Antimicrobial peptide LL-37 circulating levels in chronic obstructive pulmonary disease patients with high risk of frequent exacerbations

Background

Exacerbations of chronic obstructive pulmonary disease (COPD) increase the decline in lung function, deterioration in health status and risk of death. The assessment of exacerbation risk is important in the grading of COPD. The most common cause of COPD exacerbation is respiratory tract infection. The only known human cathelicidin antimicrobial peptide, LL-37, play an important role in innate defense against infection. Its gene expression is regulated by the bioactive form of vitamin D. The objective of the present study was to explore the relationship between LL-37 plasma levels, vitamin D status and exacerbation risk in patients with COPD.

Methods

COPD patients and normal subjects were recruited from Beijing Hospital for this study. COPD patients were divided into low risk group and high risk group according to the criteria of GOLD strategy. The plasma concentrations of LL-37 were measured by ELISA technique to explore the difference in LL-37 levels between groups. The plasma levels of 25-hydroxy vitamin D [25(OH)D] were analyzed using electrochemiluminescence immunoassay (ECLIA).

Results

A total of 84 COPD patients and 51 normal subjects (control group) were recruited. COPD patients were divided into low risk group (37 cases) and high risk group (47 cases), depending on forced expiratory volume in one second (FEV₁)%pred and exacerbation frequency in the previous year. The plasma concentrations of LL-37 in control group, low risk group and high risk group were 20.7±5.8, 19.5±4.1 and 17.9±3.9 µg/L respectively. The plasma concentration of LL-37 was significantly lower in high risk group than in control group (P=0.006). But there was no significant difference between low risk group and high risk group (P=0.152). The plasma concentrations of 25(OH)D in control group, low risk group and high risk group were 18.1±9.4, 13.1±6.9 and 9.3±5.8 ng/mL respectively. The plasma concentration of 25(OH)D was significantly higher in control group than in low risk group (P=0.004) or high risk group (P<0.001). The plasma concentration of 25(OH)D was significantly lower in high risk group than in low risk group (P=0.031). Hospitalization frequency for COPD exacerbations was negative correlated with plasma levels of LL-37 (r=−0.290, P=0.048) and 25(OH)D (r=−0.341, P=0.020) in high risk group. There was not significant correlation between LL-37 and 25(OH)D in COPD patients (r=0.115, P=0.303).

Conclusions

The plasma levels of LL-37 and 25(OH)D were lower in COPD patients with high risk of frequent exacerbations than normal subjects. Low plasma levels of LL-37 and 25(OH)D might be predictors of exacerbation risk in COPD patients.     

Resource Use Study In COPD (RUSIC): A prospective study to quantify the effects of COPD exacerbations on health care resource use among COPD patients

BACKGROUND:

There is increasing interest in health care resource use (HRU) in Canada, particularly in resources associated with acute exacerbations of chronic obstructive pulmonary disease (COPD).

OBJECTIVE:

To identify HRU due to exacerbations of COPD.

METHODS:

A 52-week, multicentre, prospective, observational study of HRU due to exacerbations in patients with moderate to severe COPD was performed. Patients were recruited from primary care physicians and respirologists in urban and rural centres in Canada.

RESULTS:

In total, 524 subjects (59% men) completed the study. Their mean age was 68.2±9.4 years, with a forced expiratory volume in 1 s of 1.01±0.4 L. Patients had significant comorbidities. There were 691 acute exacerbations of COPD, which occurred in 53% of patients: 119 patients (23%) experienced one acute exacerbation, 70 patients (13%) had two acute exacerbations and 89 patients (17%) had three or more acute exacerbations. Seventy-five patients were admitted to hospital, with an average length of stay of 13.2 days. Fourteen of the patients spent time in an intensive care unit (average length of stay 5.6 days). Factors associated with acute exacerbations of COPD included lower forced expiratory volume in 1 s (P<0.001), high number of respiratory medications prescribed (P=0.037), regular use of oral corticosteroids (OCSs) (P=0.008) and presence of depression (P<0.001). Of the 75 patients hospitalized, only 53 received OCSs, four received referral for rehabilitation and 15 were referred for home care.

CONCLUSIONS:

The present study showed a high prevalence of COPD exacerbations, which likely impacted on HRU. There was evidence of a lack of appropriate management of exacerbations, especially with respect to use of OCSs, and referral for pulmonary rehabilitation and home care.     

A Successful Multifaceted Trial to Improve Hypertension Control in Primary Care: Why Did it Work?

Background

It is important to understand which components of successful multifaceted interventions are responsible for study outcomes, since some components may be more important contributors to the intervention effect than others.

Objective

We conducted a mediation analysis to determine which of seven factors had the greatest effect on change in systolic blood pressure (BP) after 6 months in a trial to improve hypertension control.

Design

The study was a preplanned secondary analysis of a cluster-randomized clinical trial. Eight clinics in an integrated health system were randomized to provide usual care to their patients (n = 222), and eight were randomized to provide a telemonitoring intervention (n = 228).

Participants

Four hundred three of 450 trial participants completing the 6-month follow-up visit were included.

Interventions

Intervention group participants received home BP telemonitors and transmitted measurements to pharmacists, who adjusted medications and provided advice to improve adherence to medications and lifestyle modification via telephone visits.

Main measures

Path analytic models estimated indirect effects of the seven potential mediators of intervention effect (defined as the difference between the intervention and usual care groups in change in systolic BP from baseline to 6 months). The potential mediators were change in home BP monitor use, number of BP medication classes, adherence to BP medications, physical activity, salt intake, alcohol use, and weight.

Key Results

The difference in change in systolic BP was 11.3 mmHg. The multivariable mediation model explained 47 % (5.3 mmHg) of the intervention effect. Nearly all of this was mediated by two factors: an increase in medication treatment intensity (24 %) and increased home BP monitor use (19 %). The other five factors were not significant mediators, although medication adherence and salt intake improved more in the intervention group than in the usual care group.

Conclusions

Most of the explained intervention effect was attributable to the combination of self-monitoring and medication intensification. High adherence at baseline and the relatively low intensity of resources directed toward lifestyle change may explain why these factors did not contribute to the improvement in BP.KEY WORDS: Blood pressure, Hypertension, Randomized trial, Mediation, Telemonitoring, Case management     

Can a self-management education program for patients with chronic obstructive pulmonary disease improve quality of life ?

OBJECTIVE:

To assess the effects of a self-management program on health-related quality of life (HRQoL) and morbidity commonly associated with chronic obstructive pulmonary disease (COPD).

METHODS:

A total of 57 outpatients with stable COPD received four weeks of self-management education, while 45 patients received usual care. Patients were evaluated at baseline, at three months and one year following the educational intervention. The primary outcome variable was HRQoL measured by the St George’s Respiratory Questionnaire (SGRQ). The secondary outcome variables were number of emergency room visits and hospitalizations for exacerbation.

RESULTS:

The intervention group’s HRQoL improved significantly at three months (total score A=−5.0 [P=0.006]) and 12 months (total score A=−6.7 [P<0.001]), as evidenced by decreased scores on the SGRQ. In contrast, the SGRQ scores increased significantly in the control group at three months (total score A=+3.7 [P= 0.022]) and 12 months (total score A=+3.4 [P=0.032]). Global impact appeared to be responsible for the change in the intervention group. Moreover, in the intervention group, the number of hospitalizations dropped from 0.7/person/year to 0.3/person/year (P=0.017), and emergency room visits dropped from 1.1 person/year to 0.2/person/year (P=0.002), while subjects in the control group did not experience any significant decreases in these parameters.

CONCLUSIONS:

A planned education program improved HRQoL while decreasing the number of emergency room visits and hospitalizations in patients with stable COPD; this improvement persisted at 12 months.     

The impact of body mass index on inpatient- versus outpatient-treated chronic obstructive pulmonary disease exacerbations

BACKGROUND:

Increased body weight has been associated with worse prognoses for many chronic diseases; however, this relationship is less clear in patients with chronic obstructive pulmonary disease (COPD), with underweight patients experiencing higher morbidity than normal or overweight patients.

OBJECTIVE:

To assess the impact of body mass index (BMI) on the risk for COPD exacerbations.

METHODS:

The present study included 115 patients with stable COPD (53% women; mean [± SD] age 67±8 years). Height and weight were measured to calculate BMI. Patients were followed for a mean of 1.8±0.8 years to assess the prospective risk of inpatient-treated exacerbations and outpatient-treated exacerbations, all of which were verified by chart review.

RESULTS:

Cox regression models revealed that underweight patients were at greater risk for inhospital-treated exacerbations (RR 2.93 [95% CI 1.27 to 6.76) relative to normal weight patients. However, overweight (RR 0.59 [95% CI 0.33 to 1.57) and obese (RR 0.99 [95% CI 0.53 to 1.86]) patients did not differ from normal weight patients. All analyses were adjusted for age, sex, length of diagnosis, smoking pack-years, forced expiratory volume in 1 s, and time between recruitment and last exacerbation. BMI did not influence the risk of out-of-hospital exacerbations.

CONCLUSIONS:

The present study showed that underweight patients were at greater risk for inhospital exacerbations. However, BMI did not appear to be a risk factor for out-of-hospital exacerbations. This suggests that the BMI-exacerbation link may differ according to the nature of the exacerbation, the mechanisms for which are not yet known.     

Impact of viral infection on acute exacerbation of asthma in out-patient clinics: a prospective study

Background

The prevalence of viral infection triggering asthma exacerbation and its impact on the symptoms and duration of exacerbation are unclear.

Methods

Asthma and healthy control subjects were recruited from the First Affiliated Hospital of Guangzhou Medical University between February 2012 and February 2013. Nasal swabs were collected, and respiratory viruses were detected by polymerase chain reaction (PCR). All patients completed questionnaires and a lung function test. Some were followed up for 4 weeks, and symptom changes were evaluated via asthma diaries.

Results

In total, 70 patients with acute asthma exacerbations were recruited. Among them, 34 patients (48.6%) completed the 4-week follow-up study. Another 65 patients with stable asthma and 134 healthy volunteers were also included in this study. The rate of positive viral detection via PCR in acute asthma exacerbation patients was 34.2% (24/70), which is significantly higher than that of stable asthma (12/65; 18.5%; P=0.038) and normal control patients (18/134; 13.4%; P<0.001). Among the viral-positive subjects, the number of viral copies was significantly higher in acute asthma exacerbation patients [(5.00±4.63) ×10⁷ copies/L] (mean ± SD) than those in stable asthma patients [(1.24±1.44) ×10⁶ copies/L; P<0.001] or in healthy controls [(1.44±0.44) ×10⁶ copies/L; P<0.001], whose viral loads were not significantly different from one another (P=0.774). During the 4-week follow-up period, the cough scores on days 1 and 3 were significantly higher in the viral-positive group than in the viral-negative group (day 1: P=0.016; day 3: P=0.004). However, there were no significant differences between these two groups for other tested symptoms, such as dyspnea and total recovery time (P>0.05).

Conclusions

Respiratory viruses may be involved in acute asthma exacerbations, inducing more prominent and persistent cough symptoms.     

Exacerbations of COPD and symptoms of gastroesophageal reflux: a systematic review and meta-analysis

OBJECTIVE:

To examine the relationship between gastroesophageal reflux (GER) and COPD exacerbations.

METHODS:

We conducted a systematic search of various electronic databases for articles published up through December of 2012. Studies considered eligible for inclusion were those dealing with COPD, COPD exacerbations, and GER; comparing at least two groups (COPD vs. controls or GER vs. controls); and describing relative risks (RRs) and prevalence ratios-or ORs and their respective 95% CIs (or presenting enough data to allow further calculations) for the association between GER and COPD-as well as exacerbation rates. Using a standardized form, we extracted data related to the study design; criteria for GER diagnosis; age, gender, and number of participants; randomization method; severity scores; methods of evaluating GER symptoms; criteria for defining exacerbations; exacerbation rates (hospitalizations, ER visits, unscheduled clinic visits, prednisone use, and antibiotic use); GER symptoms in COPD group vs. controls; mean number of COPD exacerbations (with symptoms vs. without symptoms); annual frequency of exacerbations; GER treatment; and severity of airflow obstruction.

RESULTS:

Overall, GER was clearly identified as a risk factor for COPD exacerbations (RR = 7.57; 95% CI: 3.84-14.94), with an increased mean number of exacerbations per year (mean difference: 0.79; 95% CI: 0.22-1.36). The prevalence of GER was significantly higher in patients with COPD than in those without (RR = 13.06; 95% CI: 3.64-46.87; p < 0.001).

CONCLUSIONS:

GER is a risk factor for COPD exacerbations. The role of GER in COPD management should be studied in greater detail.     

Risk factors and outcomes associated with chronic obstructive pulmonary disease exacerbations requiring hospitalization

BACKGROUND:

Acute respiratory exacerbations are the most frequent cause of medical visits, hospitalization and death for chronic obstructive pulmonary disease (COPD) patients and, thus, exert a significant social and economic burden on society.

OBJECTIVE:

To identify the risk factors associated with hospital readmission(s) for acute exacerbation(s) of COPD (AECOPD).

METHODS:

A review of admission records from three large urban hospitals in Vancouver, British Columbia, identified 310 consecutive patients admitted for an AECOPD between April 1, 2001, and December 31, 2002. Logistic regression analysis was performed to identify risk factors for readmissions following an AECOPD.

RESULTS:

During the study period, 38% of subjects were readmitted at least once. The mean (± SD) duration from the index admission to the first readmission was 5±4.08 months. Comparative analysis among the three hospitals identified a significant difference in readmission rates (54%, 36% and 18%, respectively). Logistic regression analysis revealed that preadmission home oxygen use (OR 2.55; 95%CI 1.45 to 4.42; P=0.001), history of a lung infection within the previous year (OR 1.73; 95% CI 1.01 to 2.97; P=0.048), other chronic respiratory disease (OR 1.78; 95% CI 1.06 to 2.99; P=0.03) and shorter length of hospital stay (OR 0.97; 95% CI 0.945 to 0.995; P=0.021) were independently associated with frequent readmissions for an AECOPD.

CONCLUSIONS:

Hospital readmission rates for AECOPD were high. Only four clinical factors were found to be independently associated with COPD readmission. There was significant variability in the readmission rate among hospitals. This variability may be a result of differences in the patient populations that each hospital serves or may reflect variability in health care delivery at different institutions.     

Improving Medication Adherence through Graphically Enhanced Interventions in Coronary Heart Disease (IMAGE-CHD): A Randomized Controlled Trial

Background

Up to 50 % of patients do not take medications as prescribed. Interventions to improve adherence are needed, with an understanding of which patients benefit most.

Objective

To test the effect of two low-literacy interventions on medication adherence.

Design

Randomized controlled trial, 2 × 2 factorial design.

Participants

Adults with coronary heart disease in an inner-city primary care clinic.

Interventions

For 1 year, patients received usual care, refill reminder postcards, illustrated daily medication schedules, or both interventions.

Main Measures

The primary outcome was cardiovascular medication refill adherence, assessed by the cumulative medication gap (CMG). Patients with CMG < 0.20 were considered adherent. We assessed the effect of the interventions overall and, post-hoc, in subgroups of interest.

Key Results

Most of the 435 participants were elderly (mean age = 63.7 years), African-American (91 %), and read below the 9th-grade level (78 %). Among the 420 subjects (97 %) for whom CMG could be calculated, 138 (32.9 %) had CMG < 0.20 during follow-up and were considered adherent. Overall, adherence did not differ significantly across treatments: 31.2 % in usual care, 28.3 % with mailed refill reminders, 34.2 % with illustrated medication schedules, and 36.9 % with both interventions. In post-hoc analyses, illustrated medication schedules led to significantly greater odds of adherence among patients who at baseline had more than eight medications (OR = 2.2; 95 % CI, 1.21 to 4.04) or low self-efficacy for managing medications (OR = 2.15; 95 % CI, 1.11 to 4.16); a trend was present among patients who reported non-adherence at baseline (OR = 1.89; 95 % CI, 0.99 to 3.60).

Conclusions

The interventions did not improve adherence overall. Illustrated medication schedules may improve adherence among patients with low self-efficacy, polypharmacy, or baseline non-adherence, though this requires confirmation.KEY WORDS: coronary heart disease, medical adherence, medication management     

Evolution of the COPD Assessment Test score during chronic obstructive pulmonary disease exacerbations: Determinants and prognostic value

BACKGROUND:

An adequate evaluation of exacerbations is a primary objective in managing patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVES:

To define the profile of health status recovery during severe exacerbations of COPD using the COPD Assessment Test (CAT) questionnaire and to evaluate its prognostic value.

METHODS:

Forty-five patients with previous COPD diagnoses who were hospitalized due to severe exacerbation(s) were included in the study. These patients were treated by their respective physicians following current recommendations; health status was assessed daily using the CAT questionnaire. The CAT score, spirometry and recurrent hospitalizations were recorded one and three months after hospital discharge.

RESULTS:

Global initiative for chronic Obstructive Lung Disease (GOLD) stage was an independent determinant for increased CAT score during the first days of exacerbation with respect to postexacerbation values. From hospitalization day 5, the CAT score was similar to that obtained in the stable phase. Body mass index, GOLD stage and education level were related to health status recovery pattern. CAT score increase and the area under the curve of CAT recovery were inversely related to the forced expiratory volume in 1 s achieved three months after discharge (r= −0.606; P<0.001 and r= −0.532; P<0.001, respectively). Patients with recurrent hospitalizations showed higher CAT score increases and slower recovery.

CONCLUSIONS:

The CAT detects early health status improvement during severe COPD exacerbations. Its initial worsening and recovery pattern are related to lung function and recurrent hospitalizations.     

Should the cut-off value of D-dimer be elevated to exclude pulmonary embolism in acute exacerbation of COPD?

Objective

The aim of this study was to evaluate the D-dimer levels in patients with chronic obstructive pulmonary disease (COPD) exacerbation with and without pulmonary embolism (PE) and to attempt to define a new cut-off value for D-dimer to exclude the diagnosis of PE in patients with COPD exacerbation.

Methods

This cross-sectional study was performed between the June 2012 and January 2013. The COPD patients who were admitted to the emergency department with acute exacerbation were consecutively included. D-dimer levels were measured upon admission. All patients underwent computed tomography angiography (CTA) and Doppler ultrasonography (US) of the lower extremities.

Results

A total of 148 patients were enrolled. Fifty-three patients (36%) who did not have PE had higher than normal (>0.5 pg/mL) D-dimer levels. The D-dimer levels of the COPD patients with PE were significantly higher than those of the patients without PE (2.38±2.80 vs. 1.06±1.51 pg/mL) (P<0.001). The cut-off value for D-dimer in diagnosing PE in the COPD patients was 0.95 pg/mL. The area under the receiver operating characteristic (ROC) curve was 0.752±0.040 (95% CI: 0.672-0.831) (P<0.001).

Conclusions

This study showed that the D-dimer concentrations of COPD patients who are in the exacerbation period may be higher than normal, even without PE. The cut-off level for D-dimer was 0.95 pg/mL (sensitivity 70%, spesificity 71%) for the exclusion of PE in the patients with COPD exacerbation. The D-dimer cut-off value that is used to exclude PE in patients with acute exacerbation of COPD should be reevaluated to prevent the excessive use of further diagnostic procedures.KEY WORDS : Chronic obstructive pulmonary disease (COPD), D-dimer, pulmonary embolism (PE)     

Evaluation of von Willebrand factor in COPD patients

OBJECTIVE:

To compare the absolute serum von Willebrand factor (vWF) levels and relative serum vWF activity in patients with clinically stable COPD, smokers without airway obstruction, and healthy never-smokers.

METHODS:

The study included 57 subjects, in three groups: COPD (n = 36); smoker (n = 12); and control (n = 9). During the selection phase, all participants underwent chest X-rays, spirometry, and blood testing. Absolute serum vWF levels and relative serum vWF activity were obtained by turbidimetry and ELISA, respectively. The modified Medical Research Council scale (cut-off score = 2) was used in order to classify COPD patients as symptomatic or mildly symptomatic/asymptomatic.

RESULTS:

Absolute vWF levels were significantly lower in the control group than in the smoker and COPD groups: 989 ± 436 pg/mL vs. 2,220 ± 746 pg/mL (p < 0.001) and 1,865 ± 592 pg/mL (p < 0.01). Relative serum vWF activity was significantly higher in the COPD group than in the smoker group (136.7 ± 46.0% vs. 92.8 ± 34.0%; p < 0.05), as well as being significantly higher in the symptomatic COPD subgroup than in the mildly symptomatic/asymptomatic COPD subgroup (154 ± 48% vs. 119 ± 8%; p < 0.05). In all three groups, there was a negative correlation between FEV₁ (% of predicted) and relative serum vWF activity (r² = −0.13; p = 0.009).

CONCLUSIONS:

Our results suggest that increases in vWF levels and activity contribute to the persistence of systemic inflammation, as well as increasing cardiovascular risk, in COPD patients.     

Pharmacological treatment response according to the severity of symptoms in patients with chronic obstructive pulmonary disease

Background

Pharmacological management of chronic obstructive pulmonary disease (COPD) is recommended according to the individualized assessment of symptoms and exacerbation risks. The aim of this study was to determine the relationship between the baseline Modified British Medical Research Council (mMRC) dyspnea scale and the COPD Assessment Test (CAT) score and pharmacological treatment response in patients with COPD.

Methods

A total of 102 stable COPD patients who were enrolled in prospective cohort studies were analyzed. Pharmacological treatment responses after a 3-month treatment were assessed by changes on the mMRC dyspnea scale, CAT scores, and spirometric pulmonary functions.

Results

Sixty-two patients with a mMRC dyspnea scale ≤1 were classified as having “less dyspnea” and 40 patients with a mMRC dyspnea scale ≥2 as having “more dyspnea”. After a 3-month treatment, the mean mMRC dyspnea scale in the “more dyspnea” group was significantly decreased versus the “less dyspnea” group; however, there were no significant differences in CAT score changes or spirometric pulmonary function changes between the two groups. Baseline mMRC scales (Spearman’s rho =−0.591, P<0.001) and baseline CAT scores (Pearson’s r =−0.337, P=0.001) were significantly correlated with their changes after a 3-month treatment. Multiple logistic regression analysis demonstrated that baseline mMRC scale and CAT score were the only independent predictors of improvement greater than a minimal clinically significant difference after treatment.

Conclusions

The severity of COPD symptoms is associated with their response to pharmacotherapy. COPD patients with a higher baseline mMRC dyspnea scale and CAT score experience greater symptom reduction by pharmacotherapy.     

Airways inflammation and treatment during acute exacerbations of COPD

Introduction

Inflammation is a core feature of acute chronic obstructive pulmonary disease (COPD) exacerbations. It is important to focus on inflammation since it gives insight into the pathological changes causing an exacerbation, thereby possibly providing directions for future therapies which modify inflammation.

Objectives

To provide a cell-by-cell overview of the inflammatory processes during COPD exacerbations. To evaluate cell activation, and cytokine production, cellular interactions, damaging effects of inflammatory mediators to tissue, and the relation to symptoms at the onset of COPD exacerbations. To speculate on future therapeutic options to modify inflammation during COPD exacerbations.

Results

During COPD exacerbations, there is increased airway wall inflammation, with pathophysiological influx of eosinophils, neutrophils, and lymphocytes. Although links have been suggested between the increase in eosinophils and lymphocytes and a viral etiology of the exacerbation, and between the increase in neutrophils and a bacterial aetiology, these increases in both inflammatory cell types are not limited to the respective aetiologies and the underlying mechanisms remain elusive.

Conclusion

Further research is required to fully understand the inflammatory mechanisms in the onset and development of COPD exacerbations. This might make inflammatory pathway-specific intervention possible, resulting in a more effective treatment of COPD exacerbations with fewer side effects.     

Changes of HMGB1 and sRAGE during the recovery of COPD exacerbation

Background

Acute exacerbation of chronic obstructive pulmonary disease is associated with increased airway and systemic inflammation. However, the correlation between acute exacerbation/convalescence of chronic obstructive pulmonary disease (COPD) and simultaneous changes of high mobility group protein B1 (HMGB1) and soluble RAGE (sRAGE) levels has not been clearly clarified. The aim of this study was to assess these issues.

Methods

A total of 44 COPD patients were recruited. Following a structured interview, plasma levels of HMGB1, sRAGE, fibrinogen and serum level of high-sensitivity C-reactive protein (hsCRP) were measured in patients with acute exacerbation of COPD (AECOPD) within 24 h of hospitalization and pre-discharge (convalescence). All patients were examined with spirometry in convalescence of COPD.

Results

There was a significant decline in plasma HMGB1 (P<0.01), sRAGE (P<0.05), fibrinogen (P<0.01) and serum hsCRP (P<0.01) levels from acute exacerbation to convalescence phase of COPD. Changes of sRAGE was significantly correlated with changes of HMGB1 (r=0.4, P=0.007). COPD disease status correlated with the ratio of HMGB1/sRAGE, but not gender, age, course of disease, smoking history and FEV1% pred. Levels of HMGB1 and sRAGE were the highest in the current smoker group, and significantly decreased in ex-smoker group in both acute exacerbation and convalescence phase of COPD, however, their levels in never smoker group were higher than ex-smoker group in either phase of COPD.

Conclusions

HMGB1 and sRAGE levels were dynamically changed between exacerbation and convalescence phase of COPD, HMGB1 and sRAGE were likely not only a potential marker in COPD exacerbation but also a therapeutic target for COPD treatment.     

History of pneumonia is a strong risk factor for chronic obstructive pulmonary disease (COPD) exacerbation in South Korea: the Epidemiologic review and Prospective Observation of COPD and Health in Korea (EPOCH) study

Background

In South Korea, chronic obstructive pulmonary disease (COPD) is one of the ten leading causes of death. COPD exacerbations are significantly associated with mortality in COPD patients. This study was conducted to investigate the epidemiology of COPD in South Korea, specifically the clinical characteristics of South Korean COPD patients, the COPD exacerbation rate and the risk factors associated with COPD exacerbations.

Methods

This study covers a 2-year interval. One year was data collected retrospectively and the second year was prospectively obtained data.

Results

A total of 1,114 subjects were enrolled in the study. These subjects were observed for a period of 1 year from the enrollment, and a total of 920 subjects completed the study. A total of 1,357 COPD exacerbations occurred in 711 subjects (63.8%) out of the total of 1,114 subjects during the study period of 2 years. Multivariate logistic regression results showed that if patients had had a pneumonia before the retrospective year of analysis, they had a 18 times greater chance of having an exacerbation during the prospective year when other variables were controlled. Also, the subjects who had a history of two or more exacerbations during the retrospective year were approximately 6 times more likely to experience the COPD exacerbation compared to those who did not.

Conclusions

This study examined the demographic and clinical characteristics of South Korean COPD patients and found that a history of pneumonia and two or more occurrences of exacerbation within 1 year was significantly associated with a higher rate of COPD exacerbation.     

Two-year weight-loss maintenance in primary care-based Diabetes Prevention Program lifestyle interventions

Objective:

To investigate whether the effects on weight loss and cardiometabolic risk factor reduction of two technology-mediated lifestyle interventions for 15 months in a primary care-based translation trial sustained at 24 months (that is, 9 months after the end of intervention).

Design:

This study analyzed data from an extended follow-up of participants in the original ‘E-LITE'' (Evaluation of Lifestyle Interventions to Treat Elevated Cardiometabolic Risk in Primary Care)-randomized controlled trial, which demonstrated the effectiveness of two adapted Diabetes Prevention Program (DPP) lifestyle interventions compared with usual primary care.

Subjects:

E-LITE randomized 241 overweight or obese participants with pre-diabetes and/or metabolic syndrome to receive usual care alone (n=81) or usual care plus a coach-led (n=79) or self-directed intervention (n=81). The interventions provided coach-led group behavioral weight-loss treatment or a take-home, self-directed DVD using the same 12-week curriculum, followed by 12 additional months of technology-mediated coach contact and self-monitoring support. Participants received no further intervention after month 15. A blinded assessor conducted 24-month visits by following the measurement protocols of the original trial. Measurements include weight and cardiometabolic risk factors (waist circumference, fasting plasma glucose, resting blood pressure, triglycerides, high- and low-density lipoprotein cholesterol, total cholesterol and triglyceride to high-density lipoprotein cholesterol ratio).

Results:

At month 24, mean±s.e. changes in body mass index (trial primary outcome) and weight (kg) from baseline were –1.9±0.3 (P=0.001) and –5.4±0.9 (P<0.001) in the coach-led intervention, and –1.6±0.3 (P=0.03) and –4.5±0.9 (P=0.001) in the self-directed intervention, compared with –0.9±0.3 and 2.4±0.9 in the usual care group. In addition, both interventions led to a greater percentage of participants maintaining ⩾7% weight loss and sustained improvements in waist circumference and fasting plasma glucose levels than usual care.

Conclusion:

This study shows sustained benefits of the two primary care-based, technology-mediated DPP lifestyle interventions. The findings warrant replication in long-term studies involving diverse populations.     

Variations in the management of acute exacerbations of chronic obstructive pulmonary disease

BACKGROUND:

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a significant cause of morbidity and mortality for patients with COPD. AECOPD are the leading cause of hospital admissions in Canada. Although multiple guidelines have been developed for the acute and chronic management of COPD, there are few quality assurance studies investigating adherence to these guidelines.

METHODS:

A retrospective chart review of all patients admitted to a tertiary care hospital in 2009 for an AECOPD was performed. Using a standardized data abstraction tool, adherence to current guidelines across different physician groups and patient outcomes were assessed. Particular focus was centred on differences in management across physician groups.

RESULTS:

Overall, 293 patients were evaluated. Of these, 82.6% were treated with one or more chronic COPD medication(s) in the community, with only 17.7% of patients treated with a long-acting inhaled anticholinergic medication. For treatment of AECOPD, 58% of patients received corticosteroids and 84% received antibiotics. Compared with general medicine and the hospitalist service, the respiratory medicine service demonstrated significantly better adherence with current treatment guidelines; however, even this was less than optimal. In addition, there was poor follow-up of patients cared for outside of the respiratory service.

CONCLUSIONS:

The present study identified significant care gaps in the treatment of patients admitted with AECOPD and on their discharge.     

Prospective evaluation of gastric neurostimulation for diabetic gastroparesis in Canada

BACKGROUND:

The efficacy of gastric neurostimulation therapy for diabetic gastroparesis (GP) in a ‘real-life’ Canadian setting has not been assessed.

AIMS:

To assess changes in health-related quality of life (QoL), weekly vomiting frequency (WVF), total symptom score (TSS) and health care utilization 12 months before and after gastric neurostimulator implantation in a diabetic GP cohort.

METHODS:

Medication-refractory diabetic GP patients (n=7, four female, mean age 42 years) were prospectively recruited from 2008 to 2012. QoL scores were self-administered and obtained at baseline, 24 and 48 weeks postimplantion. WVF and TSS were assessed similarly. Health care usage, measured as hospitalization frequency and medication cost, was obtained six and 12 months before and after implant. Changes from baseline to six and 12 months for all outcomes were compared.

RESULTS:

The mean (± SD) QoL according to EuroQol was significantly better at 24 weeks after the baseline measurement (baseline 29±5, 24 weeks 52±7; P=0.03). The mean improvement in TSS was significantly better at one year postintervention (baseline score 35±5 versus 12 months 27±3; P=0.03). Changes in Short-Form 36 Health Survey and WVF were not significant. Days of GP-related hospitalization were highly variable but decreased from a median of 71 days (range 0 to 227 days) to 29 days (range two to 334 days) one year before and after surgery, respectively (P=0.735). Outpatient medication costs did not decrease to a significant extent.

CONCLUSION:

Gastric neurostimulation for diabetic GP appeared to show some beneficial palliative effects overall in the present small open-label series, but the effect is highly variable among patients, and placebo effect cannot be ruled out.