Changes in mortality among US adults with COPD in two national cohorts recruited from 1971-1975 and 1988-1994

Reduced sensitivity to thyroid hormones is associated with lung function in euthyroid individuals

Background

The thyroid gland exhibits a subtle interconnection with the lungs. We further investigated the correlation between thyroid hormone sensitivity and lung function in euthyroid individuals.

Methods

Data on spirometry and mortality for participants aged 19-79 years were extracted from the NHANES database. Obstructive lung function was defined as a forced expiratory volume in 1 s to forced vital capacity ratio (FEV1/FVC) < 0.70, while restrictive lung function was considered when FEV1/FVC ≥0.70 and baseline FVC <80 % predicted. Central and peripheral sensitivities to thyroid hormones were mainly evaluated by Thyroid Feedback Quantile-based Index (TFQI) and Free Triiodothyronine/Free thyroxine (FT3/FT4) ratio. Logistic regression and subgroup analysis were used to examine potential associations between thyroid hormone sensitivity and lung function. The association between TFQI and all-cause mortality risk was also investigated.

Results

A total of 6539 participants were analyzed, 900 with obstructive lung function and 407 with restrictive lung function. The prevalence of impaired lung function, both obstructive and restrictive, increased with higher TFQI levels. Logistic regression analysis showed that increased TFQI and decreased FT3/FT4 levels were independent risk factors for obstructive and restrictive lung function (P < 0.05). After adjusting for the impact of lung function, TFQI (HR = 1.25, 95 % CI 1.00-1.56, P = 0.048) was an independent risk factor for all-cause mortality.

Conclusion

Reduced sensitivity to thyroid hormones has been linked to impaired lung function. TFQI and FT3/FT4 are potential epidemiological tools to quantify the role of central and peripheral thyroid resistance in lung function.

Chronic obstructive pulmonary disease mortality in Spain between 1999 and 2019

INTRODUCTION

Mortality from COPD has decreased in Spain in recent years, but it is unknown whether this decline has been homogeneous among the different regions.

METHODS

From the Statistical Portal of the Ministry of Health of Spain we obtained the age-adjusted mortality rates/100,000 inhabitants for men and women in Spain and the Autonomous Communities for the years 1999-2019, using the coding of the International Classification of Diseases (ICD 10, sections J40-J44). With the adjusted rates we performed a jointpoint regression analysis to estimate an annual percentage change (APC), as well as identify possible points of trend change. Statistical significance was considered for a value of p<0.05.

RESULTS

During the study period, COPD mortality rates adjusted in Spain decreased from 28.77 deaths/100,000 inhabitants in 1999 to 12.14 deaths/100,000 inhabitants in 2019. We observed a linear decline in COPD mortality in men at national level of -3.67% per year (95% CI -4.1 to -3.4; p<0.001), with differences between the Autonomous Communities. Mortality in women also experienced a decrease in mortality in two phases, with a first period from 1999 to 2006 with a fall of -6.8% per year (95% CI -8.6 to -5.0; p<0.001) and a second period from 2006 to 2019 with a decrease in mortality of -2.1% (95% CI -2.8 to -1.3; p<0.001), with again differences between the Autonomous Communities.

CONCLUSION

Mortality rates from COPD have decreased heterogeneously among the different Autonomous Communities in both men and women.

A population-based cohort study on the risk of obstructive lung disease after bilateral oophorectomy

There is increasing evidence that sex hormones may impact the development of obstructive lung disease (OLD). Therefore, we studied the effect of bilateral oophorectomy (oophorectomy) on the development of OLD. Women were identified from the Mayo Clinic Cohort Study of Oophorectomy and Aging-2. Data were collected using the Rochester Epidemiology Project records-linkage system. A total of 1653 women who underwent oophorectomy and 1653 referent women of similar age were assessed for OLD using diagnostic codes and medical record abstraction. Women who underwent oophorectomy had an overall higher risk of all OLD, all chronic obstructive pulmonary disease (COPD), emphysema, and chronic bronchitis but not of all asthma, confirmed asthma, or confirmed COPD. The association with all OLD was stronger in women who were age ≤45 years at oophorectomy, never smokers, non-obese, and in women with benign indications; however, the interactions were not statistically significant. There was an increased risk of all asthma in women age ≤45 years at oophorectomy who took estrogen therapy. Never smokers of all ages had a stronger association of oophorectomy with all asthma and all COPD, whereas smokers had a stronger association of oophorectomy with emphysema and chronic bronchitis. Non-obese women of all ages had a stronger association of oophorectomy with all COPD, emphysema, and chronic bronchitis. The results of this study combined with the increased risk of several chronic diseases reported in previous studies suggest that oophorectomy in premenopausal women should be avoided unless there is clear evidence of a high genetic risk of ovarian cancer.

FSTL1 aggravates cigarette smoke-induced airway inflammation and airway remodeling by regulating autophagy

BACKGROUND

Cigarette smoke (CS) is a major risk factor for Chronic Obstructive Pulmonary Disease (COPD). Follistatin-like protein 1 (FSTL1), a critical factor during embryogenesis particularly in respiratory lung development, is a novel mediator related to inflammation and tissue remodeling. We tried to investigate the role of FSTL1 in CS-induced autophagy dysregulation, airway inflammation and remodeling.

METHODS

Serum and lung specimens were obtained from COPD patients and controls. Adult female wild-type (WT) mice, FSTL1^± mice and FSTL1^flox/+ mice were exposed to room air or chronic CS. Additionally, 3-methyladenine (3-MA), an inhibitor of autophagy, was applied in CS-exposed WT mice. The lung tissues and serum from patients and murine models were tested for FSTL1 and autophagy-associated protein expression by ELISA, western blotting and immunohistochemical. Autophagosome were observed using electron microscope technology. LTB4, IL-8 and TNF-α in bronchoalveolar lavage fluid of mice were examined using ELISA. Airway remodeling and lung function were also assessed.

RESULTS

Both FSTL1 and autophagy biomarkers increased in COPD patients and CS-exposed WT mice. Autophagy activation was upregulated in CS-exposed mice accompanied by airway remodeling and airway inflammation. FSTL1^± mice showed a lower level of CS-induced autophagy compared with the control mice. FSTL1^± mice can also resist CS-induced inflammatory response, airway remodeling and impaired lung function. CS-exposed WT mice with 3-MA pretreatment have a similar manifestation with CS-exposed FSTL1^± mice.

CONCLUSIONS

FSTL1 promotes CS-induced COPD by modulating autophagy, therefore targeting FSTL1 and autophagy may shed light on treating cigarette smoke-induced COPD.

Sex differences between women and men with COPD: A new analysis of the 3CIA study

BACKGROUND

There is partial evidence that COPD is expressed differently in women than in men, namely on symptoms, pulmonary function, exacerbations, comorbidities or prognosis. There is a need to improve the characterization of COPD in females.

METHODS

We obtained and pooled data of 17 139 patients from 22 COPD cohorts and analysed the clinical differences by sex, establishing the relationship between these characteristics in women and the prognosis and severity of the disease. Comparisons were established with standard statistics and survival analysis, including crude and multivariate Cox-regression analysis.

RESULTS

Overall, 5355 (31.2%) women were compared with men with COPD. Women were younger, had lower pack-years, greater FEV₁%, lower BMI and a greater number of exacerbations (all p < 0.05). On symptoms, women reported more dyspnea, equal cough but less expectoration (p < 0.001). There were no differences in the BODE index score in women (2.4) versus men (2.4) (p = 0.5), but the distribution of all BODE components was highly variable by sex within different thresholds of BODE. On prognosis, 5-year survival was higher in COPD females (86.9%) than in males (76.3%), p < 0.001, in all patients and within each of the specific comorbidities that we assessed. The crude and adjusted RR and 95% C.I. for death in males was 1.82 (1.69-1.96) and 1.73 (1.50-2.00), respectively.

CONCLUSIONS

COPD in women has some characteristic traits expressed differently than compared to men, mainly with more dyspnea and COPD exacerbations and less phlegm, among others, although long-term survival appears better in female COPD patients.

Trends in the prevalence of airflow limitation in a general Japanese population: two serial cross-sectional surveys from the Hisayama Study

OBJECTIVES

Chronic obstructive airway disease, which is characterised by airflow limitation, is a major burden on public health. Reductions in environmental pollution in the atmosphere and workplace and a decline in the prevalence of smoking over recent decades may have affected the prevalence of airflow limitation in Japan. The present epidemiological study aimed to evaluate trends in the prevalence of airflow limitation and in the influence of risk factors on airflow limitation in a Japanese community.

DESIGN

Two serial cross-sectional surveys.

SETTING

Data from the Hisayama Study, a population-based prospective study that has been longitudinally conducted since 1961.

PARTICIPANTS

A total of 1842 and 3033 residents aged ≥40 years with proper spirometric measurements participated in the 1967 and 2012 surveys, respectively.

MAIN OUTCOME MEASURES

Airflow limitation was defined as forced expiratory volume in 1 s/forced vital capacity <70% by spirometry. For each survey, the age-adjusted prevalence of airflow limitation was evaluated by sex. ORs and population attributable fractions of risk factors on the presence of airflow limitation were compared between surveys.

RESULTS

The age-standardised prevalence of airflow limitation decreased from 1967 to 2012 in both sexes (from 26.3% to 16.1% in men and from 19.8% to 10.5% in women). Smoking was significantly associated with higher likelihood of airflow limitation in both surveys, although the magnitude of its influence was greater in 2012 than in 1967 (the multivariable-adjusted OR was 1.63 (95% CI 1.19 to 2.24) in 1967 and 2.26 (95% CI 1.72 to 2.99) in 2012; p=0.007 for heterogeneity). Accordingly, the population attributable fraction of smoking on airflow limitation was 33.5% in 2012, which was 1.5-fold higher than that in 1967 (21.1%).

CONCLUSIONS

The prevalence of airflow limitation was decreased over 45 years in Japan, but the influence of smoking on airflow limitation increased with time.

Women and COPD: do we need more evidence?

The increasingly female face of chronic obstructive pulmonary disease (COPD) prevalence among women has equalled that of men since 2008, due in part to increased tobacco use among women worldwide and exposure to biomass fuels. This finding is supported by a number of characteristics. There is evidence of susceptibility to smoking and other airborne contaminants, along with epidemiological and phenotypic manifestations. COPD has thus become the leading cause of death in women in the USA. The clinical presentation is characterised by increasingly pronounced dyspnoea with a marked tendency towards anxiety and depression, undernutrition, nonsmall cell lung cancer (especially adenocarcinoma) and osteoporosis. Quality of life is also more significantly impacted. The theories advanced to explain these differences involve the role played by oestrogens, impaired gas exchange in the lungs and smoking habits. While these differences require appropriate therapeutic responses (smoking cessation, pulmonary rehabilitation, long-term oxygen therapy), barriers to the treatment of women with COPD include greater under-diagnosis than in men, fewer spirometry tests and medical consultations. Faced with this serious public health problem, we need to update and adapt our knowledge to the epidemiological changes.

The face of COPD is increasingly female. We need more evidence and a change in how the disease is managed. http://ow.ly/zueL30mWqlS

Klotho Regulates Cigarette Smoke-Induced Autophagy: Implication in Pathogenesis of COPD

INTRODUCTION

Chronic obstructive pulmonary disease is a progressive lung disease characterized by abnormal cellular responses to cigarette smoke, resulting in tissue destruction and airflow limitation. Autophagy is a fundamental cellular process that eliminates long-lived proteins and damaged organelles through lysosomal degradation pathway, though its role in human diseases remains unclear. We hypothesized that an anti-aging protein, Klotho plays an important role in regulating autophagy in response to cigarette smoke (CS).

METHODS

Autophagy was measured by detecting LC3-I and LC3-II expressions. The regulation of autophagy expression by cigarette smoke extract (CSE) was studied in vitro, and small-interfering RNA (siRNA) and recombinant Klotho were employed to investigate the role of Klotho on CSE-induced autophagy. Protein levels and phosphorylation were measured by Western blot assay.

RESULTS

CS exposure resulted in induction of autophagy in alveolar macrophages. Pretreatment of cells with Klotho attenuated CS-induced autophagy whereas knockdown of Klotho augmented CS-induced autophagy. Klotho inhibited phosphorylation of ERK, Akt, and IGF-1 in CSE-stimulated cells.

CONCLUSIONS

These data suggest that Klotho plays a critical role in the regulation of CS-induced autophagy and have important implications in understanding the mechanisms of CS-induced cell death and senescence.

A Subnational Analysis of Mortality and Prevalence of COPD in China From 1990 to 2013: Findings From the Global Burden of Disease Study 2013

BACKGROUND

The trends of COPD mortality and prevalence over the past 2 decades across all provinces remain unknown in China. We used data from the Global Burden of Disease Study 2013 (GBD 2013) to estimate the mortality and prevalence of COPD during 1990 to 2013 at a provincial level.

METHODS

Following the general analytic strategy used in GBD 2013, we analyzed the age- sex- and province-specific mortality and prevalence of COPD in China. Levels of and trends in COPD mortality and prevalence were assessed for 33 province-level administrative units during 1990 to 2013.

RESULTS

In 2013, there were 910,809 deaths from COPD in China, accounting for 31.1% of the total deaths from COPD in the world. From 1990 to 2013, the age-standardized COPD mortality rate decreased in all provinces, with the highest reduction in Heilongjiang (70.2%) and Jilin (70.0%) and the lowest reduction in Guizhou (26.8%). In 2013, the death rate per 100,000 was highest in Guizhou (196.0) and lowest in Tianjin (34.0) among men and highest in Gansu (141.1) and lowest in Beijing (23.7) among women. The number of COPD cases increased dramatically from 32.4 million in 1990 to 54.8 million in 2013. The age-standardized prevalence rate of COPD remained stable overall and varied little for all provinces.

CONCLUSIONS

COPD remains a huge health burden in many western provinces in China. The substantial increase in COPD cases represents an ongoing challenge given the rapidly aging Chinese population. A targeted control and prevention strategy should be developed at a provincial level to reduce the burden caused by COPD.

Spatiotemporal Variations in Chronic Obstructive Pulmonary Disease Mortality in China: Multilevel Evidence from 2006 to 2012

Mortality of Chronic Obstructive Pulmonary Disease (COPD) is on the decline in China. It is not known if this trend occurs across all areas or whether spatiotemporal variations manifest. We used data from the nationally representative China Mortality Surveillance System to calculate annual COPD mortality counts (2006-2012) stratified by 5-year age groups (aged > 20), gender and time for 161 counties and districts (Disease Surveillance Points, or DSP). These counts were linked to annually adjusted denominator populations. Multilevel negative binomial regression with random intercepts and slopes were used to investigate spatiotemporal variation in COPD mortality adjusting for age, gender and area-level risk factors. COPD mortality rate decreased markedly from 105.1 to 73.7 per 100,000 during 2006 to 2012 and varied over two-fold between DSPs across China. Mortality rates were higher in the west compared with the east (Rate ratio (RR) 2.15, 95% confidence intervals (CI) 1.73, 2.68) and in rural compared with the urban (RR 1.87, 95% CI 1.55, 2.25). Adjustment for age, gender, urban/rural, region, smoking prevalence, indoor air pollution, mean body mass index and socioeconomic circumstances accounted for 67% of the geographical variation. Urban/rural differences in COPD mortality narrowed over time, but the magnitude of the east-west inequality persisted without change. Immediate action via large-scale interventions to enhance the prevention and management of COPD are needed specifically within China's western region in order to tackle this crucial health inequality and leading preventable cause of death.

COPD-Related Mortality and Co-morbidities in Northeastern Italy, 2008-2012: A Multiple Causes of Death Analysis

INTRODUCTION

Analysis of COPD mortality based only on the underlying cause of death (UCOD) derived from death certificates underestimates disease burden. We analyzed the burden of COPD, as well as the pattern of reporting COPD and its co-morbidities in death certificates, using multiple-cause of death (MCOD) records.

METHODS

All 220,281 death certificates of decedents aged ≥ 40 years in the Veneto region (northeastern Italy) were analyzed through 2008-2012. The UCOD was selected by the Automated Classification of Medical Entities software. COPD was defined by ICD-10 codes J40-J44 and J47 based either on the UCOD or on any mention of COPD in death certificates (MCOD). Annual age-standardized COPD death rates were computed for 40-85 year-old subjects.

RESULTS

COPD was mentioned in 7.9% (and selected as the UCOD in 2.7%) of death certificates. In about half of these, COPD was mentioned in Part II only. After circulatory and neoplastic diseases, the most frequent chronic diseases reported in certificates with any mention of COPD were diabetes (15.2%) and dementia/Alzheimer (8.9%). Between 2008 and 2012, age-standardized death rates (/100,000/year) decreased from 39.8 to 34.0 in males and from 12.7 to 11.3 in females in the UCOD analyses. These trends were confirmed, although figures were three times greater, in the MCOD analyses.

CONCLUSIONS

MCOD analysis should be adopted to fully evaluate the burden of COPD-related mortality. Our findings support a decreasing trend in COPD-related mortality in northeastern Italy between 2008 and 2012, in line with other recent studies in Europe and beyond.

Urinary albumin-creatinine ratio, estimated glomerular filtration rate, and all-cause mortality among US adults with obstructive lung function

BACKGROUND

Elevated urinary albumin-creatinine ratio (UACR) and decreased estimated glomerular filtration rate (eGFR) predict all-cause mortality, but whether these markers of kidney damage and function do so in adults with obstructive lung function (OLF) is unclear. The objective of this study was to examine the associations between UACR and eGFR and all-cause mortality in adults with OLF.

METHODS

Data of 5,711 US adults aged 40 to 79 years, including 1,390 adults with any OLF who participated in the National Health and Nutrition Examination Survey III (1988-1994), were analyzed. Mortality follow-up was conducted through 2006.

RESULTS

During the median follow-up of 13.7 years, 650 adults with OLF died. After maximal adjustment, mean levels of UACR were higher in adults with moderate-severe OLF (7.5 mg/g; 95% CI, 6.7-8.5) than in adults with normal pulmonary function (6.2 mg/g; 95% CI, 5.8-6.6) (P = .003) and mild OLF (6.2 mg/g; 95% CI, 5.5-6.9) (P = .014). Adjusted mean levels of eGFR were lower in adults with moderate-severe OLF (87.6 mL/min/1.73 m²; 95% CI, 86.0-89.1) than in adults with normal lung function (89.6 mL/min/1.73 m²; 95% CI, 88.9-90.3) (P = .015). Among adults with OLF, hazard ratios for all-cause mortality increased as levels of UACR, modeled as categorical or continuous variables, increased (maximally adjusted hazard ratio for quintile 5 vs 1: 2.23; 95% CI, 1.56-3.18). eGFR, modeled as a continuous variable but not as quintiles, was significantly associated with mortality.

CONCLUSIONS

UACR and eGFR, in continuous form, were associated with all-cause mortality among US adults with OLF.

Associations between antioxidants and all-cause mortality among US adults with obstructive lung function

Chronic obstructive pulmonary disease is characterised by oxidative stress, but little is known about the associations between antioxidant status and all-cause mortality in adults with this disease. The objective of the present study was to examine the prospective associations between concentrations of α- and β-carotene, β-cryptoxanthin, lutein/zeaxanthin, lycopene, Se, vitamin C and α-tocopherol and all-cause mortality among US adults with obstructive lung function. Data collected from 1492 adults aged 20-79 years with obstructive lung function in the National Health and Nutrition Examination Survey III (1988-94) were used. Through 2006, 629 deaths were identified during a median follow-up period of 14 years. After adjustment for demographic variables, the concentrations of the following antioxidants modelled as continuous variables were found to be inversely associated with all-cause mortality among adults with obstructive lung function: α-carotene (P= 0·037); β-carotene (P= 0·022); cryptoxanthin (P= 0·022); lutein/zeaxanthin (P= 0·004); total carotenoids (P= 0·001); vitamin C (P< 0·001). In maximally adjusted models, only the concentrations of lycopene (P= 0·013) and vitamin C (P= 0·046) were found to be significantly and inversely associated with all-cause mortality. No effect modification by sex was detected, but the association between lutein/zeaxanthin concentrations and all-cause mortality varied by smoking status (P interaction= 0·048). The concentrations of lycopene and vitamin C were inversely associated with all-cause mortality in this cohort of adults with obstructive lung function.

Influence of sex on chronic obstructive pulmonary disease risk and treatment outcomes

Chronic obstructive pulmonary disease (COPD), one of the most common chronic diseases and a leading cause of death, has historically been considered a disease of men. However, there has been a rapid increase in the prevalence, morbidity, and mortality of COPD in women over the last two decades. This has largely been attributed to historical increases in tobacco consumption among women. But the influence of sex on COPD is complex and involves several other factors, including differential susceptibility to the effects of tobacco, anatomic, hormonal, and behavioral differences, and differential response to therapy. Interestingly, nonsmokers with COPD are more likely to be women. In addition, women with COPD are more likely to have a chronic bronchitis phenotype, suffer from less cardiovascular comorbidity, have more concomitant depression and osteoporosis, and have a better outcome with acute exacerbations. Women historically have had lower mortality with COPD, but this is changing as well. There are also differences in how men and women respond to different therapies. Despite the changing face of COPD, care providers continue to harbor a sex bias, leading to underdiagnosis and delayed diagnosis of COPD in women. In this review, we present the current knowledge on the influence of sex on COPD risk factors, epidemiology, diagnosis, comorbidities, treatment, and outcomes, and how this knowledge may be applied to improve clinical practices and advance research.

Epidemiology, genetics, and subtyping of preserved ratio impaired spirometry (PRISm) in COPDGene

BACKGROUND

Preserved Ratio Impaired Spirometry (PRISm), defined as a reduced FEV1 in the setting of a preserved FEV1/FVC ratio, is highly prevalent and is associated with increased respiratory symptoms, systemic inflammation, and mortality. Studies investigating quantitative chest tomographic features, genetic associations, and subtypes in PRISm subjects have not been reported.

METHODS

Data from current and former smokers enrolled in COPDGene (n = 10,192), an observational, cross-sectional study which recruited subjects aged 45-80 with ≥10 pack years of smoking, were analyzed. To identify epidemiological and radiographic predictors of PRISm, we performed univariate and multivariate analyses comparing PRISm subjects both to control subjects with normal spirometry and to subjects with COPD. To investigate common genetic predictors of PRISm, we performed a genome-wide association study (GWAS). To explore potential subgroups within PRISm, we performed unsupervised k-means clustering.

RESULTS

The prevalence of PRISm in COPDGene is 12.3%. Increased dyspnea, reduced 6-minute walk distance, increased percent emphysema and decreased total lung capacity, as well as increased segmental bronchial wall area percentage were significant predictors (p-value <0.05) of PRISm status when compared to control subjects in multivariate models. Although no common genetic variants were identified on GWAS testing, a significant association with Klinefelter's syndrome (47XXY) was observed (p-value < 0.001). Subgroups identified through k-means clustering include a putative "COPD-subtype", "Restrictive-subtype", and a highly symptomatic "Metabolic-subtype".

CONCLUSIONS

PRISm subjects are clinically and genetically heterogeneous. Future investigations into the pathophysiological mechanisms behind and potential treatment options for subgroups within PRISm are warranted.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT000608764.

Epidemiology and prevalence of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) represents one of the main causes of morbidity and mortality worldwide. According to the World Health Organization, approximately 3 million people in the world die as a consequence of COPD every year. Tobacco use remains the main factor associated with development of disease in the industrialized world, but other risk factors are important and preventable causes of COPD, particularly in the developing world. The purpose of this review is to summarize the literature on the subject and to provide an update of the most recent advances in the field.

Chronic obstructive pulmonary disease (COPD): evaluation from clinical, immunological and bacterial pathogenesis perspectives

Chronic obstructive pulmonary disease (COPD), a disease manifested by significantly impaired airflow, afflicts ∼14.2 million cases in the United States alone with an estimated 63 million people world-wide. Although there are a number of causes, the predominant cause is excessive tobacco smoke. In fact, in China, there have been estimates of 315,000,000 people that smoke. Other less frequent causes are associated with indirect cigarette smoke, air pollutants, biomass fuels, and genetic mutations. COPD is often associated with heart disease, lung cancer, osteoporosis and conditions can worsen in patients with sudden falls. COPD also affects both innate and adaptive immune processes. Cigarette smoke increases the expression of matrix metalloproteases and proinflammatory chemokines and increases lung titers of natural killer cells and neutrophils. Yet, neutrophil reactive oxygen species (ROS) mediated by the phagocytic respiratory burst and phagocytosis is impaired by nicotine. In contrast to innate immunity in COPD, dendritic cells represent leukocytes recruited to the lung that link the innate immune responses to adaptive immune responses by activating naïve T cells through antigen presentation. The autoimmune process that is also a significant part of inflammation associated with COPD. Moreover, coupled with restricted FEV1 values, are the prevalence of patients with single or multiple infections by bacteria, viruses and fungi. Finally, we focus on one of the more problematic infectious agents, the Gram-negative opportunistic pathogenic bacterium, Pseudomonas aeruginosa. Specifically, we delve into the development of highly problematic biofilm infections that are highly refractory to conventional antibiotic therapies in COPD. We offer a non-conventional, biocidal treatment that may be effective for COPD airway infections as well as with combinations of current antibiotic regimens for more effective treatment outcomes and relief for patients with COPD.

Obstructive lung disease in Mexican Americans and non-Hispanic whites: an analysis of diagnosis and survival in the National Health and Nutritional Examination Survey III Follow-up Study

BACKGROUND

Although obstructive lung disease (OLD), which includes COPD, affects all the populations, Hispanics seem to be protected against COPD development and progression. Whether this advantage translates into a survival benefit for this population is unknown. We aimed to determine the risk for OLD in Mexican Americans, the largest US Hispanic subgroup, compared with non-Hispanic whites and to assess all-cause mortality in subjects with OLD.

METHODS

We assessed the relationships between Mexican American ethnicity and spirometric OLD and risk of death among 6,456 US adults aged ≥ 40 years who participated in the Third National Health and Nutritional Examination Survey Follow-up Study. We used logistic and Cox regression analyses to estimate the OR for OLD among Mexican Americans and the hazard ratio (HR) for all-cause mortality among Mexican Americans with OLD, respectively.

RESULTS

After adjustment for demographic factors, socioeconomic status, and COPD risk factors, Mexican Americans had decreased odds of OLD diagnosis compared with whites (OR, 0.72 [95% CI, 0.54-0.95]). Among the 1,734 participants with OLD, 1,054 (60.8%) died during median follow-up of 12 years. In an adjusted model, Mexican Americans had no advantage in mortality from all causes (HR, 0.88 [95% CI, 0.69-1.13]). After accounting for the fact that some Mexican Americans may have moved back to Mexico and died there (thus, had no US death certificate), there was still no difference in mortality between these groups.

CONCLUSIONS

Although Mexican Americans appear to have lower risk for OLD, subjects of this ethnicity with OLD do not seem to have a survival advantage.

The association of chronic obstructive pulmonary disease, disability, engagement in social activities, and mortality among US adults aged 70 years or older, 1994-2006

PURPOSE

To assess associations among chronic obstructive pulmonary disease (COPD), disability as measured by activities of daily living (ADL) and instrumental ADL (IADL), engagement in social activities, and death among elderly noninstitutionalized US residents.

MATERIALS AND METHODS

A nationally representative sample of 9,415 adults who were aged ≥70 years and responded to the Second Supplement on Aging survey in 1994-1996 and mortality follow-up study through 2006 were assessed. Multiple logistic regression analyses were performed to assess the risk of all-cause mortality in participants with COPD after accounting for age, sex, race/ethnicity, and smoking status.

RESULTS

At baseline, approximately 9.6% of study participants reported having COPD. Compared with participants without COPD, those with COPD were significantly more likely (P<0.05) to have difficulty with at least one ADL (44.3% versus [vs] 27.5%) and with at least one IADL (59.9% vs 40.2%), significantly less likely to be engaged in social activities (32.6% vs 26.3%), and significantly more likely to die by 2006 (70.7% vs 60.4%; adjusted risk ratio 1.15, P<0.05). The association between COPD and risk for death was moderately attenuated by disability status.

CONCLUSION

COPD is positively associated with disability and mortality risk among US adults aged ≥70 years. The significant relationship between COPD and mortality risk was moderately attenuated, but was not completely explained by stages of ADL and IADL limitations and social activities.

Mortality trends in chronic obstructive pulmonary disease in Europe, 1994-2010: a joinpoint regression analysis

BACKGROUND

Findings from studies done over the past 20 years suggest that mortality from chronic obstructive pulmonary disease (COPD) is decreasing worldwide, but little information is available for trends in Europe. We aimed to describe COPD mortality trends by sex and calendar year for the period of 1994 to 2010.

METHODS

We extracted data for COPD deaths between 1994 and 2010 in the 27 countries in the European Union (EU) from the statistical office of the EU (Eurostat), using the International Classification of Diseases 10 (ICD-10) codes J40-J44 and J47. We estimated age-standardised mortality rates (ASR), and analysed data using joinpoint regression, for women and men in the EU overall and by individual country for each year. We used the standard European population as the reference and present our findings as deaths per 100,000 person-years. We compared findings for each country with the EU average by calculating standardised rate ratios (SRR) and 95% CIs.

FINDINGS

Between 1994 and 2010, there were 2,348,184 recorded COPD deaths in the EU. COPD mortality was higher in men than in women throughout the study period in all EU countries. In the EU overall, deaths per 100,000 population decreased in men almost linearly from 90·07 in 1994 to 61·33 in 2010, and in women from 26·99 in 1994 to 25·15 in 2010, representing a narrowing in gender gap over the study period. Several countries had a higher SRR mortality than the EU average-eg, Ireland, Hungary, and Belgium for men and Denmark, the UK, and the Netherlands for women. Our joinpoint regression analysis identified no statistically significant changes in the trend for the whole EU, but several countries had changing trends over the study period. In men, we recorded a 2·56% constant and statistically significant decrease in ASRs in the EU. Five countries had an increase in ASR. Overall, in women, we recorded a 0·76% statistically significant decrease in ASRs. 14 countries had an increase in ASR.

INTERPRETATION

Our findings indicate a downward trend in COPD mortality in Europe between 1994 and 2010. The data also suggest a narrowing of the gap between COPD mortality in men and in women. The wide heterogeneity in mortality rates within European countries could serve as a reference to allow informed policy making.

FUNDING

None.

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.

COPD surveillance--United States, 1999-2011

This report updates surveillance results for COPD in the United States. For 1999 to 2011, data from national data systems for adults aged≥25 years were analyzed. In 2011, 6.5% of adults (approximately 13.7 million) reported having been diagnosed with COPD. From 1999 to 2011, the overall age-adjusted prevalence of having been diagnosed with COPD declined (P=.019). In 2010, there were 10.3 million (494.8 per 10,000) physician office visits, 1.5 million (72.0 per 10,000) ED visits, and 699,000 (32.2 per 10,000) hospital discharges for COPD. From 1999 to 2010, no significant overall trends were noted for physician office visits and ED visits; however, the age-adjusted hospital discharge rate for COPD declined significantly (P=.001). In 2010 there were 312,654 (11.2 per 1,000) Medicare hospital discharge claims submitted for COPD. Medicare claims (1999-2010) declined overall (P=.045), among men (P=.022) and among enrollees aged 65 to 74 years (P=.033). There were 133,575 deaths (63.1 per 100,000) from COPD in 2010. The overall age-adjusted death rate for COPD did not change during 1999 to 2010 (P=.163). Death rates (1999-2010) increased among adults aged 45 to 54 years (P<.001) and among American Indian/Alaska Natives (P=.008) but declined among those aged 55 to 64 years (P=.002) and 65 to 74 years (P<.001), Hispanics (P=.038), Asian/Pacific Islanders (P<.001), and men (P=.001). Geographic clustering of prevalence, Medicare hospitalizations, and deaths were observed. Declines in the age-adjusted prevalence, death rate in men, and hospitalizations for COPD since 1999 suggest progress in the prevention of COPD in the United States.

Trends in the prevalence of obstructive and restrictive lung function among adults in the United States: findings from the National Health and Nutrition Examination surveys from 1988-1994 to 2007-2010

BACKGROUND

National spirometric surveillance data in the United States were last collected during 1988-1994. The objective of this study was to provide current estimates for obstructive and restrictive impairment of lung function and to examine changes since 1988-1994.

METHODS

We used data from 14,360 participants aged 20 to 79 years from the National Health and Nutrition Examination Survey (NHANES) III (1988-1994) and 9,024 participants from NHANES 2007-2010. Spirometry was conducted using the same spirometers and generally similar protocols.

RESULTS

During 2007-2010, 13.5% (SE, 0.6) of participants had evidence of airway obstruction (FEV1/FVC < 0.70): 79.9% of adults had normal lung function, 6.5% had a restrictive impairment, 7.5% had mild obstruction, 5.4% had moderate obstruction, and 0.7% had severe obstruction. Although the overall age-adjusted prevalence of any obstruction did not change significantly from 1988-1994 (14.6%) to 2007-2010 (13.5%) (P = .178), significant decreases were noted for participants aged 60 to 79 years and for Mexican Americans. The prevalence of current smoking remained high among participants with moderate (48.4%) and severe (37.9%) obstructive impairments. A significant decline in current smoking occurred only among those with normal lung function (P < .05).

CONCLUSION

Spirometry revealed little change in the prevalence of any obstructive and restrictive impairment in lung function during 2007-2010, compared with 1988-1994.

Changes in hospital mortality for United States intensive care unit admissions from 1988 to 2012

Introduction

A decrease in disease-specific mortality over the last twenty years has been reported for patients admitted to United States (US) hospitals, but data for intensive care patients are lacking. The aim of this study was to describe changes in hospital mortality and case-mix using clinical data for patients admitted to multiple US ICUs over the last 24 years.

Methods

We carried out a retrospective time series analysis of hospital mortality using clinical data collected from 1988 to 2012. We also examined the impact of ICU admission diagnosis and other clinical characteristics on mortality over time. The potential impact of hospital discharge destination on mortality was also assessed using data from 2001 to 2012.

Results

For 482,601 ICU admissions there was a 35% relative decrease in mortality from 1988 to 2012 despite an increase in age and severity of illness. This decrease varied greatly by diagnosis. Mortality fell by >60% for patients with chronic obstructive pulmonary disease, seizures and surgery for aortic dissection and subarachnoid hemorrhage. Mortality fell by 51% to 59% for six diagnoses, 41% to 50% for seven diagnoses, and 10% to 40% for seven diagnoses. The decrease in mortality from 2001 to 2012 was accompanied by an increase in discharge to post-acute care facilities and a decrease in discharge to home.

Conclusions

Hospital mortality for patients admitted to US ICUs has decreased significantly over the past two decades despite an increase in the severity of illness. Decreases in mortality were diagnosis specific and appear attributable to improvements in the quality of care, but changes in discharge destination and other confounders may also be responsible.

Elevated cardiovascular risk among adults with obstructive and restrictive airway functioning in the United States: a cross-sectional study of the National Health and Nutrition Examination Survey from 2007-2010

BACKGROUND

Reasons for the excess risk for cardiovascular disease among people with chronic obstructive pulmonary disease remain unclear. Our objective was to examine the cardiovascular risk profile for adults with obstructive and restrictive impairments of lung functioning in a representative sample of adults from the United States.

METHODS

We used data from adults aged 20-79 years who participated in the National Health and Nutrition Examination Survey from 2007 to 2010 and had a pulmonary function test. The severity of obstructive impairment was defined by adapting the Global Initiative for Chronic Obstructive Lung Disease criteria.

RESULTS

Among 7249 participants, 80.9% had a normal pulmonary function test, 5.7% had a restrictive impairment, 7.9% had mild obstructive impairment, and 5.5% had moderate or severe/very severe obstructive impairment. Participants with obstructive impairment had high rates of smoking and increased serum concentrations of cotinine. Compared to participants with normal pulmonary functioning, participants with at least moderate obstructive impairment had elevated concentrations of C-reactive protein but lower concentrations of total cholesterol and non-high-density lipoprotein cholesterol. Among participants aged 50-74 years, participants with at least a moderate obstructive impairment or a restrictive impairment had an elevated predicted 10-year risk for cardiovascular disease.

CONCLUSIONS

The high rates of smoking among adults with impaired pulmonary functioning, particularly those with obstructive impairment, point to a need for aggressive efforts to promote smoking cessation in these adults. In addition, adults with restrictive impairment may require increased attention to and fine-tuning of their cardiovascular risk profile.

Indacaterol add-on therapy improves lung function, exercise capacity and life quality of COPD patients

Chronic obstructive pulmonary disease (COPD) is a progressive, inflammatory condition, involving airways and lung parenchyma. The disease leads to airflow limitation, and pulmonary hyperinflation, resulting in dyspnea, decreased exercise tolerance, and impaired quality of life. COPD pharmacotherapy guidelines are based on a combination of long-acting beta2-agonists (LABA), long-acting antimuscarinic agents (LAMA) and methyloxantins. Recently, indacaterol, ultralong acting beta2-agonist, has been introduced. The aim of our study was to assess the impact of indacaterol add-on therapy on lung function, exercise tolerance and quality of life of COPD patients. Thirty four COPD patients, receiving stable bronchodilator therapy were randomly allocated into two arms of add-on treatment (1:1 - indacaterol:placebo) for 3 months. Indacaterol replaced LABA in all patients receiving LABA. Spirometry, lung volumes, DLCO, St George's Respiratory Questionnaire (SGRQ) and 6 min Walk Distance (6MWD) were performed before and after therapy. We found that in the indacaterol group FEV1 did not changed significantly. However, there were significant improvements in ERV, 6MWD, and 6MWD-related dyspnea score. We also found that the degree of desaturation before and after 6MWD, and fatigue levels significantly improved in the indacaterol group. The patients' quality of life also changed favorably in the indacaterol treatment arm. We conclude that the add-on therapy with indacaterol exerts positive effects in COPD patients.

TLR4 deficiency promotes autophagy during cigarette smoke-induced pulmonary emphysema

Toll-like receptors (TLRs) exert important nonimmune functions in lung homeostasis. TLR4 deficiency promotes pulmonary emphysema. We examined the role of TLR4 in regulating cigarette smoke (CS)-induced autophagy, apoptosis, and emphysema. Lung tissue was obtained from chronic obstructive lung disease (COPD) patients. C3H/HeJ (Tlr4-mutated) mice and C57BL/10ScNJ (Tlr4-deficient) mice and their respective control strains were exposed to chronic CS or air. Human or mouse epithelial cells (wild-type, Tlr4-knockdown, and Tlr4-deficient) were exposed to CS-extract (CSE). Samples were analyzed for TLR4 expression, and for autophagic or apoptotic proteins by Western blot analysis or confocal imaging. Chronic obstructive lung disease lung tissues and human pulmonary epithelial cells exposed to CSE displayed increased TLR4 expression, and increased autophagic [microtubule-associated protein-1 light-chain-3B (LC3B)] and apoptotic (cleaved caspase-3) markers. Beas-2B cells transfected with TLR4 siRNA displayed increased expression of LC3B relative to control cells, basally and after exposure to CSE. The basal and CSE-inducible expression of LC3B and cleaved caspase-3 were elevated in pulmonary alveolar type II cells from Tlr4-deficient mice. Wild-type mice subjected to chronic CS-exposure displayed airspace enlargement;, however, the Tlr4-mutated or Tlr4-deficient mice exhibited a marked increase in airspace relative to wild-type mice after CS-exposure. The Tlr4-mutated or Tlr4-deficient mice showed higher levels of LC3B under basal conditions and after CS exposure. The expression of cleaved caspase-3 was markedly increased in Tlr4-deficient mice exposed to CS. We describe a protective regulatory function of TLR4 against emphysematous changes of the lung in response to CS.