The evolution of lung cancer and impact of subclonal selection in TRACERx

Lung cancer is the leading cause of cancer-associated mortality worldwide1. Here we analysed 1,644 tumour regions sampled at surgery or during follow-up from the first 421 patients with non-small cell lung cancer prospectively enrolled into the TRACERx study. This project aims to decipher lung cancer evolution and address the primary study endpoint: determining the relationship between intratumour heterogeneity and clinical outcome. In lung adenocarcinoma, mutations in 22 out of 40 common cancer genes were under significant subclonal selection, including classical tumour initiators such as TP53 and KRAS. We defined evolutionary dependencies between drivers, mutational processes and whole genome doubling (WGD) events. Despite patients having a history of smoking, 8% of lung adenocarcinomas lacked evidence of tobacco-induced mutagenesis. These tumours also had similar detection rates for EGFR mutations and for RET, ROS1, ALK and MET oncogenic isoforms compared with tumours in never-smokers, which suggests that they have a similar aetiology and pathogenesis. Large subclonal expansions were associated with positive subclonal selection. Patients with tumours harbouring recent subclonal expansions, on the terminus of a phylogenetic branch, had significantly shorter disease-free survival. Subclonal WGD was detected in 19% of tumours, and 10% of tumours harboured multiple subclonal WGDs in parallel. Subclonal, but not truncal, WGD was associated with shorter disease-free survival. Copy number heterogeneity was associated with extrathoracic relapse within 1 year after surgery. These data demonstrate the importance of clonal expansion, WGD and copy number instability in determining the timing and patterns of relapse in non-small cell lung cancer and provide a comprehensive clinical cancer evolutionary data resource.

Sex Differences in Peripheral Artery Disease

Peripheral artery disease (PAD) is a prevalent condition that confers substantial morbidity and mortality and remains underdiagnosed as well as undertreated in the overall population. Although PAD prevalence is similar or higher in women compared with men, associations of traditional and nontraditional risk factors with PAD and clinical manifestations of PAD differ by sex and may contribute to delayed or lack of diagnosis in women. Such sex-based differences in the manifestation of PAD may arise from sexual dimorphism in the vascular substrate in health as well as sex variation in the responses to vascular stressors. Despite the availability of proven therapies for improving symptoms and reducing risk of ischemic cardiovascular and limb events among patients with diagnosed PAD, important sex differences in treatment and outcomes have been observed. We provide an overview of current knowledge regarding sex differences in the epidemiology, pathophysiology, clinical presentation, and management of PAD.

Associations between capillary glucose during pregnancy and childhood growth to the age of five: a cohort study

The objective of this study was to evaluate the relationship between random capillary glucose levels in healthy pregnant women and infant size at birth and childhood growth to the age of five years. This population-based cohort study comprised 10,937 healthy mother-child dyads. Data on highest maternal random capillary glucose level during pregnancy and sequential anthropometric data on their children during the first five years of life were gathered from the Uppsala County Mother and Child Cohort. Statistical analyses were performed with linear regression and linear mixed effect regression models. We found that higher glucose level during pregnancy was associated with higher weight z-score (β 0.10, 95% confidence interval (CI) 0.08-0.11), length z-score (β 0.05, 95% CI 0.03-0.07) and BMI z-score (β 0.09, 95% CI 0.07-0.12) at birth, adjusted for maternal BMI and country of birth, smoking during pregnancy and parity. The association did not remain at 1½, 3, 4 and 5 years of age. There was a positive relationship between higher glucose level during pregnancy and a decrease in weight z-score, height z-score and BMI z-score from birth to 5 years of age. In conclusion, higher random capillary glucose levels in pregnant healthy women were associated with greater infant size at birth, as well as decreased growth velocity in early childhood.

Perioperative Pulmonary Atelectasis: Part II. Clinical Implications

The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan, and ensure the patient's safety. Bedside diagnosis and management have benefited from recent imaging advancements such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management includes a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as noninvasive positive pressure ventilatory support may be beneficial in specific patients at high risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardiothoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions.

Persistence of sleep difficulties for over 16 years amongst 66,948 working-aged adults

The objective was to investigate the persistence of sleep difficulties for over 16 years amongst a population of working age. In this prospective cohort study, a group-based trajectory analysis of repeated surveys amongst 66,948 employees in public sector (mean age 44.7 [SD 9.4] years, 80% women) was employed. The main outcome measure was sleep difficulties based on Jenkins Sleep Scale (JSS). Up to 70% of the respondents did not experience sleep difficulties whereas up to 4% reported high frequency of notable sleep difficulties through the entire 16-year follow-up. Heavy drinking predicted sleep difficulties (OR 2.3 95% CI 1.6 to 3.3) except for the respondents younger than 40 years. Smoking was associated with sleep difficulties amongst women younger than 40 years (OR 1.2, 95% CI 1.0 to 1.5). Obesity was associated with sleep difficulties amongst men (OR 1.9, 95% CI 1.4 to 2.7) and women (OR 1.2, 95% CI 1.1 to 1.3) of middle age and amongst women older than 50 (OR 1.5, 95% CI 1.2 to 1.8) years. Physical inactivity predicted sleep difficulties amongst older men (OR 1.3, 95% CI 1.1 to 1.6). In this working-age population, sleep difficulties showed a great persistence over time. In most of the groups, the level of sleep difficulties during the follow-up was almost solely dependent on the level of initial severity. Depending on sex and age, increasing sleep problems were sometimes associated with high alcohol consumption, smoking, obesity and physical inactivity, but the strength of these associations varied.

Clinical and laboratory factors associated with coronavirus disease 2019 (Covid-19): A systematic review and meta-analysis

SARS Coronavirus-2 is one of the most widespread viruses globally during the 21st century, whose severity and ability to cause severe pneumonia and death vary. We performed a comprehensive systematic review of all studies that met our standardised criteria and then extracted data on the age, symptoms, and different treatments of Covid-19 patients and the prognosis of this disease during follow-up. Cases in this study were divided according to severity and death status and meta-analysed separately using raw mean and single proportion methods. We included 171 complete studies including 62,909 confirmed cases of Covid-19, of which 148 studies were meta-analysed. Symptoms clearly emerged in an escalating manner from mild-moderate symptoms, pneumonia, severe-critical to the group of non-survivors. Hypertension (Pooled proportion (PP): 0.48 [95% Confident interval (CI): 0.35-0.61]), diabetes (PP: 0.23 [95% CI: 0.16-0.33]) and smoking (PP: 0.12 [95% CI: 0.03-0.38]) were highest regarding pre-infection comorbidities in the non-survivor group. While acute respiratory distress syndrome (PP: 0.49 [95% CI: 0.29-0.78]), (PP: 0.63 [95% CI: 0.34-0.97]) remained one of the most common complications in the severe and death group respectively. Bilateral ground-glass opacification (PP: 0.68 [95% CI: 0.59-0.75]) was the most visible radiological image. The mortality rates estimated (PP: 0.11 [95% CI: 0.06-0.19]), (PP: 0.03 [95% CI: 0.01-0.05]), and (PP: 0.01 [95% CI: 0-0.3]) in severe-critical, pneumonia and mild-moderate groups respectively. This study can serve as a high evidence guideline for different clinical presentations of Covid-19, graded from mild to severe, and for special forms like pneumonia and death groups.

Germline determinants of humoral immune response to HPV-16 protect against oropharyngeal cancer

Although several oropharyngeal cancer (OPC) susceptibility loci have been identified, most previous studies lacked detailed information on human papillomavirus (HPV) status. We conduct a genome-wide analysis by HPV16 serology status in 4,002 oral cancer cases (OPC and oral cavity cancer (OCC)) and 5,256 controls. We detect four susceptibility loci pointing to a distinct genetic predisposition by HPV status. Our most notable finding in the HLA region, that is now confirmed to be specific of HPV(+)OPC risk, reveal two independent loci with strong protective effects, one refining the previously reported HLA class II haplotype association. Antibody levels against HPV16 viral proteins strongly implicate the protective HLA variants as major determinants of humoral response against L1 capsid protein or E6 oncoprotein suggesting a natural immune response against HPV(+)OPC promoted by HLA variants. This indicates that therapeutic vaccines that target E6 and attenuate viral response after established HPV infections might protect against HPV(+)OPC.

Associations between smoking and walking, fatigue, depression, and health-related quality of life in persons with multiple sclerosis

Smoking is associated with increased multiple sclerosis (MS) risk. In addition, some studies have reported that smoking is associated with anxiety and depression. However, the associations between smoking, walking, and fatigue are needed to be investigated. The objective was to investigate the associations between cigarette smoking and walking, fatigue, depression symptom severity, and health-related quality of life in persons with MS. Two hundred seventy-nine persons with MS were evaluated in this cross-sectional study. Study outcomes were neurological disability level, walking speed, walking endurance, perceived walking impact of MS, fatigue, depression symptom severity, and health-related quality of life. There were 95 (34.1%) current smokers who had significantly higher fatigue (p = 0.003, pη² = 0.031) and depression (p = 0.044, pη² = 0.015), and lower health-related quality of life (p = 0.003, pη² = 0.031) after adjusting for age, gender, neurological disability level, and disease duration compared to non-smokers (n = 184). There was no significant difference between smokers and non-smokers in walking measures (p > 0.05). Smoking intensity was significantly correlated with age (r = 0.487), neurological disability level (r = 0.227), disease duration (r = 0.30), walking speed (r = 0.574), walking endurance (r =  - 0.461), perceived walking impact of MS (r = 0.684), fatigue (r = 0.370), health-related quality of life (r =  - 0.259), and depression (r = 0.269) in current smokers. Cigarette smokers with MS had significantly more fatigue and depression symptom severity and less health-related quality of life compared to non-smokers. Increased pack-years of cigarette smoking was associated with worse walking ability and health-related quality of life, and greater depression symptom severity and fatigue.

The effect of triglycerides to high-density lipoprotein cholesterol ratio on the reduction of renal function: findings from China health and retirement longitudinal study (CHARLS)

BACKGROUND

Previous studies show that abnormal lipoprotein metabolism can increase the prevalence of chronic kidney disease (CKD). This study prospectively investigated the association of triglycerides to high-density lipoprotein cholesterol (TG/HDL-C) ratio and renal dysfunction in the Chinese population.

METHODS

This longitudinal cohort research examined 7,316 participants (age range: 22-93) from the China Health and Retirement Longitudinal Study (CHARLS), including 6,560 individuals with estimated glomerular filtration rate (eGFR) ≥ 60 mL/min/1.73 m2 (normal renal function, NRF) group and 756 with eGFR < 60 mL/min/1.73 m2 (impaired renal function, IRF) group. In NRF group, reduction in renal function was defined as eGFR < 60 mL/min/1.73 m2 at exit visit and in IRF group, it was defined as decline in eGFR category, average eGFR decline > 5 mL/min/1.73 m2 per year or > 30 % decrease in eGFR from baseline.

RESULTS

The study results showed that TG/HDL-C ratio was positively associated with the risk of renal function decline in the NRF group (OR 1.30, 95 %CI 1.03-1.65, P = 0.03) and the IRF group (OR 1.90, 95 %CI 1.21-3.23, P = 0.02) when adjusting for age, gender, obesity, diabetes, hypertension, waist circumference, drinking, smoking, history of heart disease and stroke, low-density lipoprotein cholesterol and eGFR category. Analysis of the IRF group indicated that relative to the group of TG/HDL-C < 1.60, the group of TG/HDL-C ≥ 2.97 had an increased risk for the decline of eGFR category (OR 1.89, 95 %CI 1.12-3.21, P = 0.02) and > 30 % decline in eGFR (OR 2.56, 95 %CI 1.05-6.38, P = 0.04).

CONCLUSIONS

The high TG/HDL-C ratio was an independent risk factor for declining renal function in the Chinese population.

Impact of vitamin C supplementation on placental DNA methylation changes related to maternal smoking: association with gene expression and respiratory outcomes

BACKGROUND

Maternal smoking during pregnancy (MSDP) affects development of multiple organ systems including the placenta, lung, brain, and vasculature. In particular, children exposed to MSDP show lifelong deficits in pulmonary function and increased risk of asthma and wheeze. Our laboratory has previously shown that vitamin C supplementation during pregnancy prevents some of the adverse effects of MSDP on offspring respiratory outcomes. Epigenetic modifications, including DNA methylation (DNAm), are a likely link between in utero exposures and adverse health outcomes, and MSDP has previously been associated with DNAm changes in blood, placenta, and buccal epithelium. Analysis of placental DNAm may reveal critical targets of MSDP and vitamin C relevant to respiratory health outcomes.

RESULTS

DNAm was measured in placentas obtained from 72 smokers enrolled in the VCSIP RCT: NCT03203603 (37 supplemented with vitamin C, 35 with placebo) and 24 never-smokers for reference. Methylation at one CpG, cg20790161, reached Bonferroni significance and was hypomethylated in vitamin C supplemented smokers versus placebo. Analysis of spatially related CpGs identified 93 candidate differentially methylated regions (DMRs) between treatment groups, including loci known to be associated with lung function, oxidative stress, fetal development and growth, and angiogenesis. Overlap of nominally significant differentially methylated CpGs (DMCs) in never-smokers versus placebo with nominally significant DMCs in vitamin C versus placebo identified 9059 candidate "restored CpGs" for association with placental transcript expression and respiratory outcomes. Methylation at 274 restored candidate CpG sites was associated with expression of 259 genes (FDR < 0.05). We further identified candidate CpGs associated with infant lung function (34 CpGs) and composite wheeze (1 CpG) at 12 months of age (FDR < 0.05). Increased methylation in the DIP2C, APOH/PRKCA, and additional candidate gene regions was associated with improved lung function and decreased wheeze in offspring of vitamin C-treated smokers.

CONCLUSIONS

Vitamin C supplementation to pregnant smokers ameliorates changes associated with maternal smoking in placental DNA methylation and gene expression in pathways potentially linked to improved placental function and offspring respiratory health. Further work is necessary to validate candidate loci and elucidate the causal pathway between placental methylation changes and outcomes of offspring exposed to MSDP. Clinical trial registration ClinicalTrials.gov, NCT01723696. Registered November 6, 2012. https://clinicaltrials.gov/ct2/show/record/NCT01723696 .

Multi-region exome sequencing reveals the intratumoral heterogeneity of surgically resected small cell lung cancer

Small cell lung cancer (SCLC) is a highly malignant tumor which is eventually refractory to any treatment. Intratumoral heterogeneity (ITH) may contribute to treatment failure. However, the extent of ITH in SCLC is still largely unknown. Here, we subject 120 tumor samples from 40 stage I-III SCLC patients to multi-regional whole-exome sequencing. The most common mutant genes are TP53 (88%) and RB1 (72%). We observe a medium level of mutational heterogeneity (0.30, range 0.0~0.98) and tumor mutational burden (TMB, 10.2 mutations/Mb, range 1.1~51.7). Our SCLC samples also exhibit somatic copy number variation (CNV) across all patients, with an average CNV ITH of 0.49 (range 0.02~0.99). In terms of mutation distribution, ITH, TMB, mutation clusters, and gene signatures, patients with combined SCLC behave roughly the same way as patients with pure SCLC. This condition also exists in smoking patients and patients with EGFR mutations. A higher TMB per cluster is associated with better disease-free survival while single-nucleotide variant ITH is linked to worse overall survival, and therefore these features may be used as prognostic biomarkers for SCLC. Together, these findings demonstrate the intratumoral genetic heterogeneity of surgically resected SCLC and provide insights into resistance to treatment.

Questioning the sex-specific differences in the association of smoking on the survival rate of hospitalized COVID-19 patients

Introduction

In the absence of a universally accepted association between smoking and COVID-19 health outcomes, we investigated this relationship in a representative cohort from one of the world’s highest tobacco consuming regions. This is the first report from the Middle East and North Africa that tackles specifically the association of smoking and COVID-19 mortality while demonstrating a novel sex-discrepancy in the survival rates among patients.

Methods

Clinical data for 743 hospitalized COVID-19 patients was retrospectively collected from the leading centre for COVID-19 testing and treatment in Lebanon. Logistic regression, Kaplan-Meier survival curves and Cox proportional hazards model adjusted for age and stratified by sex were used to assess the association between the current cigarette smoking status of patients and COVID-19 outcomes.

Results

In addition to the high smoking prevalence among our hospitalized COVID-19 patients (42.3%), enrolled smokers tended to have higher reported ICU admissions (28.3% vs 16.6%, p<0.001), longer length of stay in the hospital (12.0 ± 7.8 vs 10.8 days, p<0.001) and higher death incidences as compared to non-smokers (60.5% vs 39.5%, p<0.001). Smokers had an elevated odds ratio for death (OR = 2.3, p<0.001) and for ICU admission (OR = 2.0, p<0.001) which remained significant in a multivariate regression model. Once adjusted for age and stratified by sex, our data revealed that current smoking status reduces survival rate in male patients ([HR] = 1.9 [95% (CI), 1.029–3.616]; p = 0.041) but it does not affect survival outcomes among hospitalized female patients([HR] = 0.79 [95% CI = 0.374–1.689]; p = 0.551).

Conclusion

A high smoking prevalence was detected in our hospitalized COVID-19 cohort combined with worse prognosis and higher mortality rate in smoking patients. Our study was the first to highlight potential sex-specific consequences for smoking on COVID-19 outcomes that might further explain the higher vulnerability to death from this disease among men.

Saliva pH and Flow Rate in Patients with Periodontal Disease and Associated Cardiovascular Disease

BACKGROUND Periodontal disease, a frequent oral health problem, is connected with cardiovascular morbidity and mortality. This study aimed to assess the unstimulated saliva flow rate and saliva pH as markers of the severity of periodontal disease in patients with cardiovascular disease. MATERIAL AND METHODS A cohort of 155 patients (78 men and 77 women, aged 30-92 years) was included, and a structured questionnaire obtained information about their health status, oral healthcare behaviors, and eating habits. An oral examination was performed to assess periodontal status and presence of dental calculus. The unstimulated whole salivary flow rate and salivary pH were measured. An oral hygienization was performed, and 3 months later, salivary flow rate and pH were reevaluated. RESULTS A severe form of periodontal disease was found in 22.4% of patients. Disease severity was strongly correlated with low pH values (6.25 in stage IV periodontal disease), lower salivary flow rate (0.28 mL/min), smoking, poor oral hygiene habits and obesity, with no significant differences by sex. We observed a significant increase of pH (up to 6.30±0.17) in patients with severe periodontal disease (P=0.001) and salivary flow rate values (0.29±0.07 mL/min; P=0.014) 3 months after oral hygienization. There was a strong association between the severity of periodontal disease and presence of cardiovascular disease (P=0.001). CONCLUSIONS Our study suggests that the decrease of salivary flow rate and pH level might be associated with the severity of periodontal disease.

Effects of tumor necrosis factor (TNF) gene polymorphisms on the association between smoking and lung function among workers in swine operations

Workers in swine operations may be at increased risk of developing respiratory problems. These respiratory conditions are more prevalent among workers who are smokers. Tumor necrosis factor (TNF) genes play an important role in human immune responses to various respiratory hazards. This study aimed to investigate whether polymorphisms in TNF genes might alter the effects of smoking on lung function among workers in swine operations. Three hundred and seventy-four full-time workers from large swine operations and 411 non-farming rural dwellers in Saskatchewan were included in this study. Information on demographic and lifestyle characteristics, pulmonary function, and blood samples were obtained. Multiple linear regression analyses were used in the statistical analysis. Three promoter polymorphisms (rs1799724, rs361525, and rs1800629) in the TNF gene were investigated. Only the interaction term between smoking status and rs1799724 was significant in the multiple regression models. Among workers with the rs1799724 polymorphism (TT+TC), current smokers exhibited significantly lower lung function than nonsmokers. These associations were not observed among workers with the wild-type (CC). These findings were not observed among non-farming rural dwellers. Data demonstrated the possible involvement of TNF gene in (1) development of adverse respiratory conditions among workers who are smokers, (2) importance of smoking cessation among workers, especially those with polymorphisms in the TNF gene, and (3) potential implications in treatment, screening, and prevention.

Geographic Variation in Cardiovascular Health Among American Adults

OBJECTIVE

To evaluate the contemporary geographic trends in cardiovascular health in the United States and its relationship with geographic distribution of cardiovascular mortality.

METHODS

By use of a retrospective cross-sectional design, the 2011-2017 Behavioral Risk Factor Surveillance System (BRFSS) was queried to determine the age-adjusted prevalence of cardiovascular health index (CVHI) metrics (sum of ideal blood pressure, blood glucose concentration, lipid levels, body mass index, smoking, physical activity, and diet). Cardiovascular health was estimated as both continuous (0 to 7 points) and categorical (ideal, intermediate, poor) variables from the BRFSS. Age-adjusted cardiovascular mortality for 2017 was obtained from the Centers for Disease Control and Prevention WONDER database.

RESULTS

Among 1,362,529 American adult participants of the BRFSS 2011-2017 and all American residents in 2017, the CVHI score increased from 3.89±0.004 in 2011 to 3.96±0.005 in 2017 (P_trend<.001) nationally, with modest improvement across all regions (P_trend<.05 for all). Ideal cardiovascular health prevalence improved in the northeastern (P_trend=.03) and southern regions (P_trend=.002). In 2017, the prevalence of coronary heart disease (6.8%; 95% CI, 6.5% to 7.1%) and stroke (3.7%; 95% CI, 3.4% to 3.9%) was highest in the southern region. The CVHI score (3.81±0.01) and the prevalence of ideal cardiovascular health (12.2%; 95% CI, 11.7% to 12.7%) were lowest in the southern United States. This corresponded to the higher cardiovascular mortality in the southern region (233.0 [95% CI, 232.2- to 33.8] per 100,000 persons).

CONCLUSION

Despite a modest improvement in CVHI, only 1 in 6 Americans has ideal cardiovascular health with significant geographic differences. These differences correlate with the geographic distribution of cardiovascular mortality. An urgent unmet need exists to mitigate the geographic disparities in cardiovascular morbidity and mortality.

Blood pressure-lowering effect of repeated Waon therapy in non-smokers with hypertension

Waon therapy (WT) has been used as a thermal therapy in chronic heart failure patients. However, its effect in patients with hypertension is unclear. This study aimed to reveal the hypotensive effect of WT in patients with hypertension. WT was performed on 31 patients with hypertension (63.9 ± 11.9 years, male: 17) on standard hypertension treatment focusing on lifestyle modification and medication. Systolic and diastolic blood pressures were measured before and after WT using an upper arm automated sphygmomanometer. We investigated the effect of single and repeated (1 time/d, >5 times) WT sessions on blood pressure and further compared its effect between current smoking (n = 11, 55.4 ± 6.4 years, 8.5 ± 2.4 times) and non-smoking (n = 11, 66.9 ± 8.5 years, 12.2 ± 5.9 times) groups. A total of 370 sessions of WT were conducted. Systolic and diastolic blood pressures significantly decreased after a single WT session (systolic blood pressure: 118.5 ± 10.1 to 115.1 ± 9.0 mm Hg, P < .001; diastolic blood pressure: 70.5 ± 6.4 to 65.9 ± 5.3 mm Hg, P < .001). The blood pressure decrease following repeated WT was not significant when all participants were considered (systolic blood pressure: 122.3 ± 15.2 to 116.9 ± 19.6 mm Hg; diastolic blood pressure: 73.8 ± 16.7 to 68.2 ± 13.2 mm Hg); however, it was significant in the non-smoking group (systolic blood pressure: 124.2 ± 11.3 to 108.8 ± 13.4 mm Hg, P < .001; diastolic blood pressure: 73.6 ± 4.9 to 62.1 ± 7.6 mm Hg, P < .001). Repeated WT (at least 5 sessions) decreased blood pressure in patients with hypertension, especially in non-smokers. WT is a simple method to reduce blood pressure in non-smoking patients with hypertension.

The smoking paradox in ischemic stroke patients treated with intra-arterial thrombolysis in combination with mechanical thrombectomy-VISTA-Endovascular

BACKGROUND

The smoking-paradox of a better outcome in ischemic stroke patients who smoke may be due to increased efficacy of thrombolysis. We investigated the effect of smoking on outcome following endovascular therapy (EVT) with mechanical thrombectomy alone versus in combination with intra-arterial (IA-) thrombolysis.

METHODS

The primary endpoint was defined by three-month modified Rankin Scale (mRS). We performed a generalized linear model and reported relative risks (RR) for smoking (adjustment for age, sex, hypertension, atrial fibrillation, stroke severity, time to EVT) in patient data stemming from the Virtual International Stroke Trials Archive-Endovascular database.

RESULTS

Among 1,497 patients, 740(49.4%) were randomized to EVT; among EVT patients, 524(35.0%) received mechanical thrombectomy alone and 216(14.4%) received it in combination with IA-thrombolysis. Smokers (N = 396) had lower mRS scores (mean 2.9 vs. 3.2; p = 0.02) and mortality rates (10% vs. 17.3%; p<0.001) in univariate analysis. In all patients and in patients treated with mechanical thrombectomy alone, smoking had no effect on outcome in regression analyses. In patients who received IA-thrombolysis (N = 216;14%), smoking had an adjusted RR of 1.65 for an mRS≤1 (95%CI 0.77-3.55). Treatment with IA-thrombolysis itself led to reduced RR for favorable outcome (adjusted RR 0.30); interaction analysis of IA-thrombolysis and smoking revealed that non-smokers with IA-thrombolysis had mRS≤2 in 47 cases (30%, adjusted RR 0.53 [0.41-0.69]) while smokers with IA-thrombolysis had mRS≤2 in 23 cases (38%, adjusted RR 0.61 [0.42-0.87]).

CONCLUSIONS

Smokers had no clear clinical benefit from EVT that incorporates IA-thrombolysis.

Smoking induces the occurrence of colorectal cancer via changing the intestinal permeability

PURPOSE

Colorectal cancer (CRC) is the third most frequent cancer. Its occurrence is closely linked to lifestyle and diet habits, such as excessive intake of high-fat food, but their impact on CRC, however, remain unclear.

METHODS

Eligible CRC patients were retrospectively analyzed. Overall survival (OS) and recurrence-free survival (RFS) in smokers and non-smokers of CRC patients were assessed. APCmin/+ mice were exposed to cigarette smoking, followed by detection of CRC growth and intestinal permeability.

RESULTS

A total of 416 eligible CRC patients were recruited, involving 218 (52.4%) smokers and 198 (47.6%) non-smokers. OS was shorter in CRC smokers than in non-smokers (p=0.005), whereas smoking did not affect RFS in CRC patients (p=0.251). Cigarette smoking increased CRC tumor numbers of CRC in APCmin/+ mice. Proliferation and apoptosis of colorectal epithelial cells, and inflammatory response in mice were changed following smoking. Notably, the treatment of probiotics mixture VSL#3 decreased the number of CRC tissues and intestinal permeability in APCmin/+ mice exposed to cigarette smoking.

CONCLUSIONS

Smoking increases the susceptibility to CRC through damaging the intestinal permeability. Protecting the intestinal permeability significantly protects intestinal tracts.

The interplay of sleep duration, working hours, and obesity in Korean male workers: The 2010-2015 Korea National Health and Nutrition Examination Survey

The purpose of this study was to clarify the odds ratio for association between working hours and obesity in Korean male wage workers and investigate the role of sleep duration. This study is a cross-sectional one using large-scale national data from the Korea National Health and Nutrition Examination Survey collected between 2010 and 2015 to evaluate 2,592 male wage workers (between the ages of 19 and 60 years). Obesity was defined as 25kg/m² or more and working hours per week were categorized into <40, 40–49, 50–59, and ≥60 hours. Multiple regression analysis was performed to examine the odds ratio for association between working hours and obesity, after controlling for age, education, income, marital status, smoking, drinking, physical activity, daily energy intake, sleep duration, hypertension, diabetes, dyslipidemia, work schedule, and job category. Next, to study the mediating effect of sleep duration on the association between working hours and obesity, an analysis was performed using the Baron and Kenny method and the Sobel test. Results showed that workers with 50 to 59 hours had 1.4 times higher odds (odds ratio [OR] = 1.4, confidence interval [CI]: 1.11–1.85) of obesity and workers with 60 hours or more had 1.4 times higher odds (OR = 1.4, CI: 1.06–1.90) of obesity than workers with less than 40 hours. Sleep was found to have a mediating effect on the association between working time and body mass index. Therefore, the results of this analysis suggest that practitioners should identify potential factors such as working time and sleeping time when preventing work-related obesity.

Leisure-Time and Occupational Physical Activity Associates Differently with Epigenetic Aging

PURPOSE

Greater leisure-time physical activity (LTPA) associates with healthier lives, but knowledge regarding occupational physical activity (OPA) is more inconsistent. DNA methylation (DNAm) patterns capture age-related changes in different tissues. We aimed to assess how LTPA and OPA are associated with three DNAm-based epigenetic age estimates, namely, DNAm age, PhenoAge, and GrimAge.

METHODS

The participants were young adult (21-25 yr, n = 285) and older (55-74 yr, n = 235) twin pairs, including 16 pairs with documented long-term LTPA discordance. Genome-wide DNAm from blood samples was used to compute DNAm age, PhenoAge, and GrimAge Age acceleration (Acc), which describes the difference between chronological and epigenetic ages. Physical activity was assessed with sport, leisure-time, and work indices based on the Baecke Questionnaire. Genetic and environmental variance components of epigenetic age Acc were estimated by quantitative genetic modeling.

RESULTS

Epigenetic age Acc was highly heritable in young adult and older twin pairs (~60%). Sport index was associated with slower and OPA with faster DNAm GrimAge Acc after adjusting the model for sex. Genetic factors and nonshared environmental factors in common with sport index explained 1.5%-2.7% and 1.9%-3.5%, respectively, of the variation in GrimAge Acc. The corresponding proportions considering OPA were 0.4%-1.8% and 0.7%-1.8%, respectively. However, these proportions were minor (<0.5%) after adjusting the model for smoking status.

CONCLUSIONS

LTPA associates with slower and OPA with faster epigenetic aging. However, adjusting the models for smoking status, which may reflect the accumulation of unhealthy lifestyle habits, attenuated the associations.

Smoking Accelerates Atrioventricular Conduction in Humans Concordant with Increased Dopamine Release

Smoking is associated with cardiac arrhythmia, stroke, heart failure, and sudden cardiac arrest, all of which may derive from increased sympathetic influence on cardiac conduction system and altered ventricular repolarization. However, knowledge of the effects of smoking on supraventricular conduction, and the role of the sympathetic nervous system in them, remains incomplete. Participants with intermediate-high cardiovascular disease risk were measured for urinary catecholamines and cotinine, and 12-lead electrocardiograms (ECGs) were measured for atrial and atrioventricular conduction times, including P duration, PR interval, and PR segment (lead II), which were analyzed for associations with cotinine by generalized linear models. Statistical mediation analyses were then used to test whether any significant associations between cotinine and atrioventricular conduction were mediated by catecholamines. ECG endpoints and urinary metabolites were included from a total of 136 participants in sinus rhythm. Atrial and atrioventricular conduction did not significantly differ between smokers (n = 53) and non-smokers (n = 83). Unadjusted and model-adjusted linear regressions revealed cotinine significantly and inversely associated with PR interval and PR segment, but not P duration. Dopamine, norepinephrine, and epinephrine all inversely associated with PR interval, whereas only dopamine was also inversely associated with PR segment (p < 0.05). Dopamine and norepinephrine (but not epinephrine) also associated positively with cotinine. Dopamine mediated the relationship between cotinine and PR interval, as well as the relationship between cotinine and PR segment. Smoking is associated with accelerated atrioventricular conduction and elevated urinary dopamine and norepinephrine. Smoking may accelerate atrioventricular nodal conduction via increased dopamine production.

Multifactorial Background for a Low Biological Response to Antiplatelet Agents Used in Stroke Prevention

Effective platelet inhibition is the main goal of the antiplatelet therapy recommended as a standard treatment in the secondary prevention of non-embolic ischemic stroke. Acetylsalicylic acid (aspirin) and clopidogrel are commonly used for this purpose worldwide. A low biological response to antiplatelet agents is a phenomenon that significantly reduces the therapeutic and protective properties of the therapy. The mechanisms leading to high on-treatment platelet reactivity are still unclear and remain multifactorial. The aim of the current review is to establish the background of resistance to antiplatelet agents commonly used in the secondary prevention of ischemic stroke and to explain the possible mechanisms. The most important factors influencing the incidence of a low biological response were demonstrated. The similarities and the differences in resistance to both drugs are emphasized, which may facilitate the selection of the appropriate antiplatelet agent in relation to specific clinical conditions and comorbidities. Despite the lack of indications for the routine assessment of platelet reactivity in stroke subjects, this should be performed in selected patients from the high-risk group. Increasing the detectability of low antiaggregant responders, in light of its negative impact on the prognosis and clinical outcomes, can contribute to a more individualized approach and modification of the antiplatelet therapy to maximize the therapeutic effect in the secondary prevention of stroke.

HIV infection and COVID-19 death: a population-based cohort analysis of UK primary care data and linked national death registrations within the OpenSAFELY platform

BACKGROUND

Whether HIV infection is associated with risk of death due to COVID-19 is unclear. We aimed to investigate this association in a large-scale population-based study in England.

METHODS

We did a retrospective cohort study. Working on behalf of NHS England, we used the OpenSAFELY platform to analyse routinely collected electronic primary care data linked to national death registrations. We included all adults (aged ≥18 years) alive and in follow-up on Feb 1, 2020, and with at least 1 year of continuous registration with a general practitioner before this date. People with a primary care record for HIV infection were compared with people without HIV. The outcome was COVID-19 death, defined as the presence of International Classification of Diseases 10 codes U07.1 or U07.2 anywhere on the death certificate. Cox regression models were used to estimate the association between HIV infection and COVID-19 death; they were initially adjusted for age and sex, then we added adjustment for index of multiple deprivation and ethnicity, and then for a broad range of comorbidities. Interaction terms were added to assess effect modification by age, sex, ethnicity, comorbidities, and calendar time.

RESULTS

17 282 905 adults were included, of whom 27 480 (0·16%) had HIV recorded. People living with HIV were more likely to be male, of Black ethnicity, and from a more deprived geographical area than the general population. 14 882 COVID-19 deaths occurred during the study period, with 25 among people with HIV. People living with HIV had higher risk of COVID-19 death than those without HIV after adjusting for age and sex: hazard ratio (HR) 2·90 (95% CI 1·96-4·30; p<0·0001). The association was attenuated, but risk remained high, after adjustment for deprivation, ethnicity, smoking and obesity: adjusted HR 2·59 (95% CI 1·74-3·84; p<0·0001). There was some evidence that the association was larger among people of Black ethnicity: HR 4·31 (95% CI 2·42-7·65) versus 1·84 (1·03-3·26) in non-Black individuals (p-interaction=0·044).

INTERPRETATION

People with HIV in the UK seem to be at increased risk of COVID-19 mortality. Targeted policies should be considered to address this raised risk as the pandemic response evolves.

FUNDING

Wellcome, Royal Society, National Institute for Health Research, National Institute for Health Research Oxford Biomedical Research Centre, UK Medical Research Council, Health Data Research UK.

Longitudinal changes in reproductive hormones through the menopause transition in the Avon Longitudinal Study of Parents and Children (ALSPAC)

We characterised changes in reproductive hormones-LH, FSH, SHBG and AMH-by chronological age and time around the menopause (reproductive age) in mid-life women and explored their associations with lifestyle and reproductive factors. We used data from 1608 women from a UK cohort who had repeat hormone measures and experienced a natural menopause. Multilevel models were used to assess: (i) changes in hormones (outcomes) by reproductive age and chronological age (these age variables being the key exposures) and (ii) associations of body mass index (BMI), smoking, alcohol intake, parity and age at menarche with changes in hormones by reproductive age. Both LH and FSH increased until ~ 5 and 7 years postmenopause, respectively, after which they declined, but not to premenopausal levels. SHBG decreased slightly until ~ 4 years postmenopause and increased thereafter. AMH decreased markedly before menopause and remained low subsequently. For all hormones, the best fitting models included both reproductive and chronological age. BMI, smoking and parity were associated with hormone changes; e.g., higher BMI was associated with slower increase in LH and FSH and decrease in AMH. Reproductive and chronological age contribute to changes in LH, FSH, SHBG and AMH across mid-life in women, and BMI, smoking and parity are associated with these hormone changes.

The association of PAI-1 with 24 h blood pressure in young healthy adults is influenced by smoking and alcohol use: The African-PREDICT study

BACKGROUND AND AIMS

The association between plasminogen activator inhibitor-1 (PAI-1) and blood pressure is well established, but it is debatable whether raised PAI-1 levels precede or result from raised blood pressure. Furthermore, it is unclear whether this association already exists in the absence of overt hypertension and to what degree it is influenced by health behaviours. Our aim was to investigate the association of 24 h blood pressure with PAI-1 activity (PAI-1_act) in a young, healthy cohort, and to assess the influence of alcohol consumption and smoking on these associations.

METHODS AND RESULTS

Healthy black and white men and women (aged 20-30 years, n = 1156) were cross-sectionally analysed. Statistical analysis was performed first split by ethnicity and sex and then by alcohol consumption and smoking. Regression analyses adjusted for age revealed positive associations of 24 h blood pressure with PAI-1_act in most groups (p < 0.05). In multivariate-adjusted analyses, significance was lost in all groups except black men, who also had higher monocyte chemoattractant protein-1 (MCP-1) and von Willebrand factor antigen (vWF_ag) compared to white men (both p < 0.001). Analyses in black men, split by self-reported alcohol use and smoking, revealed 24 h blood pressure-PAI-1_act associations only in alcohol users (24 h SBP [B = 4.22, p < 0.001], DBP [B = 2.04, p = 0.015] and PP [B = 2.18, p = 0.013]) and smokers (24 h SBP [B = 6.10, p < 0.001] and PP [B = 4.33, p = 0.001]).

CONCLUSION

Our findings support a positive association between 24 h blood pressure and PAI-1, particularly in individuals with higher MCP-1 and vWF_ag levels. Furthermore, smoking and alcohol consumption play an important role in modifying the association between blood pressure and PAI-1.

Smoking cessation and related factors in middle-aged and older Chinese adults: Evidence from a longitudinal study

OBJECTIVES

There are more than 300 million smokers in China. This study aimed to evaluate the rate of smoking cessation, smoking relapse and related factors in middle-aged and older smokers in China.

METHODS

We performed a secondary analysis of data from China Health and Retirement Longitudinal Study (CHARLS) that recruited a nationally representative sample of adults aged 45 and older. Participants were 3708 smokers in 2011 who completed two waves of follow-up interviews in 2013 and 2015. Self-reported quit and relapse rates at follow-ups were estimated. Multiple logistic regressions were conducted to identify factors associated with smoking cessation and relapse.

RESULTS

The overall quit rate was 8.5% (95% CI 7.7% - 9.5%) at the 2-year follow-up in 2013, and 16.6% (95% CI 15.5% - 17.9%) at the 4-year follow up. Smoking cessation in 2013 was associated with not living in the northeast region (p = 0.003), fewer cigarettes smoked daily (p <0.001), and longer time to the first cigarette in the morning (p<0.001). Smoking cessation in 2015 was associated with older age (p = 0.049), smoking initiation at age ≥20 years (p<0.001), longer time to the first cigarette in the morning (p<0.001), and self-perceived poor health (p<0.001). Of the 317 participants who stopped smoking in 2013, 13.3% (95% CI 9.9% - 17.5%) relapsed by 2015. Smoking relapse was associated with younger age (p = 0.025), shorter time to the first cigarette in the morning (p = 0.003), and self-perception of not poor health (p = 0.018).

CONCLUSION

The overall quit rate was 8.5% at the 2-year follow up, and 16.6% at the 4-year follow up in the middle-aged and older smokers, but 13% of quitters returned to smoking in two years. Successful smoking cessation was associated with older age, lower nicotine dependence, and self-perceived poor health.

The effect of smoking on atrial and ventricular functions in healthy subjects: A speckle tracking echocardiography study

PURPOSE

Smoking is a well-known risk factor for coronary artery diseases. It is also associated with nicotine-induced myocardial dysfunction. The aim of this study was to evaluate the right and left atrial and ventricular functions in apparently healthy smokers.

METHODS

We included consecutively 80 healthy smokers (56 males, mean age:35.5 ± 8.4 years) and 70 healthy nonsmokers (44 males, mean age:33.9 ± 9.5 years). None of the subjects had any additional cardiovascular risk factor other than smoking. The right and left atrial and ventricular functions were assessed by both conventional and speckle tracking echocardiography.

RESULTS

Although there was no significant difference in left ventricular ejection fraction, the smokers had significantly lower ventricular global longitudinal strain than controls (-19.9 ± 2.0% vs -21.2 ± 1.9%, P < .001 and -18.4 ± 2.1% vs -21.8 ± 2.2%, P < .001, respectively, for the left and right ventricle). Smokers had also lower atrial reservoir and conduit strains: 35.9 ± 11.1% vs 40.2 ± 11.2%, P = .022 and 16.7 ± 6.8% vs 19.4 ± 6.8%, P = .016, respectively, for the left atrium, and 33.0 ± 10.6% vs 37.6 ± 11.2%, P = .011 and 15.2 ± 5.6% vs 18.0 ± 6.3%, P = .004, respectively, for the right atrium).

CONCLUSION

Even in apparently healthy people with no other cardiovascular risk factors, smoking is associated with impaired atrial and ventricular functions.

Expression of SARS-CoV-2 entry receptors in the respiratory tract of healthy individuals, smokers and asthmatics

SARS-CoV-2 is causing a pandemic with currently > 29 million confirmed cases and > 900,000 deaths worldwide. The locations and mechanisms of virus entry into the human respiratory tract are incompletely characterized. We analyzed publicly available RNA microarray datasets for SARS-CoV-2 entry receptors and cofactors ACE2, TMPRSS2, BSG (CD147) and FURIN. We found that ACE2 and TMPRSS2 are upregulated in the airways of smokers. In asthmatics, ACE2 tended to be downregulated in nasal epithelium, and TMPRSS2 was upregulated in the bronchi. Furthermore, respiratory epithelia were negative for ACE-2 and TMPRSS2 protein expression while positive for BSG and furin, suggesting a possible alternative entry route for SARS-CoV-2.

Pathways leading to prevention of fatal and non-fatal cardiovascular disease: An interaction model on 15 years population-based cohort study

BACKGROUND

A comprehensive study on the interaction of cardiovascular disease (CVD) risk factors is critical to prevent cardiovascular events. The main focus of this study is thus to understand direct and indirect relationships between different CVD risk factors.

METHODS

A longitudinal data on adults aged ≥35 years, who were free of CVD at baseline, were used in this study. The endpoints were CVD events, whereas their measurements were demographic, lifestyle components, socio-economics, anthropometric measures, laboratory findings, quality of life status, and psychological factors. A Bayesian structural equation modelling was used to determine the relationships among 21 relevant factors associated with total CVD, stroke, acute coronary syndrome (ACS), and fatal CVDs.

RESULTS

In this study, a total of 3161 individuals with complete information were involved in the study. A total of 407 CVD events, with an average age of 54.77(10.66) years, occurred during follow-up. The causal associations between six latent variables were identified in the causal network for fatal and non-fatal CVDs. Lipid profile, with the coefficient of 0.26 (0.01), influenced the occurrence of CVD events as the most critical factor, while it was indirectly mediated through risky behaviours and comorbidities. Lipid profile at baseline was influenced by a wide range of other protective factors, such as quality of life and healthy lifestyle components.

CONCLUSIONS

Analysing a causal network of risk factors revealed the flow of information in direct and indirect paths. It also determined predictors and demonstrated the utility of integrating multi-factor data in a complex framework to identify novel preventable pathways to reduce the risk of CVDs.

Gender differences in the modifiable risk factors associated with the presence of prediabetes: A systematic review

BACKGROUND

Prediabetes is a risk state for the future development of type 2 diabetes. Previously, it was evident that the risk factors for diabetes differ by gender. However, conclusive evidence regarding the gender difference in modifiable risk factors associated with the presence of pre-diabetes is still lacking.

AIMS

To systematically identify and summarize the available literature on whether the modifiable risk factors associated with prediabetes displays similar relationship in both the genders.

METHODS

A systematic search was performed on electronic databases i.e. PubMed, EBSCOhost, and Scopus using "sex", "gender", "modifiable risk factors" and "prediabetes" as keywords. Reference list from identified studies was used to augment the search strategy. Methodological quality and results from individual studies were summarized in tables.

RESULTS

Gender differences in the risk factor association were observed among reviewed studies. Overall, reported association between risk factors and prediabetes apparently stronger among men. In particular, abdominal obesity, dyslipidemia, smoking and alcohol drinking habits were risk factors that showed prominent association among men. Hypertension and poor diet quality may appear to be stronger among women. General obesity showed stringent hold, while physical activity not significantly associated with the risk of prediabetes in both the genders.

CONCLUSIONS

Evidence suggests the existence of gender differences in risk factors associated with prediabetes, demands future researchers to analyze data separately based on gender. The consideration and the implementation of gender differences in health policies and in diabetes prevention programs may improve the quality of care and reduce number of diabetes prevalence among prediabetic subjects.

Clustering of noncommunicable disease risk factors among adults (18-69 years) in rural population, South-India

BACKGROUND AND AIMS

Non-communicable diseases (NCDs) and its risk factors are increasing worldwide and in India. Controlling the rise in risk factors at present is crucial to prevent NCD surge in future. Current study was conducted to estimate the burden of clustering of NCD risk factors among adult population (18-69 years) residing in selected villages of rural Bengaluru, Karnataka METHODS: Population based screening for NCD risk factors were carried out among adults in rural Bengaluru during May to October 2019. NCD risk factors were screened using WHO STEPwise approach to chronic disease risk factor surveillance (STEPs) instrument and Integrated Disease Surveillance Project (IDSP) NCD risk factor tool. Presence of three or more risk factors in same individual was considered as presence of clustering of NCD risk factors. Additional analysis was done for clustering of NCD risk factors with different number of risk factors.

RESULTS

Prevalence of clustering of NCD risk factors in rural adult population was as follows; ≥2 risk factors 81.0%, ≥3 risk factors 56.3%, ≥4 risk factors 33.6%, ≥5 risk factors 14.5% and ≥6 risk factors 4.8%. The most common NCD risk factors were inadequate intake of fruits and vegetables (82.3%), physical inactivity (46.8%) and central obesity (46.4%). Clustering NCD risk factors were significantly associated with increased age, males and lower levels of education.

CONCLUSIONS

High burden of clustering of risk factor indicates the need for health policies with integrated NCD risk factors prevention strategies than targeted approach. Awareness regarding the effect of clustering needs to be increased among the primary care physicians practising in rural areas.

Smoking Is Associated With COVID-19 Progression: A Meta-analysis

INTRODUCTION

Smoking depresses pulmonary immune function and is a risk factor contracting other infectious diseases and more serious outcomes among people who become infected. This paper presents a meta-analysis of the association between smoking and progression of the infectious disease COVID-19.

METHODS

PubMed was searched on April 28, 2020, with search terms "smoking", "smoker*", "characteristics", "risk factors", "outcomes", and "COVID-19", "COVID", "coronavirus", "sar cov-2", "sar cov 2". Studies reporting smoking behavior of COVID-19 patients and progression of disease were selected for the final analysis. The study outcome was progression of COVID-19 among people who already had the disease. A random effects meta-analysis was applied.

RESULTS

We identified 19 peer-reviewed papers with a total of 11,590 COVID-19 patients, 2,133 (18.4%) with severe disease and 731 (6.3%) with a history of smoking. A total of 218 patients with a history of smoking (29.8%) experienced disease progression, compared with 17.6% of non-smoking patients. The meta-analysis showed a significant association between smoking and progression of COVID-19 (OR 1.91, 95% confidence interval [CI] 1.42-2.59, p = 0.001). Limitations in the 19 papers suggest that the actual risk of smoking may be higher.

CONCLUSIONS

Smoking is a risk factor for progression of COVID-19, with smokers having higher odds of COVID-19 progression than never smokers.

IMPLICATIONS

Physicians and public health professionals should collect data on smoking as part of clinical management and add smoking cessation to the list of practices to blunt the COVID-19 pandemic.

Smoking Is Associated With COVID-19 Progression: A Meta-analysis

INTRODUCTION

Smoking depresses pulmonary immune function and is a risk factor contracting other infectious diseases and more serious outcomes among people who become infected. This paper presents a meta-analysis of the association between smoking and progression of the infectious disease COVID-19.

METHODS

PubMed was searched on April 28, 2020, with search terms "smoking", "smoker*", "characteristics", "risk factors", "outcomes", and "COVID-19", "COVID", "coronavirus", "sar cov-2", "sar cov 2". Studies reporting smoking behavior of COVID-19 patients and progression of disease were selected for the final analysis. The study outcome was progression of COVID-19 among people who already had the disease. A random effects meta-analysis was applied.

RESULTS

We identified 19 peer-reviewed papers with a total of 11,590 COVID-19 patients, 2,133 (18.4%) with severe disease and 731 (6.3%) with a history of smoking. A total of 218 patients with a history of smoking (29.8%) experienced disease progression, compared with 17.6% of non-smoking patients. The meta-analysis showed a significant association between smoking and progression of COVID-19 (OR 1.91, 95% confidence interval [CI] 1.42-2.59, p = 0.001). Limitations in the 19 papers suggest that the actual risk of smoking may be higher.

CONCLUSIONS

Smoking is a risk factor for progression of COVID-19, with smokers having higher odds of COVID-19 progression than never smokers.

IMPLICATIONS

Physicians and public health professionals should collect data on smoking as part of clinical management and add smoking cessation to the list of practices to blunt the COVID-19 pandemic.

Predictors of accelerated FEV1 decline in adults with airflow limitation-Findings from the Health2006 cohort

To investigate predictors of accelerated decline in forced expiratory volume in 1 s (FEV₁) in individuals with preexisting airflow limitation (AL). Participants in the Health2006 baseline study aged ≥ 35 with FEV₁/ forced vital capacity (FVC) < lower limit of normal (LLN) were invited for a 10-year follow-up. At both examinations, data were obtained on demographics, spirometry, fitness level, allergy, and exhaled nitric oxide. We used multiple regression modeling to predict the annual decline in FEV₁, reported as regression coefficients ( R) and 95% confidence intervals (CIs). A total of 123 (43% of those invited) participated in the follow-up examination, where more had exercise-induced dyspnea but fewer had asthma symptoms. Being female ( R = -29.8 ml, CI: -39.7 to -19.8), diagnosed with asthma ( R = -13.7, CI: -20.4 to -7.0) or atopic dermatitis ( R = -29.0, CI: -39.7 to -18.4), and having current asthma symptoms or nightly respiratory symptoms ( R = -22.1, CI: -31.9 to -12.4 and R = -14.3, CI: -19.9 to -8.7, respectively) were significantly associated with a steeper decline in FEV₁. Although to a smaller extent, a steeper decline was also predicted by age, baseline FEV₁, waist/hip-ratio, and number of pack-years smoked. In individuals with preexisting AL, being female and having ever or current respiratory symptoms were associated with an accelerated annual decline in FEV₁.

The Effect of Comorbidities on Wound Healing

Wound healing is affected by several factors. Preexisting diagnoses may significantly alter, delay, or inhibit normal wound healing. This is most commonly seen with chronic disorders, such as diabetes and renal failure, but also occurs secondary to aging and substance abuse. Less commonly, genetic or inflammatory disorders are the cause of delayed wound healing. In some cases, it is not the illness, but the treatment that can inhibit wound healing. This is seen in patients getting chemotherapy, radiation, steroids, methotrexate, and a host of other medications. Understanding these processes may help treat or avoid wound healing problems.

Profile of Cardiovascular Disease Patients Who are Diagnosed with COPD in a Smoking-Cessation Unit

INTRODUCTION

Cardiovascular diseases (CVDs) and chronic obstructive pulmonary disease (COPD) have similar prevalence rates and risk factors, and both frequently occur in the same patient. The primary objective of the study was to evaluate the rate of COPD patients among subjects with some form of CVD referring to a smoking cessation unit. The secondary objective was to analyze the demographic and clinical profile of these subjects and to identify independent factors potentially associated with COPD.

METHODS

Observational, prospective study involving 132 patients with smoking habits, and some form of CVD, referring to the smoking cessation unit at the Pulmonology Department of the University Hospital of Cáceres, Spain, between October 2015 and March 2017.

RESULTS

A total of 58 patients (43.9%) were diagnosed with COPD. Main CVDs were: ischemic heart disease (76.5%), chronic heart failure (24.8%), peripheral arterial disease (18.5%), and atrial fibrillation (7.6%). Independent factors were: pack-years (> 30 versus < 30; odds ratio, OR 5.3; 95% CI 1.3-21.4); forced expiratory volume in the first second (OR 0.9; 95% CI 0.9-1.0); chronic heart failure (yes versus no; OR 4.7; 95% CI 1.3-16.4); and modified Medical Research Council (mMRC) dyspnea (2-3 versus 0; OR 18.7; 95% CI 1.9-182.0).

CONCLUSIONS

Four of ten patients with some form of CVD also experience COPD. Dyspnea, airflow limitation, smoking habits, and chronic heart failure were significant factors associated with COPD in patients with CVD. Smoking cessation units are useful to improve the diagnosis of COPD in these patients. Further prospective studies with a greater cohort of patients are required to corroborate the present results and to enhance the knowledge of the clinical profile of these patients.

Differences in Magnitude of Cue Reactivity Across Durations of Smoking History: A Meta-analysis

BACKGROUND

Cue-elicited craving may vary due to duration of smoking history, increasing as more years of smoking strengthen associations between nicotine intake and cues. However, research on this relationship is virtually absent. This project assessed the relationship between cue reactivity and years of smoking.

METHODS

Data from 53 studies (68 effect sizes) were analyzed. Eligible studies were those measuring self-reported craving following cue exposure in nontreatment seeking smokers and reporting mean years smoking. Preliminary subgroup analyses identified methodological factors influencing cue-reactivity effect sizes; primary meta-regression analysis assessed differences across years smoking; exploratory analyses assessed potential for ceiling effects.

RESULTS

Effect sizes varied due to abstinence requirement and cue presentation modality, but not dependence severity. Unexpectedly, meta-regression analysis revealed a decline in effect sizes across years smoking. Exploratory analyses suggested declines may have been due to a ceiling effect in craving measurement for those with longer smoking histories-more experienced smokers reported higher levels of craving at baseline or following neutral cue exposure, but all reported similar levels of craving after smoking cue exposure.

CONCLUSIONS

Methodological factors and duration of smoking history influenced measurement of cue reactivity. Highlighted were important relationships between years smoking and magnitude of cue reactivity, depending on use of baseline or neutral cue comparisons. Further research is needed to assess differences in cue reactivity due to duration of smoking history using participant-level data, directly testing for ceiling effects. In addition, cue-reactivity studies are needed across young adults to assess onset of associations between nicotine intake and cues.

IMPLICATIONS

This meta-analysis project contributes to the cue-reactivity literature by reporting on the previously ignored relationship between duration of smoking history and magnitude of cue-elicited craving. Results suggest that declines in cue-reactivity effect sizes across years of smoking may have been due to study-level methodological factors, but not due to differences in sample-level dependence severity. Cue-reactivity effect sizes were stable across years of smoking in studies using a neutral cue comparison but declined sharply in studies when baseline assessment (typically coupled with an abstinence requirement) was used.

Long-term effect of personal PM2.5 exposure on lung function: A panel study in China

Exposure to fine particulate matter (PM_2.5) have been associated with adverse respiratory outcomes, but long-term effect of personal exposure on lung function remains largely unknown. We conducted a panel study of 158 adult residents with 394 measurements of personal PM_2.5 concentration and lung function within six years to investigate the long-term association. Linear mixed models were used to identify the associations between lung function changes in relation to different levels of persistent personal PM_2.5 exposure in three or six years. We further attempted to validate resident areas (city) and smoking status as potential predictors of the long-term PM_2.5 exposure levels (persistently high/ persistently low) by generating ROC curves. Compared with subjects who had persistently low exposure level, those with persistently high levels of personal PM_2.5 exposure had an additional 3.63 % decline in FEV₁/FVC in three years (-3.63 [-7.25, -0.02]), while 7.15 % decline in six years (-7.15 [-14.27, -0.03]). BMI can modify the association. The AUCs were 0.68 (95 %CI: 0.54, 0.82), 0.75 (0.64, 0.86), and 0.82 (0.71, 0.93) for models including smoking status, resident areas, and smoking status combining resident areas respectively. These findings provide new evidence for the long-term effect of personal PM_2.5 exposure on lung function decline.

Obesity, unfavourable lifestyle and genetic risk of type 2 diabetes: a case-cohort study

AIMS/HYPOTHESIS

We aimed to investigate whether the impact of obesity and unfavourable lifestyle on type 2 diabetes risk is accentuated by genetic predisposition.

METHODS

We examined the joint association of genetic predisposition, obesity and unfavourable lifestyle with incident type 2 diabetes using a case-cohort study nested within the Diet, Cancer and Health cohort in Denmark. The study sample included 4729 individuals who developed type 2 diabetes during a median 14.7 years of follow-up, and a randomly selected cohort sample of 5402 individuals. Genetic predisposition was quantified using a genetic risk score (GRS) comprising 193 known type 2 diabetes-associated loci (excluding known BMI loci) and stratified into low (quintile 1), intermediate and high (quintile 5) genetic risk groups. Lifestyle was assessed by a lifestyle score composed of smoking, alcohol consumption, physical activity and diet. We used Prentice-weighted Cox proportional-hazards models to test the associations of the GRS, obesity and lifestyle score with incident type 2 diabetes, as well as the interactions of the GRS with obesity and unfavourable lifestyle in relation to incident type 2 diabetes.

RESULTS

Obesity (BMI ≥ 30 kg/m²) and unfavourable lifestyle were associated with higher risk for incident type 2 diabetes regardless of genetic predisposition (p > 0.05 for GRS-obesity and GRS-lifestyle interaction). The effect of obesity on type 2 diabetes risk (HR 5.81 [95% CI 5.16, 6.55]) was high, whereas the effects of high genetic risk (HR 2.00 [95% CI 1.76, 2.27]) and unfavourable lifestyle (HR 1.18 [95% CI 1.06, 1.30]) were relatively modest. Even among individuals with low GRS and favourable lifestyle, obesity was associated with a >8-fold risk of type 2 diabetes compared with normal-weight individuals in the same GRS and lifestyle stratum.

CONCLUSIONS/INTERPRETATION

Having normal body weight is crucial in the prevention of type 2 diabetes, regardless of genetic predisposition.

Effect of maternal smoking during pregnancy on childhood type 1 diabetes: a whole-of-population study

AIMS/HYPOTHESIS

Evidence of an association between maternal smoking during pregnancy (prenatal smoking) and childhood type 1 diabetes is mixed. Previous studies have been small and potentially biased due to unmeasured confounding. The objectives of this study were to estimate the association between prenatal smoking and childhood type 1 diabetes, assess residual confounding with a negative control design and an E-value analysis, and summarise published effect estimates from a meta-analysis.

METHODS

This whole-of-population study (births from 1999 to 2013, participants aged ≤15 years) used de-identified linked administrative data from the South Australian Early Childhood Data Project. Type 1 diabetes was diagnosed in 557 children (ICD, tenth edition, Australian Modification [ICD-10-AM] codes: E10, E101-E109) during hospitalisation (2001-2014). Families not given financial assistance for school fees was a negative control outcome. Adjusted Cox proportional HRs were calculated. Analyses were conducted on complete-case (n = 264,542, type 1 diabetes = 442) and imputed (n = 286,058, type 1 diabetes = 557) data. A random-effects meta-analysis was used to summarise the effects of prenatal smoking on type 1 diabetes.

RESULTS

Compared with non-smokers, children exposed to maternal smoking only in the first or second half of pregnancy had a 6% higher type 1 diabetes incidence (adjusted HR 1.06 [95% CI 0.73, 1.55]). Type 1 diabetes incidence was 24% lower (adjusted HR 0.76 [95% CI 0.58, 0.99]) among children exposed to consistent prenatal smoking, and 16% lower for exposure to any maternal smoking in pregnancy (adjusted HR 0.84 [95% CI 0.67, 1.08]), compared with the unexposed group. Meta-analytic estimates showed 28-29% lower risk of type 1 diabetes among children exposed to prenatal smoking compared with those not exposed. The negative control outcome analysis indicated residual confounding in the prenatal smoking and type 1 diabetes association. E-value analysis indicated that unmeasured confounding associated with prenatal smoking and childhood type 1 diabetes, with a HR of 1.67, could negate the observed effect.

CONCLUSIONS/INTERPRETATION

Our best estimate from the study is that maternal smoking in pregnancy was associated with 16% lower childhood type 1 diabetes incidence, and some of this effect was due to residual confounding.

Association between lifestyle factors and decreased kidney function in older adults: a community-based cross-sectional analysis of the Taipei City elderly health examination database

BACKGROUND

Impaired kidney function is the hallmark of chronic kidney disease (CKD), and is associated with increased risk of all-cause mortality in the elderly. In the present cross-sectional population-based study, we aimed to evaluate the associations between lifestyle factors (exercise habit, alcohol consumption, smoking history, and betel nut chewing) and decreased kidney function.

METHODS

The data from the Taipei City Elderly Health Examination Database (2006 to 2012) were extracted. Associations between risk factors and reduced estimated Glomerular filtration rate (eGFR) were evaluated by regression and stratification analyses.

RESULTS

A total of 297,603 participants were included in the final analysis, and 29.7% of them had reduced eGFR. Smoking was significantly associated with an elevated risk of reduced eGFR. While, physical exercise conferred to a significantly decreased adjusted odds ratio (aOR) in reduced eGFR (regular exercise, aOR = 0.79; occasional exercise, aOR = 0.87). Furthermore, the protective effect of exercise habit against reduced eGFR was not affected by comorbid conditions, such as hypertension, diabetes, obesity, and cardiovascular disease.

CONCLUSIONS

Engaging in physical exercise was beneficially associated with reduced eGFR in older individuals. Longitudinal or prospective studies are warranted for confirmation and extrapolation of the current findings.

Evaluation of oral mechanical and gustatory sensitivities and salivary cotinine levels in adult smokers

Objective: The aim was to examine oral mechanical and gustatory sensitivities in adult smokers and to estimate salivary levels of cotinine by tobacco consumption. A total of 54 adults (20-45 years old; 28 males/26 females) were divided into two sex-paired groups: smoker group (n = 27), tobacco consumers with no other chronic disease/use of chronic medication, and a control non-smoker non-exposed group with similar age (n = 27).Materials and Methods: 24 h-Recall was used to gather information about tobacco consumption, date of onset and duration of the habit. Oral mechanical evaluation comprised touch detection threshold (MDT) of upper and lower lips and tongue tip and two-point discrimination (TPD) assessments. Taste sensitivities for sweet, salty, sour and bitter were evaluated in four concentrations. Salivary cotinine was determined by high performance liquid chromatography. Statistical analysis comprised Mann-Whitney, Two-way ANOVA test and regression analysis.Results: The mean smoking time was 13.6 years (mean 8.4 mg/day; 13 cigarettes/day). A sex-effect was observed on MDT of tongue tip (higher sensitivity in females), while group-effect was observed on TPD of lower lip, showing a smaller sensitivity among smokers (p < .05; moderate effect: Eta partial2 = 0.076). Although the total score of gustatory sensitivity did not differ between groups, smokers exhibited an irregular pattern of correctly identified tastants among the different concentrations of salty, sour and bitter. The predictive model showed that salivary cotinine was dependent on "nicotine consumption on the day before" (R2 = 49%).Conclusion: A difference in tactile sensitivity of the lower lip and qualitative changes in taste sensitivity were observed in smokers.

Obesity, smoking, and risk of vasomotor menopausal symptoms: a pooled analysis of eight cohort studies

BACKGROUND

Frequent and severe vasomotor symptoms during menopause are linked with adverse health outcomes. Understanding modifiable lifestyle factors for the risk of vasomotor menopausal symptoms is important to guide preventive strategies.

OBJECTIVE

We investigated the associations between body mass index and smoking, their joint effects with the risk of vasomotor symptoms, and whether the associations differed by menopausal stage.

STUDY DESIGN

The International Collaboration for a Life Course Approach to Reproductive Health and Chronic Disease Events pooled data on 21,460 midlife women from 8 studies (median age, 50 years; interquartile range, 49-51 years) for the cross-sectional analysis. Four studies provided data for the prospective analysis (n=11,986). Multinomial logistic regression models with 4 categories of frequency/severity for the outcome of vasomotor symptoms were used to estimate relative risk ratios and 95% confidence intervals that were adjusted for within-study correlation and covariates.

RESULTS

At baseline, nearly 60% of the women experienced vasomotor symptoms. One-half of them were overweight (30%) or obese (21%), and 17% were current smokers. Cross-sectional analyses showed that a higher body mass index and smoking more cigarettes with longer duration and earlier initiation were all associated with more frequent or severe vasomotor symptoms. Never smokers who were obese had a 1.5-fold (relative risk ratio, 1.52; 95% confidence interval, 1.35-1.73) higher risk of often/severe vasomotor symptoms, compared with never smokers who were of normal-weight. Smoking strengthened the association because the risk of often/severe vasomotor symptoms was much greater among smokers who were obese (relative risk ratio, 3.02; 95% confidence interval, 2.41-3.78). However, smokers who quit at <40 years of age were at similar levels of risk as never smokers. Prospective analyses showed a similar pattern, but the association attenuated markedly after adjustment for baseline vasomotor symptoms. Furthermore, we found that the association between body mass index and vasomotor symptoms differed by menopausal status. Higher body mass index was associated with increased risk of vasomotor symptoms in pre- and perimenopause but with reduced risk in postmenopause.

CONCLUSION

High body mass index (≥25 kg/m2) and cigarette smoking substantially increased women's risk for experiencing frequent or severe vasomotor symptoms in a dose-response manner, and smoking intensified the effect of obesity. However, the effect of body mass index on the risk of vasomotor symptoms was opposite among postmenopausal women. Maintaining a normal weight before the menopausal transition and quitting smoking at <40 years of age may mitigate the excess risk of vasomotor symptoms in midlife.

Decreased handgrip strength can predict lung function impairment in male workers: a cross sectional study

BACKGROUND

Spirometry is useful for evaluating respiratory health status and predicting health-related outcomes. As spirometry requires skilled technician and takes time, it is useful to find simple way for predicting lung function impairment. The aim of this study was to investigate which tests could predict lung function impairment among workers.

METHODS

This prospective study included workers of manufacturing industry who underwent health check-ups in 2017. Subjects underwent the chronic obstructive pulmonary disease (COPD) assessment test (CAT), spirometry, and physical fitness assessments, including handgrip strength (HGS). Lung function impairment was defined as a decline in any of forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), or a FEV1/FVC ratio less than the lower limit of normal (LLN).

RESULTS

Complete data on 475 workers (366 men, 50.4% ever smokers) were available. Lung function impairment was observed in 99 subjects (64 men). Men with lung function impairment had significantly higher rate of ever-smoking, passive smoking at home in childhood, high CAT scores, and decreased HGS, compared with those without. On multivariate analyses, ever-smoking (odds ratio [OR], 2.50; 95% confidence intervals [CI], 1.25-4.97), passive smoking at home in childhood (OR, 2.71; 95% CI, 1.16-6.32), CAT scores (OR, 1.06; 95% CI, 1.01-1.12), and HGS (OR, 0.73; 95% CI, 0.57-0.92) were independently associated with lung function impairment in men.

CONCLUSIONS

Ever-smoking, passive smoking at home in childhood, high CAT scores, and decreased HGS are significantly associated with lung function impairment in men.

TRIAL REGISTRATION

Registration number: UMIN000028011. Date of registration: July 1, 2017.

Lifestyles and sexuality in men and women: the gender perspective in sexual medicine

Sexual health is strictly related with general health in both genders. In presence of a sexual dysfunction, the expert in sexual medicine aims to discover the specific weight of the physical and psychological factors can cause or con-cause the sexual problem. At the same time, a sexual dysfunction can represent a marker of the future development of a Non-communicable diseases (NCDss) as cardiovascular or metabolic diseases.In the evaluation phase, the sexual health specialist must focus on these aspects, focusing especially on the risk and protective factors that could impact on both male and female sexuality.This article presents a review of researches concerning healthy and unhealthy lifestyles and their contribute in the development of sexual quality of life in a gender-dependent manner.Among the unhealthy lifestyle, obesity contributes mostly to the development of sexual dysfunctions, due to its negative impact on cardiovascular and metabolic function. Tobacco smoking, alcohol - substance abuse and chronic stress lead to the development of sexual dysfunction in a med-long term.In order to guarantee a satisfying sexual quality of life, sexual health specialists have the responsibility to guide the patient through the adoption of healthy lifestyles, such as avoiding drugs, smoke and excessive alcohol, practicing a regular physical activity, following a balanced diet and use stress-management strategies, even before proposing both pharmaco- and/or psychotherapies.

Comparison of epidemiological and clinical features between two chronological cohorts of patients with intracerebral hemorrhage

To investigate the differences in the epidemiological and clinical characteristics of patients with intracerebral hemorrhage (ICH) treated at our institution over the last few decades. Two chronological cohorts with ten-year-interval were established and epidemiological and clinical data were retrospectively collected from patients with ICH, and data were analyzed using SPSS 13.0. The time windows for the two cohorts were from January 1, 2010 to December 31, 2014 (2010-2014 cohort) and January 1, 2000 to December 31, 2004 (2000-2004 cohort). 1598 patients with ICH were enrolled: 360 patients in the 2000-2004 cohort and 1238 patients in the 2010-2014 cohort. ICH often occurred in patients aged from 45 to 75 years, without a sex bias, accounting for 69.6% of patients. Hypertension (60.7%) was still the main risk factors. Meanwhile, the risk factors of smoking (28.9%) and drinking (23.3%) were often present in male patients but not female patients (p ≤ 0.001). The incidence of pulmonary infection, the main complication during hospitalization, was 40.8% in the 2000-2004 cohort and 61.8% in the 2010-2014 cohort (p ≤ 0.001). Moreover, the incidence of gastrointestinal hemorrhage was 12.5% in the 2000-2004 cohort and 6.0% in the 2010-2014 cohort (p ≤ 0.001). The epidemiological and clinical features have changed over the past 10 years. The mortality was reduced but still high, as evidenced by the increased hospitalization rate of patients with ICH. Current preventions and therapeutic strategies for ICH are effective, but more strategies must be developed to improve the outcome of ICH and decrease the incidence of pulmonary infection.