Experimental nasal spray for sleep apnea shows promising results

Adelaide, Australia - A drug in development for obstructive sleep apnea (OSA) has shown promising results, after researchers from Flinders University tested the treatment in people for the first time. Designed to prevent the narrowing or collapse of the upper airways during sleep, a key factor in OSA, the treatment could prove to be a potential alternative for certain people with OSA to continuous positive airway pressure (CPAP) machines, which can only be tolerated by about half of all OSA sufferers. "While further rigorous clinical evaluation and testing is required, this is a great first step and should offer some hope to the many people worldwide who suffer from sleep apnea," says study senior author Professor Danny Eckeart, Director of Flinders' sleep lab FHMRI: Sleep Health. "OSA is one of the most common sleep-related breathing disorders, with an estimated one billion sufferers, and when untreated is associated with major health and safety consequences. While CPAP machines are effective, tolerance remains a major issue for many and other treatments such as dental splints and upper airway surgery don't always work. This is why we need new treatment options for OSA. "At the moment, there are no approved drug treatments for OSA. However, with advances in our understanding of the different reasons people get OSA, the potential for effective new medications is growing stronger each year." Published in the journal Chest, the study tested the drug on 12 people with OSA using either nasal drops, a nasal spray or via direct application using an endoscope, versus a placebo. Monitoring for sleep and airway activity across several sessions, the team found consistent and sustained improvements in the patients' airways staying open throughout sleep, compared to the placebo treatment, regardless of the delivery method used. "Although a small study, our findings represent the first detailed investigation of this new treatment in people with OSA, with promising results," says study lead author Dr. Amal Osman from FHMRI: Sleep Health. "The drug we tested is designed to target specific receptors that are expressed on the surface of the upper airways, triggering them more easily to activate the surrounding muscles to keep the airway open during sleep. While there's still a long way to go in terms of clinical testing and development, our study shows targeting these receptors may be a promising avenue for future treatments." 

For more information: https://tinyurl.com/55rj7dwt

Emphysema, airway inflammation more common among marijuana than tobacco smokers

Ottawa, ON - Individuals who smoked marijuana were more likely to have emphysema, airway changes and gynecomastia than tobacco-only smokers and non-smokers, according to a study published in Radiology. “There is a public perception that marijuana is safe, safer than cigarettes, but this study raises concerns that this may not be true,” Luke Murtha, BMBS, FRCPC, of Ottawa Hospital in Canada, told Healio. “Ultimately, we need a more robust study before we can make sweeping conclusions. ”In a retrospective case-control study, Murtha and colleagues analyzed chest CT examinations of 56 marijuana smokers (34 men; mean age, 49 ± 14 years), 33 tobacco-only smokers (18 men; mean age, 60 ± 6 years) and 57 non-smokers (32 men; mean age, 49 ± 14 years) from October 2005 to July 2020 to observe differences between rates of emphysema, airway changes, gynecomastia and coronary artery calcification among the smoking groups. Researchers found that 42 (75%) marijuana smokers had emphysema, compared with three (5%; P < .001) non-smokers and 22 (67%) tobacco-only smokers, although the latter comparison did not reach statistical significance. Marijuana smokers also had more instances of para-septal emphysema, occurring in 27 (48%) individuals, whereas only three (5%; P < .001) non-smokers and eight (24%; P = .03) tobacco smokers had this emphysema subtype. According to researchers, marijuana smokers also had higher rates of airway inflammation in the form of bronchial thickening (64% vs. 11% non-smokers; P < .001; vs. 42% tobacco-only; P = .04), bronchiectasis (23% vs. 4% non-smokers; P = .002; vs. 6% tobacco-only; P = .04) and mucoid impaction (46% vs. 2% non-smokers; P < .001 vs. 15% tobacco-only; P = .003). Murtha told Healio these findings in marijuana smokers could mean the substance is harming the lungs more so than tobacco. “These instances of large and small airway diseases found for marijuana users suggests that marijuana may have additional effects on the lungs above tobacco alone,” he said. Chest CT examinations also showed that 13 out of 34 (38%) individuals who smoked marijuana had instances of gynecomastia, which was more than both non-smokers (5 of 32; 16%; P = .039) and tobacco-only smokers (2 of 18; 11%; P = .04). Because all tobacco smokers were aged older than 50 years, researchers also conducted additional age- and sex-matched subgroup analyses that included 30 marijuana smokers (23 men), 33 tobacco-only smokers (18 men) and 29 non-smokers (17 men). In this adjusted subgroup analysis, researchers found that 28 (93%) marijuana smokers had emphysema compared with 22 (67%) tobacco-only smokers (P = .009) and two (7%) non-smoking controls (P < .001), showing a significantly higher emphysema rate among marijuana smokers. Additionally, marijuana smokers had continued higher rates of bronchial thickening (83% vs. 42%; P < .001), bronchiectasis (33% vs. 6%; P = .006) and mucoid impaction (67% vs. 15%; P < .001) compared with tobacco-only smokers, with significant differences also seen between the marijuana and control groups. When asked about the results of both analyses, Murtha told Healio they were surprising.

For more information: https://tinyurl.com/5n7vxcrh

Scientists explain why upper respiratory infections are more common in colder temperatures

Boston, MA - Researchers at Mass Eye and Ear and Northeastern University have discovered a previously unidentified immune response inside the nose that fights off viruses responsible for upper respiratory infections. Further testing has revealed this protective response becomes inhibited in colder temperatures, making an infection more likely to occur. The new study, published December 6 in The Journal of Allergy and Clinical Immunology, offers the first biological mechanism to explain why viruses like the common cold, flu and COVID-19 are more likely to spike in colder seasons, according to the authors. "Conventionally, it was thought that cold and flu season occurred in cooler months because people are stuck indoors more where airborne viruses could spread more easily," said Benjamin S. Bleier, MD, FACS, director of Otolaryngology Translational Research at Mass Eye and Ear and senior author of the study. "Our study, however, points to a biological root cause for the seasonal variation in upper respiratory viral infections we see each year, most recently demonstrated throughout the COVID-19 pandemic." The nose is one of the first points of contact between the outside environment and inside the body, and as such, a likely entry point for disease-causing pathogens. Pathogens are inhaled or directly deposited (such as by the hands) into the front of the nose where they work their way backwards through the airway and into the body infecting cells, which can lead to an upper respiratory infection. How the airway protects itself against these pathogens has long been poorly understood. That is, until a 2018 study led by Dr. Bleier and Mansoor Amiji, Ph.D., Distinguished Professor of Pharmaceutical Sciences at Northeastern University, uncovered an innate immune response triggered when bacteria is inhaled through the nose: Cells in the front of the nose detected the bacteria and then released billions of tiny fluid-filled sacs called extracellular vesicles (or EVs, known previously as exosomes) into the mucus to surround and attack the bacteria. Dr. Bleier compares the release of this EV swarm to "kicking a hornets' nest." The 2018 study also showed that the EVs shuttle protective antibacterial proteins through the mucus from the front of the nose to the back of it along the airway, which then protects other cells against the bacteria before it gets too far into the body. For the new study, the researchers sought to determine if this immune response was also triggered by viruses inhaled through the nose, which are the source of some of the most common upper respiratory infections. Led by first study author Di Huang, Ph.D., a research fellow at Mass Eye and Ear and Northeastern, the researchers analyzed how cells and nasal tissue samples collected from the noses of patients undergoing surgery and healthy volunteers responded to three viruses: a single coronavirus and two rhinoviruses that cause the common cold. They found each virus triggered an EV swarm response from nasal cells, albeit using a signaling pathway different from the one used to fight off bacteria. The researchers also discovered a mechanism at play in the response against the viruses: Upon their release, the EVs acted as decoys, carrying receptors that the virus would bind itself to instead of the nasal cells. "The more decoys, the more the EVs can mop up the viruses in the mucus before the viruses have a chance to bind to the nasal cells, which suppresses the infection," said Dr. Huang. The researchers then tested how colder temperatures affected this response, which is especially relevant in nasal immunity given the internal temperature of the nose is highly dependent on the temperature of the outside air it inhales. They took healthy volunteers from a room temperature environment and exposed them to 4.4° C (39.9° F) temperatures for 15 minutes and found that the temperature inside the nose fell about 5° C. They then applied this reduction in temperature to the nasal tissue samples and observed a blunted immune response. The quantity of EVs secreted by the nasal cells decreased by nearly 42 percent and the antiviral proteins in the EVs were also impaired. "Combined, these findings provide a mechanistic explanation for the seasonal variation in upper respiratory infections," said Dr. Huang.

Limitations in self-reporting in COPD management

Santa Clara, CA - A recent commentary published by Helio looks at the need to move toward more objective standards in COPD management. Health care professionals managing COPD are attempting to embrace objective standards in both clinical and research settings. Patient self-reporting questionnaires have created a common set of criteria for assessing disease appearance and progression. Today, standardized questionnaires, which have been validated in clinical literature, have helped facilitate the development and utilization of best-practice approaches in the field of pulmonology. However, in everyday practice, important limitations of self-reporting remain, especially as more patients are treated via telehealth and other forms of remote care. First, there is a fair amount of subjectivity to the questions commonly used in questionnaires, both in phrasing and how the questions are delivered. To illustrate, consider that a standard question set in the Clinical COPD Questionnaire (CCQ) might ask the following questions: In general, how much has your COPD affected your daily functioning? How often do you struggle with shortness of breath? How often have you encountered primary symptoms, such as coughing and wheezing? How many nights per week do you encounter symptoms?  Of these four questions, the last one can be considered the most objective, as the set of criteria is limited (focusing on frequency instead of characterization). However, even this question may force a patient to consider what may or may not be considered symptomatic, introducing a degree of subjectivity, and complicating the self-reporting process. As a results, practitioners must often dive deep to understand the frequency and severity of a patient’s true experience of their symptoms. Even with more detailed questioning, a great deal of information can be lost through the subjective lens of self-reporting. Memory and other cognitive factors may impact a patient’s ability to recall signs and symptoms, especially given the advanced age of the average patient with COPD. For example, the St. George’s Respiratory Questionnaire to assess COPD requires a patient to answer the question, “How many attacks of chest trouble did you have in the last year?” with answers ranging from 3 or more times, from 3 or more times to none. The individual completing the questionnaire must not only decide how to interpret what could be considered a COPD attack, but also recall how many times these episodes occurred. Beyond a patient’s ability to recall and report accurately, there are inherent limitations to rating systems that are based on a number scale. The CCQ, which is commonly used to assess COPD symptoms during a patient visit, uses a 6-point scale to determine how often an individual is having symptoms, and requires a patient to self-assess how often they are having symptoms over the past week. In order to answer each question in the CCQ, a patient must differentiate between a symptom frequency of “a few times” (2 points) and “several times” (3 points), or “many times” (4 points) and “a great many times” (5 points). As it stands, patients can struggle to effectively characterize or quantify their condition, as the manifestation and severity of symptoms can fluctuate greatly day-to-day. Add to that the disparate ways that “a few” vs. “several” might be defined between individuals, and the 6-point scale leaves quite a lot of room for interpretation. Additionally, it is also important to note that the degree of subjectivity can be greatly diminished or exacerbated depending on whether a patient is answering questions in the presence of a care provider. When a practitioner is present, a patient may take the opportunity to ask follow-up questions in order to better quantify or characterize their answers. In a remote environment, they are usually not afforded this opportunity, instead relying on their “best guess” or gut instinct to provide answers. However, given that many of these patients only interact with their care provider every 3 to 6 months, or possibly longer, there is a tendency to paint in very broad strokes. Increased telemedicine utilization during the COVID-19 pandemic — especially among elderly and vulnerable populations, many of whom overlap with populations at risk for COPD — has made these specific challenges more salient. As a result, there  has been a push to adopt standardized, objective measurements for clinical and epidemiological purposes. This health care environment necessitates that practitioners consider new, augmented ways to derive empirical data free from the inherent subjective  filters present in patient self-reporting. 

For more information: https://tinyurl.com/4zsa99pk

US battles flu, RSV and COVID-19 simultaneously 

Nashville, TN - A surge of respiratory syncytial virus, an early start to influenza season and the ongoing COVID-19 pandemic have caused a “triple-demic” in the United States, overwhelming hospitals, experts said. At an Infectious Diseases Society of America briefing, Tina Tan, MD, FIDSA, and William Schaffner, MD, FIDSA, said Americans can reduce their risk for hospitalization or death by getting vaccinated against influenza and COVID-19 and by practicing some of the COVID-19 mitigation measures Americans have grown tired of the last few years. “Both of these vaccines provide protection against the complications of their illnesses,” said Schaffner, a professor of preventive medicine and infectious diseases at Vanderbilt University and Infectious Disease News Editorial Board Member. “They’re less capable of preventing mild illness, but they do protect against the most serious complications, including hospitalization and dying.” Schaffner said “masks work,” especially for older, frail or generally immunocompromised people, and that people should consider taking a COVID-19 test before family gatherings this holiday season. The U.S. reported 280,711 new cases of COVID-19 in the week ending Nov. 18, with a total of 2,222 new deaths and a daily average of 3,341 new hospitalizations, according to the CDC. During the week ending Nov. 12, 5.8% of outpatient visits in the U.S. were for influenza-like illness (ILI), CDC data showed — more than double the national baseline of 2.5%. Outpatient ILI visits have been higher than the national baseline since the CDC started reporting data for the 2022-2023 season last month — the first time the U.S. has been above baseline at this time of year since the 2009 H1N1 influenza pandemic. The CDC’s 12-state RSV-NET, which covers about 8% of the U.S. population, on Friday reported an RSV-associated hospitalization rate of 18 per 100,000 people. Since the beginning of the COVID-19 pandemic, seasonal RSV has shifted due to anti-SARS-CoV-2 measures, and patients with severe RSV this year have overwhelmed hospitals since early fall. “RSV faked us out. It’s come very early — it’s usually a January or February virus. Yes, there’s a triple-demic out there,” Schaffner said. Tan, a professor of pediatrics at Northwestern University Feinberg School of Medicine and IDSA vice president, said it has become “very apparent that the seasonal pattern of when RSV and influenza would peak is much earlier” because it appears the COVID-19 pandemic shifted the patterns of both viruses. Additionally, early pandemic declines in child vaccination rates because of shutdowns and lockdowns have not been reversed. “We thought they would bounce back, but they haven’t. There are a lot of unprotected children that are at risk of coming down with vaccine-preventable diseases,” Tan said. Paul Biddinger, MD, FACEP, chief of emergency preparedness at Massachusetts General Hospital, told Healio that the hospital continues to see significant strains on its overall capacity, as it has throughout the COVID-19 pandemic. The hospital has seen a “specific and dramatic” strain on its pediatric services that started in early September with a surge of children needing to be hospitalized for enterovirus and rhinovirus. “While those viruses have abated, we have been hit pretty hard by the RSV surge and have had essentially 150% occupancy of our pediatric ICU, providing ICU-level services on the floors because of necessity,” Biddinger said. According to Schaffner, in addition to the RSV surge among children, there has been a 10-fold increase in RSV deaths among adults this season. Unlike COVID-19 home rapid tests, RSV testing is less widely available, which could make the problem worse. This year’s influenza vaccine is well matched to the circulating strains, he said, and bivalent booster doses of the COVID-19 vaccines also appear effective. So, although the general public may have vaccine and COVID-19 fatigue, he said “we need to get health care providers to really make strong recommendations” for vaccinations.

For more information: https://tinyurl.com/y5ddaab2

Insomnia drug appears safe in adult, older patients with moderate to severe COPD

Nashville, TN - In a cohort of adult and older patients with moderate to severe COPD, 10 mg of lemborexant was associated with respiratory safety after single and multiple dosing, concluded data presented at CHEST Annual Meeting, as reported by Helio. This makes lemborexant (Dayvigo, Eisai), a drug approved in multiple countries for the treatment of adults with insomnia, the first dual orexin receptor antagonist to establish respiratory safety in severe COPD, according to researchers. “Lemborexant 10 mg [LEM10] was well tolerated overall, and treatment-emergent adverse events were mostly mild, and consistent with the known safety profile of lemborexant,” Jocelyn Y. Cheng, MD, senior director in clinical research, neurology, at Eisai Inc., told Healio. The multicenter, randomized, double-blind, placebo-controlled, two-period crossover study featured adult (aged 45 to < 65 years) and older (aged 65 to 90 years) patients with moderate to severe COPD and no clinically important obstructive sleep apnea. Researchers screened patients for COPD severity by spirometry performed based on Global Initiative for Obstructive Lung Disease recommendations and randomly assigned them to two 8-night treatment periods with LEM10 or placebo, with treatment periods separated by a washout of at least 14 days. In all, 30 patients (mean age, 69.2 years; 30% men) — 25 with moderate and five with severe COPD — were included, with 23.3% of patients in the adult group and 76.7% in the older group. Results indicated that during total sleep time at screening, the mean baseline peripheral oxygen saturation (SpO2) was 91.6% and apnea-hypopnea index (AHI) was 4.6. The least squares mean (LSM) difference for SpO2 was –0.43 on day 1 (single dosing), which failed to reach statistical significance, whereas the difference was 0.47 on day 8 (multiple dosing), which did reach statistical significance (P = .022) in favor of LEM10. For AHI, the LSM difference was 1.47 on day 1 and 0.24 on day 8, neither of which reached statistical significance. Researchers also noted that lemborexant was well tolerated and that treatment-emergent adverse events were mostly mild in severity and consistent with the known safety profile. “In adult and elderly subjects with moderate to severe COPD, single and multiple doses of LEM10 did not adversely affect SpO2 and AHI compared to placebo,” Cheng said. “Specifically, SpO2 was not significantly different for LEM10 vs. placebo after single dosing, and was statistically significantly different after multiple dosing, favoring LEM10, while AHI was not significantly different for LEM10 vs. placebo after single or multiple doses.” Cheng added that the data suggest that lemborexant may be a treatment option for patients with insomnia and COPD, including the older population. “Of note, this is the first dual orexin receptor antagonist to establish respiratory safety in individuals with severe COPD,” she said.

For more information: https://tinyurl.com/2ep6uf98

Researchers characterize patients who might benefit from early COPD intervention

Melbourne, Australia - Individuals with low FEV1/FVC ratio plus low FVC lifetime trajectories were at an increased risk for COPD, according to a study in The Lancet Respiratory Medicine. Patients with this mixed phenotype, as well as those with low FEV1/FVC ratio only, or the “obstructive-only” phenotype, may benefit most from early interventions for COPD, results showed. Researchers found that individuals in the mixed (37%) and obstructive-only (22%) groups had the highest incidence of COPD at age 53 years. “Interest in lifetime lung function trajectories has increased in the context of emerging evidence that COPD can arise from multiple disadvantaged lung function pathways, including those that stem from poor lung function in childhood,” N. Sabrina Idrose, MSc, PhD candidate at University of Melbourne, told Healio. “This has highlighted the opportunity to identify pre-COPD, which are people on course to develop COPD.” In a prospective cohort study, Idrose; Shyamali Dharmage, MBBS, MSc, MD, PhD; Dinh Bui, MPH, PhD; and colleagues evaluated 2,422 individuals from the Tasmanian Longitudinal Health Study who had spirometry measurements taken in childhood to middle age (7, 13, 18, 45, 50 and 53 years) to observe how FEV1/FVC ratio trajectories, FVC trajectories, and their combinations related to static lung volume and gas transfer measurements. Researchers then sought out risk factors for the different groups of spirometry patterns. Dharmage, Bui and colleagues grouped the six FEV1/FVC ratio trajectories and five FVC trajectories they found into four patterns of lifetime spirometry: obstructive-only (low FEV1/FVC ratio), restrictive-only (low FVC), mixed (low FEV1/FVC ratio and low FVC) and reference (no low FEV1/FVC ratio or low FVC). Among the patients, 25.8% had the obstructive-only trajectory, 10.5% had the restrictive-only trajectory, 3.5% had the mixed trajectory and 60.2% were in the reference category. Researchers found that individuals in the mixed (37%) and obstructive-only (22%) groups had the highest incidence of COPD at age 53 years. With the highest rates observed in the mixed group, all three subnormal patterns showed higher incidence than the reference group of childhood asthma (reference, 13% vs. obstructive-only, 24%; P < .01; restrictive-only, 20%; P < .01; mixed, 39%; P < .001), bronchitis (reference, 46% vs. obstructive-only, 54%; P < .01; restrictive-only, 53%; P < .05; mixed, 68%; P < .001) and pneumonia (reference, 12% vs. obstructive-only, 16%; restrictive-only, 17%; mixed, 19%; P < .05 for all). Patients with the mixed pattern also had higher rates of parental asthma (27% vs. 17%; P < .05) and lower rates of breastfeeding (39% vs. 44%) than the reference group. Researchers also found that individuals in the restrictive-only group struggled with lower total lung capacity and residual volume. This group also faced an increased risk for childhood underweight, “suggesting that the restrictive-only pattern might characterize individuals with poor lung development in childhood,” the researchers wrote. They also were more likely to have adult obesity, diabetes, cardiovascular conditions, hypertension and obstructive sleep apnea by age 53 years. “Our study is novel because it is the first to identify and characterize lifetime patterns of obstruction and restriction, their risk factors and their consequences,” Idrose reported to Healio recently. 

For more information: https://tinyurl.com/47jzbu46

New Canadian study shows flu vaccine can help prevent stroke

Calgary, AB - University of Calgary researchers have found a positive connection between the annual flu shot and preventing stroke reported Global News recently. The study, which is getting international attention, took a decade of health record data in Alberta and looked at the risk of stroke after getting vaccinated against influenza. “Across the study we did see a lower risk of stroke in that six-month time period post-influenza vaccination,” said study author Dr. Jessalyn Holodinsk. The latest researych builds on existing scientific knowledge of a connection between an influenza infection and stroke. “There’s a longstanding history between infections and stroke — upper respiratory tract infections are associated with stroke — so it was sort of natural to start to look at this,” Dr. Michael Hill said. “In addition, there’s a relationship between influenza and myocardial infarction – heart attacks – and so drawing the links in with stroke was a natural next step.” Hill called it a “definitive study” and anticipated another one to follow. The research was published in The Lancet Public Health, a prestigious scientific journal. Holodinsky said the quality and depth of the data set the team was looking at produced some surprising results in the connection between the flu shot and stroke prevention. season set to make major COVID-era comeback “What I was surprised by was the magnitude. I wasn’t surprised that the effect existed but I was surprised by how strong the effect was and especially that the effect existed for all adults,” she said, noting there was a protective effect regardless of existence of chronic conditions. “We all seem to benefit from this.” Hill said the connection between stroke or heart attack and upper respiratory infections like influenza or strep could also apply to COVID-19. “We know pathologically that some of the mechanisms of stroke are related to specific bacteria or viruses that will infect not only your lungs or your bronchioles, but also plaque in the carotid artery for example. So there are some mechanistic reasons to believe that preventing upper respiratory infections will also reduce your risk of ischemic events like stroke,” he said. For Holodinsky, the message from the data is clear. “What a great added bonus here too, that (the flu vaccine) might be influencing your cardiovascular risk profile as well,” she said. “I think this is great messaging for the public, especially with influenza vaccination season upon us right now, to go out and consider getting your influenza vaccination.”

Vaccine candidates for RSV ward off severe illness in older adults

Washington, DC - Prefusion F protein vaccine candidates for respiratory syncytial virus (RSV) proved safe in adults 60 and up while demonstrating an ability to thwart lower respiratory tract illness, including severe cases, a pair of large phase III trials showed. A single dose of an RSV prefusion F protein vaccine (RSVPreF3 OA) yielded a vaccine efficacy of 82.6% against lower respiratory tract illness (96.95% CI 57.9-94.1), meeting the study's primary endpoint, and vaccine efficacy landed at 94.1% against severe RSV illness (95% CI 62.4-99.9), reported Michael Ison, MD, MS, of Northwestern University Feinberg School of Medicine in Chicago, at the annual IDWeek meeting. In the second trial, a single dose of another RSV prefusion F protein vaccine (RSVPreF) showed an efficacy of 66.7% against two or more lower respiratory tract RSV symptoms (96.66% CI 28.8-85.8) and 85.7% against three or more symptoms (96.66% CI 32.0-98.7), meeting the co-primary endpoints of the study, according to Edward Walsh, MD, of the University of Rochester in New York. Currently, no vaccines exist to protect against RSV infection. According to data from the CDC, an estimated 177,000 older adults in the U.S. were hospitalized due to RSV infections in 2017 alone, and 14,000 died. "For someone that's been working in the field for a very long time, I could not be more excited about the advances we're seeing, particularly with the respiratory syncytial virus vaccines," said session moderator Kathleen Neuzil, MD, of the University of Maryland in Baltimore, introducing the anticipated trials. Participants in the trials were similar with a mean age of 68 years, about 78% were white, 37% Hispanic, 8% were Black, and 8% were Asian. Age groups again were well matched: 63% were ages 60-69 years, 32% were 70-79 years, and 6% were 80 and up. High-risk conditions included chronic cardiopulmonary conditions in 15-16%, asthma in 9%, COPD in 6%, and congestive heart failure in 2%. Additionally, 19% had diabetes and 13% had heart disease. 

For more information: https://tinyurl.com/yhhtefwy 

AstraZeneca launches new triple fixed-dose COPD therapy - Breztri Aerosphere

Mississauga, ON - AstraZeneca announced the Canadian availability of Breztri™ Aerosphere (budesonide/glycopyrronium/formoterol fumarate dihydrate), indicated for the long-term maintenance treatment to reduce exacerbations of chronic obstructive pulmonary disease (COPD) and treat airflow obstruction in patients with COPD, including chronic bronchitis and/or emphysema who are not adequately treated by a combination of an ICS/LABA or a combination of a LAMA/LABA. Preventing exacerbations is a key clinical priority, as even a single exacerbation can cause further deterioration of a patient's lung function, increase the risks of hospitalization and premature death," said Dr. Jean Bourbeau, Respirologist and Professor in the Departments of Medicine and Epidemiology & Biostatistics at McGill University. "Triple fixed-dose combination therapies, like Breztri Aerosphere, have demonstrated benefits in reducing exacerbations and mortality for eligible patients and represent an important advance in the field." About 70 per cent of exacerbations are not reported by patients to their physicians. During a severe exacerbation, symptoms like shortness of breath and increased coughing suddenly intensify, airway muscles tighten significantly and cut off air supply. This can lead to blue lips or fingers, confusion, drowsiness, extreme shortness of breath and, when not treated, death. One in four patients die within a year of a severe exacerbation. "The availability of Breztri Aerosphere in Canada marks a significant advance in care for COPD patients, and reinforces our commitment to this community," said Dr. Alex Romanovschi, Vice President, Scientific Affairs, AstraZeneca Canada. "We are proud of the potential Breztri Aerosphere has to help improve the clinical outcomes and the quality of life for people living with COPD." Health Canada's approval was based on positive results from ETHOS and KRONOS Phase III trials in moderate to very severe COPD patients. In the ETHOS trial, Breztri Aerosphere showed a statistically significant reduction in the rate of moderate or severe exacerbations compared with dual-combination therapies (glycopyrronium/formoterol fumarate) and PT009 (budesonide/formoterol fumarate) over 52 weeks. In the KRONOS trial, which included patients with no history of exacerbations in the prior 12 months, Breztri Aerosphere demonstrated a statistically significant reduction in the rate of moderate or severe exacerbation over 24 weeks vs. a dual-combination therapy (glycopyrronium/formoterol fumarate). 

For more information: Breztri News Release Oct 2022

Pfizer Initiates Phase 3 Study of mRNA-Based Influenza Vaccine

New York, NY – Pfizer Inc recently announced that the first participants have been dosed in a pivotal Phase 3 clinical trial to evaluate the efficacy, safety, tolerability and immunogenicity of the company’s quadrivalent modified RNA (modRNA) influenza vaccine candidate in approximately 25,000 healthy U.S. adults. “For years, there has been a need to better address the burden of influenza, despite the use of existing seasonal flu vaccines. Our experience with RNA viruses and mRNA technology has given us an even deeper understanding of the opportunity to potentially provide more efficacious vaccines that could further reduce the yearly rates of the severe outcomes of viral disease like flu, including hospitalization and death,” said Annaliesa Anderson, Ph.D., Senior Vice President and Chief Scientific Officer, Vaccine Research and Development, Pfizer. “We are excited to start the first Phase 3 efficacy study of an mRNA-based influenza vaccine that could potentially deliver an improved flu vaccine to help address the significant burden of this disease.” Each year, even when currently available vaccine strains match circulating influenza virus strains well, those vaccines typically confer only 40% to 60% protection, with even lower protection in years with poor matching of strains. With circulating influenza strains continually changing, predicting the best match for the next season’s vaccine is difficult for global health experts as those strains are chosen more than six months before the start of the influenza season that they target. The flexibility of mRNA technology and its rapid manufacturing could potentially allow better strain matches in future years, and in a pandemic influenza situation, mRNA technology could allow rapid, large-scale manufacturing of vaccines. mRNA-based influenza vaccines require only the genetic sequence of the virus. Influenza annually causes 140,000 to 710,000 hospitalizations, 12,000 to 52,000 deaths and about $25 billion in economic loss in the U.S. The impact of flu on racial and ethnic minority groups in the U.S. is even larger. Black Americans are 1.8 times more likely than their white counterparts to be hospitalized for flu while Latino and Indigenous Americans are 1.2 and 1.3 times more likely, respectively. Although vaccination remains one of the best ways to help prevent infection and serious illness, racial and ethnic minority communities in the U.S. continue to be vaccinated at lower rates, and clinical trial enrollment for new or improved vaccines tend to lack diversity. Pfizer made a public commitment to help reduce health disparities through its clinical trials and ensure that Pfizer’s clinical study populations fully represent the racial and ethnic diversity of the countries where trials are conducted. 

For more information: https://tinyurl.com/4zhk6pb3

Dietary flavonoids may mitigate some risk for smoking-related COPD

Perth, Australia - Higher intake of dietary flavonoids may mitigate some risk for COPD in current and former smokers, according to a study published in European Respiratory Journal. “Fruit and vegetables, as well as tea, cocoa and other plant-based foods and beverages, are dietary sources of flavonoids, which are bioactive compounds that reduce oxidative stress and systemic inflammation,” Nicola P. Bondonna, PhD, a post-doctoral research fellow at the School of Medical Health Sciences at Edith Cowan University in Perth, Australia, and colleagues wrote. “... Although epidemiological studies investigating the association between flavonoid intakes specifically and COPD are missing, there is some evidence that flavonoid intakes are favorably associated with pulmonary function parameters and less age-related decline in lung function.” The prospective cohort study included 55,413 participants in Denmark without COPD aged 50 to 65 years at baseline (mean age, 56 years; 47.6% men). Flavonoid intakes were estimated using a food frequency questionnaire. Daily median flavonoid intake was 496 mg. During a median follow-up of 21 years, 5,557 participants were diagnosed with COPD, of whom 4,013 were current smokers, 1,062 were former smokers and 482 were never smokers. Participants with the highest total flavonoid intakes had a 20% lower risk for COPD compared with participants with the lowest intakes in multivariable analyses (HR = 0.8; 95% CI, 0.74-0.87). In addition, in each flavonoid subclass, researchers identified a 6% to 22% lower risk for COPD. The researchers reported that the inverse association between flavonoid intake and risk for COPD remained among men and women, but only among current smokers (HR = 0.77; 95% CI, 0.7-0.84) and former smokers (HR = 0.82; 95% CI, 0.69-0.97), not never smokers. In addition, higher flavonoid intakes appear to have lessened the higher risk for COPD associated with smoking intensity, according to the researchers. “While the findings of this study suggest an importance of dietary flavonoids in partially mitigating the risk of COPD in people who smoke, both current and former smokers remained at a substantially higher risk of COPD than non-smokers, indicating that dietary modifications should be secondary to smoking cessation,” the researchers wrote. 

For more information: https://tinyurl.com/fxp82wzn

Global COPD prevalence, deaths and disability-adjusted life-years declined in recent years

London, UK - COPD prevalence, death and disability-adjusted life-year rates around the world were lower in 2019 than in 1990, researchers reported in The BMJ. Researchers conducted a systematic analysis of data from the Global Burden of Disease Study 2019 for 204 countries and territories between 1990 and 2019. Researchers assessed data on the prevalence, deaths and disability-adjusted life-years (DALYs) of COPD and possible attributable risk factors. Data were derived from Safiri S, et al. BMJ. 2022;doi:10.1136/bmj-2021-069679. Of the 212.3 million prevalent COPD cases reported globally in 2019, COPD accounted for 3.3 million deaths and 74.4 million DALYs. The global age-standardized point prevalence for COPD was 2,638.2 per 100,000 population, death rate was 42.5 and DALY rate was 926.1. These rates were 8.7%, 41.7% and 39.8% lower than those reported in 1990, respectively. In 2019, the highest age-standardized point prevalence for COPD was in Denmark (4,299.5 per 100,000 population), followed by Myanmar (3,963.7 per 100,000 population) and Belgium (3,927.7 per 100,000 population). Egypt, Georgia and Nicaragua had the largest increases in age-standardized point prevalence for COPD from 1990 to 2019, at 62%, 54.9% and 51.6%, respectively. In 2019, Nepal had the highest age-standardized death rate (182.5 per 100,000 population) and Japan had the lowest death rate (7.4 per 100,000 population). In 2019, Nepal had the highest age-standardized DALY rate (3,318.4 per 100,000 population) and Barbados had the lowest DALY rate (177.7 per 100,000 population). Global DALYs for COPD increased up to age 85 to 89 years before decreasing with advancing age among men. However, this rate increased up to the oldest age group of 95 years or older in women. Researchers also noted an overall reversed V-shaped association regionally between socio demographic index and the rate of age-standardized DALYs for COPD. In addition, researchers found that smoking (46%), pollution from ambient particulate matter (20.7%) and occupational exposure to particulate matter, gases and fumes (15.6%) were the greatest contributors to the rates of DALYs for COPD. “Although the point prevalence, death and DALY rates declined during the study period, the corresponding counts are increasing. With an aging population, COPD will continue to become an even greater problem in the future,” Saeid Safiri, PhD, assistant professor in the department of community medicine, the department of epidemiology and biostatistics and the Tuberculosis and Lung Disease Research Centre at Tabriz University of Medical Sciences, Iran, and colleagues wrote. “The reported global, regional and national burden of COPD, and its risk factors, could help to provide a more accurate projection of the future disease burden. This knowledge could guide policymakers in planning control measures and supply services to meet the rising health care demands that COPD and its comorbidities will create.”

For more information: https://tinyurl.com/3tm2auce

Neighborhood environmental factors influence physical activity in people with COPD

Barcelona, Spain - Population density, pedestrian street length and slope and nitrogen dioxide exposure were all associated with physical activity levels and exercise capacity of patients with COPD living in highly populated areas, researchers reported. “The ecological model of the determinants of physical activity suggests a major role for factors in the ‘environmental’ domain. In line with this notion, a range of studies have reported that environmental factors such as residential density or land-use mix, noise or noise annoyance and air pollution are associated with physical activity in the general population,” Maria Koreny, MSc, PhD, from the Barcelona Institute for Global Health, Spain, and colleagues wrote in Environmental Research. “Thus, it is likely that such environmental factors can influence the physical activity of COPD patients also.” Researchers assessed 404 patients with mild to very severe COPD (mean age, 69 years; 85% men) from a multi-city study conducted in the Catalonia region of Spain. Measurements included objective physical activity, physical activity experience and exercise capacity. Researchers estimated individual population density, pedestrian street length, slope of the terrain and annual road traffic noise exposure, nitrogen dioxide exposure and particulate matter exposure. Participants walked a mean 7,524 steps per day during the study pe riod. Higher population density was associated with 507 fewer steps, 2 hours per day more sedentary time and worse exercise capacity (–13 m per interquartile range) in multi-exposure models, according to data. Researchers reported 156 more steps and –0.1 hours per day less sedentary time were linked to pedestrian street length and better exercise capacity (15 m per interquartile range) was linked to steeper slope. Higher exposure to nitrogen dioxide was associated with higher sedentary time of 0.2 hours per day and more difficulty in physical activity. However, particulate matter and noise were not associated with physical activity or exercise capacity in this patient population, the researchers wrote. “These neighborhood environmental factors should be considered in clinical contacts with patients and when developing urban and transport planning policies that aim to promote physical activity in patients with chronic diseases,” they wrote. 

For more information: https://tinyurl.com/5yc6ne2c

Barcelona, Spain - A Danish feasibility study that tested a high-dose quadrivalent influenza vaccine versus a standard dose hinted at morbidity and mortality benefits, researchers reported. In the DANFLU-1 study, there was a 48.9% reduction in the risk of all-cause mortality and a 64% reduction in the incidence of hospitalization for influenza or pneumonia for high-dose versus standard-dose vaccination. Also, hospitalization for cardiorespiratory complaints -- a combination of any cardiovascular or respiratory illnesses -- was reduced by 12% with the high-dose vaccine, according to Tor Biering-Sørensen, MD, PhD, MPH, of the University of Copenhagen. Less than 1% of patients in both trial arms died in the 14 days after being vaccinated against influenza, and there were no significant differences in serious adverse events between the high-dose and standard-dose groups, he reported in a presentation at the European Society of Cardiology (ESC) meeting. However, Biering-Sørensen emphasized that "this is just a hypothesis-generating finding because this was just a pilot trial that was not powered for outcomes." The open-label DANFLU-1 enrolled about 12,000 patients (median age 71.7; 47.1% women), and a study with a larger patient population is needed to support the results, he added. "That study is now being planned," Biering-Sørensen said. "We know that to have a definitive result we will have to enroll 208,000 Danish citizens to have sufficient power to assess whether the high-dose vaccine will reduce outcomes for pneumonia or influenza, and also to see if the high dose will reduce the risk of cardiovascular outcomes." High-dose vaccines contain 60 μg of hemagglutinin antigen for each strain, while standard-dose vaccines contain 15 μg, and "high-dose vaccines are approved for adults aged 65 years and older in most countries, and for those 60 years and older in some countries," he explained in an ESC press release. " However, only a few countries offer older adults a high-dose vaccine by default. Thus, high-dose vaccines are not widely implemented despite accumulating evidence of additional protection against influenza infection and influenza-related morbidity compared with standard-dose vaccines." Biering-Sørensen noted that he would use the high dose for his patients now because "we already know that the high dose protects at least 25% greater than the standard dose against influenza. We know that the high dose can prevent against the influenza, but we cannot yet say that the high dose prevents hospitalization." Amit Khera, MD, a spokesperson for the American Heart Association, said that "in the United States, the high dose is generally recommended for the elderly because there is a better immune response." Previous research has that the flu vaccine was tied to a lower risk of fatal and nonfatal cardiovascular events within a year. Khera is at the University of Texas Southwestern Medical School in Dallas. He reiterated that the DANFLU-1 "was underpowered to show which dose prevented outcomes." Also, patients in the trial were "all-comers" over age 65, "but not necessarily those with cardiovascular disease." Khera, who was not involved in the study, said that he offered high-dose influenza vaccine to his elderly patients, and that the current trial "does remind us that vaccine is feasible, it is safe, and whether the high dose or low dose is the right dose, it doesn't take away the necessity to vaccinate our vulnerable patients." The trial was integrated into the Danish vaccination program, with only one study visit at the time of vaccination, and registry-based follow-up occurring after.

For more information: https://tinyurl.com/44kcx5ar

The link between environmental toxins and cognitive disorders

Bundoora, VIC, Australia – The term environmental toxins may conjure up images of nuclear plants and other industrial machinery that may seem irrelevant a lung patients’ day-to-day lives. However, humans often come into contact with environmental toxins through cars, cigarettes, or certain makeup items, among other products. Emerging research suggests that some toxins may lead to cognitive impairments and the development of brain health issues among patients. Patients should be aware of what they consume or come into contact with that may pose dangerous risks. The negative effects of cigarette smoke on the lungs and pulmonary function is common knowledge. But brain health is also at stake when patients are exposed to cigarette smoke and e-cigarette vapor. According to a study published by Frontiers in Molecular Neuroscience, cigarette smoke exposure has a direct influence on memory retention. Researchers came to this finding by testing mice for working and spatial memory retention with the use of objects. Results showed that the mice that were exposed to cigarette smoke couldn't discern between known and novel objects throughout the retention phase. Mice that didn’t undergo cigarette smoke exposure, on the other hand, could successfully tell the difference. Along with memory retention issues, mice that were exposed to cigarette smoke also showed signs of a compromised hippocampus characterized by “changes in astrocyte density as well as a reduction in synaptophysin and dendritic spines,” according to the authors. A study published by Brain, Behavior, and Immunity described the cognitive changes in mice that were exposed to tobacco-flavored e-vapor from nicotine-containing (18 mg/L) or nicotine-free (0 mg/L) e-fluids. All mice were exposed twice a day over the course of 6 weeks. Researchers found that exposure to e-vapor led to significant impairments in short-term memory function independent of diet and the presence of nicotine. The mice also experienced systemic inflammation. Further research is needed to establish concrete conclusions about e-vaping and cognitive dysfunction in humans. For now, animal studies suggest a strong connection between the two. In addition to cigarette smoking and vaping, exposure to heavy metals may also prove dangerous to brain health—especially to patients with autism spectrum disorder (ASD). An article published by Neuroscience and Biobehavioral Reviews states that children with ASD have a harder time eliminating toxic metals, including aluminum, lead, and cadmium, among others.  Because of this, they tend to accumulate higher concentrations of the metals they’re exposed to. 

For more information: https://tinyurl.com/37rabr7

Flu Shots Tied to Lower Stroke Risk

Madrid, Spain - Annual flu shots were tied to lower ischemic stroke risk, a case-control study in Spain showed. Older adults who received an influenza vaccine were 12% less likely to have an ischemic stroke versus people who weren't vaccinated (adjusted OR 0.88, 95% CI 0.84-0.92), according to Francisco Jose de Abajo, MD, MPH, PhD, of the University of Alcalá in Madrid, and colleagues. Stroke risk reduction  appeared early (15-30 days: adjusted OR 0.79, 95% CI 0.69-0.92) and declined slightly over time (over 150 days: adjusted OR 0.92, 95% CI 0.87-0.98), the researchers reported in Neurology. "Studies have shown that getting the flu increases your risk of having a stroke, but research is still being collected on whether getting the flu vaccine can help protect against a stroke," de Abajo said in a statement. "This observational study suggests that those who have a flu shot have a lower risk of stroke," he added. "To determine whether this is due to a protective effect of the vaccine itself or to other factors, more research is needed." Seasonal influenza may transiently increase the risk of vascular events, noted Dixon Yang, MD, and Mitchell Elkind, MD, both of Columbia University in New York City, in an accompanying editorial. "Acute systemic inflammation may drive this relationship, possibly through endothelial dysfunction, atherosclerotic plaque instability, and a pro-coagulant state," Yang and Elkind wrote. "It therefore stands to reason that influenza vaccination may diminish the associated stroke risk, but the evidence has been mixed." "In two meta-analyses of observational studies, individuals who received the influenza vaccine were less likely to have a stroke, but the included studies were heterogenous, relatively small, and potentially limited by biases," they observed. de Abajo and colleagues compared 14,322 people in a Spanish primary care database who had a first stroke and no cancer history from January 2002 through December 2015 with 71,610 age- and sex-matched controls. Overall, 9,542 incident strokes were non-cardioembolic and 4,780 were cardioembolic. Patients were considered vaccinated if they had a recorded flu shot at least 14 days before their index stroke in the same flu season. Vaccinated participants had a mean age of 78.8, and unvaccinated participants had a mean age of 71.8. Overall, 41.4% of stroke patients and 40.5% of controls were vaccinated (unadjusted OR 1.05, 95% CI 1.01-1.10). Vaccinated people had a higher prevalence of vascular risk factors, diseases, and co-medication than non-vaccinated people. After accounting for confounding variables, reduced risks were seen for both non-cardioembolic (adjusted OR 0.88, 95% CI 0.83-0.93) and cardioembolic (adjusted OR 0.90, 95% CI 0.83-0.98) ischemic strokes. "The reduced risk of ischemic stroke associated with influenza vaccination remained statistically significant in both age categories examined (younger than 65 years and equal to or older than 65 years), in both men and women, and in patients with vascular risk factors or established vascular disease, but not in patients without vascular risk factors," de Abajo and co-authors wrote. Pneumococcal vaccination, used as a negative control in the study, was not linked with reduced stroke risk. The findings provide evidence that older individuals with medical comorbidities may have a moderately reduced risk of ischemic stroke after a flu shot, the editorialists noted. "Takeaways from this study may also be applicable to vaccines against other infections, if not pneumococcus," they wrote. "In particular, a timely consideration would be vaccination against SARS-CoV-2, which has been shown to cause inflammation-mediated thrombosis," Yang and Elkind added.  The study had several limitations, the researchers acknowledged. Unmeasured confounders may have influenced results. It's also possible the index date may not have corresponded with stroke onset but the date the stroke was recorded in primary care records. "To accommodate for such potential mismatch between the two dates, we performed a sensitivity analysis looking at vaccinations performed beyond 30 days before the index date and the main results did not materially change," de Abajo and colleagues noted.

For more information: https://tinyurl.com/55y94pk4

COPD World News - Week of September 4, 2022

Symptom burden in patients with COPD continues over time

Drammen, Norway - High symptom burden patterns in patients with COPD are consistent over time and individual symptom experiences should be the main focus in treatment among these patients, researchers concluded in Respiratory Medicine Journal. “Subgroups of patients with specific symptom experience patterns have been associated with defined clinical characteristics and lower health-related quality of life,” Vivi L. Christensen, MD, from the department of nursing and health sciences at the University of South-Eastern Norway, Drammen, Norway, and colleagues wrote. “Identifying such subgroups may indicate possible treatment opportunities.” Researchers reported results of a follow-up study of 267 adults with moderate, severe and very severe COPD in Norway. Using the Memorial Symptom Assessment Scale (MSAS), researchers identified three subgroups based on patients’ symptoms at baseline: low (n = 28), intermediate (n = 112) and high (n = 127). Researchers evaluated transitions between these subgroups at 3, 6, 9 and 12 months and differences in symptom scores and health-related quality of life. After 12 months, 64.7% of patients with COPD remained in the high symptom burden class and 81.8% had low symptom burden. At 12 months, pairwise comparisons for respiratory function measurements were not significantly different between the groups, according to the results. Patients with high symptom burden were more likely to be female (66.2% vs. 43.3% and 46%), have more comorbidities (3.3 vs. 1.3 and 2), reported a higher number of symptoms at all time points as measured by the MSAS (19.15 vs. 4.92 and 10.46) and have worse health-related quality of life scores (1.29 vs. 0.29 and 0.67) compared with patients in the low and intermediate symptom burden groups. The most commonly reported symptom at 12 months was shortness of breath (probability: 1.000 in high group, 0.964 in intermediate group; 0.742 in low group). The second most commonly reported symptom was lack of energy among patients with intermediate and high symptom burden (probability: 0.929 and 0.984, respectively). “The reclassification rates along with the MSAS and [St. George’s Respiratory Questionnaire] scores as well as the patient characteristics in the current study, provide meaningful information about the stability in COPD patients’ symptom experience and underlines the importance of a broad and individualized symptom assessment,” the researchers wrote. “Our findings suggest that the symptom burden in COPD patients continues over time.”

For more information: https://tinyurl.com/5aweeybj

Emphysema often present before abnormal spirometry, particularly in Black men

Chicago, IL - Emphysema is often present before spirometry findings become abnormal, with disproportionate rates seen in Black men, according to new findings published in Annals of Internal Medicine. “According to this observational study of Black and white adults in the United States, a substantial proportion of middle-aged adults with ‘normal’ spirometry findings based on race-specific equations have emphysema on CT. This is disproportionately seen among Black men,” Gabrielle Y. Liu, MD, internist in the division of pulmonary and critical care medicine at Northwestern University Feinberg School of Medicine, and colleagues wrote. “This is also true when race-neutral equations are used to determine FEV1 percent predicted; however, the use of race-neutral measures attenuates the racial disparity in emphysema prevalence among those with an FEV1 between 80% and 120% of predicted. The increased rates of emphysema among Black men persist after further adjustment for age and smoking. ”Data were derived from Liu GY, et al. Ann Intern Med. 2022;doi:10.7326/M22-020.The observational study focused on clinical and spirometry data from the CARDIA study in 2015-2016 and CT scans conducted in 2010-2011 among 2,674 participants. The primary outcome was emphysema prevalence among participants with various normal  spirometry measures, including an FEV1/FVC ratio of 0.7 or greater or at least the lower limit of normal and an FEV1 between 80% and 99% or between 100% and 120% of predicted. The cohort comprised 485 Black men, 762 Black women, 659 white men and 768 white women. Among those with a race-specific FEV1 between 80% and 99% of predicted, 6.5% had emphysema. In those with FEV1 between 80% and 99% of predicted, compared with white men, emphysema prevalence was 3.9-fold higher among Black men and 1.9-fold higher among Black women compared with white women. Among those with a race-specific FEV1 between 100% and 120% of predicted, the prevalence of emphysema was 4%. Among these participants, emphysema prevalence was 6.4-fold higher among Black men compared with white men, but Black and white women had similar prevalence of 2.6% and 2%, respectively. Researchers reported attenuation of racial differences in emphysema prevalence among men and elimination of racial differences among women with the use of race-neutral equations to identify those with an FEV1 percent predicted between 80% and 120%. “These findings magnify the need to reconsider the use of race-specific spirometry reference equations in favor of race-neutral equations,” the researchers wrote. “We conclude that visual emphysema should be included in definitions of ‘early COPD’ and CT imaging should be incorporated into the evaluation of those with suspected impaired respiratory health and normal spirometry findings.” 

For more information: https://tinyurl.com/yvu9hvtm

COPD World News - Week of August 21, 2022

London, UK - Imperial researchers have built a new easy-to-use test that could diagnose non-infectious diseases like heart attacks and cancers more quickly. The new test works by detecting molecular signals in the body called biomarkers, which are already used in things like COVID-19 testing where the presence of SARS-CoV-2 genes indicates COVID-19. There are also biomarkers for non-infectious diseases: for example, prostate specific antigen (PSA) in the blood can sometimes act as a biomarker to indicate the presence of prostate cancer. Diagnostic tests based on RNA or DNA often require controlled temperatures and involve multiple steps. The new test can be used at room temperature in a user-friendly process.The researchers hope this could enable quicker and easier diagnostics in settings like GP surgeries, as well as in resource-limited clinics in developing countries. The new test, called CrisprZyme, has been developed by a team of researchers led by Imperial College London, MIT, and Max Delbrück Center for Molecular Medicine in Berlin. They say the test could boost access to biomarker diagnostics. The results of preliminary lab studies of the test are published today in Nature Nanotechnology. Author Dr. Marta Broto, of Imperial's Department of Materials, said: "As well as potentially boosting access to diagnostics in developing countries, this technology could bring us a step closer to personalized diagnostics at home or at the GP surgery. By making clinical diagnostic tests simpler, we will be able to provide clinicians with the right tools to test at the same GP surgery instead of having to reschedule for follow-up analyses and blood tests." CrisprZyme builds on CRISPR diagnostic tests, which use RNA—the messenger that helps create proteins—to detect biomarkers in biological fluids like blood or urine. In their current form, these tests detect RNA and then amplify this RNA by creating many copies so that the signal is easier to read. However, these amplifying technologies must be temperature controlled to work, which requires expensive equipment. Additionally, although they tell medics whether an infectious disease is present, they cannot provide information about how much biomarker is present, which is important for monitoring non-infectious diseases like heart diseases and cancer.

For more information:https://tinyurl.com/2ybzdrzx

Smoking quit attempts declined during COVID-19 pandemic

Rochester, NY - Among U.S. adults, there was an immediate decrease in smoking-cessation activities during the COVID-19 pandemic, according to new data published in JAMA Network Open. “This cross-sectional study found that, starting in 2020 quarter 2, the prevalence of past-year quit attempts among U.S. adults decreased to its lowest level since 2011,” Priti Bandi, PhD, principal scientist in surveillance and health equity science at the American Cancer Society, and colleagues wrote. “Simultaneously, observed nicotine replacement therapy retail sales across 31 U.S. states decreased by a mean of 1% to 13% vs. expected sales. These findings suggest an immediate decrease in serious quitting activity among U.S. smokers after the COVID-19 pandemic onset, a decrease that persisted throughout 2020.” This cross-sectional study used data from 2011 to 2020 from 788,008 individuals (55.7% men) who reported smoking in the past year who participated in the Behavioral Risk Factor Surveillance System survey. Researchers utilized retail sales data from 2017 to July 2021 for 1,004 unique nicotine replacement therapy universal product codes in 31 states in the U.S. The main outcomes were changes in annual self-reported prevalence of past-year quit attempts, recent successful smoking cessation before (2011-2019) and during (2020) the COVID-19 pandemic, and sales volume changes in nicotine gum, lozenge and patch brands for 1,271 4-week sales periods from 2017 to February 2020 and for 558 4-week sales periods from March 2020 to July 2021 of the COVID-19 pandemic. The prevalence of annual past-year quit attempts decreased from 65.2% in 2019 to 63.2% in 2020. The largest smoking-cessation activity decreases were reported in individuals aged 45 to 64 years (61.4% vs. 57.7%), individuals with two or more comorbidities (67.1% vs. 63%) and Black individuals (72.5% vs. 68.4%). From 2019 to 2020, recent successful smoking cessation remained unchanged, according to the researchers. During the pre-pandemic period from 2011 to 2019, 4-week nicotine replacement therapy sales volume was 105.6 million for nicotine gum pieces, 51.9 million for lozenges and 2 million for nicotine patches. During the pandemic in 2020, 4-week nicotine replacement therapy sales were lower at 1.2% for nicotine gum, 13% for lozenges and 6.4% for nicotine patches. “These results, when taken together with reports of increased cigarette sales during the pandemic, suggest the urgent need to reengage smokers in evidence-based quitting strategies, especially among individuals experiencing disproportionately negative outcomes during the pandemic,” the researchers wrote.

Cigarette smoking disproportionately affects women who have smaller airways

Birmingham, Alabama - Smaller airways in women may explain their worse respiratory outcomes in chronic obstructive pulmonary disease (COPD), a large cohort study suggested. For never-smokers and ever-smokers alike, CT imaging revealed that men had thicker airway walls than women, who also had smaller airway lumen dimensions after accounting for height and total lung capacity. "It is plausible that the increased airway wall thickness associated with cigarette smoking disproportionately affects women who have smaller airways," wrote study authors led by Surya Bhatt, MD, from the University of Alabama at Birmingham, in Radiology. As for outcomes, a unit change in either segmental airway wall area percentage or segmental lumen diameter was associated with particularly worse forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) ratios, more dyspnea, poorer respiratory quality of life, lower 6-minute walk distance, and worse survival in women compared with men (all P<0.01). "When airways narrow due to cigarette smoking, the impact on symptoms and survival is greater in women than in men," Bhatt explained in a press release. Historically, COPD has been more frequent in men, but changing factors in smoking behavior and urbanization have resulted in its prevalence becoming more similar between the sexes, according to the investigators. Meanwhile, they noted that women experience worse COPD symptoms for a given degree of airflow obstruction. Age-adjusted rates of COPD-related deaths are on the decline in men, but not in women, who tend to have greater airflow obstruction and faster lung function decline after adjustment for smoking burden. "The assumption that women have smaller airways is long standing and is on the basis of comparisons of the trachea and main stem bronchi, but few studies have compared distal airways in healthy individuals or accounted for differences in lung size," Bhatt and colleagues wrote. "The prevalence of COPD in women is fast approaching that seen in men, and airway disease may underlie some of the high COPD numbers in women that we are seeing," Bhatt said in the press release. He and his group had performed a secondary analysis of the Genetic Epidemiology of Chronic Obstructive Pulmonary Disease study. This was a multicenter, observational cohort study that had never, current, and former smokers enrolled from January 2008 to June 2011 and followed until November 2020. Participants were 420 lifetime non-smokers (mean age 60 years, 57% women, 81% non-Hispanic white) and 9,363 ever-smokers (mean age 60 years, 46% women, and 67% non-Hispanic white).

For more information https://tinyurl.com/yjf4rvys

More evidence: Smoking raises risk of bone fractures—another reason to quit

Initiating single-inhaler triple therapy for COPD improved persistence, outcomes vs. multiple inhalers

Madrid, Spain - Initiating single-inhaler triple therapy for COPD, compared with multiple-inhaler triple therapy, resulted in improved persistence, which led to reductions in mortality, exacerbations and health care resource use in patients with COPD. “Single (or fixed-dose) combination inhalers offer advantages to COPD patients by simplifying complex inhaler regimens, and single inhaler delivery of dual or triple therapy in COPD improves adherence and persistence compared with delivery using multiple inhalers,” Bernardino Alcázar-Navarrete, MD, from the pulmonology unit at the Virgen de las Nieves University Hospital, Granada, and CIBERES at the Carlos III Health Institute, Madrid, and colleagues wrote in Chest. “However, there is little evidence regarding the effectiveness of single-inhaler triple therapy vs. multiple-inhaler triple therapy in terms of exacerbation prevention and patient persistence, as well as economic impact.” Researchers conducted a real-world, observational, retrospective cohort study and evaluated electronic health records to identify 4,625 patients with COPD aged 40 years and older who initiated single-inhaler triple therapy (n = 1,011; mean age, 71.2 years; 73.4% men) or multiple-inhaler triple therapy (n = 3,614; mean age, 70.9 years; 74% men) from June 2018 to December 2019. Researchers assessed comparative data on persistence, COPD exacerbation rates and health care resource utilization and costs during 12 months of follow-up. Sixty-two percent of patients had moderate airflow limitation and 26.5% of patients had severe airflow limitation. At 12-month follow-up, compared with patients who initiated multiple-inhaler triple therapy, those who initiated single-inhaler triple therapy had higher persistence (HR = 1.37; 95% CI, 1.22-1.53; P < .001), reduced COPD exacerbations (HR = 0.68; 95% CI, 0.61-0.77; P = .001) and reduced risk for all-cause mortality (HR = 0.67; 95% CI, 0.63-0.71; P = .027). In addition, initiation of single-inhaler triple therapy was associated with significantly reduced health care resource utilization, with a mean annual cost savings of 408 euros compared with multiple-inhaler triple therapy. The researchers reported persistence was associated with improved COPD exacerbation rates compared with non persistence and substantial adjusted mean annual cost savings for both single- and multiple-inhaler triple therapy initiation.

For more information: https://tinyurl.com/4b8zkdwv

Fourth-generation vaping devices increase risk to immune cells

Chapel Hill, NC - Not all electronic cigarette devices are created equal. Some fourth-generation models—such as Juul devices—are associated with unique changes in markers of immune responses inside our airways, according to a new paper from UNC School of Medicine researchers led by toxicologist Ilona Jaspers, Ph.D., director of the UNC Center for Environmental Medicine, Asthma, and Lung Biology and director of the UNC Curriculum in Toxicology and Environmental Medicine. Lead author Elise Hickman, Ph.D., a recent graduate from Jaspers' lab, and colleagues, who published their research in the American Journal of Respiratory and Critical Care Medicine, found that users of fourth-generation nicotine-salt-containing devices display a unique mix of cellular biomarkers indicative of immune suppression. "Our work demonstrates the importance of considering device type in future clinical, epidemiological, and mechanistic studies on the health effects of e-cigarettes," said Jaspers, professor of pediatrics and microbiology and immunology. "We also think this research can help regulators determine which products cause the most severe types of biological changes in airway cells important for maintaining proper health." Electronic cigarettes have increased in popularity over the past decade. Some people began using them as a means to quit smoking, thinking vaping was a safer alternative, both in the short-term and long-term. Also, because electronic cigarettes lack tar, consumers assumed vaping decreased their risk of cancer down the road. "It's impossible to know if vaping decreases cancer risk or many other long-term conditions," Jaspers said. "It took 60 years of research to show that smoking causes cancer." E-cigarettes have been around for about 15 years. "Still, the research from our lab and many others has shown many of the same acute biological effects in the airways that we have documented in smokers," she said. "And we've seen some changes to cells and immune defenses in people who vape that, frankly, we've never seen before, which is very concerning." Most concerning to researchers, doctors, and public health officials is the fact that teenagers who would not have otherwise tried cigarettes began using e-cigarettes, which contain nicotine—a drug with its own health implications even beyond addiction—and thousands of chemicals, many of which the FDA approved for eating but not inhaling. This research does not reveal evidence that e-cigarettes cause cancer, emphysema, COPD, or other long-term diseases associated with long-term cigarette smoking. But researchers think that altering immune responses in the respiratory tract over the course of many years, especially for teens, could play a major role in the development of long-term health conditions and in susceptibility to inhaled pathogens.

 For more information: https://tinyurl.com/8cdjjdd6

BioNTech, Pfizer to start testing universal vaccine for coronaviruses

Mainz, Germany- Germany's BioNTech, Pfizer's partner in COVID-19 vaccines, said the two companies would start tests on humans of next-generation shots that protect against a wide variety of coronaviruses in the second half of the year. Their experimental work on shots that go beyond the current approach include T-cell-enhancing shots, designed to primarily protect against severe disease if the virus becomes more dangerous, and pan-coronavirus shots that protect against the broader family of viruses and its mutations. In presentation slides posted on BioNTech's website for its investor day, the German biotech firm said its aim was to "provide durable variant protection". The two partners, makers of the Western world's most widely used COVID-19 shot, are currently discussing with regulators enhanced versions of their established shot to better protect against the Omicron variant and its sublineages. The virus' persistent mutation into new variants that more easily evade vaccine protection, as well as waning human immune memory, have added urgency to the search by companies, governments and health bodies for more reliable tools of protection. As part of a push to further boost its infectious disease business, BioNTech said it was independently working on precision antibiotics that kill superbugs that have grown resistant to currently available anti-infectives. BioNTech, which did not say when trials could begin, is leaning on the technology of PhagoMed, which it acquired in October last year. The Vienna-based antibiotics developer has done work on enzymes, made by bacteria-killing viruses, that break through the bacterial cell wall. Drug-resistant infections are on the rise, driven by antibiotic overuse and leaks into the environment in antibiotics production. Public health researchers put the combined number of people dying per year from antibiotic-resistant infections in the United States and the European Union at close to 70,000. 

For more information: https://tinyurl.com/yn57dfrv

Health-care workers call for government help as burnout worsens and staff shortages increase

Ottawa, ON - Health-care workers and health sector organizations say the high rate of burnout and staff shortages in hospitals across the country has become "endemic" — and they're calling on the federal government to sit down with provinces and territories to find solutions. The number of job vacancies among health-care practitioners — mostly in hospitals — increased almost 92 per cent in the September to December 2021 period compared to the same period pre-pandemic in 2019, Statistics Canada data show. Paul-Émile Cloutier is CEO of HealthCareCAN, an organization that represents health organizations and hospitals. He said the situation is getting worse and leading to longer wait times and surgery delays. 'The system is bleeding people at all levels and it's not just the [intensive care unit] or the emergency, it's across the board," said Cloutier. "It's like sleepwalking into a catastrophe." Cloutier said there are 13 different health-care systems in provinces and territories across the country and no central body collecting and analyzing data. His organization wants to see a new nationwide body that can deal with capacity issues and address the problem of vacancies caused by burnout.  Dr. Katharine Smart, president of the Canadian Medical Association, told CBC Power & Politics guest host David Cochrane on Friday that she met recently with Health Minister Jean-Yves Duclos to discuss the issues facing Canada's health-care system. "I think what we need is federal leadership to really recognize these challenges that we're seeing across the health-care system aren't unique to one province or territory," she said. "We need that leadership to really define what are the key elements where we need action, and we need the funding to go solve some of those problems."12 days agoDuration8:47 Duclos announced in March that the federal government would give $2 billion to the provinces and territories to help clear the health-care backlog created by the years-long pandemic crisis. Health Canada spokesperson Anne Génier said the government is taking other steps to reduce health system backlogs and address workforce burnout. In a statement issued to CBC News, she pointed to a $140-million commitment in the federal budget to support the Wellness Together Canada online portal. The portal provides free and confidential mental health and substance abuse tools and services to frontline workers and makes legislative changes meant to keep workplaces free from threats, violence and harassment.  "A safe working environment is critical to support the retention of health-care workers," Génier said in the statement. Génier noted that the budget also provides $115 million over five years, and $30 million each year thereafter, to expand a program that recognizes foreign health-care credentials and enables health-care professionals from abroad to work in Canada. Millions of dollars more were earmarked to address the supply and retention of health-care workers in rural and remote Canadian communities, she said. But Cloutier and Smart both said Ottawa must do more. 

For more information: https://tinyurl.com/yckmykx2

Non-respiratory symptom dominance linked with depression in patients with COPD

Seoul, SK - In a new study, a non-respiratory symptom-dominant elevation in the COPD assessment test total score was associated with depression in adults with COPD, researchers reported in Respiratory Medicine. The researchers aimed to evaluate characteristics of the COPD assessment test to determine whether non-respiratory symptom-dominant status is linked with depression status in patients with COPD. They noted that “there is no established method to distinguish patients whose [COPD assessment test] scores are high because of their depressive symptoms from patients whose [COPD assessment test] scores are high because they have severe respiratory symptoms caused by COPD. The researchers analyzed data from 226 patients in the KYOTO cohort (mean age, 71.6 years; 93.8% men) in Japan and 924 patients in the Korea COPD Subgroup Study (KOCOSS) cohort (mean age, 69.2 years; 98.1% men). Nearly one-quarter (23.5%) of patients in the KYOTO cohort and 11.2% in the KOCOSS cohort had a depression diagnosis (Patient Health Questionnaire-9 score 5 or Beck Depression Inventory-II score 17, respectively). Non-respiratory symptom dominance was observed among 24.3% of patients in the KYOTO cohort and 26.9% of patients in the KOCOSS cohort. Patients in both cohorts had a significantly higher prevalence of depression compared with patients with respiratory symptom dominance, according to the researchers. Researchers reported that both the COPD assessment test score and non-respiratory symptom dominance were significantly associated with depression in both cohorts. In addition, symptomatic patients with a COPD assessment test score of 10 or more also experienced preserved and significant associations, the researchers wrote. “Patients with COPD and depression had a higher sum score for the last 4 items (Q5-Q8; Q5678, non-respiratory symptoms) than they did for the first four items (Q1-Q4; Q1234, respiratory symptoms). This ‘non-respiratory symptom-dominant’ status, Q1234 Q5678, could be a significant suspicious feature for depression in patients with COPD,” Yoko Hamakawa, MD, from the department of respiratory medicine at the Graduate School of Medicine at Kyoto University, Japan, and colleagues wrote. The researchers noted that screening tools that are easy to administer are “essential for detecting depression” in this patient population. “Depression negatively affects the course of COPD, and regular treatment for COPD using bronchodilators and/or inhaled corticosteroids cannot always relieve depressive symptoms,” Hamakawa and colleagues wrote. “Therefore, determining and providing adequate treatment is vital. Treatment for depression is important for mental health but is a ‘treatable trait’ for patients with COPD.”

Health experts help breathe new life into COPD care

London, UK - New global quality standards can help guide health policy change to address the third leading cause of death worldwide. Chronic obstructive pulmonary disease (COPD), is a progressive respiratory disease estimated to affect up to one in 10 adults over the age of 40 in the EU. Mortality from respiratory diseases is the third main cause of death in EU countries, and 40 percent of these deaths result from COPD. Beyond the physical and emotional cost, this chronic respiratory disease also carries a hefty economic burden, including loss of productivity and mounting healthcare costs, as well as placing an immense burden on healthcare systems. A single COPD exacerbation can increase the risk of future hospitalization by 21 percent. Experts estimate global COPD costs will rise to $4.8 trillion in 2030. Despite the significant impact of COPD on patients and healthcare systems, and medical progress in diagnostics and disease management, COPD is often unknown, resulting in it being undertreated, under-prioritized10 and underfunded. Tonya Winders, CEO and President of the Global Allergy and Airways Patient Platform, describes the impact of this on people with COPD: “National standards that ensure patients are getting the right diagnosis and care to manage their chronic respiratory disease have, for the most part, been absent. For many people, this means a COPD diagnosis often leads to poor quality of life, declining health and fear.” John Hurst, professor of respiratory medicine at University College London says, “COPD does not receive attention proportionate to its burden on individuals and society. With the COPD mortality rate rising, we desperately need to create a basic level of care that a person living with COPD should expect.” While the COVID-19 pandemic has thrust respiratory diseases into the spotlight and has resulted in some increased recognition of respiratory diseases as a key public health issue, much more needs to be done. especially in support of patients with COPD. For example, as part of its Healthier Together initiative, the EU has identified chronic respiratory diseases as a priority, but falls short of a clear prioritization of COPD. Both experts stress that healthcare systems and policymakers must act urgently to prioritize COPD. “To catalyze this change, the first step we needed to take was defining exactly what optimal standards of care should look like for COPD,” says Winders. With the COPD mortality rate rising, we desperately need to create a basic level of care that a person living with COPD should expect.

For more information: https://tinyurl.com/wsmsy4vf

Study links poor sleep to increased risk of COPD flare-ups

Bethesda, Maryland - Poor sleep is associated with a significantly increased risk of life-threatening flare-ups in people with chronic obstructive pulmonary disease, or COPD, according to a new study supported by the National Institutes of Health. The risk for these flare-ups—sudden bouts of worsening breathing—was 25% to 95% higher in people who experienced poor sleep than in people who had good quality sleep. The findings suggest that poor sleep may be a better predictor of flare-ups than even a person's history of smoking. The observational study, one of the largest to look at the links between sleep quality and COPD flare-ups, was largely supported by the National Heart, Lung, and Blood Institute (NHLBI), part of the NIH. Its findings appear online on June 6 in the journal Sleep. COPD, a progressive, incurable lung condition that makes breathing difficult, affects more than 16 million adults in the United States and is a leading cause of death. COPD flare-ups, also known as exacerbations, can last for days and even weeks and are triggered by a variety of factors ranging from pollutants to cold and flu viruses. Poor sleep can weaken the immune system of a healthy person and make them more susceptible to colds and the flu; and this vulnerability can increase in people with COPD. Although scientists have long known that people with COPD often experience sleep disturbances, the role of poor sleep as a trigger of COPD exacerbations has been understudied, with major research on this topic providing conflicting evidence. The current study fills an important knowledge gap, investigators say. "Among those who already have COPD, knowing how they sleep at night will tell me much more about their risk of a flare-up than knowing whether they smoked for 40 versus 60 years," said lead study author Aaron Baugh, M.D., a clinical fellow at the University of California San Francisco Medical School and a practicing pulmonologist. "That is very surprising and is not necessarily what I expected going into this study. Smoking is such a central process to COPD that I would have predicted it would be the more important predictor in the case of exacerbations." For the study, the researchers followed 1,647 people with confirmed COPD who were enrolled in the Subpopulations and Intermediate Outcome Measures in COPD Study (SPIROMICS), a multi-center U.S. longitudinal study funded by the NHLBI and the COPD Foundation and designed to evaluate COPD subpopulations, outcomes, and biomarkers. All the participants in this specific study were current or former tobacco smokers with a confirmed diagnosis of COPD, and they underwent at least one initial sleep evaluation upon enrollment. The researchers recorded COPD flare-ups over a three-year follow-up period and compared these measurements against the sleep quality of the participants. The researchers used a common tool for analyzing self-reported sleep quality—a combination of seven sleep measures, including sleep duration, timing of sleep, and frequency of disturbances. The scores ranged from worse sleep quality to best sleep. The researchers reported their results after looking at how a person's risk for flare-ups changed after one year. They found that in general, poor sleep quality was strongly associated with a higher total of COPD flare-ups. Compared to those participants with the best possible sleep, those who were at the threshold or at the base level of poor sleep had a 25% increased chance of having a COPD flare-up within the next year. Those with the worst sleep had a nearly 95% increased risk of having a COPD exacerbation within the next year. While the findings apply to all races and ethnicities, the study has particular relevancy for Black Americans, Baugh said. That's because past studies show that this group tends to have poorer sleep quality than other races and ethnicities. As poorer sleep is now linked to worse COPD outcomes, the current study may help explain why Black Americans as a group tend to do worse when they have COPD, compared to other racial and ethnic groups, the researchers suggested. "Our work provides a strong rationale into paying more attention to sleep than we have in the past, from both a clinical and research perspective," said Baugh, who has a special interest in studying COPD disparities. "While we now know that sleep quality can predict future exacerbations, we don't know whether improving sleep quality will yield direct improvements in COPD outcomes. We encourage future studies that can look at the impact of interventions, whether at the individual or community level."Marishka Brown, Ph.D., director of the NHLBI's National Center on Sleep Disorders Research, agreed that this study is an important milestone. "Sleep has not been extensively studied as a modifier of COPD outcomes," Brown said. "This study adds to a growing knowledge base demonstrating the harmful effects of poor sleep on health in general but can be particularly  damaging in people with devastating preexisting conditions, such as COPD."

For more information: https://medicalxpress.com/news/2022-06-links-poor-copd-flare-ups.html

A smoke-free generation: New Zealand's tobacco ban

Wellington, NZ - Many countries will monitor the results of New Zealand's plan to ban sales of tobacco to anyone born after 2009 reported Chris McCall in a recent edition of The Lancet. This year, New Zealand will launch a bold plan to eliminate smoking and eventually render sales of tobacco completely illegal. The key element of the plan is the introduction of a so-called Smokefree Generation, meaning anyone born on or after Jan 1, 2009, will be banned from ever buying tobacco products. Proponents say it is achievable and realistic. Critics say it could badly backfire, make banned smoking glamorous and tempting, or fuel an already burgeoning black market, reminiscent of the one in alcohol that started in the USA a century ago under prohibition.The world is watching. Malaysia has also  said it wants to introduce its own Smokefree Generation, as has Denmark. Smokers’ rights advocates have condemned it as an attack on personal freedoms, while New Zealand's small retailers say it could put them out of business. Even legal experts who oppose smoking have expressed concerns about its discriminatory nature, because a Smokefree Generation will eventually mean some New Zealand adults will be banned from buying tobacco while other, slightly older adults are not. Supporters argue that effects on personal freedoms will be small, and far less substantial than the reduced health costs of smoking. Even in a small country such as New Zealand, where most of the population no longer smokes, government figures show up to 5000 deaths a year are still attributable to the habit. These include 2000 cancer deaths, of which 1200 are due to lung cancer. The infectious diseases physician and government minister behind the plan has no doubt about its morality. Associate Health Minister Ayesha Verrall told The Lancet her experience as a working doctor seeing patients gasping for breath from chronic obstructive pulmonary disease (COPD), a condition primarily caused by smoking, convinced her that more had to be done. “It was routine on your night on call to admit patients with COPD whose usual life was being unable to walk to do their shopping, in some cases being unable to walk to the mailbox. Tobacco has made them a prisoner in their own home”, Verrall said, recalling people having amputations as a result of smoking, who she described as “maimed” by tobacco. Prime Minister Jacinda Ardern's Labour government faces an election next year, but currently holds an outright majority in the House of Representatives, so there is little doubt the changes will become law. Verrall said legislation to support the  Smokefree Aotearoa 2025 Action Plan would enter the house within the next few months and be law by the end of the year. The plan has three main components: the Smokefree Generation, a drastic 95% reduction of the number of retail outlets allowed to sell tobacco products, and mandating the sale of low nicotine products. The plan also promotes vaping as a harm reduction measure. These changes will be implemented over several years, with plans to implement the Smokefree Generation at the start of 2027. New Zealand's Smokefree Environments and Regulated Products Act 1990 will be amended, so that instead of setting a minimum age for buying tobacco products, currently age 18 years, it would define a date of birth after which individuals would be permanently banned from buying tobacco products. Anyone born on or after Jan 1, 2009, will never be able to legally buy cigarettes. In practice, it would be decades before sales of tobacco products would be completely illegal, but the generation currently at school would feel the effects very soon. “What we are saying with the Smokefree Generation is that there is no safe age to start smoking. This is a very strong message. We seek to change the environment around smokers, by reducing the availability of tobacco, by reducing retail outlets. This is changing the environment”, Verrall said.Despite the name, the plan's immediate goal is to reduce smoking prevalence to less than 5% for all population groups by 2025. The government says over time it will save NZ$5·25 billion in health expenditure. It has set aside $36·6 million over 4 years to scale up so-called stop smoking services.

For more information: https://tinyurl.com/5n89n3np

Respiratory roundtable recommends that we continue to mask up

Ottawa, ON - As provincial, territorial and federal public health guidelines on COVID-19 continue to evolve, the COVID-19 Respiratory Roundtable recognizes that people, businesses and workplaces will react differently to any changes. Nevertheless, a common goal for all Canadians is to remain healthy. As a group of professional societies and patient organizations working closely with individuals living with lung disease and supporting the lung health of Canadians, members of the COVID-19 Respiratory Roundtable are concerned about the ongoing risk of COVID-19, particularly in the wake of easing of public health restrictions. People’s choices make a difference Despite a relatively high rate of vaccination across Canada, the risk of COVID-19 spread remains. The group urges that we need to be mindful of how the individual choices we make will affect vulnerable and high-risk groups: the elderly, children under five years of age who are not yet vaccinated, individuals with underlying health conditions and the health care professionals who have been working to protect and provide high-quality health care to Canadians throughout the pandemic. Wearing a mask also helps to protect you. An estimated 10% of those infected will experience Long COVID – a range of long-term symptoms, some quite serious, even for people who had mild initial illness. Improving indoor air quality is only part of the solution You may have heard that organizations and facilities are working to increase ventilation to improve indoor air quality. Keep in mind that although improving indoor air quality is an important measure, proper ventilation alone cannot protect you from exposure to the virus responsible for COVID-19. This is particularly true during close, unmasked contact and in the absence of other protective measures. The COVID-19 Respiratory Roundtable urges Canadians to continue wearing a mask indoors especially in poorly ventilated areas and when physical distancing may not be possible or proves to be challenging in crowded areas. If wearing a face mask is not possible, we recommend that individuals instead minimize exposure to indoor congregate settings.

For more information: http://copdcanada.info/74.html

Global quality standards for COPD management proposed

Cambridge, UK – A multidisciplinary group of clinicians with expertise in COPD management together with patient advocates from eight countries participated in a review of quality standards worldwide. The principal objective was to achieve consensus on global health system priorities to ensure consistent standards of care for COPD. These quality standard position statements were either evidence-based or reflected the combined views of the panel. Despite being a leading cause of death worldwide, chronic obstructive pulmonary disease (COPD) is underdiagnosed and underprioritized within healthcare systems. The group found that existing healthcare policies should be revisited to include COPD prevention and management as a global priority. The researchers described health system quality standard position statements that should be implemented as a consistent standard of care for patients with COPD. On the These experts adopted five quality standard position statements, including the rationale for their inclusion, supporting clinical evidence, and essential criteria for quality metrics. These quality standard position statements emphasize the core elements of COPD care, including (1) diagnosis, (2) adequate patient and caregiver education, (3) access to medical and nonmedical treatments aligned with the latest evidence-based recommendations and appropriate management by a respiratory specialist when required, (4) appropriate management of acute COPD exacerbations, and (5) regular patient and caregiver follow-up for care plan reviews. These practical quality standards may be applicable to and implemented at both local and national levels. While universally applicable to the core elements of appropriate COPD care, they can be adapted to consider differences in healthcare resources and priorities, organizational structure, and care delivery capabilities of individual healthcare systems. They encourage the adoption of these global quality standards by policymakers and healthcare practitioners alike to inform national and regional health system policy revisions to improve the quality and consistency of COPD care worldwide.

For more information: https://link.springer.com/article/10.1007/s12325-022-02137-x

Different responses to pulmonary rehabilitation in COPD patients with different work efficiencies

New Taipei City, Taiwan - New report looks at different responses to pulmonary rehab amongst COPD patients. Chronic obstructive pulmonary disease (COPD) often involves the cardiopulmonary dysfunction that deteriorates health-related quality of life (HRQL) and exercise capacity. Work efficiency (WE) indicates the efficiency of overall oxygen consumption (VO2) during exercise. This study investigated whether different WEs have different effects on pulmonary rehabilitation (PR). The researchers here looked at forty-five patients with stable COPD who were scheduled for PR. The pulmonary rehab programs consisted of twice-weekly sessions for three months. These patients were comprehensively evaluated by cardiopulmonary exercise testing and COPD assessment test (CAT) before and after PR. They compared these parameters between patients with a normal versus poor WE. The researchers found that twenty-one patients had a normal WE and twenty-four patients had a poor WE (< 8.6 mL/min/watt). Patients with a poor WE had earlier anaerobic metabolism, a poorer oxygen pulse, lower exercise capacity, more exertional dyspnea, and a poorer health related quality of life than those with a normal WE. Pulmonary rehab improved exercise capacity, HRQL, anaerobic threshold, exertional dyspnea and leg fatigue in patients with either normal or poor WE. However, significant improvement of WE, oxygen pulse, respiratory frequency (Rf) during exercise, chest tightness, activity and sleepiness by CAT were noted only in patients with a poor WE. Among the patients with a poor work efficiency, 29% patients had their work efficiency return to normal after pulmonary rehabilitation. They concluded that the patients with different WE had different responses to PR. PR improved exercise capacity and HRQL regardless of a normal or poor WE. However, WE, oxygen pulse, Rf during exercise, chest tightness, activity and sleepiness were only improved in patients with a poor work efficiency. 

For the full report: https://tinyurl.com/38huykef

Risk of death more than doubles with COVID-19 and flu co-infection

Edinburgh, Scotland - Adults who are hospitalized with COVID-19 and the flu at the same time are at a greater risk for serious illness and death, according to a new study. Researchers from the University of Edinburgh, University of Liverpool, Leiden University and Imperial College London studied more than 305,000 hospitalized COVID-19 patients and published their findings in The Lancet on Friday. Of the patients studied, nearly 7,000 had respiratory viral co-infections with 227 of these patients simultaneously having seasonal influenza and COVID-19. According to the study, patients with a co-infection of SARS-CoV-2, the virus that causes COVID-19, and influenza viruses were four times more likely to need ventilation during their hospital stay. The study also suggested these patients were 2.4 times more likely to die than patients hospitalized with just COVID-19. "We are seeing a rise in the usual seasonal respiratory viruses as people return to normal mixing, so we can expect flu to be circulating alongside COVID-19 this winter," Calum Semple, a professor of outbreak medicine at the University of Liverpool and one of the researchers behind the study, said in a press release on Monday. "We were surprised that the risk of death more than doubled when people were infected by both flu and COVID-19 viruses." Researchers said they hope this information could be used to help hospitals and ICUs better prepare for flu season. Although they note that co-infections are not very common, the study's authors suggested testing hospital patients for influenza viruses as a way to mitigate risks for patients. They also reiterated the importance of getting vaccinated against COVID-19 as well as getting the seasonal flu shot each year. "It is now very important that people get fully vaccinated and boosted against both viruses, and not leave it until it is too late," Semple said. According to a press release from the University of Edinburgh, this research is the largest-ever study of people with COVID-19 and other endemic respiratory viruses. The research was also delivered to the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC), which was created in 2013 to share information and prepare for any future pandemics. 

For more information: https://tinyurl.com/bdhzd5jp

Risk for incident depression, antidepressant prescriptions elevated in patients with COPD

Nottingham, UK - Patients with confirmed COPD had an increased risk for depression and were more likely to receive a prescription for antidepressant medication than individuals without COPD, according to data published in Respiratory Medicine. “Mechanisms underlying the association between depression in COPD are not fully understood. Risk factors associated with increased prevalence of depression in COPD are likely multiple and include age, female gender and smoking. The COPD severity has also been associated with an increased prevalence of depression, regardless of how COPD severity is defined,” Rayan A. Siraj, MSc, from the division of respiratory medicine at the University of Nottingham, U.K., and colleagues wrote. “Breathlessness is a core symptom in COPD and has been associated with worse depression symptoms. There may also be a link between COPD and depression through lower socioeconomic class; a risk factor linked to both conditions.” Data were derived from Siraj RA, et al. Respir Med. 2022;doi:10.1016/j.rmed.2022.106804. The large population-based cohort study included 44,362 patients with confirmed COPD (mean age, 67.8 years; 37.5% women) in The Health Improvement Network (THIN) database. Patients were matched with individuals without COPD (n = 124,140; mean age, 67.5 years; 33.7% women) by age, sex and general practitioner. The incidence rate of depression was higher in patients with COPD compared with individuals without COPD: 11.4 vs. 5.7 per 1,000 person-years after COPD diagnosis (P < .001). In addition, patients with COPD also had more antidepressant prescriptions compared with individuals without COPD (17.9% vs. 11.7%; P < .001). Patients with COPD were 42% more likely to have incident depression (adjusted HR = 1.42; 95% CI, 1.32-1.53; P < .001) and 40% more likely to receive a prescription for antidepressant medication (aHR = 1.4; 95% CI, 1.35-1.45; P < .001) compared with individuals without COPD. The incidence of both depression and antidepressant prescription was also greater among patients with COPD (aHR = 1.41; 95% CI, 1.36-1.46; P < .001). In the cohort, 2,339 patients with COPD reported worse breathlessness and a Medical Research Council (MRC) dyspnea score of 4 to 5. Compared with the 20,853 patients with less breathlessness and an MRC dyspnea score of 1 to 3, these patients had a higher risk for incident depression (aHR = 1.28; 95% CI, 1.01-1.63; P = .044), antidepressant prescription (aHR = 1.29; 95% CI, 1.16-1.44; P < .001) or either (aHR = 1.32; 95% CI, 1.19-1.46; P < .001). “Early identification of depression allows health care professionals to develop appropriate treatment strategies, guide the choice of pharmacological and nonpharmacological therapies and minimize the risk of missing critical patients’ symptoms; all of which contribute to better clinical outcomes,” the researchers wrote.

For more information: https://tinyurl.com/4rfasds8

New study looks at role of air pollutants in asthma and COPD

Magdeburg, Germany- In this review, researchers discuss the molecular and immunological mechanisms involved in physical barrier disruption induced by major airborne pollutants and outline their implications in the pathogenesis of asthma and COPD. Chronic exposure to environmental pollutants is a major contributor to the development and progression of obstructive airway diseases, including asthma and COPD. Understanding the mechanisms underlying the development of obstructive lung diseases upon exposure to inhaled pollutants will lead to novel insights into the pathogenesis, prevention and treatment of these diseases. The respiratory epithelial lining forms a robust physicochemical barrier protecting the body from inhaled toxic particles and pathogens. Inhalation of airborne particles and gases may impair airway epithelial barrier function and subsequently lead to exaggerated inflammatory responses and airway remodelling, which are key features of asthma and COPD. In addition, air pollutant-induced airway epithelial barrier dysfunction may increase susceptibility to respiratory infections, thereby increasing the risk of exacerbations and thus triggering further inflammation. In this review, we discuss the molecular and immunological mechanisms involved in physical barrier disruption induced by major airborne pollutants and outline their implications in the pathogenesis of asthma and COPD. We further discuss the link between these pollutants and changes in the lung microbiome as a potential factor for aggravating airway diseases. Understanding these mechanisms may lead to identification of novel targets for therapeutic intervention to restore airway epithelial integrity in asthma and COPD. They conclude that Inhalation of PM and noxious gases that are emitted into the air in cities on a daily basis is a risk factor for the development of asthma and COPD. Current knowledge on the pathogenesis of these lung diseases confirms the negative impacts of air pollutants on lung function in patients with airway diseases. Airway epithelial barrier disruption is one of the central features of asthma and COPD, and air pollution is considered to be a major trigger for its development. We have summarised the key mechanisms regulating airway epithelial barrier disruption upon exposure to various air pollutants, of which ROS-mediated mechanisms appear to be the common mechanism. Airway epithelial barrier dysfunction induced by air pollutants perpetuates inflammation and airway remodelling and increases susceptibility to infections which may explain the higher rate of exacerbations observed in the patients with asthma and patients with COPD living in polluted areas. As high levels of urban gas phase air pollutants were shown to be particularly associated with occurrence of COPD exacerbations, it is essential to widely scrutinise the impacts of these pollutants on airway epithelial barriers. Although changes in the lung microbiome induced by air pollutants may facilitate airway infection and as such exacerbations, the direct link with barrier dysfunction is unknown and requires further investigations. Furthermore, due to the role of viral and fungal pathogens in airway epithelial barrier dysfunction, it is relevant to investigate the impact of air pollutants on the lung virome and mycobiome and to delineate how putative changes may contribute to barrier dysfunction. Restoring barrier function by therapeutic compounds, particularly those suppressing excessive ROS production by AECs, such as resveratrol and for instance VitD3 in combination with the routine ICS/LABA/LAMA medications, may be an effective strategy to prevent development of new cases as well as exacerbations in current patients with asthma and patients with COPD residing in polluted areas.

For full details of the study published in The European Respiratory Review: https://tinyurl.com/3ayvap2s

Home dust allergen exposures common in patients with COPD

Baltimore, MD - Home dust allergen exposures are common in patients with COPD and exposure is associated with adverse outcomes in those who also have allergen sensitization, researchers reported in American Journal of Respiratory and Critical Care Medicine. “Environmental pollutant exposures, particularly indoor particulate matter exposures, have been associated with adverse outcomes in COPD, particularly among those with allergic sensitization,” Nirupama Putcha, MD, MHS, associate professor in the division of pulmonary and critical care medicine at Johns Hopkins University School of Medicine, and colleagues wrote. “However, to date, the association of allergen exposures with outcomes in COPD is not clearly known.” Researchers assessed allergen sensitization to five common indoor allergens: cat, dog, cockroach, mouse and dust mite. The study included 183 former smokers with COPD (mean age, 67.3 years; 44% women). Researchers assessed home-settled dust for the presence of corresponding allergens and determined patients’ sensitization and exposure status, adjusted for symptoms, lung function and exacerbations. Thirty-three percent of individuals were sensitized to at least one tested allergen: 22% sensitized to dust mite, 21% to cockroach, 11% to cat, 9.8% to dog and 2% to mouse. Seventy-seven percent of participants were exposed to at least one tested allergen and 17% had sensitization with a corresponding allergen exposure. Sensitization and exposure were associated with 8.3% lower lung function (beta = –8.29), higher St. George’s Respiratory Questionnaire total score (beta = 6.71) and a more than twofold higher risk for any reported exacerbation (OR = 2.31; 95% CI, 1.11-4.79) after adjustment. Among participants with lower lung function, these associations appeared more pronounced; individuals with an FEV1 percent predicted less than 50% had higher associations with risk for any exacerbation (OR = 3.77; 95% CI, 1.45-9.77) compared with individuals with an FEV1 percent predicted of 50% or more. “This study highlights the potential value of environmental modification strategies that have the potential to reduce morbidity and health care utilization in patients with COPD and allergic sensitization,” the researchers wrote. “Further studies are still required to better understand the specific allergens that, when targeted and mitigated, have the highest potential to improve outcomes.”

For more information: https://tinyurl.com/4u3hmjkk

Impact of coexisting dementia on inpatient outcomes for patients admitted with a COPD exacerbation

Nottingham, UK - People with COPD are at a higher risk of cognitive dysfunction than the general population. However, the additional impact of dementia amongst such patients is not well understood, particularly in those admitted with a COPD exacerbation. Researchers here assessed the impact of coexisting dementia on inpatient mortality and length of stay (LOS) in patients admitted to hospital with a COPD exacerbation, using the United States based National Inpatient Sample database. Patients aged over 40 years and hospitalised with a primary diagnosis of COPD exacerbation from 2011 to 2015 were included in the study. Cases were grouped into patients with and without dementia. Multivariable logistic regression analysis, stratified by age, was used to assess risk of inpatient deaths. Cox regression was carried out to compare death rates and competing risk analysis gave estimates of discharge rates with time to death a competing variable. A total of 576,381 patients were included into the analysis, of which 35,372 (6.1%) had co-existent dementia. There were 6413 (1.1%) deaths recorded. The odds of inpatient death were significantly greater in younger patients with dementia (41– 64 years) [OR (95% CI) dementia vs without: 1.75 (1.04– 2.92), p=0.03]. Cases with dementia also had a higher inpatient mortality rate in the first 4 days [HR (95% CI) dementia vs without: 1.23 (1.08– 1.41), p=0.002] and a longer LOS [sub-hazard ratio (95% CI) dementia vs without: 0.93 (0.92– 0.94), p< 0.001].
The researchers concluded that dementia as a comorbidity is associated with worse outcomes based on inpatient deaths and LOS in patients admitted with COPD exacerbations.

For more information: https://www.dovepress.com/articles.php?article_id=73585

The ongoing battle to address respiratory health in people experiencing homelessness

London, UK - Spurred into action by the COVID-19 pandemic, the British government tried something completely new. It made a serious effort to tackle homelessness. Local authorities in England were instructed to get people experiencing homelessness off the streets, out of communal shelters and into safe, single-room accommodation. Hotel rooms, bed and breakfasts, and student halls were booked en masse. Landlords were prevented from evicting tenants and welfare payments were increased. Alistair Story is the founder and clinical lead of Find and Treat, a specialist outreach service for homeless populations, funded by the National Health Service and based out of University College London Hospital. “If you have your own place, you have somewhere to eat, wash, and sleep in private. You have your own toilet. You can get warm. You can get dry. These are the sorts of things that keep people alive”, explained Story. According to the Office of National Statistics, there was a 12% decrease in deaths among people experiencing homelessness in England and Wales in 2020, compared with the previous year. There were just 13 documented deaths from COVID-19. “We saw something that we thought we would never see”, added Story. “This problem of homelessness, which was supposed to be chronic, intractable and irresolvable, became something that could be taken off the streets. It could be fixed. Individuals who were sleeping in shop doorways suddenly had a roof over their heads.” It now looks as if the fix was only temporary. The eviction ban has ended. Welfare payments have been cut. The nation is entering a cost-of-living crisis. The charity Shelter has warned that a surge in homelessness is likely. “We're flooded with calls from families and people of all ages who are homeless or on the verge of losing their home”, stated chief executive Polly Neate, in a press release late last year. The Lancet Respiratory Medicine visited Find and Treat on an icy day in December, 2021. The mobile clinic was parked in a small alleyway half a mile from the Houses of Parliament. Apartments in a development a few yards away were being offered for £1·75 million. The same street is home to a hostel, something of a rarity in that it is willing to accept people who have been ejected from other services or are still using drugs. “It is a bit of hardcore here; we see people who are entrenched in rough sleeping”, said Joyce, a young nurse who has been working with Find and Treat for a year or so. The van was in its first week back on duty, after a major refurbishment. A small ramp takes you into the waiting area. The mobile x-ray unit stands to the left. On the right, a door leads to the consulting room, where Joyce was offering vaccines against pneumonia, influenza, and COVID-19. The clinic had dispensed more than 7000 doses of the Pfizer vaccine against COVID-19 since the previous March. The booster campaign was well underway, though there were also plenty of people who were receiving their first and second doses. Over the next few weeks, the clinic would see a lot of cases linked to the omicron variant of SARS-CoV-2, mostly mild infections. ” Find and Treat's major focus is active case-finding for tuberculosis. The x-ray machine delivers the results on the spot. “Respiratory health is really poor among the people we see”, said Story. Most hostel residents have long histories of rough sleeping. “People here have survived outside with next to nothing, sleeping in doorways and under bridges inhaling traffic pollution. It wrecks their immune system. People get multiple pneumonias and early-onset chronic obstructive pulmonary disease [COPD]”, said Story. Users of crack-cocaine are exceptionally vulnerable. The drug is smoked, typically in short-stemmed, home-made pipes. The smoke is incredibly hot. “X-rays sometimes show up shocking damage in young people, which we are pretty sure comes down to thermal airways injury”, said Story. “Crack-cocaine takes out your first line of defence, the alveolar macrophages, and leaves you at much greater risk of any kind of respiratory infection.” High rates of tobacco use compound the problem, especially given the obstacles people experiencing homelessness encounter when trying to access stop-smoking services. “Our clients are just as likely as anyone else to want to quit smoking, but hardly any services are set up to help”, notes Story. Last year, WHO warned that the COVID-19 pandemic had “reversed years of global progress in tackling tuberculosis”. In 2020, the worldwide death toll from the disease rose for the first time in over a decade. Services all over the world have been badly affected. Find and Treat is no exception. “We have not had the capacity to do things at scale for the past 14 months”, said Story. “We are seeing a lot of delayed diagnosis, which leads to extended chains of transmission, and we are getting multiple calls from public health colleagues across the country to try to respond to outbreaks. Moreover, tuberculosis tends to rise during economic contractions. The reversed progress of the past couple of years could easily mark the beginnings of a downward trend. “Now is the time to ramp up case-finding and invest in supporting people to take their treatment”, said Story. “But I am not hopeful this is going to happen.” He added that the government's commitment to addressing homelessness seems to have waned. “There are no long-term strategies to sort out people's housing status”, said Story. “The pandemic has accelerated inequality; the next few years are going to be really tough.”

Omicron sub-lineage BA.2 not making people sicker in South Africa

Gauteng, South Africa - The BA.2 version of the Omicron variant of the coronavirus, while potentially more transmissible than its BA.1 predecessor, has not led to more hospitalizations or more severe disease in South Africa, researchers have found. Using national databases to track patients diagnosed with COVID-19 from Dec. 1 through Jan. 20, researchers reported on medRxiv ahead of peer review that hospitalization rates were 3.4% for those infected with original Omicron and 3.6% for individuals with BA.2 infections. Among 3,058 patients who required hospitalization for COVID-19, severe disease was diagnosed in 33.5% of original-Omicron patients and 30.5% of BA.2 patients. "By the end of January 2022, most COVID-19 infections were due to BA.2," said Dr. Nicole Wolter of South Africa's National Institute for Communicable Diseases in Gauteng. "We found that individuals that were infected with BA.2 did not have a higher risk of being admitted to hospital," she said. "While BA.2 may have a competitive advantage over BA.1 in some settings, the clinical profile of illness remains similar," the researchers concluded. However, they noted that because many people in South Africa had previously been infected with earlier variants, their findings may not be typical or translate easily to other countries.

For more information: https://tinyurl.com/mrxvayw9

Spirometry can be removed from list of Aerosol Generating Procedures (AGPs)

Bristol, UK - The AERATOR study showed that spirometry, PEFR & FeNO testing do not generate significant aerosols in comparison with cough. Standard viral filters are sufficiently effective to allow guidelines to remove lung function testing from the list of AGPs - according to conclusions from the AERATOR study led by Dr. Sadiyah Sheikh, which were recently published in Thorax. Pulmonary function tests are fundamental to the diagnosis and monitoring of respiratory diseases. There is uncertainty around whether potentially infectious aerosols are produced during testing and there are limited data on mitigation strategies to reduce risk to staff. Healthy volunteers and patients with lung disease underwent standardised spirometry, peak flow and FENO assessments. Aerosol number concentration was sampled using an aerodynamic particle sizer and an optical particle sizer. Measured aerosol concentrations were compared with breathing, speaking and voluntary coughing. Mitigation strategies included a standard viral filter and a full-face mask normally used for exercise testing (to mitigate induced coughing). 147 measures were collected from 33 healthy volunteers and 10 patients with lung disease. The aerosol number concentration was highest in coughs (1.45–1.61 particles/cm3), followed by unfiltered peak flow (0.37–0.76 particles/cm3). Addition of a viral filter to peak flow reduced aerosol emission by a factor of 10 without affecting the results. On average, coughs produced 22 times more aerosols than standard spirometry (with filter) in patients and 56 times more aerosols in healthy volunteers. FENO measurement produced negligible aerosols. Cardiopulmonary exercise test (CPET) masks reduced aerosol emission when breathing, speaking and coughing significantly. Lung function testing produces less aerosols than voluntary coughing. CPET masks may be used to reduce aerosol emission from induced coughing. The researchers concluded that standard viral filters are sufficiently effective to allow guidelines to remove lung function testing from the list of aerosol-generating procedures.

For more information: http://dx.doi.org/10.1136/thoraxjnl-2021-217671

COPD World News - Week of February 20, 2022

Omicron BA.2 sub-variant spreading

Vancouver, BC - A more contagious Omicron sub-variant known as BA.2 could complicate reopening plans now underway in most provinces. GETTY IMAGES The highly contagious Omicron sub-variant known as BA.2 is gaining a foothold in Canada just as provinces begin removing pandemic restrictions, according to newly released data.  The spread of BA.2, which is believed to be 1.4 times as contagious as the already highly transmissible original Omicron sub-variant, could complicate reopening plans now underway in most provinces. As it becomes dominant in the coming weeks, BA.2 could extend the current wave of the pandemic, increase case counts, or slow the decrease in cases at a time when provinces are dropping gathering restrictions and mask mandates. Experts say it will have an influence on case counts in Ontario but will likely not be a complete game changer. The Omicron wave is receding, booster rates are relatively high and some 3.5 million people were infected with COVID-19 during the intense Omicron wave that began in December, meaning there is widespread immunity. Sarah Otto, a professor of evolutionary virology and mathematical modelling at the University of British Columbia, and a leading Canadian expert on BA.2, said its rise in Canada “does not necessarily mean a second major Omicron wave will happen, more likely we’ll see a prolonged peak or a shoulder in the Omicron wave.” But scientists are watching it closely because there remains so much uncertainty about it and because it has been associated with a renewed spike in cases in some countries. Denmark, which dropped all pandemic restrictions in January, including masks, is now seeing record high case counts with the BA.2 sub-variant dominant. A recent study, led by Japanese researchers, argues that BA.2 is different enough from BA.1, and a bigger threat to public health, that it should not be considered Omicron at all, but should be given its own Greek name. The study found that it transmits at 1.4 times the rate of BA.1, replicates more easily in nasal cells and that experiments in hamsters show it is more virulent than BA.1 “Our multi-scale investigations suggest that the risk of BA.2 for global health is potentially higher than BA.1,” wrote the authors. Early research on BA.2 suggests that people who have been infected with BA.1 will not be re-infected with it, said Otto, who is tracking the sub-variant. That could lessen its impact in Ontario where, according to Dr. Peter Juni, scientific director of Ontario’s Science Advisory Table, some 3.5 million people were infected with Omicron between the beginning of December and the end of January, giving them immunity to the new sub-variant. Its virulence compared to the earlier sub-variant is not entirely understood, said Doug Manuel, a senior scientist at The Ottawa Hospital Research Institute and a member of Ontario’s Science Advisory Table, but he said there are no “red flags” suggesting it could be more virulent. Fully understanding its implications will take time, he said. In a report released this week, the B.C. COVID-19 modelling group, of which Otto is a member, found that BA.2 represents about 35 per cent of all COVID-19 cases in Alberta, nearly 12 per cent of cases in Ontario and 8.3 per cent of cases in British Columbia. Otto cautions that data about genetic sequencing of SARS-CoV-2 is frequently delayed and fragmentary across the country, which could mean BA.2 is now more widespread and could represent as much as 99 per cent of cases in Alberta and 34 per cent of cases in Ontario. Alberta, which dropped pandemic restrictions relatively quickly before the Omicron wave really began to diminish there, could see a bigger impact from the BA.2 variant, she said, such as a prolonged peak or double peak. Ontario, where case counts have dropped steadily in the past month, could be “spared the worst” of the BA.2 wave, she said. That is largely because so many people were infected with the original sub-variant of Omicron and booster rates are high Juni, who supports the province’s stepped reopening plans, says BA.2 will represent less of a challenge to the province since its main difference over BA.1, so far, appears to be transmissibility. Manuel said scientists, including wastewater researchers, continue to watch BA.2 closely. He said he and others have been paying close attention to Denmark, which was one of the first countries to drop all pandemic restrictions. But, unlike Ontario, Manuel said Denmark opened up completely while cases were still increasing. Ontario, which will drop most pandemic restrictions aside from indoor masks on March 1, is opening more cautiously than many jurisdictions at a time when the Omicron wave is receding. But many say masking requirements should not be lifted until the impact of reopening, and of the new sub-variant, are reviewed and understood. Otto cautioned against dropping mask mandates too soon, saying mandating masks in public places such as buses and in grocery stores is a “mild inconvenience” that can have a substantial impact on reducing transmission when cases are still relatively high. Premier Doug Ford suggested this week that he would like to see all pandemic restrictions gone sooner rather than later, saying he is “done with the pandemic.”

For more information: https://tinyurl.com/2p8zat25

Referral to pulmonary rehab program ‘sub-optimal’ among suitable patients with COPD

Perth, Australia - Fewer than half of patients with COPD deemed suitable for pulmonary rehabilitation received a referral to a pulmonary rehabilitation program across three tertiary hospitals in Australia, according to findings published in Chest. “The implementation of pulmonary rehabilitation programs is problematic with earlier work showing that the proportion of people with COPD who are actually referred to a pulmonary rehabilitation program from primary or tertiary care is as low as 16%,” Sarah Hug, BSc, with the faculty of health sciences at the Curtin School of Allied Health and the department of physiotherapy at Royal Perth Hospital, Australia, and colleagues wrote. “Addressing this implementation gap is recognized as a global priority by international respiratory societies and understanding the reasons for suboptimal referral behaviors is an important first step.” Researchers recruited 391 adults with COPD (mean age, 69 years; 55% men) who were deemed appropriate candidates for pulmonary rehabilitation programs across three tertiary hospitals in Australia. Researchers collected data on age, gender, lung function, smoking status and interest in participating in a pulmonary rehabilitation program using interviews and medical records. Pulmonary rehabilitation referrals were tracked via electronic referral systems, medical records, and discussion with participants and physiotherapists responsible for coordination. There were 156 participants suitable for pulmonary rehabilitation and, of these, 47% were referred to a pulmonary rehabilitation program. “Although suboptimal, the proportion referred in our study was considerably higher than what is reported in earlier work,” the researchers wrote. Eighty-two participants suitable for rehabilitation were classified as missed referrals, with 11% offered referrals with the health care professional not completing said referral and 18% offered referral by a health care professional but denied the program. The only variable separating participants who were vs. who were not referred to a pulmonary rehabilitation program was the interest they had in attending a program, with a mean difference in interest on the visual analogue scale of 22 U. The most frequently reported barriers to not attending a pulmonary rehabilitation program reported by 26% of participants were related to environmental context and resources factors, including problems with travel distance, transport, paring or the inflexibility of programs that led to difficulties fitting it into their schedule. Researchers noted that attitudes of already doing enough exercise (5%), introverted personality traits (4%) and feelings of unworthiness (1%) reduced a participant’s interest in attending a pulmonary rehabilitation program. “Collaborations among people with COPD, clinicians and researchers presents a unique opportunity to develop novel strategies to enhance people’s interest and improve referral to pulmonary rehabilitation programs among people with COPD in our tertiary setting,” the researchers wrote.

 For more information: https://tinyurl.com/yvpeb868

Adults, particularly those with obesity, gained weight during COVID-19 lock-down

San Luis Obispo, CA - The stay-at-home mandates to limit the spread of COVID-19 were associated with greater reported weight gain among adults with obesity during 3 months, according to study data published in Obesity. Researchers conducted an observational cohort study aimed to assess the weight gain by BMI for adults during the COVID-19 lockdown in the U.S., and the behavioral and psychosocial effects of this potential weight gain. A higher percentage of adults with obesity gained at least 2 kg of body weight during the COVID-19 lockdown compared with adults with normal weight at baseline. Data were derived from Seal A, et al. Obesity. 2021;doi:10.1002/oby.23293.  “We observed that state stay-at-home mandates, designed to slow the spread of COVID-19, had unintended consequences of promoting weight gain that disproportionately impacted individuals with obesity,” Adam Seal, PhD, a postdoctoral researcher at California Polytechnic State University in San Luis Obispo, and colleagues wrote. “In light of these data, as COVID-19 restrictions are lifted, it may be even more important to support programs and lifestyle interventions to reduce body weight, increase physical activity and promote mental health.” The researchers administered a national questionnaire in May 2020 and again in August 2020, with 1,516 adults (78.8% women; 86.7% white; 26.7% with obesity) responding both times. The questionnaire asked about height, weight, physical activity levels and dietary information as well as psychosocial and behavioral information, such as depressive symptoms, stress levels and sleep patterns. The researchers used the Epidemiological Studies Depression Scale (CES-D) to measure depressive symptoms among participants. At 3 months, about 30% of all participants reported any weight gain from baseline, with 18.4% reporting weight gain of more than 2 kg, a nearly 1% (0.6 kg) increase (76.7-77.3 kg; P = .002). Among participants with obesity, 26% reported a weight gain of more than 2 kg compared with 14.8% of those of normal weight (P < .001). Additionally, 53.3% of participants with obesity maintained a weight within 2 kg compared with 72.5% of participants with normal weight (P < .001), suggesting that weight gain “disproportionately affected individuals with obesity compared with individuals of normal weight,” according to the researchers.  Notably, the researchers found that fewer baseline minutes of physical activity per day (beta = 0.107; P = .004), greater decreases in amount of physical activity per day (beta = 0.076; P = .026), depressive symptoms (beta = 0.098; P = .034) and more additional time preparing food (beta = 0.075; P = .031) were all associated with weight gain. The authors said that the 0.6 kg weight gain is surprising considering the time frame of the study, and that if continued at the same rate, weight gain would “far exceed typical weight gain in a single year.”

For more information: https://tinyurl.com/2p8t5y9u

Montreal study looks at Dementia: How to prevent cognitive decline

Montreal, PQ - Physical activity, nutrition and cognitively stimulating activities are all known to be good ways to prevent Alzheimer's disease and dementia. And older adults at risk can access a variety of lifestyle services to that end, including diet regimes and exercises for their body and mind. Now an international team of researchers led by Université de Montréal psychology professor Sylvie Belleville has determined how many of those intervention sessions are needed prevent cognitive decline in people at risk: only about a dozen. Published in Alzheimer's & Dementia : The Journal of the Alzheimer's Association, the study by Dr. Belleville and colleagues at the universities of Toulouse and Helsinki show that 12 to 14 sessions are all that’s were needed to observe an improvement in cognition. Until now, the number of sessions or "doses” needed for optimal effect has been unknown. “In pharmacological studies, every effort is made to define an optimal treatment dose needed to observe the expected effects, “ said Belleville, a neuropsychologist and researcher at the research centere of the Université de Montréal affiliated Institut universitaire de gériatrie de Montréal. “This is rarely done in non-pharmacological studies, especially those on the prevention of cognitive decline, where little information is available to identify this dose. “Defining an optimal number of treatment sessions is therefore crucial.,” she continued. “Indeed, proposing too few sessions will produce no noticeable improvement effects, but too many sessions is also undesirable as these interventions are costly. They are costly both for the individual who follows the treatments, in terms of time and involvement, and for the organization offering these treatments.” The study is based on a secondary analysis of data from the three-year Multidomain Alzheimer Preventive Trial (MAPT) and looked at 749 participants who received a range of interventions aimed at preventing cognitive decline. These included dietary advice, physical activity and cognitive stimulation to improve or maintain physical and cognitive abilities. In their research, Belleville’s team noted that people’s individuality should be considered when determining the optimal treatment dose. They evaluated the effects of the sessions in terms of each participant’s age, gender, education level, and cognitive and physical condition. The relationship between the “dose” each received, and their cognitive improvement was then analyzed. The main results show an increase with dose followed by a plateau effect after 12 to 14 sessions. In other words, you need enough dose to see an effect but offering more than 12 to 14 sessions of treatment does not mean better results. That said, participants with lower levels of education or more risk factors for frailty did benefit from more sessions. The conclusion? It’s important to identify and target an optimal dose and to customize the treatment for each individual, the researchers say. Not only is “dosage” an important component of behavioural interventions, it can also provide valuable information when time and money are limited, helping public-health agencies develop effective prevention programs and offer guidance to older adults and clinicians.

For more information: https://tinyurl.com/4djux423

Exercising after COVID-19: What doctors need to know

Iowa City, Iowa - For many people, the pandemic has made an already-fraught relationship with fitness even worse–especially for those who’ve suffered a decline in fitness following a bout with COVID-19. Even after mild COVID-19 illness, many people need time to recover.  Emerging research has focused on several health issues linked to the return to exercise after COVID-19 infection. First, COVID-19 can lead to cardiac injury, including viral myocarditis, which can increase the risk of disease and death, according to the authors of guidance published in the BMJ.  The authors highlighted the results of a study suggesting ongoing myocardial inflammation as demonstrated by serum troponin levels and cardiovascular MRI findings at 71 days post-diagnosis. Although 67% convalesced at home, 33% needed hospitalization. Other risks include throwing clots, with pulmonary emboli linked to COVID-19. To date, it is unclear what the long-term pulmonary implications are, but data from the 2003 SARS-CoV epidemic indicated long-lasting impairments in pulmonary function and exercise capacity in survivors. One last concern that could interfere with function is psychiatric repercussions, such as psychosis. Psychosis can even crop up as a presenting symptom of COVID-19, with PTSD, anxiety, and depression also on the table further into the illness. According to the most recent research, between 10% and 20% of those infected with SARS-CoV-2 develop long-haul COVID-19 symptoms 12 weeks after the acute symptomatic phase. This manifestation is challenging to diagnose, with no current gold standard. This lack of diagnostic measures makes therapy unsure. Based on evidence from other chronic conditions, however, exercise may help. The authors of a narrative review published in the International Journal of Environmental Research and Public Health support the prospect of using exercise to counter the ill effects of long-haul symptoms. “There is sufficient evidence suggesting that tailored and supervised exercise training may be an effective multisystemic therapy for post-COVID-19 syndrome that suits the diversity of the cases and symptoms,” wrote the authors. “A multidisciplinary and integrative approach including exercise sciences is essential where clinical conditions are addressed but must integrate neurocognitive and psychological aspects into the assessment, as well as the social impact that this pathology entails.” Further research needs to be done to understand which types of exercise, as well as the intensity and load, are required to combat COVID-19. On a related note, physical deconditioning is the most common cause of impaired VO2max in those experiencing severe pneumonitis secondary to COVID-19, according to the results of a study published in the European Respiratory Journal. The authors wrote that these findings “underscore the importance of an early rehabilitative intervention in survivors of severe COVID-19 pneumonitis.” The authors of the aforementioned BMJ article suggested a stepwise approach to ensuring safety and decreasing the risk associated with returning to exercise. The patient should be ready to return to exercise following an asymptomatic stretch of 7 days. However, activities of daily living should be handily accomplished before a return to strenuous activity. There should also be no signs or symptoms of myocarditis or myocardial injury, such as chest pain, shortness of breath, heart failure, etc.  A primary care physician should evaluate the patient for ongoing symptoms, with rehabilitation services involved as necessary. It is not yet known whether graded physical activity is advisable, but graduated rehabilitation may be advisable in those who were hospitalized for COVID-19. Physical examination and diagnostic evaluation—including ECG, serum troponin levels, and echocardiography—could compel a referral to cardiology, although findings such as costochondritis could be managed by primary care. Findings of concern include additional heart sounds, edema, fibrosis, pleural effusion, and novel arrhythmias. Cough and breathlessness should dissipate after a few weeks, but persistent, progressive, or decompensating symptoms could indicate pulmonary embolism, pneumonia, or post-inflammatory bronchoconstriction. These patients should be referred out accordingly. Although exercise can boost mood and well-being, the patient should be psychologically ready for the endeavor. Mood, sleep, inclination, and appetite should all be assessed. Systems of support may be useful, such as self-care resources, community services, and peer support, as well as counseling and rehabilitation services.

For more information: https://tinyurl.com/4k36yb98

Smoking cessation after lung cancer diagnosis linked to nearly 30% improvement in survival

Florence, Italy - Quitting smoking at or around time of diagnosis conferred a significant survival benefit for patients with lung cancer, according to results of a meta-analysis published in Journal of Thoracic Oncology. Treating physicians should educate these patients on the benefits of smoking cessation even after diagnosis and provide them with necessary support, researchers wrote.“It is really never too late to quit. Critically, this is a message for the patients, and for the doctors, as well,” Saverio Caini, MD, PhD, senior medical epidemiologist at Institute for Cancer Research, Prevention and Clinical Network (ISPRO) in Italy, told Healio. “Even if they are diagnosed with lung cancer, they can raise their chance to survive quite a lot by quitting smoking as soon as possible. Actually, we recommend that smoking cessation programs become fully integrated into multidisciplinary cancer care.”Caini and colleagues pursued avenues to increase the chances of survival for patients with lung cancer because, despite advances in immunotherapy, lung cancer on average is associated with a worse prognosis than many other cancers. “Everyone knows that smoking is a risk factor for lung cancer, and many [patients with lung cancer] are diagnosed when they are still active smokers,” Caini said. “Despite this, there was no certainty on whether (and how much) stopping smoking after diagnosis could improve survival.” The meta-analysis included 21 articles published between 1980 and October 2021 on the effect of smoking cessation at or around the time of diagnosis among a total of 10,938 patients with lung cancer. “We were surprised by the small number of studies that could be included, only 21, which is a tiny number compared to the number of studies that examine, for instance, the association between smoking and the risk [for] developing cancer,” Caini said. Caini and colleagues used random effect meta-analysis models to pool study-specific data into summary relative risk [SRR] and corresponding confidence intervals. Results showed patients who quit smoking after diagnosis had a 29% improvement in OS compared with patients who continued to smoke after their diagnosis (SRR = 0.71; 95% CI, 0.64-0.8). Researchers found benefits of quitting smoking regardless of histologic subtype, with SRRs for OS between quitters and continued smokers of 0.77 (95% CI, 0.66-0.9) among patients with non-small cell lung cancer based on eight studies, 0.75 (95% CI, 0.57-0.99) among patients with small cell lung cancer based on four studies, and 0.81 (95% CI, 0.68-0.96) among patients with lung cancer of both or unspecified histologic type based on six studies. Caini and colleagues were surprised by the magnitude of the effect.“A 20% to 30% reduction in the risk of dying for those who quit post-diagnosis to those who continue is huge because it falls in the range of the survival benefit that chemotherapy and immunotherapy bring to [patients with cancer],” Caini said. “We believe that not all doctors and health professionals are aware that smoking cessation — an intervention tolerable by everyone, with practically no adverse effects and costless — can produce such a big benefit for people with a disease as severe as lung cancer.” Based on the findings, oncologists and health care systems should educate, encourage and put systems in place to help patients quit smoking at time of diagnosis, even with the challenges it presents to many patients “It’s difficult because [patients with lung cancer} may be disheartened and discouraged and feel too depressed to engage themselves in smoking cessation, especially considering that they may have been smoking for decades, which makes quitting even more complicated,” Caini said. “Patients must be made aware that smoking cessation can be nearly as effective (for improving the chance of surviving) as chemotherapy, immune therapy, radiation therapy, etc., and that there is plenty of support for them if they decide to attempt to stop.”

For more information: https://tinyurl.com/55p6jrkc

Fluticasone-based ICS, LABA therapy changes airway microbiome in COPD

Vancouver, BC - Fluticasone-based inhaled corticosteroid treatment substantially changed airway microbiome diversity in patients with COPD, according to new data published in the American Journal of Respiratory and Critical Care Medicine. “Inhaled corticosteroids, especially potent ones like fluticasone, can change the microbial communities (which are called microbiome) of airways of COPD patients, rendering them more susceptible for pneumonia,” Don D. Sin, MD, director and De Lazzari Family Chair at the Centre for Heart Lung Innovation, Canada Research Chair in COPD and professor of medicine in the division of respiratory medicine in the department of medicine at St. Paul’s Hospital, Vancouver, British Columbia, told Healio. “We were puzzled as to why the use of inhaled corticosteroids increased the risk of pneumonia in COPD patients. We hypothesized that these therapeutics would adversely change the airway microbiome of COPD patients.” The study enrolled 63 clinically stable patients with COPD. Use of inhaled corticosteroid (ICS) was discontinued and substituted with formoterol (Teva) 12 µg twice daily. Patients were randomly assigned to receive budesonide/formoterol 400/12 µg (n = 20; mean age, 66.3 years; 85% men), fluticasone/salmeterol 250/50 µg (n = 22; mean age, 66 years; 77.3% men) or formoterol only 12 µg (n = 21; mean age, 62.5 years; 85.7% men), all twice daily for 12 weeks. The primary outcome was the comparison of airway microbiome changes during 12 weeks between the ICS/long-acting beta agonist (LABA) and LABA only groups. A total of 56 patients completed all clinic visits after seven patients withdrew between the first and second bronchoscopy visits. Airway microbiota diversity showed significant differences across groups following the treatment period with the most significant changes observed among those who received fluticasone/salmeterol and formoterol alone. In addition, longitudinal differential abundance analyses demonstrated more pronounced airway microbial shifts from baseline among those who received fluticasone/salmeterol. These greater shifts were related to reduced abundances of Pasteurellas, Pasteurellaceae and Haemophilus, according to Sin, it was surprising to find that 3-month LABA therapy improved the airway microbiome in this patient population and that 25% of patients who withdrew from ICS developed breathing troubles and dropped out. “New corticosteroids are being developed for COPD. We need to find out their effects on the airway microbiome of COPD patients before they are widely deployed in clinical care,” Sin said. “We also need to find out which bacterial organisms are responsible for keeping the airway microbiome healthy and develop novel therapeutics to restore the airway microbiome of COPD patients.”