Clinical outcomes of spontaneous bacterial peritonitis due to extended-spectrum beta-lactamase-producing Escherichia coli or Klebsiella pneumoniae: a retrospective cohort study

Purpose

The aim of this study was to (1) evaluate the clinical outcomes of spontaneous bacterial peritonitis (SBP) due to extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli or Klebsiella pneumoniae (EK) and (2) investigate the relationship between the adequacy of initial antibiotic treatments and patient outcomes.

Methods

We conducted a retrospective cohort study of cirrhotic patients with SBP caused by EK. We evaluated the 30-day mortality rate and used Cox proportional hazard models to identify risk factors for mortality.

Results

Between January 2006 and December 2012, a total of 231 episodes of SBP due to EK were recorded. Among them, 52 were caused by ESBL-producing EK (ESBL-EK). The 30-day mortality rate was significantly higher in patients with SBP due to ESBL-EK than in those with non-ESBL-producing EK (non-ESBL-EK) (34.6 vs. 18.4 %, respectively; p = 0.013). Multivariate analysis revealed that ESBL production [adjusted HR (aHR) 1.82, 95 % confidence interval (CI) 1.00–3.31], nosocomial infection (aHR 2.24, 95 % CI 1.26–3.95), septic shock (aHR 4.84, 95 % CI 2.70–8.65), higher Child-Pugh score (aHR 1.57, 95 % CI 1.28–1.92), and higher Charlson comorbidity index (aHR 1.37, 95 % CI 1.15–1.64) were independent risk factors for 30-day mortality in the total cohort. When we analyzed patients with SBP due to ESBL-EK separately, septic shock (aHR 3.64, 95 % CI 1.40–9.77), accompanying bacteremia (aHR 3.71, 95 % CI 1.37–10.08), and hepatocellular carcinoma (aHR 3.21, 95 % CI 1.20–8.56) were independent risk factors.

Conclusions

Both 7- and 30-day mortalities for SBP due to ESBL-EK were significantly higher than for SBP due to non-ESBL-EK. Initial antibiotic choice was not associated with poor clinical outcomes in patients with SBP due to ESBL-EK.     

The Impact of Low Subcutaneous Fat in Patients with Nontuberculous Mycobacterial Lung Disease

Background

Nontuberculous mycobacteria (NTM) are pathogens that cause chronic respiratory disease, even in immunocompetent patients. We hypothesized that low subcutaneous fat is a predisposing factor for NTM lung disease.

Methods

Following a retrospective review of medical records from between 2005 and 2012, a total of 148 patients with NTM lung disease and 142 age- and sex-matched controls were enrolled. We evaluated subcutaneous fat using chest computed tomography (CT) scans at the midpole level of the left kidney.

Results

The median age of the patients was 62 years and 60.8 % were female. Approximately 71 % were classified into a nodular bronchiectatic group. The patient group had significantly less subcutaneous fat than the control group (39.3 vs. 53.0 cm², p = 0.001). Patients with both localized disease (43.5 vs. 53.0 cm², p = 0.042) and extensive disease (35.9 vs. 53.0 cm², p < 0.0001) had less subcutaneous fat compared with the control group. No difference in subcutaneous fat was observed with respect to the increasing bacterial load in sputum (p = 0.246). In 20 patients with prominent disease progression during the follow-up period, no significant difference was observed between subcutaneous fat at the initial diagnosis and that at the follow-up CT (36.2 vs. 42.0 cm², p = 0.47).

Conclusion

Our results suggest that lower subcutaneous fat may contribute to host susceptibility to NTM lung disease.     

Lower Health Literacy is Associated with Poorer Health Status and Outcomes in Chronic Obstructive Pulmonary Disease

BACKGROUND

Limited health literacy is associated with poor outcomes in many chronic diseases, but little is known about health literacy in chronic obstructive pulmonary disease (COPD).

OBJECTIVE

To examine the associations between health literacy and both outcomes and health status in COPD.

PARTICIPANTS, DESIGN AND MAIN MEASURES

Structured interviews were administered to 277 subjects with self-report of physician-diagnosed COPD, recruited through US random-digit telephone dialing. Health literacy was measured with a validated three-item battery. Multivariable linear regression, controlling for sociodemographics including income and education, determined the cross-sectional associations between health literacy and COPD-related health status: COPD Severity Score, COPD Helplessness Index, and Airways Questionnaire-20R [measuring respiratory-specific health-related quality of life (HRQoL)]. Multivariable logistic regression estimated associations between health literacy and COPD-related hospitalizations and emergency department (ED) visits.

KEY RESULTS

Taking socioeconomic status into account, poorer health literacy (lowest tertile compared to highest tertile) was associated with: worse COPD severity (+2.3 points; 95 % CI 0.3–4.4); greater COPD helplessness (+3.7 points; 95 % CI 1.6–5.8); and worse respiratory-specific HRQoL (+3.5 points; 95 % CI 1.8–4.9). Poorer health literacy, also controlling for the same covariates, was associated with higher likelihood of COPD-related hospitalizations (OR?=?6.6; 95 % CI 1.3–33) and COPD-related ED visits (OR?=?4.7; 95 % CI 1.5–15). Analyses for trend across health literacy tertiles were statistically significant (p?<?0.05) for all above outcomes.

CONCLUSIONS

Independent of socioeconomic status, poor health literacy is associated with greater COPD severity, greater COPD helplessness, worse respiratory-specific HRQoL, and higher odds of COPD-related emergency health-care utilization. These results underscore that COPD patients with poor health literacy may be at particular risk for poor health-related outcomes.     

The Effect of Quitting Smoking on Costs and Healthcare Utilization in Patients with Chronic Obstructive Pulmonary Disease: A Comparison of Current Smokers Versus Ex-Smokers in Routine Clinical Practice

Purpose

Chronic obstructive pulmonary disease (COPD) is a prevalent condition mainly related to smoking, which is associated with a substantial economic burden. The purpose was to compare healthcare resource utilization and costs according to smoking status in patients with COPD in routine clinical practice.

Methods

A retrospective cohort nested case–control study was designed. The cohort was composed of male and female COPD outpatients, 40 years or older, covered by the Badalona Serveis Assistencials (a health provider) health plan. Cases were current smokers with COPD and controls (two per case) were former smokers with COPD (at least 12 months without smoking), matched for age, sex, duration of COPD, and burden of comorbidity. The index date was the last visit recorded in the database, and the analysis was performed retrospectively on healthcare resource utilization data for the 12 months before the index date.

Results

A total of 930 COPD records were analyzed: 310 current and 620 former smokers [mean age 69.4 years (84.6 % male)]. Cases had more exacerbations, physician visits of any type, and drug therapies related to COPD were more common. As a consequence, current smokers had higher average annual healthcare costs: €3,784 (1,888) versus €2,302 (2,451), p < 0.001. This difference persisted after adjusting for severity of COPD.

Conclusions

Current smokers with COPD had significantly higher use of healthcare resources, mainly COPD drugs and physician visits, compared with former smokers who had abstained for at least 12 months. As a consequence, current smokers had higher healthcare costs to the National Health System in Spain than ex-smokers.     

Clinical and pathological characteristics of mycobacterial tenosynovitis and arthritis

Purpose

To investigate the clinical characteristics and pathological features of patients with mycobacterial tenosynovitis and arthritis.

Methods

All patients with tenosynovitis and arthritis caused by Mycobacterium tuberculosis (MTB) and nontuberculous mycobacteria (NTM) who were treated at a medical center in Taiwan from 2001 to 2010 were analyzed.

Results

Thirty-two patients with mycobacterial tenosynovitis and arthritis were identified. MTB was isolated exclusively from patients with arthritis of large joints (n = 11), while NTM were isolated from patients with arthritis of large joints (n = 4) and from those with tenosynovitis (n = 17). Among patients with tenosynovitis due to NTM, the most commonly found NTM were M. marinum (n = 7), M. intracellulare (n = 5), and M. abscessus (sensu stricto) (n = 2). Six of the seven patients with tenosynovitis due to M. marinum had suffered fishing-related injuries to the hands. All four patients with NTM arthritis had recurrent septic arthritis after surgery. NTM were isolated once from the debrided tissue specimens in three of these patients; the other patient died of systemic infection caused by M. intracellulare and multiple bacterial pathogens.

Conclusion

Mycobacterial tenosynovitis should be considered in patients who present with indolent symptoms of chronic tenosynovitis. Complete clinical information, including history of trauma or joint replacement surgery and underlying systemic disease, is helpful in establishing an early diagnosis of the disease.     

Mycobacterial Infections in Patients Treated with Tumor Necrosis Factor Antagonists in South Korea

Background

The aims of this study were to determine the incidence of tuberculosis (TB) and nontuberculous mycobacteria (NTM) lung disease in patients who were treated with tumor necrosis factor (TNF) antagonists in South Korea and to evaluate their clinical characteristics.

Methods

We surveyed all patients (N = 509) who were treated with TNF antagonists at Severance Hospital, South Korea, between January 2002 and December 2011. We reviewed the patients’ medical records and collected microbiological, radiographic, and clinical data, including the type of TNF blocker(s) used and the results of tuberculin skin tests and interferon-gamma release assays.

Results

Rheumatoid arthritis (43.6 %) and ankylosing spondylitis (27.9 %) were the most common diseases in the patients treated with TNF antagonists. Patients received etanercept (33.4 %), infliximab (23.4 %), or adalimumab (13.2 %). The remaining patients received two or more TNF antagonists (30 %). Nine patients developed TB, and four patients developed NTM lung disease. After adjustment for age and sex, the standardized TB incidence ratio was 6.4 [95 % CI 3.1–11.7] compared with the general population. The estimated NTM incidence rate was 230.7 per 100,000 patients per year.

Conclusions

Our results show that mycobacterial infections increase in patients treated with TNF antagonists. The identification of additional predictors of TB for the treatment of latent tuberculosis infection and the careful monitoring and timely diagnosis of NTM-related lung disease are needed for patients who receive long-term therapy with TNF antagonists.     

Clinical Usefulness of the Two-Question Assessment Tool for Depressive Symptoms in Japanese Patients with Chronic Obstructive Pulmonary Disease

Purpose

Depressive symptoms are highly prevalent in patients with chronic obstructive pulmonary disease (COPD) and have been associated with poor outcomes. Developing a concise questionnaire to measure depressive symptoms in COPD patients is needed in outpatient settings. We evaluated the clinical usefulness of a concise two-question instrument to assess depressive symptoms in patients with COPD.

Methods

The study was conducted as a cross-sectional analysis in patients with COPD. All patients completed a self-reported questionnaire consisting of the two-question instrument, as well as a shortened version of the Center for Epidemiologic Studies Depression Scale (CESD-10) to measure depressive symptoms. Performance of the two-question instrument was evaluated using the results for CESD-10 as standard. We also measured patients’ health-related quality of life using the Medical Outcomes Study 8-Item Short-Form Health Survey (SF-8) to determine whether the instrument was related to SF-8.

Results

Sensitivity of the two-question instrument in the detection of depressive symptoms was 73.3 % (95 % confidence interval [CI] 51–95.7), specificity was 73 % (95 % CI 58.7–87.3), and area under the receiver operating characteristics curve was 0.73 (95 % CI 0.59–0.87). When study patients were divided into two groups with a cutoff of 1 point on the two-question instrument, scores for all subscales of the SF-8 except “bodily pain” were significantly lower in patients with than without depressive symptoms.

Conclusions

This concise two-question instrument is useful as assessment of depressive symptom in patients with COPD in busy outpatient settings.     

Clinical Outcomes and Cost Analysis of Exacerbations in Chronic Obstructive Pulmonary Disease

Background

Exacerbations are a major cause of disability, hospital admissions, and increased healthcare costs in patients with chronic obstructive pulmonary disease (COPD). This study investigated the clinical outcomes of outpatients with moderate to severe exacerbated COPD and their related costs.

Methods

An observational study on the outcomes of ambulatory exacerbations of COPD was conducted. The course of the exacerbation was evaluated at a follow-up visit at 4 weeks. A cost analysis that encompassed the use of healthcare resources for treatment of the exacerbation was performed.

Results

A total of 260 patients were included, with a mean age of 68.3 years and a mean FEV₁ (% predicted) of 58.9 %. Twenty-two percent of patients had significant cardiovascular comorbidity. The most frequently prescribed antibiotics were moxifloxacin in 137 cases and amoxicillin–clavulanate in 50 cases. The rate of failure at 4 weeks was 12.5 %, with no differences between the two most prescribed antibiotics; however, patients treated with moxifloxacin had symptoms for 1.9 fewer days (P = 0.01). The mean cost of the exacerbation was €344.96 (95 % CI: €48.55–€641.78), with 9.6 % of the costs for drugs and 72.9 % for hospital care of patients for whom treatment had failed.

Conclusions

Antibiotic treatment of our population was in compliance with local guidelines. The rate of failure observed in our study was lower than that reported in previous studies; however, the small percentage of patients that required hospital attention generated almost two-thirds of the total costs of the exacerbations.     

Comparative-Effectiveness of Revascularization Versus Routine Medical Therapy for Stable Ischemic Heart Disease: A Population-Based Study

BACKGROUND

Randomized studies have shown optimal medical therapy to be as efficacious as revascularization in stable ischemic heart disease (IHD). It is not known if these efficacy results are reflected by real-world effectiveness.

OBJECTIVE

To evaluate the comparative effectiveness of routine medical therapy versus revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in stable IHD.

DESIGN

Observational cohort study.

PATIENTS

Stable IHD patients from 1 October 2008 to 30 September 2011, identified using a Registry of all angiography patients in Ontario, Canada.

INTERVENTION

Revascularization, defined as PCI/CABG within 90 days after index angiography.

MAIN MEASURES

Death, myocardial infarction (MI) or repeat PCI/CABG. Revascularization was compared to medical therapy using a) multivariable Cox-proportional hazard models with therapy strategy treated as a time-varying covariate; and b) a propensity score matched analysis. Post-angiography medication use was determined.

KEY RESULTS

We identified 39,131 stable IHD patients, of whom 15,139 were treated medically, and 23,992 were revascularized (PCI?=?15,604; CABG?=?8,388). Mean follow-up was 2.5 years. Revascularization was associated with fewer deaths (HR 0.76; 95 % CI 0.68–0.84; p?<?0.001) ,MIs (HR 0.78; 95 % CI 0.72–0.85; p?<?0.001) and repeat PCI/CABG (HR 0.59; 95 % CI 0.50–0.70; p?<?0.001) than medical therapy. In the propensity-matched analysis of 12,362 well–matched pairs of revascularized and medical therapy patients, fewer deaths (8.6 % vs 12.7 %; HR 0.75; 95 % CI 0.69–0.81; p?<?0.001) , MIs (11.7 % vs 14.4 %; HR 0.84; 95 % CI 0.77–0.93 p?<?0.001) and repeat PCI/CABG ( 17.4 % vs 24.1 %;HR 0.67; 95 % 0.63–0.71; p?<?0.001) occurred in revascularized patients, over the 4.1 years of follow-up. The revascularization patients had higher uptake of clopidogrel (70.3 % vs 27.2 %; p?<?0.001), β-blockers (78.2 % vs 76.7 %; p?=?0.010), and statins (94.7 % vs 91.5 %, p?<?0.001) in the 1-year post-angiogram.

CONCLUSIONS

Stable IHD patients treated with revascularization had improved risk-adjusted outcomes in clinical practice, potentially due to under-treatment of medical therapy patients.     

Exhaled Nitric Oxide Predicts Eosinophilic Airway Inflammation in COPD

Purpose

Chronic obstructive pulmonary disease (COPD) with eosinophilic airway inflammation may represent a unique phenotype, possibly with shared features of COPD and asthma. The role of exhaled nitric oxide (eNO) in identifying COPD patients with sputum eosinophilia was examined in this study.

Methods

Ninety COPD patients without past medical history of asthma or allergic diseases were prospectively enrolled, and their eNO, lung function, and cellular profile of induced sputum were measured. Eosinophil cationic protein and IgE in sputum and venous blood also were determined. Subjects with and without sputum eosinophilia (>3 %) were compared. The role of eNO in the prediction of sputum eosinophilia was assessed in a logistic regression model.

Results

Patients with sputum eosinophilia had significantly higher levels of eNO (29 vs. 18 ppb, p = 0.01) than those without. The difference in serum total IgE (168 vs. 84.9 IU/ml, p = 0.057) and percentages of positive allergen test results (48.3 vs. 29.5 %, p = 0.082) showed a trend toward significance. The sputum eosinophil level was significantly correlated to the eNO level (r = 0.485, p < 0.001). The eNO level at the cutoff of 23.5 ppb had the maximum sum of sensitivity (62.1 %) and specificity (70.5 %). The unadjusted and adjusted odds ratios of a higher eNO level (>23.5 ppb) in the prediction of sputum eosinophilia were 3.909 (confidence interval (CI) 1.542–9.91, p = 0.004) and 4.329 (CI 1.306–14.356, p = 0.017), respectively.

Conclusions

eNO is a good marker to identify COPD patients with eosinophilic airway inflammation.     

Chronic obstructive pulmonary disease: an emerging comorbidity in HIV-infected patients in the HAART era?

Purpose

The objective of our study was to evaluate the presence of respiratory symptoms and chronic obstructive pulmonary disease (COPD) in a human immunodeficiency virus (HIV)-infected outpatient population and to further investigate the role of highly active antiretroviral therapy (HAART) and other possibly associated risk factors.

Methods

We consecutively enrolled in a cross-sectional study HIV-infected patients and HIV-negative age, sex and smoking status matched controls. All participants completed a questionnaire for pulmonary symptoms and underwent a complete spirometry.

Results

We enrolled 111 HIV-infected patients and 65 HIV-negative age- and sex-matched controls. HIV-infected patients had a significantly higher prevalence of any respiratory symptom (p = 0.002), cough (p = 0.006) and dyspnoea (p = 0.02). HIV-infected patients also had a significantly higher prevalence of COPD in respect of HIV-negative controls (p = 0.008). Furthermore, HIV-infected individuals had significantly (p = 0.002) lower forced expiratory volume at one second (FEV1) and FEV1/forced vital capacity (FVC) ratio (Tiffeneau index) (p = 0.028), whereas the total lung capacity (TLC) was significantly higher (p = 0.018). In the multivariate analysis, significant predictors of respiratory symptoms were current smoking [adjusted odds ratio (AOR) 11.18; 95 % confidence interval (CI) 3.89–32.12] and previous bacterial pneumonia (AOR 4.41; 95 % CI 1.13–17.13), whereas the only significant predictor of COPD was current smoking (AOR 5.94; 95 % CI 1.77–19.96). HAART receipt was not associated with respiratory symptoms nor with COPD.

Conclusions

We evidenced a high prevalence of respiratory symptoms and COPD among HIV-infected patients. HIV infection, current cigarette smoking and previous bacterial pneumonia seem to play a significant role in the development of respiratory symptoms and COPD. Thus, our results suggest that the most at-risk HIV-infected patients should be screened for COPD to early identify those who may need specific treatment.     

Collateral Damage: Depressive Symptoms in the Partners of COPD Patients

Background

Depression is a frequent comorbidity in COPD patients and is associated with greater physical impairment, increased health-care utilization, and worse outcomes. The presence of depressive symptoms in the partners of COPD patients has not been evaluated.

Methods

We evaluated the partners of 230 consecutive COPD patients included in a prospective study. Depressive symptoms were evaluated using Beck’s Depression Inventory (BDI) on the first day of admission for COPD exacerbation. Patients were followed-up for 1 year.

Results

Significant depressive symptoms were present in 39.6 % of the COPD patients and in 40.9 % of their partners. Beck scores were higher in the partners of patients with severe airflow obstruction and in those with ≥2 exacerbations and ≥1 hospitalizations for COPD exacerbation during the 1-year follow-up. The BDI score of the patients’ partners was significantly correlated with the BDI score of the COPD patients (r _s = 0.422). In multivariate analysis, depressive symptoms in the COPD patients were an independent predictor of depressive symptoms in their partners (OR 4.136, 95 % CI 1.991–8.594; p < 0.001).

Conclusions

A large proportion of the partners of COPD patients present significant depressive symptoms. The identification of those patients and their partners represents a possible target for intervention.     

Hospital Readmissions with Exacerbation of Obstructive Pulmonary Disease in Illicit Drug Smokers

Purpose

Patients with obstructive pulmonary disease (asthma or chronic obstructive pulmonary disease—COPD) who smoke illicit drugs are at an increased risk of hospital admissions. We compared hospital readmission rates due to exacerbations of obstructive pulmonary disease amongst patients who were current/ex-illicit drug smokers versus current/ex-tobacco smokers.

Methods

We reviewed all the admissions between January 2009 and September 2011 with a presumptive diagnosis of an ‘exacerbation of COPD’ retrospectively from our COPD admission database.

Results

There were 950 sequential hospital admissions in 709 patients over a 33-month period; 250 ex-tobacco smokers, 370 current tobacco smokers and 89 current/ex-illicit drug smokers. Recurrent hospital admission rates with exacerbation of obstructive pulmonary disease were higher in the illicit drug smokers compared with current/ex-tobacco smokers (1.00 versus 0.22/0.26, p < 0.001). Illicit drug smokers were younger [50 versus 72.9/69.9 (mean 71.2) years, p < 0.001] and had shorter length of hospital stay [7.44 versus 9.28/10.69 (mean 9.87) days, p = 0.038]. Illicit drug smokers with FEV₁ < 1 litre (L) had higher readmissions than ex/current tobacco smokers with FEV₁ < 1 L (p < 0.001). Admissions requiring non-invasive ventilation for type 2 respiratory failure were more common in illicit drug smokers (8.4 versus 3 %, p < 0.002).

Conclusion

We have shown that readmission rates in illicit drug smokers with FEV₁ < 1 L are higher than in tobacco smokers. Studies are needed to determine whether targeting these illicit drug users with an intensive community intervention package (to include early therapy, pulmonary rehabilitation) will reduce readmission rates in this often neglected population.     

Association Between Vitamin D Status and COPD Phenotypes

Background

It has been suggested that identifying phenotypes in chronic obstructive pulmonary disease (COPD) might improve treatment outcome and the accuracy of prediction of prognosis. In observational studies vitamin D deficiency has been associated with decreased pulmonary function, presence of emphysema and osteoporosis, upper respiratory tract infections, and systemic inflammation. This could indicate a relationship between vitamin D status and COPD phenotypes. The aim of this study was to assess the association between vitamin D levels and COPD phenotypes. In addition, seasonality of vitamin D levels was examined.

Methods

A total of 91 patients from a Danish subpopulation of the “Evaluation of COPD Longitudinally to Identify Predictive Surrogate End-points” cohort took part in a biomarker substudy. Vitamin D concentration was measured from blood samples taken at two visits, approximately 6 months apart. The participants were 40–75-year-old patients with COPD and had a smoking history of >10 pack-years.

Results

Fifty-six patients had 25-hydroxyvitamin D measured from blood samples from both visits. In the final model of the multivariate analyses, the factors that were associated with vitamin D deficiency at the first visit were age (OR: 0.89, p = 0.02) and summer season (OR: 3.3, p = 0.03). Factors associated with vitamin D level also at the first visit were age (B: 0.9, p = 0.02) and 6 min walking distance (B: 0.05, p = 0.01).

Conclusion

Vitamin D was not associated with COPD phenotypes and season did not seem to be a determinant of vitamin D levels in patients with moderate to severe COPD.     

Celiac Disease: Similar Presentations in the Elderly and Young Adults

Background/Aims

Studies have shown that celiac disease can affect individuals in all age groups. However, few studies have described the disease in the elderly. The goal of this study is to characterize celiac disease in the elderly by comparing to a population of young adults with celiac disease.

Methods

Review of a tertiary center database of patients with celiac disease was performed to identify two groups of patients, an elderly cohort ≥65 years and a young adult cohort aged 18–30 years, with biopsy-confirmed celiac disease. Information obtained included symptom duration, clinical presentation, small intestinal pathology, associated conditions, and the presence of bone disease.

Results

Included in the study were 149 young adult and 125 elderly patients; the latter represented 12.4% of the patients in our database. The duration of symptoms prior to diagnosis was similar, 5.8 ± 12 years and 6.14 ± 12.6 years in the young adult and elderly cohorts, respectively (p = 0.119). There was no significant difference in the mode of presentation of illness. Diarrhea was the main presenting symptom (49% in young adults vs. 50% in the elderly, p = 0.921). There was a similar prevalence of autoimmune disease (19% in young adults vs. 26% in the elderly, p = 0.133). Thyroid disease and neuropathy were more prevalent in the elderly (p = 0.037 and p = 0.023, respectively). The degree of villous atrophy and prevalence of bone disease were similar in each group.

Conclusions

Surprisingly, the presentation of celiac disease both clinically and histologically is similar in elderly and young adult patients. The factors triggering disease at any given age remain unclear and warrant further study.     

Increased Sympathetic Nerve Activity in COPD is Associated with Morbidity and Mortality

Background

Chronic obstructive lung disease (COPD) is a major cause of comorbidity and mortality. Systemic effects, such as sympathetic activation, might contribute to progression and severity of the disease.

Objectives

This study investigated whether increased sympathetic activity is associated with increased long-term morbidity and mortality with COPD.

Methods

Following a baseline registration of muscle sympathetic nerve activity (MSNA), 21 COPD patients and 21 matched healthy control subjects were contacted after a mean follow-up period of 7 years. Information about the number of hospitalizations during follow-up was obtained from patients who were still alive. Information about the time of death was collected from relatives of the deceased and local registration offices. The primary endpoint was the comparison of MSNA in living patients without hospitalizations versus MSNA in the patients who died or had at least one hospitalization due to exacerbation of COPD.

Results

At baseline, MSNA was significantly increased, whereas forced expiratory volume in 1 s and arterial oxygen tension (PaO₂) were significantly decreased in patients compared with controls. MSNA was significantly higher in COPD patients who had reached the combined endpoint of hospitalization or death during follow-up (n = 12) compared with patients who were still alive at follow-up and had not been hospitalized (n = 8): 60.3 ± 15.8 (SD) bursts/min versus 40.5 ± 17.5 bursts/min; p = 0.022.

Conclusions

Our data suggest that sympathetic activation is related to adverse outcome in COPD. Although this finding has to be replicated in larger studies, it implies that neurohumoral activation could be a potential therapeutic target in COPD.     

Ursodiol and Colorectal Cancer or Dysplasia Risk in Primary Sclerosing Cholangitis and Inflammatory Bowel Disease: A Meta-Analysis

Background

Patients with primary sclerosing cholangitis (PSC) and colonic inflammatory bowel disease (IBD) demonstrate increased risk of colorectal cancer. Prior studies have yielded conflicting information on the relationship between ursodiol (UDCA) and the risk of colorectal cancer or dysplasia in this group.

Aims

To examine the impact of UDCA on risk of colorectal cancer or dysplasia in adult PSC and IBD patients.

Methods

A systematic review and meta-analysis of case–control and cohort studies was performed. Subgroup analysis compared the effects of “low-to-medium” (<25 mg/kg/day) versus “high” dose (≥25 mg/kg/day) UDCA exposures.

Results

Inclusion and exclusion criteria, as well as all variables, were determined a priori. Seven papers, with 707 participants and greater than 5,751 person-years of follow-up time, met the criteria for final analysis. The overall pooled relative risk using a random effects model was not statistically significant (RR = 0.87, 95 % CI 0.51–1.49, p = 0.62). Subgroup analysis by UDCA dose category in a random effects model was not statistically significant (RR = 0.64, 95 % CI 0.38–1.07, p = 0.09), but suggested a possible trend in risk reduction at low-to-medium-dose exposures that may warrant further investigation.

Conclusion

UDCA use was not associated with risk of colorectal cancer or dysplasia in adult PSC and IBD patients, but UDCA dose was a source of heterogeneity across studies. Subgroup analysis suggests a possible trend toward decreased colorectal cancer risk in low-to-medium-dose exposures. Additional study of UDCA treatments at low doses in PSC and IBD patients may be warranted.     

Longitudinal Lung Volume Changes in Patients with Chronic Obstructive Pulmonary Disease

Background

The progression of lung hyperinflation in patients with chronic obstructive pulmonary disease (COPD) has not been studied in a long-term prospective cohort. We explored the longitudinal changes in lung volume compartments with the aim of identifying predictors of a rapid decline of the inspiratory capacity to total lung capacity ratio (IC/TLC).

Methods

The study population comprised 324 patients with COPD who were recruited prospectively. Annual rates of changes in pulmonary function, including forced expiratory volume in 1 s (FEV₁), forced vital capacity (FVC), total lung capacity (TLC), functional residual capacity (FRC), residual volume (RV), vital capacity (VC), IC, and IC/TLC, were estimated using the random coefficient models.

Results

The mean annual rates of changes in pre- and post-bronchodilator FEV₁ were ?23.0 mL/year (p < 0.001) and ?26.5 mL/year (p = 0.004). The mean annual rates of changes in VC, IC, TLC, and IC/TLC were ?33.7 mL/year (p = 0.007), ?53.9 mL/year (p < 0.001), ?43.7 mL/year (p = 0.012), and ?0.65 %/year (p = 0.001), respectively. RV, FRC, and RV/TLC did not change significantly during the study period. Multivariate logistic regression analysis showed that a high modified Medical Research Council (MMRC) dyspnea scale score, a high Charlson comorbidity index value, and low post-bronchodilator FEV₁ were associated with rapid decline in IC/TLC.

Conclusion

MMRC dyspnea scale, post-bronchodilator FEV_1, and the Charlson comorbidity index at baseline were independent predictors of a rapid decline in IC/TLC.     

Hepatitis C Virus Infection and Coronary Artery Disease Risk: A Systematic Review of the Literature

Background and Aims

While hepatitis C virus (HCV) infection has been implicated in increasing the risk of coronary artery disease (CAD), conflicting reports exist regarding this association. We performed a systematic review to further investigate this association.

Methods

We conducted a PubMed search of original research articles from January 1, 1995 to June 30, 2013 to identify case–control and cohort studies evaluating the association between HCV and CAD using keyword terms [“hepatitis c” or “HCV”] and [“coronary artery disease” or “heart disease” or “atherosclerosis.”] The primary CAD-related endpoints included myocardial infarction, congestive heart failure, need for coronary artery bypass grafting, or transluminal percutaneous coronary angioplasty. Binary outcomes are reported as odds ratios (OR) with 95 % confidence interval (CI).

Results

We identified five studies (four cohort studies and one case–control study) that met our inclusion criteria. A significant association between HCV and CAD was demonstrated in one cohort study (adjusted HR 1.27; 95 % CI 1.22–1.31). One cohort study demonstrated a decreased risk of CAD associated with HCV (adjusted OR 0.74; 95 % CI 0.71–0.76). The remaining studies did not find a significant association between HCV and risk of CAD.

Conclusions

The current systematic review demonstrates that the association between HCV and CAD remains unclear. We need more large, long-term cohort studies with clear definitions of patient population and endpoints to better ascertain the association between HCV and CAD.