Type 2 Diabetes and the Lung - Cause and Consequence.

Coronary atherosclerosis and chronic obstructive pulmonary disease (COPD) are highly prevalent, and two of the commonest causes of morbidity and mortality in the Australian population. They share cigarette smoking as an important risk factor, and frequently coexist. Drugs which act on the beta-adrenergic receptor are important therapeutic tools in both diseases. However, beta-receptor antagonists, which are commonly used to treat cardiac disease, theoretically may cause adverse respiratory effects and are traditionally avoided in patients with obstructive airways disease. This work seeks to explore the short and longer term effects of beta-blocker medications, when used for treatment of cardiac disease in patients with coexisting obstructive airways disease. Specifically, the aims of this research are: 1. To estimate the prevalence of coexisting obstructive airways disease amongst patients with cardiac disease 2. To investigate current beta-blocker prescribing practice in patients with obstructive airways disease 3. To document adverse respiratory effects of beta-blocker medications, in terms of symptoms, lung function and other longer term health outcomes. Within 24 hours of hospital admission for suspected cardiac disease, patients were screened for airways obstruction, using spirometry. Spirometry results demonstrated a high level of coexistence of cardiac disease and obstructive airways disease, about twice that cited in previously published estimates. Documentation of beta-blocker prescribing practices within the Royal Prince Alfred Hospital's Cardiology Unit revealed minimal prescription of these medications to patients with previously diagnosed chronic obstructive airways disease and asthma, despite limited evidence of adverse effects of beta-blocker use in such patients. This notably occurred even when guidelines recommended beta-blockade as first line therapy, and where survival benefit was established. However, many patients with obstructive spirometry, but no formal diagnosis of obstructive airways disease, did receive betablockers. Longitudinal analysis of symptom assessment, lung function and health outcomes was performed. Lung function and respiratory symptoms data were collected over a twelve month period and data pertaining to beta-blocker discontinuation, respiratory exacerbations, acute cardiac events and survival were collected over almost six years. There was no indication of a statistically significant adverse beta-blocker effect on lung function, respiratory symptoms or survival but beta-blocker medications did appear to increase respiratory exacerbation rates. This work confirms the very high frequency of obstructive airways disease existing in combination with cardiac disease in an Australian urban population, which had been suspected but not previously documented. However, its major contribution is to provide prospective long term respiratory health outcome data for the use of betablocker medications in this group.

Targeted Deletion of Jun/AP-1 in Alveolar Epithelial Cells Causes Progressive Emphysema and Worsens Cigarette Smoke–Induced Lung Inflammation

BackgroundDespite the fact that heart failure and chronic obstructive pulmonary disease (COPD) often exist together and have serious clinical and economic implications, they have mostly been studied separately. Our aim was to study prevalence of coexisting heart failure and COPD in a Swedish population. A further goal was to describe levels of other comorbidity and investigate where the patients received care: primary, secondary care or both.MethodsWe conducted a register-based, cross-sectional study. The population included all people older than 19 years, living in Östergötland County in Sweden. The data were obtained from the Care Data Warehouse register from the year 2006. The diagnosis-based Adjusted Clinical Groups Case-Mix System 7.1 was used to describe the comorbidity level.ResultsThe prevalence of the diagnosis of heart failure in patients with COPD was 18.8 % while it was 1.6 % in patients without COPD. Age standardized prevalence was 9.9 and 1.5 %, respectively. Standardized relative risk for the diagnosis of heart failure in patients with COPD was 6.6. The levels of other comorbidity were significantly higher in patients with coexisting heart failure and COPD compared to patients with either heart failure or COPD alone. Primary care was the only care provider for 36.2 % of patients with the diagnosis of heart failure and 20.7 % of patients with coexisting diagnoses of heart failure and COPD. Primary care participated furthermore in shared care of 21.5 % of patients with the diagnosis of heart failure and 21.7 % of patients with coexisting diagnoses of heart failure and COPD. The share of care between primary and secondary care varied depending on levels of comorbidity both in patients with coexisting heart failure and COPD and patients with heart failure alone.ConclusionPatients with coexisting diagnoses of heart failure and COPD are common in the Swedish population. Patients with coexisting heart failure and COPD have higher levels of other comorbidity than patients with heart failure or COPD alone. Primary care in Sweden participates to a great extent in care of patients with diagnoses of heart failure alone and coexisting heart failure and COPD.

Background: Chronic Obstructive Pulmonary Disease (COPD) is often associated with comorbidities, especially cardiovascular, that have a heavy burden in terms of hospitalization and mortality. Since no conclusive data exist on the prevalence and type of comorbidities in COPD patients in Italy, we planned the INDACO observational pilot study to evaluate the impact of comorbidities in patients referred to the outpatient wards of four major hospitals in Rome. Methods: For each patient we recorded anthropometric and anamnestic data, smoking habits, respiratory function, GOLD (Global initiative for chronic Obstructive Lung Disease) severity stage, Body Mass Index (BMI), number of acute COPD exacerbations in previous years, presence and type of comorbidities, and the Charlson Comorbidity Index (CCI). Results: Here we report and discuss the results of the first 169 patients (124 males, mean age 74±8 years). The prevalence of patients with comorbidities was 94.1% (25.2% of cases presented only one comorbidity, 28.3% two, 46.5% three or more). There was a high prevalence of arterial hypertension (52.1%), metabolic syndrome (20.7%), cancers (13.6%) and diabetes (11.2%) in the whole study group, and of anxiety-depression syndrome in females (13%). Exacerbation frequency was positively correlated with dyspnea score and negatively with BMI. Use of combination of bronchodilators and inhaled corticosteroids was more frequent in younger patients with more severe airways obstruction and lower CCI. Conclusions: These preliminary results show a high prevalence of comorbidities in COPD patients attending four great hospitals in Rome, but they need to be confirmed by further investigations in a larger patients cohort.

Chronic obstructive pulmonary disease (COPD) is a significant and rising global health problem. It is a complex disease with genetic, epigenetic, and environmental influences characterized by progressive airflow limitation, chronic inflammation in the lungs, and associated systemic inflammation. No effective cure for COPD exists to date and research into new therapies will be essential if this disease is to be managed in the future. Obesity with the metabolic syndrome and malnutrition represent two poles of metabolic abnormalities that may relate to systemic inflammation. The metabolic syndrome is present in almost 50% of COPD patients. Instead, peripheral skeletal muscle dysfunction is an established systemic feature of COPD. Malnutrition varies from 20% to 50% in patients with COPD. Reduction in body weight by more than 10% of the ideal weight is an independent negative prognostic factor in COPD. We assume that in patients with COPD and concurrent alteration of nutritional status at least three factors play a role in the systemic inflammatory syndrome: the severity of pulmonary impairment, the degree of obesityrelated adipose tissue hypoxia, and the severity of systemic hypoxia due to reduced pulmonary functions. Further research should elucidate the complex relationship between obstructive lung disease and systemic inflammation and oxidant stress, as well as the role of systemic inflammation in coexisting conditions, such as obesity and malnutrition. In this scenario, diet is a modifiable risk factor for COPD that appears to be more than an option to prevent and modify the course of COPD. Mounting evidence from human studies and experimental investigations have shed new light on the relationship between diet, lung function and COPD development, showing protective or harmful role of certain foods, nutrients and dietary patterns on pulmonary function and COPD development. In particular, beneficial effects on lung function and COPD development have been described for dietary antioxidants including vitamins and polyphenols, mainly from fresh fruits and vegetables, n-3 polyunsaturated fatty acids (PUFA) as well as dietary patterns rich in these constituents, possibly through antioxidant and anti-inflammatory mechanisms. A better understanding of dietary influences on COPD will hopefully lead to design more effective and personalized approach for the nutritional prevention and treatment of this disabling condition.

The aim of this study was to investigate the cardiovascular comorbidity in patients with chronic obstructive pulmonary disease (COPD) and the assessment of the risk of stroke by means of the scale CHA2DS2-VASc. <b>Methods:</b> 215 patients with chronic obstructive pulmonary disease (COPD) were observed. The investigated group was made by the patients having the long experience of smoking. Research of function of external breath was studied with multimodular installation of type «Master-Lab/Jaeger. Charlson index was noted. The risk of stroke was studied by means of the scale CHA2DS2-VASc <b>Results:</b> the arterial hypertension was detected in 59.02% of patients with COPD, atrial fibrillation was noted in 10.24% of patients. The risk of stroke, rated on a scale CHA2DS2-VASc was 3,24 ± 1,8. The stroke in the past was noted in 4.49% patients. Myocardial infarction was observed in 10.73%, angina - at 14.15% patients, pulmonary embolism was associated in 2.93% of patients with COPD. the Charlson index was 4 ,23 ± 1,33 in COPD 2 stage, 4,51 ± 1,3 in COPD 3 stage, 4,75 ± 1,48 in COPD 4 stage. The correlation coefficient between stroke risk scale CHA2DS2-VASc and comorbidity index Charlson was r 0,89, p˂0,005. The correlation coefficient between stroke risk and an indicator the duration of smoking was r 0,84, p˂0,005. <b>Conclusions:</b> the risk of stroke was connected with Index of comorbidity in COPD patients, frequency of cardiovascular comorbidity was high in COPD patients.

Commentary on Zheng Y, Yee BJ, Wong K, Grunstein R, Piper A. A pilot randomized trial comparing CPAP versus bilevel PAP spontaneous mode in the treatment of hypoventilation disorder in patients with obesity and obstructive airway disease. J Clin Sleep Med. 20XX;XX(XX):XXX-XXX. doi:10.5664/jcsm.9506.

BackgroundChronic obstructive pulmonary disease (COPD) is one of the leading causes of death and loss of disability-adjusted life-years. However, many COPD patients are not diagnosed because of underrecognition or underdiagnosis of this disease among many patients and physicians. One possible reason is underrecognition of spirometry. In this study, we examined the prevalence of airflow limitation and underlying disease in patients with airflow limitation.MethodologyFrom April 2006 to March 2008, patients who had spirometry performed were examined. The original disease of patients, pulmonary function tests, smoking status, and respiratory symptoms were surveyed from their medical records.ResultsOf all patients who had spirometry performed, 15.8% showed airflow limitation (FEV1/FVC < 0.7). A variety of diseases were observed in patients with airflow limitation. Among all diseases, cardiovascular disease was the highest and gastrointestinal malignant disease had the second highest prevalence in patients with airflow limitation.ConclusionCOPD might be frequent in conditions of comorbidity in patients treated for various diseases. Attention should be paid to the possibility of co-existence of COPD and the influence of COPD on these patients.

Chapter 4 - Obesity and obstructive lung disease: An epidemiologic review

Objective:to assess the diagnostic significance of atrial and brain natriuretic peptides for the detection of chronic heart failure in comorbid patients with atrial fibrillation and chronic obstructive pulmonary disease.Materials and methods:120 patients depending on the presence of chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF) and atrial fibrillation (AF) were divided into the following groups: I group (n=28) — patients with COPD without cardiovascular disease (CVD), II group — patients with CHF and COPD without AF (n=30), III group — patients with CHF and AF without COPD (n=33), IV group — patients with CHF, AF and COPD (n=29). Th e concentration of precursors of brain and atrial natriuretic peptides (NUP) (NT-proBNP and MR-proANP) was evaluated.Results:The level of NT-proBNP exceeded the reference values in all patients with CHF (I, II, III groups). In patients with CHF, AF and COPD the highest values of NT-proBNP concentrations were obtained, which were 2.2 times higher in the group of patients with CHF and COPD without AF (p=0.000) and 1.9 times higher in patients with CHF and AF without COPD (p=0.01). Comparative analysis of the MR-proANP level allowed to judge a higher concentration of this indicator in patients with CHF and COPD without COPD in comparison with the level of the marker in the groups of patients with CHF, AF and COPD (p=0.001), CHF and COPD without AF (p=0.000) and COPD without CVD (p=0.000).Conclusions:in patients with AF and COPD, the study of brain NUP NT-proBNP in connection with structural and functional changes of the right ventricle, against the background of existing cardiac arrhythmias and pulmonary pathology is preferable to determine the presence and severity of CHF. The elevated level of MR-proANP is of diagnostic value in patients with AF and CHF without COPD, due to the increased volume load on the Atria due to the presence of AF.

Chronic obstructive pulmonary disease (COPD) is a global health issue with high social and economic costs. Concomitant chronic cardiac disorders are frequent in patients with COPD, likely owing to shared risk factors (e.g., aging, cigarette smoke, inactivity, persistent low-grade pulmonary and systemic inflammation) and add to the overall morbidity and mortality of patients with COPD. The prevalence and incidence of cardiac comorbidities are higher in patients with COPD than in matched control subjects, although estimates of prevalence vary widely. Furthermore, cardiac diseases contribute to disease severity in patients with COPD, being a common cause of hospitalization and a frequent cause of death. The differential diagnosis may be challenging, especially in older and smoking subjects complaining of unspecific symptoms, such as dyspnea and fatigue. The therapeutic management of patients with cardiac and pulmonary comorbidities may be similarly challenging: bronchodilators may have cardiac side effects, and, vice versa, some cardiac medications should be used with caution in patients with lung disease. The aim of this review is to summarize the evidence of the relationship between COPD and the three most frequent and important cardiac comorbidities in patients with COPD: ischemic heart disease, heart failure, and atrial fibrillation. We have chosen a practical approach, first summarizing relevant epidemiological and clinical data, then discussing the diagnostic and screening procedures, and finally evaluating the impact of lung-heart comorbidities on the therapeutic management of patients with COPD and heart diseases.

COPD is often accompanied by other chronic diseases that are also associated with systemic inflammation, such as obesity, diabetes, and arteriosclerosis. Recent data indicate that nocturnal oxygen desaturation and coexisting metabolic syndrome are related to systemic inflammation in patients with COPD. Alveolar hypoxia and consequent hypoxemia increase in prevalence as COPD severity increases. Chronic hypoxemia contributes to the development of adverse sequelae of COPD, such as pulmonary hypertension, atherosclerosis, lung microbiome diversity and systemic inflammation. COPD is a heterogeneous disease with airway inflammation driven by bacterial infections, few studies to date they examined microbiology or infection. The introduction of cultureindependent techniques for the microbiological analysis of respiratory samples confirmed that respiratory system hosts a large number of microorganisms, which include a wide range of bacteria. Regular exposure to tobacco smoke, lifestyle and food pattern can change the microbiome in healthy smokers and at-risk COPD patients, increasing the presence of a limited number of genres that reach a high relative abundance, a pattern, which can be considered as a dysbiosis. We assume that in patients with COPD and concurrent obesity and lung dysbiosis at least three factors play a role in the systemic inflammatory syndrome. Recent data showed that changes in the lung microbiome are associated with numerous exacerbations of COPD and are involved in mediating inflammatory responses of the host in some patients. Further research should elucidate the complex relationship between obstructive lung disease, obesity and lung microbiome diversity systemic inflammation accompanying these different conditions, and the causative role of systemic inflammation in obese COPD with nocturnal oxygen desaturation.

Background: the presence of chronic productive cough seems to be an independent risk factor for the development of chronic obstructive pulmonary disease (COPD) in current smokers. Stage 0 disease, or sub-clinical COPD, correlates with the risk of further developing COPD. Spirometry is indicated when a person presents with respiratory symptoms. The aim of this study was to investigate the correlation between spirometry and symptoms in a group of current smokers. Methods: thirty eight men and twenty women known as current smokers and presenting with respiratory symptoms were recruited. Respiratory symptoms were: dyspnea, chronic productive cough, and wheezing. A non-smokers control group was also recruited, age and sex matched. Impaired respiratory function, correlated with obstructive lung disease, as stated in current guidelines, was defined as FEV1/VC ratio <;0.70. The results were analyzed using SPSS 10 for Windows; data are reported as mean, standard deviations and standard errors. The statistical significance was given by a p value <;0.05. Results: from the total of fifty eight patients with respiratory symptoms, 55% had spirometric changes (FEV 1/VC ratio <;0.70). Lower age, female gender, higher body mass index (BMI) and smoking index were related to significant respiratory symptoms despite an FEV (1)/VC ratio of >/=0.70. The most common problem in the quality assessment was an insufficient exhalation time. There were statistically significant differences (p <; 0.05) between men and women in our group regarding the correlation between symptoms and spirometry, especially when it comes to chronic cough and dyspnea, women having more often normal spirometric results, with mild or moderate symptoms. Conclusions: Half of our group of current smokers with symptoms had their suspected diagnosis confirmed with spirometry. Our data indicate that female gender, smoking index, higher BMI and shorter exhalation time increase the risk of being diagnosed with COPD without fulfilling the spirometric criteria for the disease. On the other hand, smokers who complain of this symptom should be regarded as being at high risk for the development of COPD, and should be closely monitorized. Patients with smoking-related symptoms should be offered spirometry as they may benefit from symptom-relieving treatment.

Spirometry, the measurement of forced expiratory volume in 1 s and forced vital capacity, is recommended in the diagnosis and management of the obstructive lung diseases asthma and chronic obstructive pulmonary disease (COPD). The present report describes spirometry use in Manitoba and tests the hypothesis that regional spirometry use correlates with the prevalence of physician-diagnosed obstructive lung diseases. Spirometry is renumerated on a fee-for-service basis by Manitoba Health. Like other physician services, billing data include a diagnosis, patient identifiers, as well as the patient's sex, date of birth and residential postal code. Physician billings for spirometry for 1991 to 1998 were analyzed, comparing data with billings for physician visits for obstructive diseases. Four age groups were examined, as were income quintiles in Winnipeg, Manitoba. In addition, the prevalence of physician-diagnosed obstructive diseases were compared with spirometry rates in 49 service use areas of the province. Annually, about 3% of the Manitoba population underwent spirometry, and in aggregate, about 14% underwent spirometry during the eight years of the study. Rates in Winnipeg were higher than in the remainder of the province. Spirometry rates did not increase with time, and people who underwent spirometry had 1.4 to 1.7 tests/year. In children, higher income quintiles were tested more than lower income quintiles, while in adults, income quintiles were tested with equal frequency. People with obstructive lung disease accounted for about 75% of those tested, and in people with these diagnoses, the likelihood of testing increased approximately linearly with the number of physician visits for asthma or COPD. Children with asthma were tested less often than adults, and adults with asthma or both asthma and COPD were tested more often than those with COPD alone. In adults with asthma or asthma and COPD who had more than 10 physician visits for these diagnoses, testing rates were more than 70%, and multiple tests were common. In patients labelled with COPD only and with more than 20 physician visits, about one-third did not undergo spirometry. In children aged five to 14 years and in adults 15 to 44 years old, regional spirometry rates correlated well with regional asthma rates. Regional spirometry rates also correlated significantly with regional rates of asthma and/or COPD in people older than 34 years old. Spirometry use is considerably higher in patients with asthma than in patients with COPD, suggesting that guidelines are followed more closely in patients with asthma, and that many patients are labelled with COPD without appropriate documentation. Spirometry use is apparently indicative of physician interest in the problem of obstructive lung diseases.

Background:Research studies have found different prevalence rates for co-morbidities in patients with chronic obstructive pulmonary disease (COPD).Aims:The aim of our study was to investigate the prevalence of co-morbidities as well as functional limitations in subjects with COPD.Methods:The study was based on a nationally representative sample of the population of Serbia. Information on the health of the population was obtained from interviews and anthropometric measurements. In this study we analysed a total of 10,013 respondents aged 40 years or older. There were 653 subjects with COPD and 9,360 respondents without COPD.Results:Out of the 10,013 respondents, 5,377 were aged 40–59 years and 4,636 were 60 years or older. The prevalence of COPD was 5.0% in respondents aged 40–59 years and 8.3% in those aged 60 years or older; the total prevalence was 6.5%. The most prevalent co-morbidities among respondents with COPD were hypertension (54.5%) and dyslipidaemia (26.5%). The prevalence of all analysed co-morbidities was higher in respondents with COPD and the difference was highly statistically significant, except for stroke and malignancies, for which the difference was significant. Analysis showed that respondents with COPD had a higher prevalence of all analysed clinical factors (dizziness, obesity, anaemia and frailty) and functional impairments (mobility and hearing and visual impairment) compared with respondents without COPD. For those aged 40–59 years the difference was highest for mobility difficulty (four times higher prevalence in COPD patients) and anaemia (three times higher in COPD patients).Conclusion:Our analysis showed that the most prevalent co-morbidities in COPD were hypertension, dyslipidaemia, chronic renal disease and anxiety/depression. The finding suggests that health professionals should actively assess co-morbidities in patients with COPD.