inflammatory and cardiac autonomic effects that may contribute to the cardiovascular mortality associated with short-term exposure.

COPD and gender differences: an update

Chronic obstructive lung disease (COPD) is one of the most prevalent health conditions, and a major cause of morbidity and mortality around the globe. Once thought of primarily as a disease of men, COPD is now known to be increasingly prevalent among women. Although increasing tobacco consumption among women during the past several decades might explain some of this increase, the relationship may be more complex, including factors such as differential susceptibility to tobacco, anatomic and hormonal differences, behavioral differences, and differences in response to available therapeutic modalities. Moreover, women with COPD may present differently, may have a different pattern of comorbidities, and may have a better survival after acute exacerbations. Care providers continue to have a gender bias that may affect both diagnosis and treatment. Future work should focus on factors that lead to gender differences in COPD as well as gender-specific treatment strategies.

Ventilation heterogeneity is associated with airway responsiveness in asthma but not COPD

Airway hyperresponsiveness (AHR) occurs in both asthma and COPD. In older people with asthma, AHR is associated with increased acinar ventilation heterogeneity, but it is unknown if this association exists in COPD. Thirty one COPD and 19 age-matched asthmatic subjects had measures of spirometry, lung volumes, exhaled nitric oxide, ventilation heterogeneity, and methacholine challenge. Indices of acinar (Sacin) and conducting (Scond) airway ventilation heterogeneity were calculated from the multiple breath nitrogen washout. Predictors of AHR were then determined. In COPD, AHR was predicted by lower Sacin and lower FVC (model r(2)=0.35, p=0.001). In asthma, AHR was predicted by higher Sacin and higher residual volume (model r(2)=0.62, p<0.001). These findings suggest that airway responsiveness in COPD and asthma is determined by underlying disease-specific processes, rather than a common pattern of physiological abnormality.

Bronchial responsiveness to dry air hyperventilation in smokers may predict decline in airway status using indirect methods

Background

Disabling respiratory symptoms and rapid decline of lung function may occur in susceptible tobacco smokers. Bronchial hyperresponsiveness (BHR) elicited by direct challenge methods predicts worse lung function outcomes. The aim of this study was to evaluate whether BHR to isocapnic hyperventilation of dry air (IHDA) was associated with rapid deterioration in airway status and respiratory symptoms.

Methods

One hundred twenty-eight smokers and 26 age- and sex-matched healthy individuals with no history of smoking were investigated. All subjects completed a questionnaire. Spirometry and impulse oscillometry (IOS) measurements were recorded before and after 4 min of IHDA. The tests were repeated after 3 years in 102 smokers and 11 controls.

Results

Eighty-five smokers (66 %) responded to the challenge with a ≥2.4-Hz increase in resonant frequency (F_res), the cutoff limit defining BHR, as recorded by IOS. They had higher F_res at baseline compared to nonresponding smokers [12.8 ± 3.2 vs. 11.5 ± 3.4 Hz (p < 0.05)] and lower FEV₁ [83 ± 13 vs. 89 ± 13 % predicted (p < 0.05)]. Multivariable logistic regression analysis indicated that wheezing (odds ratio = 3.7, p < 0.01) and coughing (odds ratio = 8.1, p < 0.05) were significantly associated with hyperresponsiveness. An increase in F_res was recorded after 3 years in responding smokers but not in nonresponders or controls. The difference remained when subjects with COPD were excluded.

Conclusions

The proportion of hyperresponsive smokers was unexpectedly high and there was a close association between wheezing and coughing and BHR. Only BHR could discriminate smokers with rapid deterioration of airway status from others.

Rationale for earlier treatment in COPD: a systematic review of published literature in mild-to-moderate COPD

COPD is progressive and typically begins many years before a definite diagnosis is made. As the rate of decline in lung function may be faster in the initial stages of the disease, early intervention could be beneficial to control symptoms and affect disease progression and outcomes. A systematic review of published literature relating to mild-to-moderate COPD (patients with FEV(1) ≥50% predicted) was performed to evaluate the level of impairment and natural history or disease progression over time, and impact of interventions on the outcomes of patients with early-stage disease. Of the 79 published articles included in this analysis, 31 reported randomized controlled trials; the remaining 48 articles reported studies of non-randomized and/or observational design. Nine of the randomized controlled trials were ≥6 months' duration, enabling assessment of outcomes over time. Most of the randomized controlled trials were in patients with moderate COPD (GOLD stage II); few included patients with the mildest stages of the disease (i.e., stage I). The results show that even patients with milder or moderate COPD can have substantial limitations and physical impairment, which worsen over time. Encouragement of smoking cessation, in conjunction with management of symptoms and treating activity limitation and exacerbations by appropriate non-pharmacologic and pharmacologic management at the earliest possible stage, could positively affect the impact and progression of the disease.

Sex Differences in the Effects of Inhaled Corticosteroids on Weight Gain among Patients with Asthma

Background. Studies have shown that asthma and asthma exacerbations are related to body weight and that this relationship might be sex-specific. While oral corticosteroids have been associated with weight gain, little is known about the effect of inhaled corticosteroid (ICS) use on short-term weight gain. The purpose of the present study was to examine whether ICSs would be associated with weight gain among asthmatic patients. Methods. A total of 180 adult patients with physician-diagnosed asthma provided details of their medical history and demographic information, along with height and weight at baseline and at one year. Weight change was defined as follow-up minus baseline weight. General linear models were used to assess the relationship between ICS dose (fluticasone propionate equivalent) and sex. Results. Significant main effects of sex (P=.005) and ICS dose (P=.036) and an interaction effect of sex and ICS dose (P=.003) on weight change were observed. Further analysis of the interaction indicated that women had greater weight gain, while men had decreased weight with increased ICS dose. Conclusions. Findings suggest that ICSs may trigger weight gain in females and highlight the need for studies to confirm this relationship and examine the potential underlying mechanisms.

Assessing the effect of high-repetitive single limb exercises (HRSLE) on exercise capacity and quality of life in patients with chronic obstructive pulmonary disease (COPD): study protocol for randomized controlled trial

Background

Single-limb knee extension exercises have been found to be effective at improving lower extremity exercise capacity in patients with chronic obstructive pulmonary disease (COPD). Since the positive local physiological effects of exercise training only occur in the engaged muscle(s), should upper extremity muscles also be included to determine the effect of single limb exercises in COPD patients.

Methods/design

Trial design: a prospective, assessor-blind, block randomized controlled, parallel-group multicenter trial. Participants: stage II-IV COPD patients, > 40 years of age, ex-smokers, with stable medical treatment will be included starting May 2011. Recruitment at three locations in Sweden. Interventions: 1) high-repetitive single limb exercise (HRSLE) training with elastic bands, 60 minutes, three times/week for 8 weeks combined with four sessions of 60 minutes patient education, or 2) the same patient education alone. Outcomes: Primary: determine the effects of HRSLE on local muscle endurance capacity (measured as meters walked during 6-minute walk test and rings moved on 6-minute ring and pegboard test) and quality of life (measured as change on the Swedish version of the Chronic Respiratory Disease Questionnaire). Secondary: effects on maximal strength, muscular endurance, dyspnea, self-efficacy, anxiety and depression. The relationship between changes in health-related variables and changes in exercise capacity, sex-related differences in training effects, feasibility of the program, strategies to determine adequate starting resistance and provide accurate resistance for each involved movement and the relationship between muscle fatigue and dyspnea in the different exercise tests will also be analyzed. Randomization: performed by a person independent of the recruitment process and using a computer random number generator. Stratification by center and gender with a 1:1 allocation to the intervention or control using random block sizes. Blinding: all outcome assessors will be blinded to group assignment.

Discussion

The results of this project will contribute to increase the body of knowledge regarding COPD and HRSLE.

Trial registration

ClinicalTrials.gov Identifier: NCT01354067. Registration date: 2011-05-11. First participant randomized: 2011-09-02

Early impact of smoking on lung function, health, and well-being in adolescents

BACKGROUND

Smoking is the single most important risk factor for the development of chronic obstructive pulmonary disease, and more than 80% of adult smokers started smoking before the age of 20. The aim of our study was to evaluate the early impact of smoking on lung function, health, and well-being in adolescents.

METHODS

Twenty-four non-smokers (10 male, 14 female, mean age 17.6 years) and 24 smokers (mean of 3.5 pack-years; 15 male, 9 female, mean age 17.8 years) were compared in terms of lung function, bronchial hyperreactivity (BHR), levels of exhaled carbon monoxide (eCO), exhaled nitric oxide (eNO), and blood counts. A questionnaire containing items from the ISAAC study was used to detect differences in health and well-being.

RESULTS

There were no significant differences in lung function values between non-smokers and smokers (VC 95% vs. 103%, FEV(1) 106% vs. 116%, FEV(1) %/VC MAX 94.6% vs. 95.2%), whereas BHR significantly differed (P < 0.05). Furthermore, significant differences were found for eCO, eNO, Hb, leukocytes, and neutrophils. Health and well-being in terms of sleep and physical activity were significantly worse in smokers.

CONCLUSION

Our results suggest an early impact of smoking on health after as few as 3.5 pack-years. Early signs of smoking are an increase in BHR, changes in blood count and a decrease of eNO even before changes in lung function become apparent.

Bronchial hyperresponsiveness in women with chronic obstructive pulmonary disease related to wood smoke

Purpose

Chronic obstructive pulmonary disease (COPD) related to wood smoke exposure is characterized by important inflammation of the central and peripheral airways without significant emphysema. The objective of this study is to describe the bronchial hyperresponsiveness (BHR) level in women with COPD related to wood smoke exposure and to compare it with the BHR in women with COPD related to tobacco smoking.

Materials and methods

Two groups of women with stable COPD were studied: (1) wood smoke exposed (WS-COPD); and (2) tobacco smoke exposed (TS-COPD). A methacholine challenge test (MCT) was performed in all patients according to American Thoracic Society criteria. BHR levels were compared using the methacholine concentration, which caused a 20% fall in the FEV₁ (PC₂₀).

Results

Thirty-one patients, 19 with WS-COPD and 12 with TS-COPD, were included. There were no significant differences between the groups in baseline FVC, FEV₁, IC, FEF_25–75, and FEF_25–75/FVC. All 31 patients had a positive MCT (PC₂₀ < 16 mg/mL) and the fall in the FEV₁ and IC was similar in both groups. The severity of BHR was significantly higher in the WS-COPD patients (PC₂₀: 0.39 mg/mL) than in the TS-COPD patients (PC₂₀: 1.24 mg/mL) (P = 0.028). The presence of cough, phlegm, and dyspnea during the test were similar in both groups.

Conclusion

We found moderate to severe BHR in women with WS-COPD, which was more severe than in the TS-COPD women with similar age and airflow obstruction. This paper suggests that the structural and inflammatory changes induced by the chronic exposure to wood smoke, described in other studies, can explain the differences with TS-COPD patients. Future studies may clarify our understanding of the impact of BHR on COPD physiopathology, phenotypes, and treatment strategies.

Reconsidering sex-based stereotypes of COPD

Chronic obstructive pulmonary disease (COPD) has historically been considered a disease of older, white, male smokers, as illustrated in Frank Netter's classic images of the 'pink puffer' and 'blue bloater'. However, women may be more susceptible to COPD than men, and the disease course may be reflective of that increased susceptibility. From a review of epidemiological data of COPD, we found differences in the way men and women present with COPD symptoms, a bias in the way COPD symptoms are treated in men and women, and differences in susceptibility to airway obstruction based on age, sex, and smoking history. These data show that classic stereotypes of COPD - including male predominance - should be abandoned, and that there are not two but multiple COPD phenotypes, which are characterised by differences between women and men in susceptibility, symptoms, and disease progression. These differences impact on physician perception. Although further research into this concept is needed, the differences we found should prompt, in the short term, changes in the way (and in whom) COPD is evaluated, diagnosed, and treated; in the long term, these differences should prompt research into the prognosis of COPD based on sex differences.

The relationship between inspiratory lung function parameters and airway hyper-responsiveness in subjects with mild to moderate COPD

BACKGROUND

The aim of this study was to evaluate the effects of increasing doses of inhaled histamine on the forced expiratory volume in one second (FEV1), inspiratory lung function parameters (ILPs) and dyspnea in subjects with mild to moderate chronic obstructive pulmonary disease (COPD) METHODS: Thirty-nine (27 males and 12 females) stable COPD patients (GOLD stages I and II) inhaled a maximum of six sequential doses of histamine according to ERS standards until one of these provocative doses produced a 20% decrease in FEV1 (PD20). The effects on the FEV1, the forced inspiratory volume in one second (FIV1), inspiratory capacity (IC), forced inspiratory flow at 50% of the vital capacity (FIF50), peak inspiratory flow (PIF) and dyspnea score by a visual analogue scale (VAS) were measured and investigated after each dose step

RESULTS

After each dose of histamine, declines in all of the lung function parameters were detected; the largest decrease was observed in the FEV1. At the PD20 endpoint, more FEV1 responders than ILP responders were found. Among the ILPs, the FIV1 and IC best predicted which patients would reach the PD20 endpoint. No significant correlations were found between any of the lung function parameters and the VAS results

CONCLUSIONS

In COPD patients, the FEV1 and ILPs declined after each dose of inhaled histamine. FEV1 was more sensitive to histamine than the ILPs. Of the ILPs, FIV1 and IC were the best predictors of reaching the PD20 endpoint. No statistically significant correlations were found between the lung function parameters and the degree of dyspnea.

Comparison of the bronchodilating effects of inhaled β₂-agonists after methacholine challenge in a human lung reperfusion model

The aim of the present investigation was to compare the onset of action and intrinsic activity of the long-acting β(2)-agonist GW597901 with the fast- and short-acting salbutamol as model compounds using an isolated human lung reperfusion model. Twelve resected human lung lobes were challenged with methacholine (MCh) and subsequently nebulised with either GW597901 or salbutamol. Prostaglandin E(2) (PGE(2)) concentrations in the perfusion fluid were compared with the dose of MCh that was required to induce a bronchoconstriction. After successful MCh provocation, nebulisation of GW597901 and salbutamol fully reversed any observed bronchoconstriction. The bronchodilating effect was more pronounced for GW597901. Salbutamol revealed an immediate onset of action while the effect of GW597901 was observed with an approximate delay of 6 min. Higher doses of MCh were required for a successful bronchial challenge in the presence of elevated PGE(2) levels (r=0.8171, p ≤ 0.05). For the first time, an isolated perfused human lung model has been established for comparing the onset of action and potency of a short- and long-acting β(2)-agonist. We therefore conclude that it is an alternative for determination of drug effect characteristics and suitable for supplementing or predicting clinical data.

Secreted osteopontin is highly polymerized in human airways and fragmented in asthmatic airway secretions

BACKGROUND

Osteopontin (OPN) is a member of the small integrin-binding ligand N-linked glycoprotein (SIBLING) family and a cytokine with diverse biologic roles. OPN undergoes extensive post-translational modifications, including polymerization and proteolytic fragmentation, which alters its biologic activity. Recent studies suggest that OPN may contribute to the pathogenesis of asthma.

METHODOLOGY

To determine whether secreted OPN (sOPN) is polymerized in human airways and whether it is qualitatively different in asthma, we used immunoblotting to examine sOPN in bronchoalveolar lavage (BAL) fluid samples from 12 healthy and 21 asthmatic subjects (and in sputum samples from 27 healthy and 21 asthmatic subjects). All asthmatic subjects had mild to moderate asthma and abstained from corticosteroids during the study. Furthermore, we examined the relationship between airway sOPN and cellular inflammation.

PRINCIPAL FINDINGS

We found that sOPN in BAL fluid and sputum exists in polymeric, monomeric, and cleaved forms, with most of it in polymeric form. Compared to healthy subjects, asthmatic subjects had proportionately less polymeric sOPN and more monomeric and cleaved sOPN. Polymeric sOPN in BAL fluid was associated with increased alveolar macrophage counts in airways in all subjects.

CONCLUSIONS

These results suggest that sOPN in human airways (1) undergoes extensive post-translational modification by polymerization and proteolytic fragmentation, (2) is more fragmented and less polymerized in subjects with mild to moderate asthma, and (3) may contribute to recruitment or survival of alveolar macrophages.

Impairment of quality of life in women with chronic obstructive pulmonary disease

BACKGROUND

There is ample evidence of the differences between genders in chronic obstructive pulmonary disease (COPD). The purpose of this study was to identify the factors that contribute to these differences.

METHODS

This was a multi-center, cross-sectional observational study including 4574 patients of 40 years of age and older who attended primary care and pulmonary clinics. Data were collected on COPD characteristics, comorbidities, quality of life as assessed by both the EuroQoL 5D questionnaire (EQ-5D) and the Airways Questionnaire 20 (AQ20), and prevalence of anxiety and depression. Data collected were compared between males and females.

RESULTS

Mean age was 67 years and 740 patients (16.7%) were female. Women were significantly younger, had better pulmonary function, and smoked less; however, they showed poorer quality of life (EQ-5D: 0.6 [SD = 0.3] versus 0.7 [0.3]; p < 0.001; and AQ20: 10.4 [SD = 4.6] versus 9.2 [SD = 4.5]; p < 0.001) and a higher rate of anxiety (34.5% versus 20.6%; p < 0.001) and depression (31.7% versus 22.1%; p < 0.001). In a multivariate analysis, female gender was significantly associated to poorer quality of life (AQ20) but not to a higher rate of dyspnea.

CONCLUSION

Women with COPD are younger and have lower rates of impaired lung function; however, they show poorer quality of life and more frequent COPD-associated anxiety and depression.