Pulmonary Rehabilitation for Moderate COPD (GOLD 2) –Does it Have an Effect?

Background: Although pulmonary rehabilitation is an integrated part of standard care in patients with severe COPD, it is uncertain whether those with less severe COPD benefit from such treatment. The aim of the present survey was to evaluate the effect of rehabilitation in patients with moderate COPD and to determine their willingness to participate in rehabilitation. Material and methods: In a single-centre, randomized, placebo-controlled, unblinded clinical trial, participants comprised 61 of 133 referred subjects with moderate COPD. Of the 61 participants, 35 were randomized to receive rehabilitation and 26 subjects to receive standard COPD care from their GP. After randomization 19 subjects dropped out. Results: Effects of physical training were seen during the period of intervention. Compared with those receiving standard GP care, those receiving rehabilitation showed improvements in walking distance and leg strength as well as improvements in quality of life; however, the effect was temporary, and at 18 months’ follow-up there was no significant difference between the groups. Only 61 subjects of the referred group of 133 with moderate COPD accepted the offer of rehabilitation. Conclusion: Although an effect was found of pulmonary rehabilitation in subjects with moderate COPD, it disappeared over 18 months. Only a minority of patients with moderate COPD referred for rehabilitation accepted and completed the treatment offer.     

Disrupted White Matter Integrity in Heroin Dependence: A Controlled Study Utilizing Diffusion Tensor Imaging

Objectives: Fractional anisotropy (FA) via diffusion tensor imaging (DTI) can quantify the white matter integrity. Exposure to addictive drugs, such as alcohol, cocaine, methamphetamine, marijuana, and nicotine has been shown to alter FA. White matter abnormalities have been shown, but it remains unclear whether the white matter FA is altered in heroin dependence. Methods: Utilizing DTI, we investigated the FA difference between heroin-dependent and control subjects by a voxel-based strategy. The FA values of the identified regions were calculated from the FA image of each subject and were correlated with clinical features including months of heroin use, age, education, and dose of methadone. Results: Reduced FA among 16 heroin dependent subjects was located in the bilateral frontal sub-gyral regionsm, right precentral and left cingulate gyrus. FA in the right frontal sub-gyral was negatively correlated with duration of heroin use. Conclusion: The disrupted white matter integrity in right frontal white matter may occur in continuous heroin abuse.     

慢性阻塞性肺疾病病患的认知功能探讨

目的评估慢性阻塞性肺疾病(慢阻肺)病患的认知功能状态,以及与临床资料的相关性。方法从2014年10月-2018年12月,160例符合标准的受试者入组;认知评估使用蒙特利尔(MoCA)量表,获取临床资料并完成相关性分析。结果约46%的慢阻肺病患存在认知功能障碍。四组受试者的MOCA总分为:健康对照组26.47±1.31、慢阻肺病患轻度组24.77±2.61、中度组22.39±3.64、重度组21.92±2.65;相比对照组,慢阻肺受试者的认知得分降低(p<0.05),表现在注意、定向、抽象思维、延迟记忆、视空间与执行功能。组间比较亦有统计学差异;同时慢阻肺受试者的MoCA总分和肺功能中FEV 1有正相关(r=0.377,P<0.001),与血气分析中PaO 2有正相关性(r=0.295,P<0.05),与PaCO 2无相关性(r=0.059,P>0.05)。结论慢阻肺病患存在特定的认知障碍。低氧血症、肺功能中的FEV 1降低可能是造成慢阻肺认知障碍的病理生理学机制。     

Significance of Medication History at the Time of Entry into the COPDGene Study: Relationship with Exacerbation and CT Metrics

Background: Despite the importance of respiratory medication use in COPD, relatively little is known about which clinical phenotypes were associated with respiratory medications. Methods: To determine the association between respiratory medication use and exacerbations or quantitative CT metrics, we analyzed medication history from 4,484 COPD subjects enrolled in the COPDGene Study. Results: 2,941 (65.6%) subjects were receiving one or more respiratory medications; this group experienced more frequent exacerbations in the year before study entry and had increased gas trapping, emphysema, and subsegmental airway wall area, compared to the patients who were on no respiratory medication. In subgroup analysis, subjects who were on triple therapy (long-acting beta2-agonist [LABA], long-acting muscarinic antagonist [LAMA], and inhaled corticosteroids [ICS]) had the highest frequencies of exacerbations and severe exacerbations and tended to have increased quantitative measures of emphysema and gas trapping on CT compared to other five groups. After adjustment for confounding variables, the triple therapy group experienced more exacerbations and severe exacerbations compared with other five groups. In addition, the LABA+LAMA+ICS group was more likely to have emphysema and gas trapping on CT than other groups in multivariable logistic analysis. Interestingly, the total number of respiratory medications was significantly associated with not only the frequency of exacerbations but also gas trapping and airway wall thickness as assessed by CT scan in multivariable analysis. Conclusions: These results suggest that the use of respiratory medications, especially the number of medications, may identify a more severe phenotype of COPD that is highly susceptible to COPD exacerbations.     

Cost analysis of chronic obstructive pulmonary disease in a tertiary care setting in Taiwan

Background and objective: The prevalence of COPD in the Western Pacific is increasing. The present study determined the total direct health‐care costs for the management of COPD patients with differing degrees of disease severity. The study also aimed to find the key cost drivers in the management of COPD. Methods: COPD patients were recruited from a tertiary care hospital during April 2002 and March 2003. One‐year costs were identified by applying cost data to medical information obtained by review of medical records. Costs included those for medications, oxygen therapy, laboratory and diagnostic tests, clinic visits, emergency room visits and hospital stays. Results: There were 160 patients recruited. Patients were categorized by COPD severity: moderate A COPD (50 ≤ FEV₁% < 80; n = 54), moderate B COPD (30 ≤ FEV₁% < 50; n = 54) and severe COPD (FEV₁% < 30; n = 52). Patients with moderate A, moderate B and severe COPD had an average of 0.82, 2.6 and 3.5 exacerbations per year, respectively. Average numbers of emergency room visits were 0.41 ± 0.94, 1.20 ± 1.39 and 1.73 ± 2.44 per year in moderate A, moderate B and severe COPD patients, respectively. The mean total direct costs were New Taiwan dollars 288 825, 149 031 and 38 203 for severe COPD, moderate B COPD and moderate A COPD, respectively. The total annual cost was correlated with the disease severity. Hospitalization contributed the major portion of cost and also correlated with disease severity. Conclusions: There is a correlation between the cost of COPD and disease severity with hospitalization owing to disease exacerbation being a major contributor to cost. The keys to reducing health‐care costs lie with reducing the frequency of exacerbations and the disease severity.     

Concordance between Doppler and pulsed-wave Doppler tissue imaging in estimation of the degree of left ventricular dysfunction and correlating it to the degree of chronic obstructive pulmonary disease

Objective

As a consequence of leftward shift of the interventricular septum and of pericardial restraint, related to the degree of right ventricular dilation, alveolar hypoxia and related pulmonary vascular changes, left ventricular function is influenced by chronic obstructive pulmonary disease (COPD). The aim of this study was to assess the prevalence of echocardiographic abnormalities by conventional echocardiography and Doppler tissue imaging (DTI) in COPD patients according to the degree of disease severity.

Methods

We enrolled forty consecutive patients with COPD and twenty matched control. Twenty of the patients were suffering from mild form of COPD, twenty were suffering from severe form of COPD as decided by pulmonary function test and arterial blood gases and twenty apparently healthy non COPD control persons were subjected to echocardiographic assessment to left ventricular diastolic and systolic functions by conventional echocardiography and DTI at the mitral annulus.

Results

There were no significant statistical difference between the three groups as regards the age and the gender. There were significant statistical differences between the patients and the control as regards the diastolic functions of the left ventricle. E and A waves obtained by conventional Doppler and by DTI showed significant statistical difference between mild, severe forms of COPD and control subjects. The degree of diastolic dysfunction increased significantly with increase of the severity of COPD.

Conclusion

Left ventricular diastolic function is significantly affected in patients with COPD and the degree of affection is related to the severity of COPD.     

Associations between fractional anisotropy and problematic alcohol use in juvenile justice-involved adolescents

Abstract

Background: Studies have shown associations between heavy alcohol use and white matter alterations in adolescence. Youth involved with the juvenile justice system engage in high levels of risk behavior generally and alcohol use in particular as compared to their non-justice-involved peers. Objectives: This study explored white matter integrity among justice-involved adolescents. Analyses examined fractional anisotropy (FA) and mean diffusivity (MD) between adolescents with low and high levels of problematic alcohol use as assessed by the Alcohol Use Disorders Identification Test (AUDIT). Methods: Participants (N?=?125; 80% male; 14–18 years) completed measures assessing psychological status and substance use followed by diffusion tensor imaging (DTI). DTI data for low (n?=?51) and high AUDIT (n?=?74) adolescents were subjected to cluster-based group comparisons on skeletonized FA and MD data. Results: Whole-brain analyses revealed significantly lower FA in clusters in the right and left posterior corona radiata (PCR) and right superior longitudinal fasciculus (SLF) in the high AUDIT group, as well as one cluster in the right anterior corona radiata that showed higher FA in the high AUDIT group. No differences in MD were identified. Exploratory analyses correlated cluster FA with measures of additional risk factors. FA in the right SLF and left PCR was negatively associated with impulsivity. Conclusion: Justice-involved adolescents with alcohol use problems generally showed poorer FA than their low problematic alcohol use peers. Future research should aim to better understand the nature of the relationship between white matter development and alcohol use specifically as well as risk behavior more generally.     

The Effect of Chronic Sputum Production on Respiratory Symptoms in Severe COPD

Background: Chronic sputum production is a significant but variable complaint in COPD; its effect on symptom burden has not been comprehensively described. We sought to characterize the daily burden of chronic sputum production in severe COPD and the phenotype of those with chronic sputum symptoms. Methods: We studied 50 outpatients with severe COPD who used an electronic diary to document peak expiratory flow (PEF) and respiratory symptoms daily for up to 2 years. A sputum index was derived based on complaints of sputum quantity, color, and consistency, and patients were divided into groups based on average daily sputum index (Low, Medium, High). The presence and severity of respiratory symptoms were scored by a novel method using daily changes in symptoms and PEF from baseline and were categorized into mild, moderate, and severe. Percent emphysema was measured using quantitative CT. Results: In the 14,500 observation days, severe symptom days were greater in the Medium and High groups (379/6089, 1609/4091, and 2624/4317 observation days in Low, Medium, and High, p < 0.0001). The same trend was found even when sputum complaints were removed from the symptom severity score. Observed/predicted PEF ratio was lower in the High group (0.56 ± 0.24, 0.55 ± 0.19, and 0.42 ± 0.12 in each group, p < 0.05 for High compared to Medium and Low). Percent emphysema inversely correlated with average sputum index and quantity (r = ?0.449 and r = ?0.584, respectively, p < 0.05). Conclusions: Increased sputum production in severe COPD is frequently encountered daily and is associated with more respiratory symptoms, worse airflow obstruction, and less emphysema.     

Circulating Hematopoietic Progenitor Cells are Decreased in COPD

Rationale: Bone marrow derived progenitor cells participate in the repair of injured vessels. The lungs of individuals with emphysema have reduced alveolar capillary density and increased endothelial apoptosis. We hypothesized that circulating levels of endothelial and hematopoietic progenitor cells would be reduced in this group of patients. Objectives: The goal of this study was to measure circulating levels of endothelial progenitor cells (EPCs) and hematopoietic progenitor cells (HPCs) in subjects with COPD and to determine if progenitor levels correlated with disease severity and the presence of emphysema. Methods: Peripheral blood mononuclear cells were isolated from 61 patients with COPD and 32 control subjects. Levels of EPCs (CD45^dim CD34₊) and HPCs (CD45⁺ CD34⁺ VEGF-R2⁺) were quantified using multi-parameter flow cytometry. Progenitor cell function was assessed using cell culture assays. All subjects were evaluated with spirometry and CT scanning. Measurements and Main Results: HPC levels were reduced in subjects with COPD compared to controls, whereas circulating EPC levels were similar between the two groups. HPC levels correlated with severity of obstruction and were lowest in subjects with severe emphysema. These associations remained after correction for factors known to affect progenitor cell levels including age, smoking status, the use of statin medications and the presence of coronary artery disease. The ability of mononuclear cells to form endothelial cell colony forming units (EC-CFU) was also reduced in subjects with COPD. Conclusions: HPC levels are reduced in subjects with COPD and correlate with emphysema phenotype and severity of obstruction. Reduction of HPCs may disrupt maintenance of the capillary endothelium, thereby contributing to the pathogenesis of COPD.     

Physical Activity Patterns in Patients in Different Stages of Chronic Obstructive Pulmonary Disease

It has previously been suggested that exercise capacity is decreased in COPD and that it is associated with degree of disease. The reduced exercise capacity may plausibly be due to low levels of physical activity in this patient group. The aim of the present study was to assess exercise capacity and physical activity in different stages of COPD and to examine the associations between exercise capacity, pulmonary function and degree of physical activity. A total of 44 COPD patients and 17 healthy subjects participated in the study. Exercise capacity was assessed using the 6-minute walking test and physical activity was assessed using an accelerometer worn all waking hours during 7 days. Mean exercise capacity was significantly lower in COPD patients compared with healthy subjects. Mean physical activity level and time spent at least moderately active were significantly lower in patients with moderate and severe COPD compared with healthy subjects while no differences in time spent sedentary were observed between the study groups. Pulmonary function, mean physical activity level and time spent at least moderately physically active were significantly associated with exercise capacity in the patients. We conclude that patients with moderate and severe COPD are less physically active compared with healthy subjects. Furthermore, mean physical activity level and physical activity of at least moderate intensity are positively associated with exercise capacity in COPD, while time spent sedentary is not, which stresses an important role of physical activity on exercise capacity in these patients.     

Tomographic and functional findings in severe COPD: comparison between the wood smoke-related and smoking-related disease

OBJECTIVE:

Wood smoke exposure is a risk factor for COPD. For a given degree of airway obstruction, the reduction in DLCO is smaller in individuals with wood smoke-related COPD than in those with smoking-related COPD, suggesting that there is less emphysema in the former. The objective of this study was to compare HRCT findings between women with wood smoke-related COPD and women with smoking-related COPD.

METHODS:

Twenty-two women with severe COPD (FEV₁/FVC ratio < 70% and FEV₁ < 50%) were divided into two groups: those with wood smoke-related COPD (n = 12) and those with smoking-related COPD (n = 10). The two groups were compared regarding emphysema scores and airway involvement (as determined by HRCT); and functional abnormalities-spirometry results, DLCO, alveolar volume (VA), the DLCO/VA ratio, lung volumes, and specific airway resistance (sRaw).

RESULTS:

There were no significant differences between the two groups in terms of FEV₁, sRaw, or lung hyperinflation. Decreases in DLCO and in the DLCO/VA ratio were greater in the smoking-related COPD group subjects, who also had higher emphysema scores, in comparison with the wood smoke-related COPD group subjects. In the wood smoke-related COPD group, HRCT scans showed no significant emphysema, the main findings being peribronchial thickening, bronchial dilation, and subsegmental atelectasis.

CONCLUSIONS:

Female patients with severe wood smoke-related COPD do not appear to develop emphysema, although they do show severe airway involvement. The reduction in DLCO and VA, with a normal DLCO/VA ratio, is probably due to severe bronchial obstruction and incomplete mixing of inspired gas during the determination of single-breath DLCO.     

Physical training and testing in patients with chronic obstructive pulmonary disease

Introduction: The effects of different training modes need to be investigated further in patients with chronic obstructive pulmonary disease (COPD). Both advanced laboratory tests and field tests are used in patients with COPD to evaluate effects of interventions such as pulmonary rehabilitation. Aims: The overall aims of the studies were to investigate the effects of different training modalities on exercise capacity and on health‐related quality of life (HRQoL) in patients with moderate or severe COPD and, further, to explore two of the physical field tests used in pulmonary rehabilitation, the 12‐min walk test and the incremental shuttle walking test (ISWT). Materials and Methods: Patients with moderate or severe COPD were included. In study I (n = 57), the 12‐min walk test was performed three times within 1 week. Exercise‐induced hypoxemia (EIH) was assessed by pulse oximeter and was defined as SpO₂ < 90%. In study II (n = 93), performance on ISWT was compared to performance on two different cycle tests. In study III (n = 42), the effects of two different combination training programmes were compared when training twice a week for 8 weeks. One programme was mainly based on endurance training (group A), and the other was based on resistance training and on callisthenics (group B). In study IV (n = 60), endurance training with interval resistance was compared to endurance training with continuous resistance. Results: In study I, the 12‐min walking distance (12MWD) did not increase on retesting in patients with EIH, but increased significantly on retesting in the non‐EIH patients. In study II, the ISWT was as good a predictor of peak exercise capacity (W peak) as peak oxygen uptake (VO₂ peak) was. In study III, W peak and 12MWD increased in group A but not in group B. HRQoL, anxiety and depression were unchanged in both groups. Ratings of perceived exertion at rest were significantly lower in group A than in group B after training and during 12 months of follow‐up. Twelve months post training, 12MWD was back to baseline in group A, but was significantly shorter than at baseline in group B. Patients with moderate and severe COPD responded to training in the same way. In study IV, both interval and continuous endurance training increased W peak, VO₂ peak, peak exhaled carbon dioxide (VCO₂ peak) and 12MWD. Likewise, HRQoL, dyspnoea during activities of daily life, anxiety and depression improved similarly in both groups. At a fixed, sub‐maximal workload (isotime), the interval training reduced oxygen cost and ventilatory demand significantly more than the continuous training did. Conclusions: EIH affects the retest effects on 12MWD. W peak can be predicted from an ISWT similarly well as from VO₂ peak. A short training programme can improve W peak and 12MWD when based mainly on endurance training. Both patients with moderate and severe COPD respond to training in the same way. A short endurance training intervention can possibly delay decline in 12MWD for 1 year. Both interval and continuous endurance training improves physical performance and HRQoL. Interval training lowers the energy cost of sub‐maximal work more than continuous training does.     

Prognostic value of C-reactive protein in chronic obstructive pulmonary disease

To establish whether C-reactive protein (CRP) is an independent predictor of all-cause mortality and hospitalization in chronic obstructive pulmonary disease (COPD), we followed 200 patients with COPD and 201 age- and gender -matched controls for a median time of 4.2 years (range, 0.2–5.1 years). Airflow obstruction was rated moderate if forced expiratory volume in one second (FEV₁) was 50–69% of the predicted value, or severe if FEV₁ was <50%. The CRP level was categorized as low (≤3 mg/L) or high (>3 mg/L). The hazard of death was estimated by a proportional hazard regression model, using controls with low CRP as the reference category. Fifty subjects died: 41 (21%) among the COPD and 9 (4%) among the controls (p < 0.0001). The hazard of death in moderate COPD was not significantly higher than in the reference category, independently of the CRP level. In severe COPD with a low CRP, the hazard of death is 3.4 times higher than in the reference category (p = 0.008); in severe COPD and a high CRP it is 9.6 times higher (p < 0.0001). The rate of hospitalization in COPD patients with a high CRP is 1.9 times higher than in those with a low CRP [95% confidence interval (CI), 1.2–3.2]. In severe COPD, it is 6.9 times higher than in moderate COPD (95% CI, 3.8–12.7). A high CRP level is a significant amplifier of the risk of death only in severe COPD. The degree of airflow obstruction is a strong independent predictor of COPD-related outcomes.     

Elevated oxidative stress and reciprocal reduction of vascular endothelial growth factor levels with severity of COPD

STUDY OBJECTIVES: The prevalent theory concerning the pathogenesis of COPD is that it is an imbalance between oxidants and antioxidants. However, it has been reported that a decrease in vascular endothelial growth factor (VEGF) might affect the pathogenesis of COPD. Therefore, this study was designed to examine the differences between oxidative stress and VEGF levels, and the severity of COPD. DESIGN: Controlled cross-sectional analysis. SETTING: University hospital. PARTICIPANTS: Twelve healthy control subjects and 57 COPD patients were included in this study. These COPD patients were divided into four groups based on the Global Initiative for Chronic Obstructive Lung Disease classification (mild COPD, 14 patients; moderate COPD, 15 patients; severe COPD, 16 patients; very severe COPD, 12 patients). MEASUREMENTS AND RESULTS: Inflammatory markers, degree of oxidative stress, and VEGF levels were examined in sputum samples from all subjects. Nitrogen oxide levels in induced sputum were significantly higher in COPD patients than in healthy control subjects, and they increased with increases in the severity of COPD. In contrast, peroxynitrite inhibitory activity decreased with increases in the severity of COPD. Therefore, the mean (SD) peroxynitrite stress (ie, the nitrogen oxide level/peroxynitrite inhibitory activity ratio) steeply increased with increases in the severity of COPD (mild COPD: 8.4; SD, 1.5; p = 0.02; moderate COPD: 10.8; SD, 1.4; p < 0.0001; severe COPD: 14.5; SD, 2.5; p < 0.0001; very severe COPD: 18.3; SD, 4.1; p < 0.0001) compared with that of healthy control subjects. VEGF levels in induced sputum reciprocally decreased with severity of COPD (mild COPD: 1,360 pg/mL; SD, 800 pg/mL; p = 0.97; moderate COPD: 1,180 pg/mL; SD, 760 pg/mL; p = 0.50; severe COPD: 650 pg/mL; SD, 450 pg/mL; p = 0.007; very severe COPD: 480 pg/mL, SD, 240 pg/mL; p = 0.002). In addition, peroxynitrite inhibitory activity in COPD patients exhibited an accelerated decline from the mean VEGF level in healthy control subjects. CONCLUSIONS: Elevated oxidative stress levels and a reciprocal reduction of VEGF levels in induced sputum were prominent with increases in the severity of COPD. Thus, epithelial cell injury mediated by oxidative stress may induce the decrease in lung VEGF levels, resulting in the promotion of the development of COPD.     

Burden of Exacerbations in Patients with Moderate to Very Severe COPD in the Netherlands: A Real-life Study

Objective: The objective of this study was to compare rates of different types of acute exacerbations of COPD (AECOPDs) and healthcare utilization among patients with different severities of COPD. Methods: Data for this study was obtained from the PHARMO Database Network, which includes drug dispensing records from pharmacies, hospitalization records and information from general practitioners. Patients with moderate to very severe COPD (GOLD II-III-IV) and a moderate or severe AECOPD between 2000 and 2010 were included in the study. Moderate and severe AECOPDs were defined by drug use and hospitalizations respectively. Study patients were followed from the first AECOPD to end of registration in PHARMO, death or end of study period, whichever occurred first. During follow-up, all recurrent AECOPDs were characterized and healthcare utilization was assessed. RESULTS: Of 886 patients in the study, 52% had GOLD-II, 34% GOLD-III and 14% had GOLD-IV. The overall AECOPD recurrence rate per person year (PY) increased from 0.63 for patients with GOLD-II to 1.09 for patients with GOLD-III and 1.33 for patients with GOLD-IV. The rate of severe AECOPD was 0.06, 0.14 and 0.17 per PY, respectively. Conclusion: AECOPD recurrence rates and healthcare utilization are significantly higher among patients with more severe COPD.     

COPD assessment tests scores are associated with exacerbated chronic obstructive pulmonary disease in Japanese patients

BackgroundGuidelines recommend chronic obstructive pulmonary disease (COPD) assessment tests (CATs) for evaluation of symptoms and management risks. To investigate whether CAT can predict moderate or severe exacerbations in Japanese COPD patients, a single-blinded prospective study was performed.MethodsA 123 Japanese COPD patients were classified into high-CAT (n=64) and low-CAT (n=59) groups. The frequencies and periods of moderate or severe exacerbation and hospitalization were compared between the two groups. Multivariate logistic regression analysis was performed to investigate whether CAT could predict exacerbations. A receiver operating characteristic (ROC) curve analysis was employed to find an appropriate CAT score for exacerbation.ResultsThe high-CAT group was significantly older, had a lower body mass index, and had a lower airflow obstruction as compared to the low CAT group. The frequency of moderate or severe exacerbation (1.3±1.3 events per patient per year, p<0.0001) and hospitalizations (0.2±0.4, p=0.0202) in the high-CAT group was significantly higher than in the low-CAT group (0.4±0.7 and 0.0±0.1, respectively). Multivariate logistic regression analysis showed that both high CAT score and low airflow obstruction were independently predictive of frequent moderate or severe COPD exacerbation. ROC analysis showed that the best cut-off CAT score for moderate or severe COPD exacerbation was 8 points.ConclusionOur present results indicate that COPD Japanese patients showing high CAT scores have a poor prognosis, and that the CAT score is able to predict exacerbation in Japanese COPD.     

Characteristics of asthma and COPD overlap syndrome (ACOS) in the Canadian population

Objective: Asthma is a chronic disease affecting both children and adults, whereas chronic obstructive pulmonary disease (COPD) is a respiratory disease most commonly related to smoking and is usually seen in adults. When the airway disease shares features of both asthma and COPD, the phenotype is referred to as asthma and COPD overlap syndrome (ACOS). The objective of this cross-sectional study is to characterize ACOS in the Canadian population. Methods: Data from the first three cycles of the Canadian Health Measures Survey (CHMS) were used in this study. The study included 9059 subjects aged 30?years and above. The CHMS included a detailed interviewer-administered questionnaire and spirometry measurements. Based on the self-report, subjects were categorized into control, ACOS, COPD only and asthma only groups. Results: The prevalence of ACOS, COPD and asthma groups was 1.59%, 2.21% and 6.65%, respectively. The proportion of females was significantly greater than males in the ACOS group. The proportion of wheeze was highest in the ACOS group (64.93%) whereas the prevalence of shortness of breath was the highest in the COPD group (46.25%). Heart disease, cancer, arthritis and liver disease were more prevalent in the ACOS group than in COPD, asthma and control groups. Severity of airway obstruction was the highest in the ACOS group and was followed by COPD, asthma and control groups, respectively. Conclusions: Characteristics of ACOS in the Canadian population were similar to those observed in the developed countries and longitudinal studies are required to determine the incidence and risk factors of ACOS.     

Bronchodilator reversibility, airway eosinophilia and anti-inflammatory effects of inhaled fluticasone in COPD are not related

Background and objective: Bronchodilator reversibility (BDR) is common in smoking‐related COPD, but the airway pathology underlying this has not been described. In particular, it is not known whether BDR is associated with underlying airway eosinophilia and whether BDR is predictive of a better response to inhaled corticosteroid (ICS) treatment. Methods: A double‐blind, placebo‐controlled, randomized 2 : 1 study of fluticasone propionate (FP), 500 µg twice daily versus placebo over 6 months was performed in subjects with mild to moderate COPD. Subjects with a clinical history of asthma were excluded, but not on BDR criteria alone. Induced sputum, BAL and endobronchial biopsies (EBB) were performed in 36 subjects at baseline, and 30 of these provided a second full set of samples (FP, n = 19; placebo, n = 11). Results: Baseline BDR was not related to airway eosinophilia and did not predict response to ICS. Post‐bronchodilator FEV₁ increased in the FP group compared with the placebo group (P = 0.05), and there were within‐treatment group reductions in total symptom scores with FP (P < 0.05). Compared with placebo, FP reduced macrophage numbers but increased neutrophil numbers in EBB (P = 0.01 and P = 0.003, respectively). BAL neutrophil and epithelial cell numbers were also reduced with FP (P = 0.03 for both). There were within‐treatment group reductions in the numbers of EBB mast cells and CD8+ve lymphocytes with FP (P = 0.007). Conclusions: BDR was not related to any particular inflammatory phenotype or any clinical or anti‐inflammatory response to ICS in these subjects with mild to moderate COPD.     

Matrix metalloproteinase-2 protein in lung periphery is related to COPD progression

BACKGROUND: There is increasing evidence that matrix metalloproteinases (MMPs) may contribute to the pathogenesis of COPD, but their role in humans is not completely understood. We performed this study to quantify the expression of MMP-2 in a population of COPD patients at different stages of severity. METHODS: We collected surgical specimens from 46 subjects, as follows: 10 smokers with severe COPD (Global Initiative for Chronic Obstructive Lung Disease [GOLD] stage III-IV); 13 smokers with mild/moderate COPD (GOLD stage I-II); 12 control smokers; and 11 nonsmoking control subjects. We quantified MMP-2 expression in alveolar macrophages, alveolar walls, peripheral airways, and pulmonary arterioles by immunohistochemistry. RESULTS: In all compartments, MMP-2 expression was increased both in smokers with severe COPD and in smokers with mild/moderate COPD compared to control smokers and nonsmokers (p < 0.05 for all comparisons). Only in alveolar macrophages was MMP-2 expression increased in smokers with severe COPD compared to smokers with mild/moderate COPD (p = c0.002). Moreover, MMP-2 expression was inversely related to values of FEV1/FVC ratio (p < 0.0001; r = -0.71) and Pao2 (in millimeters of Hg) [p = 0.005; r = -0.49], and was positively related to emphysema score (p = 0.01; r = 0.65) and residual volume percent predicted (p = 0.04; r = 0.49). A stepwise increase in the total number of alveolar macrophages was observed in the four groups of subjects examined, with the highest value in those with severe COPD. CONCLUSION: This study shows that MMP-2 expression in the lung periphery progressively increases as lung function worsens and the degree of emphysema increases. These results suggest that MMP-2 may be a key mediator of the mechanisms leading to lung tissue remodeling and inflammation in patients with severe COPD.     

Postoperative outcome after coronary artery bypass grafting in chronic obstructive pulmonary disease

BACKGROUND:

It is uncertain if the presence and severity of airflow obstruction in chronic obstructive pulmonary disease (COPD) is predictive of surgical morbidity and mortality after coronary artery bypass grafting (CABG).

METHODS:

Retrospective study of patients who underwent CABG between 1998 and 2003 in a university-affiliated hospital for whom a preoperative spirometry was available. COPD was diagnosed in smokers or ex-smokers 50 years of age or older in the presence of irreversible airflow obstruction. Patients were divided into three groups depending on the spirometry: controls (forced expiratory volume in 1 s [FEV₁] 80% or more, FEV₁/forced vital capacity [FVC] greater than 0.7), mild to moderate COPD (FEV₁ 50% or more and FEV₁/FVC 0.7 or less) and severe COPD (FEV₁ less than 50% and FEV₁/FVC 0.7 or less).

RESULTS:

Among the 411 files studied, 322 (249 men, 68±8 years of age) were retained (controls, n=101; mild to moderate COPD, n=153; severe COPD, n=68). The mortality rate (3.0%, 2.6% and 0%, respectively) was comparable among the three groups. Patients with severe COPD had a slightly longer hospital stay than controls (mean difference 0.7±1.4 days, P<0.05). Pulmonary infections were more frequent in severe COPD (26.5%) compared with mild to moderate COPD (12.4%) and controls (12.9%), P<0.05. Atrial fibrillation tended to be more frequent in severe COPD than in the other two groups.

CONCLUSION:

Mortality rate associated with CABG surgery is not influenced by the presence and severity of airflow obstruction in patients with COPD. The incidence of pulmonary infections and length of hospital stay were increased in patients with severe COPD.