COPD World News - 2022
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.”
For more information: https://tinyurl.com/m9zn4t2tOmicron 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.”
For more information: https://tinyurl.com/3hd44c93