Chronic airflow obstruction attributable to poverty in the multinational Burden of Obstructive Lung Disease (BOLD) study.

Poverty is strongly associated with all-cause and chronic obstructive pulmonary disease (COPD) mortality. Less is known about the contribution of poverty to spirometrically defined chronic airflow obstruction (CAO)-a key characteristic of COPD. Using cross-sectional data from an asset-based questionnaire to define poverty in 21 sites of the Burden of Obstructive Lung Disease study, we estimated the risk of CAO attributable to poverty. Up to 6% of the population over 40 years had CAO attributable to poverty. Understanding the relationship between poverty and CAO might suggest ways to improve lung health, especially in low-income and middle-income countries.

Association of respiratory symptoms and lung function with occupation in the multinational Burden of Obstructive Lung Disease (BOLD) study.

BACKGROUND: Chronic obstructive pulmonary disease has been associated with exposures in the workplace. We aimed to assess the association of respiratory symptoms and lung function with occupation in the Burden of Obstructive Lung Disease study. METHODS: We analysed cross-sectional data from 28 823 adults (≥40 years) in 34 countries. We considered 11 occupations and grouped them by likelihood of exposure to organic dusts, inorganic dusts and fumes. The association of chronic cough, chronic phlegm, wheeze, dyspnoea, forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1)/FVC with occupation was assessed, per study site, using multivariable regression. These estimates were then meta-analysed. Sensitivity analyses explored differences between sexes and gross national income. RESULTS: Overall, working in settings with potentially high exposure to dusts or fumes was associated with respiratory symptoms but not lung function differences. The most common occupation was farming. Compared to people not working in any of the 11 considered occupations, those who were farmers for ≥20 years were more likely to have chronic cough (OR 1.52, 95% CI 1.19-1.94), wheeze (OR 1.37, 95% CI 1.16-1.63) and dyspnoea (OR 1.83, 95% CI 1.53-2.20), but not lower FVC (ß=0.02 L, 95% CI -0.02-0.06 L) or lower FEV1/FVC (ß=0.04%, 95% CI -0.49-0.58%). Some findings differed by sex and gross national income. CONCLUSION: At a population level, the occupational exposures considered in this study do not appear to be major determinants of differences in lung function, although they are associated with more respiratory symptoms. Because not all work settings were included in this study, respiratory surveillance should still be encouraged among high-risk dusty and fume job workers, especially in low- and middle-income countries.

The association of spirometric small airways obstruction with respiratory symptoms, cardiometabolic diseases, and quality of life: results from the Burden of Obstructive Lung Disease (BOLD) study.

BACKGROUND: Spirometric small airways obstruction (SAO) is common in the general population. Whether spirometric SAO is associated with respiratory symptoms, cardiometabolic diseases, and quality of life (QoL) is unknown. METHODS: Using data from the Burden of Obstructive Lung Disease study (N = 21,594), we defined spirometric SAO as the mean forced expiratory flow rate between 25 and 75% of the FVC (FEF25-75) less than the lower limit of normal (LLN) or the forced expiratory volume in 3 s to FVC ratio (FEV3/FVC) less than the LLN. We analysed data on respiratory symptoms, cardiometabolic diseases, and QoL collected using standardised questionnaires. We assessed the associations with spirometric SAO using multivariable regression models, and pooled site estimates using random effects meta-analysis. We conducted identical analyses for isolated spirometric SAO (i.e. with FEV1/FVC ≥ LLN). RESULTS: Almost a fifth of the participants had spirometric SAO (19% for FEF25-75; 17% for FEV3/FVC). Using FEF25-75, spirometric SAO was associated with dyspnoea (OR = 2.16, 95% CI 1.77-2.70), chronic cough (OR = 2.56, 95% CI 2.08-3.15), chronic phlegm (OR = 2.29, 95% CI 1.77-4.05), wheeze (OR = 2.87, 95% CI 2.50-3.40) and cardiovascular disease (OR = 1.30, 95% CI 1.11-1.52), but not hypertension or diabetes. Spirometric SAO was associated with worse physical and mental QoL. These associations were similar for FEV3/FVC. Isolated spirometric SAO (10% for FEF25-75; 6% for FEV3/FVC), was also associated with respiratory symptoms and cardiovascular disease. CONCLUSION: Spirometric SAO is associated with respiratory symptoms, cardiovascular disease, and QoL. Consideration should be given to the measurement of FEF25-75 and FEV3/FVC, in addition to traditional spirometry parameters.

The role of modeling studies in asthma management and clinical decision-making: a Delphi survey of physician knowledge and perceptions.

OBJECTIVE: To investigate the knowledge and perceptions of physicians on the role of modeling studies in asthma, using a modified Delphi procedure. METHODS: Group opinions among a panel of respiratory experts were obtained using two online questionnaires and a virtual scientific workshop. A consensus was pre-defined as agreement by >75% of participants. RESULTS: From 26 experts who agreed to participate, 22 completed both surveys. At the end of the process, the panel rated their own understanding of modeling as good (77%) but that among physicians in general as poor (77%). Participants agreed that data from modeling studies should be used, at least sometimes, to inform treatment guidelines (91%) and could be useful for guiding clinical decisions (100%). Perceived barriers to using modeling studies were 'A lack of understanding' (81%) and 'A lack of standardized methodology' (82%). Based on data from two modeling studies, no consensus was reached on physicians recommending regular inhaled corticosteroids (ICS) versus as-needed therapy for patients with mild asthma, whereas 77% agreed that they would recommend regular ICS over maintenance and reliever therapy for ≥80% of their patients with moderate asthma. No consensus was reached on the value of modeling data in relation to empirical data. CONCLUSION: There is overall support among respiratory experts for the usefulness of modeling data to guide asthma treatment guidelines and clinical decision making. More publications on modeling data using robust models and accessible terminology will aid the understanding of physicians in general and help clarify the evidence-based value of modeling studies.

Chronic airflow obstruction and ambient particulate air pollution.

Smoking is the most well-established cause of chronic airflow obstruction (CAO) but particulate air pollution and poverty have also been implicated. We regressed sex-specific prevalence of CAO from 41 Burden of Obstructive Lung Disease study sites against smoking prevalence from the same study, the gross national income per capita and the local annual mean level of ambient particulate matter (PM2.5) using negative binomial regression. The prevalence of CAO was not independently associated with PM2.5 but was strongly associated with smoking and was also associated with poverty. Strengthening tobacco control and improved understanding of the link between CAO and poverty should be prioritised.

COPD: Gaps in the GOLD Recommendations and Related Imperative Research Needs.

The GOLD 2020 updates added more lucidity on the treatment of COPD. However, few diagnostic dilemmas still exist. Research is needed on the use of the CAT score in assessing symptoms for the diagnosis of COPD. Further work-up is needed on diagnostic instability of spirometry, and diagnostic role of the lower limit of normal (LLN) criteria, slow vital capacity (FEV1/VC), forced inspiratory vital capacity (FEV1/FIVC), and rapid FEV1 decline. Incorporating parameters of lung hyperinflation and exercise capacity in the COPD diagnostic criteria might add value in its diagnosis and management. GOLD's approach towards routine CT imaging needs to be reviewed. Establishing a "pre-COPD" stage can be helpful in the early diagnosis and intervention to reduce the rapid lung function decline among at-risk individuals. The use of mMRC score as a surrogate to assess the overall severity of COPD related symptoms should be reviewed. The therapeutic guidance role of sputum eosinophils should be studied in patients with intermediate and low blood eosinophil counts.

Reduced forced vital capacity is independently associated with ethnicity, metabolic factors and respiratory symptoms in a Caribbean population: a cross-sectional study.

BACKGROUND: Relationships between low forced vital capacity (FVC), and morbidity have previously been studied but there are no data available for the Caribbean population. This study assessed the association of low FVC with risk factors, health variables and socioeconomic status in a community-based study of the Trinidad and Tobago population. METHODS: A cross-sectional survey was conducted using the Burden of Obstructive Lung Disease (BOLD) study protocol. Participants aged 40 years and above were selected using a two-stage stratified cluster sampling. Generalized linear models were used to examine associations between FVC and risk factors. RESULTS: Among the 1104 participants studied a lower post-bronchodilator FVC was independently associated with a large waist circumference (- 172 ml; 95% CI, - 66 to - 278), Indo-Caribbean ethnicity (- 180 ml; 95% CI, - 90 to - 269) and being underweight (- 185 ml; 95% CI, - 40 to - 330). A higher FVC was associated with smoking cannabis (+ 155 ml; 95% CI, + 27 to + 282). Separate analyses to examine associations with health variables indicated that participants with diabetes (p = 0∙041), history of breathlessness (p = 0∙007), and wheeze in the past 12 months (p = 0∙040) also exhibited lower post-bronchodilator FVC. CONCLUSION: These findings suggest that low FVC in this Caribbean population is associated with ethnicity, low body mass index (BMI), large waist circumference, chronic respiratory symptoms, and diabetes.

Spirometric instability - another hurdle in achieving real-world COPD diagnostic criteria?

Globally, mortality, morbidity and the economic burden of chronic obstructive pulmonary disease (COPD) are on the rise. In addition, its diagnosis continues to pose challenges to the physicians, which is compounded further by its new feature "spirometric instability." Based on the findings from the two recent observational studies, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommended repeat spirometry for the individuals with a fixed ratio between 0.6 and 0.8. In this perspective, we discuss the uncertainties and consequences of this critical update in the 2018 GOLD report.

Does the 'slipping slipper sign' in patients with diabetes predict the presence of retinopathy and nephropathy?

BACKGROUND: Previous research had noted that an affirmative response in patients with diabetes to the question 'Have you ever lost your slipper/flip-flop from your feet while walking and not realised that you have done so'? That is, the presence of the 'slipping slipper sign' (SSS) reflected the presence of severe diabetic peripheral neuropathy with a high degree of precision. The objective of the current study was to determine whether the SSS may also predict the presence of diabetic retinopathy and/or nephropathy since microvascular complications are known to cosegregate. SUBJECTS AND METHODS: Among 100 patients with diabetes, including 33 cases with the SSS and 67 controls without the SSS, data on demography, dipstick proteinuria as well as the presence and staging of diabetic retinopathy were obtained. RESULTS: The mean (SD) age of all patients was 54.6 (13.0) years, mean duration of diabetes was 12.7 (10.2) years and mean haemoglobin A1c (HbA1c) 8.42 (1.95) %; 43% were males. All 33 (100%) of the patients with SSS but only 12 (18%) of the patients without SSS were found to exhibit diabetic retinopathy, p<0.001. Among those patients with retinopathy, proliferative retinopathy was far more likely (39%) in the SSS group compared with non-SSS subjects (8%). Similarly, 15 (46%) with SSS and only 4 (6%) without SSS were found to have dipstick proteinuria. The sensitivity of the SSS for retinopathy was 73% and the specificity was 100% with a positive predictive value (PPV) of 100% and negative predictive value (NPV) of 82%. For proteinuria, both the sensitivity and specificity was 78%. CONCLUSIONS: Both diabetic retinopathy and dipstick proteinuria are strongly associated with the presence of the SSS that therefore holds potential as a tool for easier identification of this high-risk group.

Reality and understanding of asthma control.

The aim of this study was to describe the level and perception of control in severe asthma in Trinidad after the introduction of revised guidelines for asthma management. Adult asthmatics (N = 329) at Trinidad's chest clinics were cross-sectionally examined for guideline-defined disease control. Patients' mean (SD) age was 54.36 (14.9) years, with body mass index = 28.54 (7.4) kg/meter(2), and females were proportionally more (246, 74.74%). Measured (45.29%) and perceived (18.96%) uncontrolled disease were poorly concordant (κ statistic = 0.197). Co-morbidity (≥2 conditions) correlated with uncontrolled disease in 55.80% of patients (Spearman correlation p = 0.03). Absolute peak expiratory flow was higher (p < 0.001) in controlled and/or partially controlled disease than in uncontrolled asthma. Routine work limitation, night-time disturbances, work absenteeism, exacerbations, rescue inhalation and perceived control correlated with uncontrolled asthma (p < 0.001). Few patients self-monitored lung function (9.73%) or kept an asthma diary (6.69%), but 65.1% believed they had to live with their symptoms. The asthma burden was at least one hospitalization (53.80%) and emergency department visit (66.36%) in the past year, cough (74.49%), dyspnoea (84.50%), wheezing (80.55%) and chest tightness (66.87%). After the revised guidelines, uncontrolled asthma and related morbidity remain suboptimal, with disagreeing actual and perceived control. Efforts to transform guidelines into patient care with realistic interpretation of control are recommended.

A public health approach to reducing violence within the CARICOM region.

Widespread crime has become a worldwide problem so much so that violence is now ranked fourth globally in its contribution to disability-adjusted life years in the 10 to 24 age group. Homicides, a surrogate marker of violent crime, have shown an upward trend in almost all of the CARICOM countries, and homicide rates over the past 3 years have consistently increased, though the pattern of violence varies by country. This background has informed the need for greater emphasis on the need for a different approach to dealing with crime in the CARICOM region. The CARICOM governments recently hosted a symposium on crime and violence as a public health issue. The public health approach to crime has been used with measurable success in different parts of the world and, more recently in Trinidad, one of the CARICOM countries. The paper outlines the outcomes of the symposium and discusses its implications for the region.

Prevalence of chronic cough, its risk factors and population attributable risk in the Burden of Obstructive Lung Disease (BOLD) study: a multinational cross-sectional study.

Background: Chronic cough is a common respiratory symptom with an impact on daily activities and quality of life. Global prevalence data are scarce and derive mainly from European and Asian countries and studies with outcomes other than chronic cough. In this study, we aimed to estimate the prevalence of chronic cough across a large number of study sites as well as to identify its main risk factors using a standardised protocol and definition. Methods: We analysed cross-sectional data from 33,983 adults (≥40 years), recruited between Jan 2, 2003 and Dec 26, 2016, in 41 sites (34 countries) from the Burden of Obstructive Lung Disease (BOLD) study. We estimated the prevalence of chronic cough for each site accounting for sampling design. To identify risk factors, we conducted multivariable logistic regression analysis within each site and then pooled estimates using random-effects meta-analysis. We also calculated the population attributable risk (PAR) associated with each of the identifed risk factors. Findings: The prevalence of chronic cough varied from 3% in India (rural Pune) to 24% in the United States of America (Lexington,KY). Chronic cough was more common among females, both current and passive smokers, those working in a dusty job, those with a history of tuberculosis, those who were obese, those with a low level of education and those with hypertension or airflow limitation. The most influential risk factors were current smoking and working in a dusty job. Interpretation: Our findings suggested that the prevalence of chronic cough varies widely across sites in different world regions. Cigarette smoking and exposure to dust in the workplace are its major risk factors. Funding: Wellcome Trust.

Beyond airflow obstruction: acknowledging the diversity of abnormal spirometry patterns.

Restrictive spirometry patterns and PRISm may not be the same, potentially leading to missed detection of a considerable number of individuals with abnormal spirometry. It is essential to consider all spirometry indices carefully during interpretation. https://bit.ly/43pXzep.

FOMO (fate of online media only) in infectious disease modeling: a review of compartmental models.

Mathematical models played in a major role in guiding policy decisions during the COVID-19 pandemic. These models while focusing on the spread and containment of the disease, largely ignored the impact of media on the disease transmission. Media plays a major role in shaping opinions, attitudes and perspectives and as the number of people online increases, online media are fast becoming a major source for news and health related information and advice. Consequently, they may influence behavior and in due course disease dynamics. Unlike traditional media, online media are themselves driven and influenced by their users and thus have unique features. The main techniques used to incorporate online media mathematically into compartmental models, with particular reference to the ongoing COVID-19 pandemic are reviewed. In doing so, features specific to online media that have yet to be fully integrated into compartmental models such as misinformation, different time scales with regards to disease transmission and information, time delays, information super spreaders, the predatory nature of online media and other factors are identified together with recommendations for their incorporation.

Leveraging research, community and collaboration towards robust COVID-19 mental health response in the Caribbean.

The CARICOM region has experienced significant challenges during the COVID-19 pandemic, one being issues surrounding mental health. This article seeks to highlight that mental health was a major issue prior to the pandemic and the situation could be potentially worst. Therefore we suggest supporting communities remains a pivotal tool in the armamentarium in dealing with diseases that have psychosocial aspects. Collaboration with regional bodies, transnational organizations and philanthropic entities and the process of health diplomacy will open the means through which valuable resources can become available. CARICOM as a Regional health body should be empowered to recognize population mental health challenges as a real and present danger to the well-being of the persons under its care and have an actionable plan that is realistic and sustainable.

Small airways obstruction and its risk factors in the Burden of Obstructive Lung Disease (BOLD) study: a multinational cross-sectional study.

BACKGROUND: Small airways obstruction is a common feature of obstructive lung diseases. Research is scarce on small airways obstruction, its global prevalence, and risk factors. We aimed to estimate the prevalence of small airways obstruction, examine the associated risk factors, and compare the findings for two different spirometry parameters. METHODS: The Burden of Obstructive Lung Disease study is a multinational cross-sectional study of 41 municipalities in 34 countries across all WHO regions. Adults aged 40 years or older who were not living in an institution were eligible to participate. To ensure a representative sample, participants were selected from a random sample of the population according to a predefined site-specific sampling strategy. We included participants' data in this study if they completed the core study questionnaire and had acceptable spirometry according to predefined quality criteria. We excluded participants with a contraindication for lung function testing. We defined small airways obstruction as either mean forced expiratory flow rate between 25% and 75% of the forced vital capacity (FEF25-75) less than the lower limit of normal or forced expiratory volume in 3 s to forced vital capacity ratio (FEV3/FVC ratio) less than the lower limit of normal. We estimated the prevalence of pre-bronchodilator (ie, before administration of 200 µg salbutamol) and post-bronchodilator (ie, after administration of 200 µg salbutamol) small airways obstruction for each site. To identify risk factors for small airways obstruction, we performed multivariable regression analyses within each site and pooled estimates using random-effects meta-analysis. FINDINGS: 36 618 participants were recruited between Jan 2, 2003, and Dec 26, 2016. Data were collected from participants at recruitment. Of the recruited participants, 28 604 participants had acceptable spirometry and completed the core study questionnaire. Data were available for 26 443 participants for FEV3/FVC ratio and 25 961 participants for FEF25-75. Of the 26 443 participants included, 12 490 were men and 13 953 were women. Prevalence of pre-bronchodilator small airways obstruction ranged from 5% (34 of 624 participants) in Tartu, Estonia, to 34% (189 of 555 participants) in Mysore, India, for FEF25-75, and for FEV3/FVC ratio it ranged from 5% (31 of 684) in Riyadh, Saudi Arabia, to 31% (287 of 924) in Salzburg, Austria. Prevalence of post-bronchodilator small airways obstruction was universally lower. Risk factors significantly associated with FEV3/FVC ratio less than the lower limit of normal included increasing age, low BMI, active and passive smoking, low level of education, working in a dusty job for more than 10 years, previous tuberculosis, and family history of chronic obstructive pulmonary disease. Results were similar for FEF25-75, except for increasing age, which was associated with reduced odds of small airways obstruction. INTERPRETATION: Despite the wide geographical variation, small airways obstruction is common and more prevalent than chronic airflow obstruction worldwide. Small airways obstruction shows the same risk factors as chronic airflow obstruction. However, further research is required to investigate whether small airways obstruction is also associated with respiratory symptoms and lung function decline. FUNDING: National Heart and Lung Institute and Wellcome Trust. TRANSLATIONS: For the Dutch, Estonian, French, Icelandic, Malay, Marathi, Norwegian, Portuguese, Swedish and Urdu translations of the abstract see Supplementary Materials section.

The role of bronchodilator treatment in the prevention of exacerbations of COPD.

Exacerbations of chronic obstructive pulmonary disease (COPD) are natural events in the progression of the disease, and are characterised by acute worsening of symptoms, especially dyspnoea. These heterogeneous events follow increased airway inflammation, often due to infection, and lead to decreased airflow and increased lung hyperinflation relative to stable COPD. Although exacerbation frequency generally increases as COPD progresses, some patients experience frequent exacerbations (≥ 2 per year) independently of disease severity. Exacerbations, especially frequent exacerbations, are associated with impaired health-related quality of life, reduced physical activity and poor disease prognosis. The cornerstone of pharmacotherapy for stable COPD is long-acting bronchodilators, including the long-acting ß(2)-agonists (LABAs) and long-acting anti-muscarinic agents (LAMAs) alone or combined with inhaled corticosteroids (ICS). While ICS treatment can potentially reduce the risk of exacerbations, clinical studies have demonstrated the efficacy of LABAs and LAMAs in reducing COPD symptoms, primarily by reducing lung hyperinflation secondary to reduced airway resistance. Sustained reduction in lung hyperinflation may in turn lessen dyspnoea during an exacerbation. Indeed, recent studies suggest that bronchodilators may also reduce the incidence of, or prevent, exacerbations. Using data from recent studies, this review explores the evidence and possible mechanisms through which bronchodilators may prevent exacerbations.