Clusters of comorbidities in idiopathic pulmonary fibrosis.

INTRODUCTION: Comorbidities are common in patients with idiopathic pulmonary fibrosis (IPF) and negatively impact health-related quality of life, health-care costs and mortality. Retrospective studies have focused on individual comorbidities, but clusters of multiple comorbidities have rarely been analysed. This study aimed to comprehensively and prospectively assess comorbidities in a multicentre, real-world cohort of patients with IPF, including prespecified conditions of special interest and to analyse clusters of comorbidities and examine characteristics, disease course and mortality of the clusters. METHODS: Several measurements, questionnaires, medications and medical history were combined to assess comorbidities. Using self-organizing maps, clusters of comorbidities were identified and phenotypes characterized. Disease course was assessed using mixed effects models and mortality using Cox regression. RESULTS: One-hundred and fifty IPF patients were included prospectively. All except one patient suffered from at least one comorbidity and multimorbidity was common. Arterial hypertension, gastro-oesophageal reflux disease, hypercholesterolemia, emphysema and obstructive sleep apnea were most prevalent. Four comorbidity clusters were identified. Each cluster had distinct comorbidity profiles, patient characteristics, symptom burden and disease severity. Patients with fewer comorbidities had better exercise capacity and less dyspnea at baseline, but a trend towards faster deterioration was observed. Mortality analyses showed no significant differences between clusters. CONCLUSIONS: Multimorbidity is prevalent in patients with IPF. Four specific clusters of comorbidities may represent phenotypes in IPF. A trend towards faster decline in exercise capacity and dyspnea was observed in patients with fewer comorbidities. Increased knowledge of comorbidities facilitates prevention and treatment of comorbidities in patients with IPF.

Spirometric assessment of emphysema presence and severity as measured by quantitative CT and CT-based radiomics in COPD.

BACKGROUND: The mechanisms underlying airflow obstruction in COPD cannot be distinguished by standard spirometry. We ascertain whether mathematical modeling of airway biomechanical properties, as assessed from spirometry, could provide estimates of emphysema presence and severity, as quantified by computed tomography (CT) metrics and CT-based radiomics. METHODS: We quantified presence and severity of emphysema by standard CT metrics (VIDA) and co-registration analysis (ImbioLDA) of inspiratory-expiratory CT in 194 COPD patients who underwent pulmonary function testing. According to percentages of low attenuation area below - 950 Hounsfield Units (%LAA-950insp) patients were classified as having no emphysema (NE) with %LAA-950insp < 6, moderate emphysema (ME) with %LAA-950insp ≥ 6 and < 14, and severe emphysema (SE) with %LAA-950insp ≥ 14. We also obtained stratified clusters of emphysema CT features by an automated unsupervised radiomics approach (CALIPER). An emphysema severity index (ESI), derived from mathematical modeling of the maximum expiratory flow-volume curve descending limb, was compared with pulmonary function data and the three CT classifications of emphysema presence and severity as derived from CT metrics and radiomics. RESULTS: ESI mean values and pulmonary function data differed significantly in the subgroups with different emphysema degree classified by VIDA, ImbioLDA and CALIPER (p < 0.001 by ANOVA). ESI differentiated NE from ME/SE CT-classified patients (sensitivity 0.80, specificity 0.85, AUC 0.86) and SE from ME CT-classified patients (sensitivity 0.82, specificity 0.87, AUC 0.88). CONCLUSIONS: Presence and severity of emphysema in patients with COPD, as quantified by CT metrics and radiomics can be estimated by mathematical modeling of airway function as derived from standard spirometry.

Economic Burden of Chronic Conditions Among Survivors of Cancer in the United States.

Purpose The prevalence of cancer survivorship and chronic health conditions is increasing. Limited information exists on the economic burden of chronic conditions among survivors of cancer. This study examines the prevalence and economic effect of chronic conditions among survivors of cancer. Methods Using the 2008 to 2013 Medical Expenditure Panel Survey, we present nationally representative estimates of the prevalence of chronic conditions (heart disease, high blood pressure, stroke, emphysema, high cholesterol, diabetes, arthritis, and asthma) and multiple chronic conditions (MCCs) and the incremental annual health care use, medical expenditures, and lost productivity for survivors of cancer attributed to individual chronic conditions and MCCs. Incremental use, expenditures, and lost productivity were evaluated with multivariable regression. Results Survivors of cancer were more likely to have chronic conditions and MCCs compared with adults without a history of cancer. The presence of chronic conditions among survivors of cancer was associated with substantially higher annual medical expenditures, especially for heart disease ($4,595; 95% CI, $3,262 to $5,927) and stroke ($3,843; 95% CI, $1,983 to $5,704). The presence of four or more chronic conditions was associated with increased annual expenditures of $10,280 (95% CI, $7,435 to $13,125) per survivor of cancer. Annual lost productivity was higher among survivors of cancer with other chronic conditions, especially stroke ($4,325; 95% CI, $2,687 to $5,964), and arthritis ($3,534; 95% CI, $2,475 to $4,593). Having four or more chronic conditions was associated with increased annual lost productivity of $9,099 (95% CI, $7,224 to $10,973) per survivor of cancer. The economic impact of chronic conditions was similar among survivors of cancer and individuals without a history of cancer. Conclusion These results highlight the importance of ensuring access to lifelong personalized screening, surveillance, and chronic disease management to help manage chronic conditions, reduce disruptions in employment, and reduce medical expenditures among survivors of cancer.

Equally inequitable? A cross-national comparative study of racial health inequalities in the United States and Canada.

Prior research suggests that racial inequalities in health vary in magnitude across societies. This paper uses the largest nationally representative samples available to compare racial inequalities in health in the United States and Canada. Data were obtained from ten waves of the National Health Interview Survey (n = 162,271,885) and the Canadian Community Health Survey (n = 19,906,131) from 2000 to 2010. We estimated crude and adjusted odds ratios, and risk differences across racial groups for a range of health outcomes in each country. Patterns of racial health inequalities differed across the United States and Canada. After adjusting for covariates, black-white and Hispanic-white inequalities were relatively larger in the United States, while aboriginal-white inequalities were larger in Canada. In both countries, socioeconomic factors did not explain inequalities across racial groups to the same extent. In conclusion, while racial inequalities in health exist in both the United States and Canada, the magnitudes of these inequalities as well as the racial groups affected by them, differ considerably across the two countries. This suggests that the relationship between race and health varies as a function of the societal context in which it operates.

Comparison of systemic health conditions between African American and Caucasian complete denture patients.

PURPOSE: To compare prevalence of systemic health conditions (SHC) between African American and Caucasian edentulous patients presenting for complete dentures (CD) at an urban dental school. METHODS: The study included patients presenting for CD 1/1-12/31/2010, ages 20 to 64 years, and either African American or Caucasian. Covariates included: age group, gender, employment status, Medicaid status, smoking history, and alcohol consumption. SHC included at least one of the following: arthritis, asthma, cancer, diabetes, emphysema, heart attack, heart murmur, heart surgery, hypertension, or stroke. RESULTS: The group (n = 88) was 44.3% African American, 65.9% ≥50, 45.5% male, 22.7% employed, and 67.0% with at least one SHC. African Americans were older (p = 0.001) and more likely to have one or more SHC (p = 0.011). Patients with at least one SHC were older (p = 0.018) and more likely female (p = 0.012). The total sample logistic regression model assessing SHC yielded only gender as statistically significant (males < OR 0.32, 95% CI 0.11 to 0.92). Caucasian males were less likely to have SHC (OR 0.17, 95% CI 0.04 to 0.77), and Caucasians ≥50 were more likely (OR 5.36, 95% CI 1.19 to 24.08). African Americans yielded no significant associations. CONCLUSIONS: Among selected completely edentulous denture patients at an urban dental school, two out of three patients had at least one SHC. This exploratory study suggests there may be health status differences between African American and Caucasian patients in this setting, calling for further study.

Chronic obstructive pulmonary disease and associated health-care resource use - North Carolina, 2007 and 2009.

Chronic obstructive pulmonary disease (COPD), including emphysema and chronic bronchitis, is a progressive condition in which airflow becomes limited, making it difficult to breathe. Chronic lower respiratory diseases, primarily COPD, are the third leading cause of death in the United States, and 5.1% of U.S. adults report a diagnosis of emphysema or chronic bronchitis. Smoking is the primary cause of COPD, and at least 75% of COPD deaths are attributable to smoking in the United States. Information on state-specific prevalence of COPD is sparse, as are data on the use of COPD-related health-care resources. To understand how COPD affects adults in North Carolina and what resources are used by persons with COPD, 2007 and 2009 data from the North Carolina COPD module of the Behavioral Risk Factor Surveillance System (BRFSS) were analyzed. Among 26,227 respondents, 5.7% reported ever having been told by a health professional that they had COPD. Most adults with COPD reported ever having had a diagnostic breathing test (76.4% in 2007 and 82.4% in 2009). Among adults with COPD, 43.0% reported having gone to a physician and 14.9% visited an emergency department (ED) or were admitted to a hospital (2007) for COPD-related symptoms in the previous 12 months. Only 48.1% of persons reported daily use of medications for their COPD (2007). These results indicate that many adults with COPD might not have had adequate diagnostic spirometry, and many who might benefit from daily medications, such as long-acting bronchodilators and inhaled corticosteroids, are not taking them. Continued and expanded surveillance is needed to evaluate the effectiveness of prevention and intervention programs and support efforts to educate the public and physicians about COPD symptoms, diagnosis, and treatment.

Lung transplantation in the United States, 1998-2007.

This article highlights trends and changes in lung and heart-lung transplantation in the United States from 1998 to 2007. The most significant change over the last decade was implementation of the Lung Allocation Score (LAS) allocation system in May 2005. Subsequently, the number of active wait-listed lung candidates declined 54% from pre-LAS (2004) levels to the end of 2007; there was also a reduction in median waiting time, from 792 days in 2004 to 141 days in 2007. The number of lung transplants performed yearly increased through the decade to a peak of 1 465 in 2007; the greatest single year increase occurred in 2005. Despite candidates with increasingly higher LAS scores being transplanted in the LAS era, recipient death rates have remained relatively stable since 2003 and better than in previous years. Idiopathic pulmonary fibrosis became the most common diagnosis group to receive a lung transplant in 2007 while emphysema was the most common diagnosis in previous years. The number of retransplants and transplants in those aged > or =65 performed yearly have increased significantly since 1998, up 295% and 643%, respectively. A decreasing percentage of lung transplant recipients are children (3.5% in 2007, n = 51). With LAS refinement ongoing, monitoring of future impact is warranted.

Comparison assessment methods of smoking consequences use in primary care.

Cigarette smoking is an independent factor influences on development of smoke related diseases (for example COPD, emphysema). The aim of the study was to check correlation between the changes in respiratory tract and use additional tests such as: a spirometric test, a chest radiogram and measurement of exhaled carbon monoxide among subjects. In the study took part 398 people: 182 active smokers, 145 ex-smokers and 71 never smokers. Average age of participants was 49.3 +/- 14.7 years, and number of years smoked cigarettes was 28 among men and 22 among women (p < 0.001). COPD has been diagnosed at 110 women (36-32.7% active smokers, 44-40% never smokers and 30-27.3% former smokers) and at 108 men (53-40.8% active smokers, 52-23.9% never smokers and 77-35.3% former smokers). Emphysema has been diagnosed at 22 women (11-50% active smokers, 3-13.6% never smokers, 8-36.4% former smokers) and at 54 men (23-42.6% active smokers, 1-1.9% never smokers, 30-55.6% former smokers). The measurement of carbon monoxide in exhaled air was noted at 122 active smokers, 2 never smokers and 31 former smokers. In comparison to the chest radiogram, the spirometric test (COPD and emphysema) with the level of CO exhaled by subjects showed strong dependence for emphysema ( = 8.655; p < 0.004; C = 0.207) and for COPD ( = 10.522; p < 0.002; C = 0.228). The same statistically significant correlation showed results among active smokers for emphysema (= 6.919; p = 0.008528; C = 0.272) and for COPD ( = 43.512; p < 0.001; C = 0.633). The research showed that there are strong dependence between gender and tobacco smoking, and also correlation between respiratory tests used in this paper and changes which appeared as results of tobacco smoking.

Relative risk and economic consequences of inpatient care among patients with renal failure.

During the final phases of chronic renal disease, inpatient care comprises an enormous share of morbidity and direct medical costs. Using an attributable risk methodology, this study calculated inpatient resource utilization and associated costs for chronic renal failure (CRF) and ESRD. A national hospital survey was used to identify the 348,962 hospitalizations for patients with renal failure in 1991. Among persons under the age of 65, pre-ESRD CRF patients had the same number of hospitalizations (nearly 75,000) as ESRD patients. Age-adjusted relative risk calculations indicate that patients with renal failure experience greater inpatient morbidity compared with other populations with chronic, progressive diseases. For example, compared with persons with diabetes, ischemic heart disease, hypertension, and emphysema, renal patients were at significantly higher risk of hospitalization for congestive heart failure, pneumonia, sepsis, electrolyte disorders, and gastrointestinal hemorrhage. Overall, renal failure patients were ten times more likely to be hospitalized (relative risk, 10.0; 95% confidence interval, 10.00 to 10.04) and, on average, were hospitalized nearly 1 day longer (P < 0.01) compared with the non-renal failure population in 1991. As a result, the economic consequences of inpatient care for the treatment of renal failure were enormous. In 1991, 222,827 hospitalizations, 1.5 million days of inpatient care, and $2.2 billion were attributable to renal failure. Further studies that examine other components of direct medical costs (e.g., long-term care, outpatient care, and pharmaceuticals) as well as indirect costs associated with the treatment and care of renal failure patients are warranted.

[Recent results in emphysema research]. / Neue Ergebnisse der Emphysemforschung.

The incidence as well as the medical, social and economic importance of lung emphysema are evaluated. Results of experimental emphysema research, including the author's own investigations on rats are discussed. Inhalation of tobacco smoke is one of the most important etiologic factors. The pathogenetic role of endogenous enzymes, in particular protease-antiprotease imbalance, is elaborated. The survey is completed with the reference of prophylactic investigations and with an outlook on the main points of future research.