Leicester, UK - A study of more than 300,000 people has found that exposure to outdoor air pollution is linked to decreased lung function and an increased risk of developing chronic obstructive pulmonary disease (COPD). COPD is a long-term condition linked to reduced lung function that causes inflammation in the lungs and a narrowing of the airways, making breathing difficult. According to the Global Burden of Disease (GBD) project COPD is the third leading cause of death worldwide, and the number of global COPD deaths are expected to increase over the next ten years. Lung function normally declines as we age, but the new research published today (9 July, 2019) in the European Respiratory Journal suggests that air pollution may contribute to the ageing process and adds to the evidence that breathing in polluted air harms the lungs. Anna Hansell is Professor of Environmental Epidemiology in the Centre for Environmental Health and Sustainability at the University of Leicester, UK, and was part of the research team. She said: “There are surprisingly few studies that look at how air pollution affects lung health. To try and address this, we assessed more than 300,000 people using data from the UK Biobank study to examine whether air pollution exposure was linked to changes in lung function, and whether it affected participants’ risk of developing COPD.” The researchers used a validated air pollution model to estimate the levels of pollution that people were exposed to at their homes when they enrolled in the UK Biobank study. The types of pollutants the researchers investigated included particulate matter (PM10), fine particulate matter (PM2.5) and nitrogen dioxide (NO2), which are produced by burning fossil fuels from car and other vehicle exhausts, power plants and industrial emissions. Participants answered detailed health questionnaires as part of the UK Biobank data collection, and lung function was measured using spirometry tests performed by medical professionals at Biobank assessment centers at enrolment between 2006 and 2010. Spirometry is a simple test used to help diagnose and monitor certain lung conditions by measuring how much air can be breathed out in one forced breath. The research team then conducted multiple tests to see how long-term exposure to higher levels of the different air pollutants was linked to changes to participants’ lung function. The participants’ age, sex, body mass index (BMI), household income, education level, smoking status, and exposure to secondhand smoke were accounted for in the analyses. Further analyses also looked at whether working in occupations that increase the risk of developing COPD impacted disease prevalence. The data showed that for each annual average increase of five micrograms per cubic meter of PM2.5 in the air that participants were exposed to at home, the associated reduction in lung function was similar to the effects of two years of ageing. When the researchers assessed COPD prevalence, they found that among participants living in areas with PM2.5 concentrations above World Health Organization (WHO) annual average guidelines of ten micrograms per cubic meter (10 µg/m3), COPD prevalence was four times higher than among people who were exposed to passive smoking at home, and prevalence was half that of people who have ever been a smoker. The current EU air quality limits for PM2.5 is 25 micrograms per cubic meter (25 µg/m3), which is higher than the levels that the researchers noted as being linked to reduced lung function. Professor Hansell explained: “In one of the largest analyses to date, we found that outdoor air pollution exposure is directly linked to lower lung function and increased COPD prevalence. We found that people exposed to higher levels of pollutants had lower lung function equivalent to at least a year of ageing. “Worryingly, we found that air pollution had much larger effects on people from lower income households. Air pollution had approximately twice the impact on lung function decline and three times the increased COPD risk on lower-income participants compared to higher-income participants who had the same air pollution exposure. “We accounted for participants’ smoking status and if their occupation might affect lung health, and think this disparity could be related to poorer housing conditions or diet, worse access to healthcare or long-term effects of poverty affecting lung growth in childhood. However, further research is needed to investigate the differences in effects between people from lower- and higher-income homes.” The researchers were not able to track participants’ exposure to pollutants in their daily lives, and say that study participants were generally wealthier and healthier than the wider general public, which could have resulted in underestimations of the strength of the links between declining lung function and air pollution exposure. Professor Tobias Welte from Hannover University, Germany, is President of the European Respiratory Society and was not involved in the study. He said: “The findings of this large study reinforce that exposure to polluted air seriously harms human health by reducing life expectancy and making people more prone to developing chronic lung disease. “Access to clean air is a fundamental need and right for all citizens in Europe. Governments have a responsibility to protect this right by ensuring that maximum pollutant levels indicated by the World Health Organization are not breached across our cities and towns. Breathing is the most basic human function required to sustain life, which is why we must continue to fight for the right to breathe clean air.” The research team are conducting further studies to look at whether genetic factors interact with air pollution and its effects on health.
For more information: https://tinyurl.com/y3sgbrbp
New South Wales, Australia - Patient activation is associated with health behaviors including lifestyle behaviors (exercise, diet), clinical indicators (body mass index [BMI], blood pressure, cholesterol), health service utilization (hospitalizations, use of emergency departments, participation in preventive screening and immunizations, and having regular checkup), and reporting better patient experience. Patient activation is defined as “having the knowledge, skill, and confidence to manage one’s health and health care”. Chronic disease self-management is important to manage symptoms, prevent complications, and participate in treatment decisions, and this requires a high level of activation. Previous research in people with chronic obstructive pulmonary disease (COPD) has shown that only a minority of people with COPD are activated for self-management, and patient activation can be influenced by anxiety, illness perception, BMI, age, disease severity, and comorbidities. An association between COPD and activation has also been shown to be dependent on social support. Patient activation is a significant predictor of health behaviors; however, the level of activation in people attending a pulmonary rehabilitation program and the effect of pulmonary rehabilitation on patient activation have not been measured. Furthermore, the potential determinants and relationship between patient activation and characteristics of people attending pulmonary rehabilitation have not previously been reported. The Patient Activation Measure (PAM) was measured in people with a chronic respiratory disease or congestive cardiac failure at a baseline pulmonary rehabilitation assessment and again at the completion of the 8-week outpatient program. This study included 194 people with chronic respiratory disease or congestive cardiac failure (41% male; mean [standard deviation, SD] age: 73  years; mean [SD] forced expiratory volume in 1 second % predicted: 60% [20%]). The pulmonary rehabilitation program was completed by 61% (n = 118) of participants. The mean (SD) PAM score at baseline was 60.5 (15.7), which improved to 65.4 (15.5) after completion of the pulmonary rehabilitation program (P = .001). In a stepwise forward multiple regression analysis, anxiety, lung information needs, and health-related quality of life impact were found to be significant determinants of baseline PAM. This model explained 12% (P < .001) of the variance. The researchers concluded that people with a chronic respiratory disease or congestive cardiac failure commencing a pulmonary rehabilitation program demonstrated a moderate level of activation, which improved following an 8-week hospital outpatient pulmonary rehabilitation program. Anxiety, a higher level of lung information needs, and greater health-related quality of life impact were significantly associated with poor patient activation. Lead author of the study; Renae J McNamara, Dept. of Physiotherapy, Prince of Wales Hospital, New South Wales, Australia.
For more information: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6558947/
Reykjavik, Iceland – A recent study by Jonina Sigurgeirsdottir and colleagues at the Faculty of Medicine, University of Iceland, looked at patients’ experiences, self-reported needs, and needs-driven strategies to cope with self-management of COPD. In this phenomenological study, 10 participants with mild to severe COPD were interviewed 1–2 times, until data saturation was reached. In total, 15 in-depth interviews were conducted, recorded, transcribed, and analyzed. The results concluded that COPD negatively affected participants’ physical and psychosocial well-being, their family relationships, and social life. They described their experiences of COPD like fighting a war without weapons in an ever-shrinking world with a loss of freedom at most levels, always fearing possible breathlessness. Fourteen needs were identified and eight clusters of needs-driven strategies that participants used to cope with self-management of COPD. Coping with the reality of COPD, a life-threatening disease, meant coping with dyspnea, feelings of suffocation, indescribable smoking addiction, anxiety, and lack of knowledge about the disease. Reduced participation in family and social life meant loss of ability to perform usual and treasured activities. Having a positive mindset, accepting help and assuming healthy lifestyle was important, as well as receiving continuous professional health care services. The participants’ needs-driven strategies comprised conducting financial arrangements, maintaining hope, and fighting their smoking addiction, seeking knowledge about COPD, thinking differently, facing the broken chain of health care, and struggling with accepting support. Procrastination and avoidance were also evident. Finally, the study also found that participants experienced a perpetuating cycle of dyspnea, anxiety, and fear of breathlessness due to COPD which could lead to more severe dyspnea and even panic attacks. The researchers concluded COPD negatively affects patients’ physical and psychosocial well-being, family relationships and, social life. Identifying patients’ self-reported needs and needs-driven strategies can enable clinicians to empower patients by educating them to improve their self-management.
For more information: https://www.dovepress.com/articles.php?article_id=45880
Chicago, IL - Air pollution may be damaging every organ and virtually every cell in the human body, according to a comprehensive new global review. The research shows head-to-toe harm, from heart and lung disease to diabetes and dementia, and from liver problems and bladder cancer to brittle bones and damaged skin. Fertility, fetuses and children are also affected by toxic air, the review found. The systemic damage is the result of pollutants causing inflammation that then floods through the body and ultrafine particles being carried around the body by the bloodstream. Air pollution is a “public health emergency”, according to the World Health Organization, with more than 90% of the global population enduring toxic outdoor air. New analysis indicates 8.8m early deaths each year – double earlier estimates – making air pollution a bigger killer than tobacco smoking. But the impact of different pollutants on many ailments remains to be established, suggesting well-known heart and lung damage is only “the tip of the iceberg”. “Air pollution can harm acutely, as well as chronically, potentially affecting every organ in the body,” conclude the scientists from the Forum of International Respiratory Societies in the two review papers, published in the journal Chest. “Ultrafine particles pass through the [lungs], are readily picked up by cells, and carried via the bloodstream to expose virtually all cells in the body.” Prof Dean Schraufnagel, at the University of Illinois at Chicago and who led the reviews, said: “I wouldn’t be surprised if almost every organ was affected. If something is missing from the review it is probably because there was no research yet.” The review represents “very strong science”, said Dr Maria Neira, WHO director of public and environmental health: “It adds to the very heavy evidence we have already. There are more than 70,000 scientific papers to demonstrate that air pollution is affecting our health.” She said she expected even more impacts of air pollution to be shown by future research: “Issues like Parkinson’s or autism, for which there is some evidence but maybe not the very strong linkages, that evidence is coming now.”
For more information: https://tinyurl.com/yy2cqckw
Motala, Sweden – A recent study led by Helena Johansson of the Department of Medicine, Linkoping University, Motala, Sweden looked at the consequences of symptom burden of COPD. Chronic obstructive pulmonary disease is a prevalent illness that, due to its symptoms and treatment, entails a significant burden for the affected person, and his/her family, health care and private finances. The researchers believed that knowledge and understanding are sparse regarding COPD-affected persons’ own lived experiences and about the symptom burden and its effect on their daily life. Due to this knowledge gap the aim of their study was to identify and describe the symptom burden and its effect on daily life in people with COPD, based on their own lived experiences. Eleven males and 14 females in GOLD stages III and IV, in an age range of 58–82 years, were interviewed. An interview guide was used to direct the face-to-face interviews. Data was analyzed with thematic analysis following the six steps according to Braun and Clarke. The results highlighted one theme: an altered everyday life. The altered everyday life leads to a need for support to handle everyday life and for different strategies to live as desired. Persons with COPD need to take each day as it comes and their life is not easy to plan since it depends on how they feel from day to day. Life is handled with several strategies such as breathing techniques, and ways to take care of the home and garden as well as the emotions. Support from the next of kin, society and the health care service is important. This study provides the insight that persons with COPD in stages III and IV have an altered life caused by the symptom burden. They must struggle with strategies to handle everyday life. There is a need of support from the next of kin and society to facilitate daily living, but this support needs to be well-balanced.
For more information: https://tinyurl.com/yylfk6zw
Orebro, Sweden – A recent study led by researcher Joakim Aberg of the School of Medicine, Orebro University, Orebro, Sweden looked at the differences by sex in the care of patients with COPD. Women with chronic obstructive pulmonary disease (COPD) have more symptoms, more exacerbations, lower health status scores, and more comorbidity. However, it is unclear whether management of COPD differs by sex. They looked at a population included 1329 primary and secondary care patients with a doctor´s diagnosis of COPD in central Sweden. Data were obtained from patient questionnaires and included patient characteristics and data on achieved COPD care. Analyses included cross-tabulations, chi-squared test and multiple logistic regression using several measures in COPD management as dependent variables, female sex as independent variable, and with adjustment for age groups, previous exacerbations, COPD Assessment Test, level of dyspnea assessed by the modified Medical Research Council scale, comorbid conditions, self-rated moderate/severe disease, level of education and body mass index. The researchers found that womenwere more likely to receive triple therapy (OR 1.86 (95% CI 1.38–2.51)), to have any maintenance treatment (OR 1.82 (95% CI 1.31–2.55)), to be on sick leave (OR 2.16 (95% CI 1.19–3.93)), to have received smoking cessation support (OR 1.80 (95% CI 1.18–2.75)) and to have had pneumococcal vaccination (OR 1.82 (95% CI 1.37–2.43)), all independently of age, severity of disease or other potential confounders.They concluded that the management of COPD differs by sex, with women being more actively managed than men. It is unclear whether this is due to patient- or care-related factors.
For more information: https://tinyurl.com/yxb4j23a
Toronto, ON - There is limited knowledge on what proportions of patients with COPD receive ambulatory care from primary care physicians, pulmonologists, or other specialists. Researchers here evaluated the types and combinations of physicians who provide ambulatory care to patients with COPD. They conducted a population-based cross-sectional study using health administrative datasets from Ontario, Canada between April 1, 2014 and March 31, 2015. Individuals age 35 years and older with physician-diagnosed COPD were identified, using a previously validated COPD case definition. The primary outcomes were ambulatory visits to primary care physicians, pulmonologists, and all other specialists within a 1-year period. There were 895,155 individuals identified as having physician-diagnosed COPD. Of those, 56,533 individuals (6.3%) had no ambulatory care visits, 802,327 (89.6%) saw primary care physicians, and 95,782 (10.7%) consulted pulmonologists. By comparison, 736,496 (82.3%) saw other specialists, and 218,997 (24.5%) saw cardiologists. There were 32,473 individuals (3.6%) who underwent COPD-related hospitalizations. Of those in the sub-cohort with one hospitalization, about 30.0% saw pulmonologists; 43.7% of those who underwent two or more hospitalizations saw pulmonologists, and 9.9% with no hospitalization consulted pulmonologists. The researchers concluded that primary care physicians play a substantial role in caring for patients with COPD. But only one-half as many patients with COPD saw pulmonologists than cardiologists, suggesting that COPD may receive less specialty care compared with other chronic medical conditions. This information can help inform COPD care strategies to improve COPD care and minimize exacerbations and associated health-care costs. It also suggests a need for more research to provide guidance on when patients with COPD should be referred to pulmonologists. The study was led by Dr. Eunice E. Cho of the University of Toronto. Drs Graham Mecredy, Harvey Wong, Mathew Stanbrook and Andrea Gershon collaborated. Their study was published in the journal Chest.
For more information: http://tinyurl.com/y4jwjrok
Omuta City, Japan - In subjects aged greater than 50 years, researchers determined how respiratory function, respiratory symptoms, and the prevalence of COPD were influenced by exposure to air pollution and cigarette smoke. They performed screening in 433 individuals from Omuta City, Japan (an area with high levels of air pollution), via spirometry and medical questionnaires. A high estimated COPD prevalence rate of 16% was reported for non-smokers. The estimated prevalence rate of COPD was 29% and 37% in seniors (50- to 74-years group) and in the elderly (>75 years group), respectively, in a population of smokers. They also noted that levels of suspended particulate matter correlated with COPD. The consequences of smoking or chronic exposure to air pollution (>5 years) were: decreased respiratory function, exacerbated respiratory symptoms, and increased prevalence of COPD. To facilitate early detection of respiratory disease in elderly patients, periodic screening for these subjects was strongly advised.
For more information: http://tinyurl.com/y59zwe5u
Bethesda, Maryland - The first clinical trial of an innovative universal influenza vaccine candidate is examining the vaccine’s safety and tolerability as well as its ability to induce an immune response in healthy volunteers. Scientists at the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, developed the experimental vaccine, known as H1ssF_3928. H1ssF_3928 is designed to teach the body to make protective immune responses against diverse influenza subtypes by focusing the immune system on a portion of the virus that varies relatively little from strain to strain. The vaccine candidate was developed as part of a broader research agenda to create a so-called “universal” influenza vaccine that can provide long-lasting protection for all age groups from multiple influenza subtypes, including those that might cause a pandemic. “Seasonal influenza is a perpetual public health challenge, and we continually face the possibility of an influenza pandemic resulting from the emergence and spread of novel influenza viruses,” said NIAID Director Anthony S. Fauci, M.D. “This Phase 1 clinical trial is a step forward in our efforts to develop a durable and broadly protective universal influenza vaccine.” The clinical trial is being conducted at the NIH Clinical Center in Bethesda, Maryland. It is being led by Grace Chen, M.D., of NIAID’s Vaccine Research Center (VRC) Clinical Trials Program. “This Phase 1 clinical trial is the culmination of years of research and development made possible by the unique collaborative setting that the VRC offers by bringing together top scientists, manufacturing expertise, and an outstanding clinical team,” said VRC Director John Mascola, M.D. A team of VRC scientists developed the universal influenza vaccine prototype. The VRC expects the clinical trial to complete enrollment by the end of 2019 and hopes to begin reporting results in early 2020. More information about the trial and be found at ClinicalTrials.gov - use search identifier NCT03814720.
For more information: http://tinyurl.com/y45cuzwc
Chicago, IL - Dementia affects an estimated 47 million people worldwide, and this number is expected to rise to 131 million in 2050, resulting in huge social and economic costs. Several lines of evidence have listed smoking as a modifiable risk factor for the most common form of dementia – Alzheimer's disease (AD). "Not everyone who smokes will get dementia, but stopping smoking is thought to reduce your risk down to the level of non-smokers," according to the Alzheimer's Society. Some of the reasoning behind this assertion includes the presence of toxins in cigarette smoke that may increase oxidative stress and inflammation -- two stressors linked to the development of AD. However, it is not clear what single constituent or combination of chemicals could trigger the inexorable passage from mild cognitive impairment to AD. Genetic traits may distinguish some smokers from the general population when it comes to assessing the role of smoking in the onset of dementia. Many smokers may also die prematurely before they reach an age at which dementia will develop. In addition, it may be difficult to tease out the influences of other lifestyle risk factors. For instance, smokers are also likely to drink alcohol – another known risk factor for dementia. Erin Abner, PhD, of the University of Kentucky in Lexington, and colleagues wanted to explore the smoking-dementia association using a different method of data analysis. "The underlying data [in the earlier studies] was solid, but the analysis didn't take into account the idea of competing risk of mortality, which we felt was an important factor to consider in this case since smoking is so strongly associated with earlier death," Abner said in a news release. "If, for example, we were studying cancer deaths and smoking, and one of the people in the study died from heart disease, what do we do with that person's data?" she explained. "That person can't possibly die from cancer since a competing event (death from heart disease) has occurred. If we ignore that information, the data are not telling the right story." Data drawn from the University of Kentucky's Alzheimer's Disease Center's BRAiNS cohort, which provided a large sample of initially cognitively normal older adults (age 60+) followed for many years, with ample exposure to tobacco smoking (52.7% of participants had a smoking history) were used in this competing risk analysis. When deaths that occurred during the study period were treated as competing events, smoking was no longer associated with dementia. Simply put, smokers tended to die of causes that were not associated with dementia. "While our study results could influence smoking-cessation policy and practice, we feel that the most important consequence of our work is to demonstrate how this method could change the way we approach dementia research and to advocate for its adoption in the appropriate areas of study," she said in the press statement. "To be clear, we are absolutely not promoting smoking in any way. We're saying that smoking doesn't appear to cause dementia in this population."
For more information: https://tinyurl.com/y2mm8x3o
Daily aspirin use may reduce respiratory morbidity in COPD
San Diego, CA - Research study recently published in CHEST reported that aspirin use in COPD has been associated with reduced all-cause mortality in meta-regression analysis with few equivocal studies. However, the effect of aspirin on COPD morbidity is unknown. Self-reported daily aspirin use was obtained at baseline from SPIROMICS participants with COPD (FEV1/FVC < 70%). Acute exacerbations of COPD (AECOPD) were prospectively ascertained through quarterly structured telephone questionnaires up to 3 years and categorized as moderate (symptoms treated with antibiotics or oral corticosteroids) or severe (requiring ED visit or hospitalization). Aspirin users were matched one-to-one with nonusers, based on propensity score. The association of aspirin use with total, moderate, and severe AECOPD was investigated using zero-inflated negative binomial models. Linear or logistic regression was used to investigate the association with baseline respiratory symptoms, quality of life, and exercise tolerance. Among 1,698 participants, 45% reported daily aspirin use at baseline. Propensity score matching resulted in 503 participant pairs. Aspirin users had a lower incidence rate of total AECOPD (adjusted incidence rate ratio [IRR], 0.78; 95% CI, 0.65-0.94), with similar effect for moderate but not severe AECOPD (IRR, 0.86; 95% CI, 0.63-1.18). Aspirin use was associated with lower total St. George’s Respiratory Questionnaire score (β, –2.2; 95% CI, –4.1 to –0.4), reduced odds of moderate-severe dyspnea (modified Medical Research Council questionnaire score ≥ 2; adjusted odds ratio, 0.69; 95% CI, 0.51-0.93), and COPD Assessment Test score (β, –1.1; 95% CI, –1.9 to –0.2) but not 6-min walk distance (β, 0.7 m; 95% CI, –14.3 to 15.6). The researchers concluded that daily aspirin use is associated with reduced rate of COPD exacerbations, less dyspnea, and better quality of life. Randomized clinical trials of aspirin use in COPD are warranted to account for unmeasured and residual confounding.
For more information: https://tinyurl.com/y2t5hcyf
Toronto, ON – An interview recently published by the Canadian Medical Association highlighted the gap between diagnosis and treatment in Canada. As a family doctor at St. Michael’s Hospital in Toronto, Dr. Persaud details a typical scenario he sees in his practice. A patient with poorly controlled diabetes or high blood pressure comes in and he prescribes them medication, but the patient doesn’t take it because they can’t afford it. At some point, the same patient returns with the same problem. In his early years of practice, Dr. Persaud believed there was nothing he could do to fix this cycle. But once some of these same patients started having heart attacks and strokes, he felt compelled to act. “It’s unacceptable that people are being harmed unnecessarily, when there are relatively inexpensive treatments that could prevent it,” Dr. Persaud explains. “There are millions of people across Canada who can’t afford medications, so let’s do something that might inform public policy and improve the situation for everyone.” So in 2016, Dr. Persaud launched the CLEAN Meds (Carefully selected and easily accessible at no charge medications) study, a randomized controlled trial testing the effects of providing patients access to more than 125 “essential medicines” for free. Almost 800 people are now taking part in the study through seven health centres: four in Toronto and three in the Manitoulin Island area. At the time they were enrolled, all the patients had reported being unable to afford a medication during the previous 12 months. “The current system - a mishmash of private insurance, public insurance and no insurance - is a mess that leaves taxi drivers, factory workers, entrepreneurs, musicians and others in a position where often, they can’t afford to take medications, and have to make very difficult decisions.” Half of the participants were randomly placed in the control group, without any additional support for filling their prescription. The other half were assigned to the intervention group and had a pharmacist in the study mail their medications — for free — directly to their homes. A patient with diabetes, for instance, would receive metformin and insulin at no charge. “By comparing the two groups, we can determine the effects of free and convenient access to medications,” says Dr. Persaud. “Do people take the medications as instructed, are the medications more likely to be prescribed appropriately, and do people have better control of their conditions and diseases?” The list of essential medicines created for the study is adapted from a similar list published by the World Health Organization and tailored to the Canadian market. It ranges from inexpensive medications such as acetaminophen and vitamin D to what Dr. Persaud calls “fantastically expensive” biologics such as dolutegravir, a new HIV treatment that costs roughly $10,000 a year. He says several drugs that are commonly prescribed were kept off the list because there was no evidence, they are effective. Results from the first 12 months of the CLEAN Meds study are expected to be published in early 2019, shortly before the Advisory Council on the Implementation of National Pharmacare issues its final report. The council, chaired by Dr. Eric Hoskins, is leading a national dialogue on how to implement affordable national pharmacare for Canadians and their families, employers and governments.
For more information: https://www.cma.ca/dr-nav-persaud
Lung transplant patients told to fund-raise to pay for life saving treatment
Halifax, NS - CBC Radio reported that some patients in Atlantic Canada can't afford cost of lung transplants, and are choosing to die instead. Atlantic Canadian patients who need lung transplants must move to Toronto for the life-saving surgery, but because the high cost of the move is not fully financially supported, some are simply choosing to die. "I have now had three patients, from Nova Scotia, who have decided not to go," said Dr. Meredith Chiasson, a respirologist based in Halifax. Those patients have not died yet, but "are coming to the end of their lives," she told The Current's guest host Piya Chattopadhyay. Lung transplants are covered by the health-care system, but as the operation is not available in Atlantic Canada, patients must relocate to Toronto for potentially six to 12 months. Each province has its own allowances to help with the cost: patients from P.E.I. get $1,000 a month; there's $1,500 a month available in Nova Scotia and New Brunswick; and $3,000 a month for those from Newfoundland and Labrador. They face financial ruin to get a new lung. Some are choosing to die instead That financial aid can fall short of Toronto's high cost of living however, leaving patients scrambling to make up the difference. Natalie Jarvis, a patient who spoke to CBC News, tried to find accommodation in Toronto and was quoted rental rates as high as $5,000 a month. Chiasson said that in order to get her patients to Ontario for treatment, she has to tell them to fundraise. "I hate having to tell them that right now, when you can barely speak a full sentence, I need you to go out and pound the pavement to try and earn money so you can live," she told Chattopadhyay. You are going to have to do fundraising or something else to come up with this money, because right now it's not coming from our government,” said Dr. Meredith Chiasson. "I tell them that's the reality of the situation we're in right now: you are going to have to do fundraising or something else to come up with this money, because right now it's not coming from our government." She said that conversations around health become secondary at that point, as money becomes the focus. "I have a hard time getting them to listen to some of the other things I need them to hear," she said. "We need to talk about the drugs they have to take, and the side-effects, and survival after a lung transplant. "There's a big conversation we need to have about transplants, but all they focus on is the money."
For more information: https://tinyurl.com/y2o6e3n9
Salzburg, Austria There are several reports on underdiagnosis of COPD, while little is known about COPD overdiagnosis and overtreatment. Researchers here describe the overdiagnosis and the prevalence of spirometrically defined false positive COPD, as well as their relationship with overtreatment across 23 population samples in 20 countries participating in the BOLD Study between 2003 and 2012. A false positive diagnosis of COPD was considered when participants reported a doctor’s diagnosis of COPD, but postbronchodilator spirometry was unobstructed (FEV1/FVC > LLN). Additional analyses were performed using the fixed ratio criterion (FEV1/FVC < 0.7). Among 16,177 participants, 919 (5.7%) reported a previous medical diagnosis of COPD. Postbronchodilator spirometry was unobstructed in 569 subjects (61.9%): false positive COPD. A similar rate of overdiagnosis was seen when using the fixed ratio criterion (55.3%). In a subgroup analysis excluding participants who reported a diagnosis of “chronic bronchitis” or “emphysema” (n = 220), 37.7% had no airflow limitation. The site-specific prevalence of false positive COPD varied greatly, from 1.9% in low- to middle-income countries to 4.9% in high-income countries. In multivariate analysis, overdiagnosis was more common among women, and was associated with higher education; former and current smoking; the presence of wheeze, cough, and phlegm; and concomitant medical diagnosis of asthma or heart disease. Among the subjects with false positive COPD, 45.7% reported current use of respiratory medication. Excluding patients with reported asthma, 34.4% of those with normal spirometry still used a respiratory medication. The researchers concluded that false positive COPD is frequent. This might expose non-obstructed subjects to possible adverse effects of respiratory medication. The study was published in the journal CHEST.
For more information: https://journal.chestnet.org/article/S0012-3692(19)30066-2/fulltext
The risks of e-cigarette use in COPD might be greater than in people without COPD
Sydney, Australia – A study recently published in the European Respiratory Journal looked at e-cigarettes that are often used as an alternative to cigarette smoking and as nicotine replacement therapy. Some suggestions are that they are markedly less harmful than cigarettes to the user. The confusion around the safety of e-cigarettes stems from contradictory findings in which variations in experimental methodology and the testing of different devices has not been accounted for. The harms associated with their use are not well understood and this is commonly misconceived as meaning that they are a healthy alternative to smoking. This misconception is further exacerbated by physicians and public health bodies which have made recommendations without strong scientific evidence. Multiple studies have concluded that e-cigarette vapour exposure could lead to inflammation, emphysema and a greater risk of bacterial and viral infection. The lack of a defined model for e-cigarette exposure for both in vitro cellular and in vivo animal studies has led to contradictory findings between studies. Such differences can be attributed to different devices (first versus fourth generation), vaporisation temperature, different E-liquids or the concentration of e-cigarette vapour used. The confusion caused by contradictory findings leaves consumers and clinicians to form their own opinions about e-cigarettes safety which may lead to further public health issues in the future. Furthermore, no studies have compared responses in cells from people with chronic obstructive pulmonary disease (COPD), a disease state where the use of e-cigarettes is particularly attractive. However, COPD lung cells are known to be hyperresponsive to a range of environmental stimuli including cigarette smoke and pollution, and therefore might also respond differently to e-cigarette vapour. The aim of this study was to evaluate dose–response relationships of e-cigarette stimulation of primary airway smooth muscle cells (ASMCs) from people with and without COPD under realistic physiological conditions. ASMCs were chosen for this study because of their contribution to pathological processes in COPD. Not only is smooth muscle bulk increased in COPD airways, ASMCs have been shown to secrete increased inflammatory mediators and chemokines compared with cells from smokers without COPD, suggesting their response to inflammatory stimuli might contribute to lung inflammation and/or disease progression in COPD. We have previously shown that ASMCs and airway fibroblasts from people with COPD are hyperresponsive to cigarette smoke, and hypothesised that they would also be hyperresponsive to e-cigarettes. We also hypothesised that the increased toxic by-product formation seen at higher vaporisation temperatures would result in greater cytotoxicity in ASMCS. Patients with COPD, or smokers, might switch to e-cigarettes as an alternative nicotine source, believing that they are safer. All e-cigarette aerosols increased CXCL8 production in ASMCs irrespective of flavour or nicotine concentration. This suggests that e-cigarettes would stimulate lung neutrophilic inflammation. Furthermore, our data suggests that e-cigarette aerosol stimulates COPD cells in a similar manner to cigarette smoke, resulting in an increased production of CXCL8 from COPD cells compared with non-COPD cells. Overall, our data suggests that COPD patients should avoid using e-cigarettes as a smoking cessation aid as they have a similar ability to stimulate inflammation and lung damage as cigarette smoke, and thus potentially accelerate their disease progression.
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Triple therapy (ICS/LABA/LAMA) in COPD: thinking out of the box
London, UK - Triple inhaler therapy in COPD might in some real-life situations be useful outside of the strict indications reported by the registration agencies, but at the same time in some other situations it could be better avoided, even when recommended. A current hot topic in COPD is that two “fixed triple” combinations of an inhaled corticosteroid (ICS), a long-acting β2-agonist (LABA) and a long-acting muscarinic antagonist (LAMA) in a single inhaler have become available for patients with COPD, and a third triple therapy is in advanced development with the first large randomised clinical trial (RCT) recently published in Lancet Respiratory Medicine Vol 5 Issue 1.Whether triple therapy in a single inhaler outperforms the three individual components given in separate inhalers is unknown. In fact, there is only one study where the triple therapy in a single inhaler was compared to triple therapy in separate inhalers, but the LAMA was different with glycopyrronium in the former (BDP/FF/G) and tiotropium in the latter. The two triple therapies were equally effective, and both superior to tiotropium alone . For the time being, the additional benefit of a fixed triple LABA/LAMA/ICS combination is related to convenience for the patient, and possibly improved compliance. However, the researchers here speculated that the simultaneous delivery to the target organ of three agents with different mechanisms of action may improve positive interactions between them. In addition, triple therapy might improve activity levels through bronchodilation or reduced breathlessness, and thereby improve respiratory muscle strength and impact upon disease progression.There is only one triple therapy currently available in Canada as a single inhaler. The brand name if Trelegy Ellipta - fluticasone-furoate/vilanterol/umeclidinium
1 Vestbo J, Papi A, Corradi M, et al. Single inhaler extrafine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease (TRINITY): a double-blind, parallel group, randomised controlled trial. Lancet 2017; 389: 1919–1929.
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London, UK - If you thought ditching regular smokes for an e-cig or heated tobacco device was a way to save your lungs, you’d be wrong. That’s the message coming from a team of Australian researchers who say that any kind of smoking is ‘toxic’. It’s at odds with plenty of campaigners who say that vaping and heated tobacco devices are safer than traditional cigarettes. But the scientists took a look at a ‘next generation’ heated tobacco device on sale globally and found it still damaged human lungs by changing their structure and creating an inflammatory response. Dr Sukhwinder Sohal led the study from the University of Tasmania, which looked at cigarettes, e-cigarettes and the heated tobacco IQOS device made by tobacco giant Philip Morris International. ‘Our results suggest that all three are toxic to the cells of our lungs and that these new heated tobacco devices are as harmful as smoking traditional cigarettes. ‘Damage to these two types of lung cells can destroy lung tissue leading to fatal diseases such as chronic obstructive pulmonary disease, lung cancer and pneumonia, and can increase the risk of developing asthma, including in unborn children. ‘So we should not assume that these devices are a safer option.’ While e-cigarettes and heated tobacco still contain nicotine (the addictive substance in ciggies) but it’s in liquid form and is heated into vapour. Which limits some of the damage caused by standard cigarette smoke and ash. As part of the study, the team did lab tests on the effects of all three devices on epithelial cells (which line your organs) and smooth muscle cells taken from the human airways. Cigarette smoke and heated tobacco were highly toxic while vaping induced a ‘cry for help’ inflammatory response. Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, who was not involved in the research, said the study suggested a need for ‘considerable caution’ on heat-not-burn products, although their impact is not fully understood. E-cigarettes produce vaporized nicotine (PA) He said: ‘E-cigarettes are often presented as safer than cigarettes because they also deliver nicotine but contain no tar, the cause of lung cancer. ‘But they contain many things not found in conventional cigarettes. ‘We really have very little idea about the specific risks associated with e-cigarettes but the evidence that is emerging indicates that they are far from safe, with risks to the heart and lungs. This study adds to that body of evidence.’ Public Health England has urged smokers to use e-cigarettes, calling concerns over vaping ‘false fears’. But the study, published in the journal ERJ Open Research, says both e-cigarettes and heated tobacco devices causes the same type of damage to cells seen in people with chronic obstructive pulmonary disease (COPD), asthma, bronchitis and emphysema who struggle to breathe. Smoking tobacco will destroy your epithelial cells (Getty Images) Professor Charlotta Pisinger is Chair of the European Respiratory Society’s Tobacco Control Committee and was not involved in the research. She said: ‘These new heated tobacco devices are marketed as producing 95% lower levels of toxic compounds because the tobacco is heated, not burned. However, the first independent studies have shown that combustion is taking place and toxic and carcinogenic compounds are released, some in lower levels than in conventional cigarette smoke, others in higher levels. ‘A review of the tobacco industry’s own data on these devices has shown that, in rats, there is evidence of lung inflammation, and there is no evidence of improvement in lung inflammation and function in smokers who switch to heated tobacco.’ ‘The introduction and vigorous marketing of new devices is very tempting to smokers who want to stop smoking and mistakenly believe they can switch to another harmless tobacco product. ‘It is also opening another avenue for attracting young people to use and become addicted to nicotine. This study adds to evidence that these new devices are not the safe substitute to cigarette smoking they are promoted to be.
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Effectiveness of long-term use of statins in COPDLanzhou, Gansu, People’s Republic of China - Researchers here performed a general meta-analysis to assess the efficacy of long-term treatment of statins for chronic obstructive pulmonary disease (COPD), and to answer which one is better. For the effect of mortality, inflammatory factors, and lung function index in COPD patients, pooled estimates were produced. They identified the eligible studies from PubMed, Web of Science, Embase, and China National Knowledge Infrastructure, and performed a network meta-analysis to synthetically compare the effectiveness of using different statins in COPD patients. Reduced risks of all-cause mortality, heart disease-related mortality, and COPD acute exacerbation were found in association with statin use in COPD patients in general meta-analysis. In network meta-analysis, the higher cumulative probability in reducing C-reactive protein (CRP) in COPD patients was shown by fluvastatin (97.7%), atorvastatin (68.0%), and rosuvastatin (49.3%) vs other statins. Fluvastatin and atorvastatin more effectively attenuated CRP and pulmonary hypertension (PH) in COPD patients. Overall, statins can attenuate the risk of mortality, the level of CRP, and PH in COPD patients.
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London, UK - Cigarette smokers who attempted to stop smoking with electronic cigarettes and behavioral support were almost twice as likely to be abstinent a year later than those using nicotine-replacement therapies (NRT), a randomized trial showed. British researchers randomly assigned adults attending U.K. National Health Service stop-smoking services to receive either NRT products of their choice, including combinations of products, provided for up to 3 months, or an e-cigarette starter pack (e-liquid strength, 18 mg/mL) with instructions to purchase further e-liquids in the flavors and nicotine strength of their choice. Both groups were also offered weekly behavioral support, reported Dunja Przulj, PhD, of Queen Mary University in London, and colleagues. A year later, the sustained abstinence rate was almost twice as high among the smokers randomized to the e-cigarette group: 18.0% versus 9.9% (relative risk 1.83, 95% CI 130-2.58, P<0.001), they wrote in the New England Journal of Medicine. Przulj said the study findings confirm that e-cigarettes are an effective way for smokers to quit smoking. But in an accompanying editorial, Belinda Borrelli, PhD, and George T. O'Connor, MD, both of Boston University, noted that while just 9% of study participants in the NRT arm who were not smoking 1 year after randomization were still using nicotine replacement, 80% of those who stopped smoking using e-cigarettes were still vaping 1 year later. "This differential pattern of long-term use raises concerns about the health consequences of long-term e-cigarette use," they wrote, adding that e-cigarette vapor has been shown to contain toxins that have the potential to negatively impact human cells. They further noted that early studies in mice and humans suggested that these biologic effects impact lung function, although to a lesser extent than cigarette smoking. And, the editorialists worried about second-hand effects on children of those who continue vaping. Not only could those include direct health impacts, but children could also pick up the habit themselves from viewing parents as role models. "These findings argue against complacency in accepting the transition from tobacco smoking to indefinite e-cigarette use as a completely successful smoking-cessation outcome," Borrelli and O'Connor wrote. The randomized trial originally included 886 participants recruited at three NHS smoking cessation service sites from May of 2015 to February of 2018. Adult smokers were invited to participate if they were not pregnant or breast-feeding, had no strong preference to use or not use NRT or e-cigarettes, and were not using either type of product at recruitment. Those randomized to the e-cigarette arm of the trial received a second-generation refillable e-cigarette with one 30 ml bottle of nicotine e-liquid. They were encouraged to purchase future e-liquids online or from local vape shops, and to experiment with different nicotine strengths and flavors if the provided e-liquid did not meet their needs. Participants in the NRT group were informed about the range of products available (gum, patch, lozenge, nasal spray, inhalator, mouth spray, mouth strip, and microtabs) and they selected their preferred product. Combination use -- typically a patch and fast-acting oral NRT -- was encouraged. Participants could also switch products during the trial. The behavioral therapy was offered to both treatment groups as weekly one-on-one sessions delivered for at least 4 weeks after the quit date. Participants were contacted by telephone at weeks 26 and 52, and interviewers asked about product use and smoking abstinence. Respondents who reported abstinence or a reduction in smoking of at least 50% at 52 weeks were invited back to provide carbon monoxide readings to confirm smoking status. Overall, adherence was similar in the two groups, but e-cigarettes were used more frequently and for longer than nicotine replacement over 52 weeks (63 of 79 e-cigarette users who quit smoking were still vaping at 1-year vs four of 44 NRT users who quit smoking cigarettes). "Both e-cigarettes and nicotine-replacement were perceived to be less satisfying than cigarettes," the researchers wrote. "However, e-cigarettes provided greater satisfaction and were rated as more helpful to refrain from smoking than nicotine-replacement products
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