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1.
Artículo en Inglés | MEDLINE | ID: mdl-31365298

RESUMEN

RATIONALE: Less invasive, non-surgical approaches are needed to treat severe emphysema. OBJECTIVE: Evaluate the effectiveness and safety of the Spiration® Valve System versus optimal medical management. METHODS: In this multicenter, open-label, randomized, controlled trial, subjects aged ≥40 years with severe, heterogeneous emphysema were randomized 2:1 to Spiration Valve System with medical management (treatment) or medical management alone (control). MEASUREMENTS: The primary efficacy outcome was the difference in mean forced expiratory volume in 1 second (FEV1) from baseline to 6 months. Secondary effectiveness outcomes included: difference in FEV1 responder rates, target lobe volume reduction, hyperinflation, health status, dyspnea, and exercise capacity. The primary safety outcome was the incidence of composite thoracic serious adverse events. All analyses were conducted by determining the 95% Bayesian credible intervals (BCI) for the difference between treatment and control arms. MAIN RESULTS: Between October 2013 and May 2017, 172 participants (53.5% male, mean age 67.4) were randomized to treatment (n=113) or control (n=59). Mean FEV1 showed statistically significant improvements between the treatment and control groups - between-group difference at 6 and 12 months, respectively of 0.101 liters (95% BCI: 0.060, 0.141) and 0.099 liters (95% BCI: 0.048, 0.151). At 6 months, the treatment group had statistically significant improvements in all secondary endpoints except 6 minute walk distance. Composite thoracic serious adverse event incidence through 6 months was greater in the treatment group (31.0% vs 11.9%), primarily due to a 12.4% incidence of serious pneumothorax. CONCLUSIONS: In patients with severe heterogeneous emphysema, the Spiration Valve System shows significant improvement in multiple efficacy outcomes, with an acceptable safety profile. TRIAL REGISTRATION: www.clinicaltrials.gov Identifier NCT01812447. Open Access: This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).

2.
JAMA ; 321(24): 2438-2447, 2019 06 25.
Artículo en Inglés | MEDLINE | ID: mdl-31237643

RESUMEN

Importance: According to numerous current guidelines, the diagnosis of chronic obstructive pulmonary disease (COPD) requires a ratio of the forced expiratory volume in the first second to the forced vital capacity (FEV1:FVC) of less than 0.70, yet this fixed threshold is based on expert opinion and remains controversial. Objective: To determine the discriminative accuracy of various FEV1:FVC fixed thresholds for predicting COPD-related hospitalization and mortality. Design, Setting, and Participants: The National Heart, Lung, and Blood Institute (NHLBI) Pooled Cohorts Study harmonized and pooled data from 4 US general population-based cohorts (Atherosclerosis Risk in Communities Study; Cardiovascular Health Study; Health, Aging, and Body Composition Study; and Multi-Ethnic Study of Atherosclerosis). Participants aged 45 to 102 years were enrolled from 1987 to 2000 and received follow-up longitudinally through 2016. Exposures: Presence of airflow obstruction, which was defined by a baseline FEV1:FVC less than a range of fixed thresholds (0.75 to 0.65) or less than the lower limit of normal as defined by Global Lung Initiative reference equations (LLN). Main Outcomes and Measures: The primary outcome was a composite of COPD hospitalization and COPD-related mortality, defined by adjudication or administrative criteria. The optimal fixed FEV1:FVC threshold was defined by the best discrimination for these COPD-related events as indexed using the Harrell C statistic from unadjusted Cox proportional hazards models. Differences in C statistics were compared with respect to less than 0.70 and less than LLN thresholds using a nonparametric approach. Results: Among 24 207 adults in the pooled cohort (mean [SD] age at enrollment, 63 [10.5] years; 12 990 [54%] women; 16 794 [69%] non-Hispanic white; 15 181 [63%] ever smokers), complete follow-up was available for 11 077 (77%) at 15 years. During a median follow-up of 15 years, 3925 participants experienced COPD-related events over 340 757 person-years of follow-up (incidence density rate, 11.5 per 1000 person-years), including 3563 COPD-related hospitalizations and 447 COPD-related deaths. With respect to discrimination of COPD-related events, the optimal fixed threshold (0.71; C statistic for optimal fixed threshold, 0.696) was not significantly different from the 0.70 threshold (difference, 0.001 [95% CI, -0.002 to 0.004]) but was more accurate than the LLN threshold (difference, 0.034 [95% CI, 0.028 to 0.041]). The 0.70 threshold provided optimal discrimination in the subgroup analysis of ever smokers and in adjusted models. Conclusions and Relevance: Defining airflow obstruction as FEV1:FVC less than 0.70 provided discrimination of COPD-related hospitalization and mortality that was not significantly different or was more accurate than other fixed thresholds and the LLN. These results support the use of FEV1:FVC less than 0.70 to identify individuals at risk of clinically significant COPD.


Asunto(s)
Volumen Espiratorio Forzado , Hospitalización/estadística & datos numéricos , Enfermedad Pulmonar Obstructiva Crónica/diagnóstico , Capacidad Vital , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Modelos de Riesgos Proporcionales , Enfermedad Pulmonar Obstructiva Crónica/mortalidad , Medición de Riesgo/métodos
3.
Chest ; 2019 Jun 22.
Artículo en Inglés | MEDLINE | ID: mdl-31233744

RESUMEN

BACKGROUND: Tobacco smoke exposure is associated with emphysema and pulmonary fibrosis, both of which are irreversible. We have developed a new objective CT analysis tool that combines densitometry with machine learning to detect high attenuation changes in visually normal appearing lung (NormHA) that may precede these diseases. METHODS: We trained the classification tool by placing 34,528 training points in chest CT scans from 297 COPDGene participants. The tool was then used to classify lung tissue in 9,038 participants as normal, emphysema, fibrotic/interstitial, or NormHA. Associations between the quartile of NormHA and plasma-based biomarkers, clinical severity, and mortality were evaluated using Jonckheere-Terpstra, pairwise Wilcoxon rank-sum tests, and multivariable linear and Cox regression. RESULTS: A higher percentage of lung occupied by NormHA was associated with higher C-reactive protein and intercellular adhesion molecule 1 (P for trend for both < .001). In analyses adjusted for multiple covariates, including high and low attenuation area, compared with those in the lowest quartile of NormHA, those in the highest quartile had a 6.50 absolute percent lower percent predicted lower FEV1 (P < .001), an 8.48 absolute percent lower percent predicted forced expiratory volume, a 10.78-meter shorter 6-min walk distance (P = .011), and a 56% higher risk of death (P = .003). These findings were present even in those individuals without visually defined interstitial lung abnormalities. CONCLUSIONS: A new class of NormHA on CT may represent a unique tissue class associated with adverse outcomes, independent of emphysema and fibrosis.

4.
Ann Am Thorac Soc ; 16(9): 1091-1098, 2019 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-31185181

RESUMEN

The role of noninvasive positive pressure ventilation (NIV) in severe chronic obstructive pulmonary disease (COPD) has been controversial. Over the past two decades, data primarily obtained from Europe have begun to define the clinical characteristics of patients likely to respond, the role of high-intensity NIV, and the potential best timing of initiating therapy. These approaches, however, have not been validated in the context of the U.S. healthcare delivery system. Use of NIV in severe COPD in the United States is limited by the practicalities of doing in-hospital titrations as well as a complex system of reimbursement. These systematic complexities, coupled with a still-emerging clinical trial database regarding the most effective means to deliver NIV, have led to persistent uncertainty regarding when in stable severe COPD treatment with NIV is actually appropriate. In this review, we propose an assessment algorithm and treatment plan that can be used in clinical practice in the United States, but we acknowledge that the absence of pivotal clinical trials largely precludes a robust evidence-based approach to this potentially valuable therapy.

5.
Chronic Obstr Pulm Dis ; 6(3)2019 May 10.
Artículo en Inglés | MEDLINE | ID: mdl-31075813

RESUMEN

The COPD Foundation has tried to address gaps in chronic obstructive pulmonary disease (COPD) care by providing COPD Pocket Consultant Guide cards to U.S. health care providers. Since launching the card in 2007, there have been numerous updates and more than 800,000 of these cards have been distributed at no charge to health care professionals. The most recent versions have concentrated on presenting an algorithm for COPD management based on 7 severity domains: spirometry, symptoms, exacerbations, oxygen requirements, the presence of chronic bronchitis or emphysema and comorbidities. To increase the usability and reach of this tool, the COPD Pocket Consultant Guide is now available as an app for iOS and Android. This updated version of the app includes new COPD and asthma/COPD overlap flow charts; an interactive therapy chart that takes into account modified Medical Research Council (mMRC), COPD Assessment Test (CAT), and spirometry scores; anxiety and depression screeners; up-to-date medication charts in both brand and generic formats; a checklist to aid in determining when a patient should be referred to a pulmonologist and more. Potential use of the COPD Pocket Consultant Guide app in clinical care is discussed.

6.
Am J Respir Crit Care Med ; 200(4): 454-461, 2019 Aug 15.
Artículo en Inglés | MEDLINE | ID: mdl-30758975

RESUMEN

Rationale: Cor pulmonale (right ventricular [RV] dilation) and cor pulmonale parvus (RV shrinkage) are both described in chronic obstructive pulmonary disease (COPD). The identification of emphysema as a shared risk factor suggests that additional disease characterization is needed to understand these widely divergent cardiac processes.Objectives: To explore the relationship between computed tomography measures of emphysema and distal pulmonary arterial morphology with RV volume, and their association with exercise capacity and mortality in ever-smokers with COPD enrolled in the COPDGene Study.Methods: Epicardial (myocardium and chamber) RV volume (RVEV), distal pulmonary arterial blood vessel volume (arterial BV5: vessels <5 mm2 in cross-section), and objective measures of emphysema were extracted from 3,506 COPDGene computed tomography scans. Multivariable linear and Cox regression models and the log-rank test were used to explore the association between emphysema, arterial BV5, and RVEV with exercise capacity (6-min-walk distance) and all-cause mortality.Measurements and Main Results: The RVEV was approximately 10% smaller in Global Initiative for Chronic Obstructive Lung Disease stage 4 versus stage 1 COPD (P < 0.0001). In multivariable modeling, a 10-ml decrease in arterial BV5 (pruning) was associated with a 1-ml increase in RVEV. For a given amount of emphysema, relative preservation of the arterial BV5 was associated with a smaller RVEV. An increased RVEV was associated with reduced 6-minute-walk distance and in those with arterial pruning an increased mortality.Conclusions: Pulmonary arterial pruning is associated with clinically significant increases in RV volume in smokers with COPD and is related to exercise capacity and mortality in COPD.Clinical trial registered with www.clinicaltrials.gov (NCT00608764).

7.
COPD ; 16(1): 82-88, 2019 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-30789041

RESUMEN

Telephone quitlines are an effective population-based strategy for smoking cessation, particularly among individuals with tobacco-related diseases such as chronic obstructive pulmonary disease (COPD). Expanding quitline services to provide COPD-focused self-management interventions is potentially beneficial; however, data are needed to identify specific treatment needs in this population. We conducted a telephone-based survey (N = 5,772) to examine educational needs, behavioral health characteristics, and disease-related interference among individuals with COPD who received services from the American Lung Association (ALA) Lung Helpline. Most participants (73.7%) were interested in COPD-focused information, and few had received prior instruction in breathing exercises (33.9%), energy conservation (26.5%), or airway clearing (32.1%). About one-third of participants engaged in regular exercise, 16.3% followed a special diet, and 81.4% were current smokers. Most participants (78.2%) reported COPD-related interference in daily activities and 30.8% had been hospitalized within the past six months for their breathing. Nearly half of participants (45.4%) reported current symptoms of anxiety or depression. Those with vs. without anxiety/depression had higher rates of COPD-related interference (83.9% vs. 73.5%, p < .001) and past six-month hospitalization (33.4% vs. 28.3%, p < .001). In conclusion, this survey identified strong interest in disease-focused education; a lack of prior instruction in specific self-management strategies for COPD; and behavioral health needs in the areas of exercise, diet, and smoking cessation. Anxiety and depression symptoms were common and associated with greater disease burden, underscoring the importance of addressing coping with negative emotions. Implications for self-management treatments that target multiple behavioral needs of COPD patients are discussed.

8.
Psychooncology ; 28(3): 561-569, 2019 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-30680852

RESUMEN

OBJECTIVE: Continuing to smoke after a cancer diagnosis undermines prognosis. Yet few trials have tested Food and Drug Administration (FDA)-approved tobacco use medications in this population. Extended use varenicline may represent an effective treatment for cancer patients who smoke given barriers to cessation including a prolonged time line for relapse. METHODS: A placebo-controlled randomized trial tested 12 weeks of varenicline plus 12 weeks of placebo (standard [ST]) vs 24 weeks of varenicline (extended [ET]) with seven counseling sessions for treatment-seeking cancer patients who smoke (N = 207). Primary outcomes were 7-day biochemically confirmed abstinence at weeks 24 and 52. Treatment adherence and side effects, adverse and serious adverse events, and blood pressure were assessed. RESULTS: Point prevalence and continuous abstinence quit rates at weeks 24 and 52 were not significantly different across treatment arms (P's > 0.05). Adherence (43% of sample) significantly interacted with treatment arm for week 24 point prevalence (odds ratio [OR] = 2.31; 95% confidence interval [CI], 1.15-4.63; P = 0.02) and continuous (OR = 5.82; 95% CI, 2.66-12.71; P < 0.001) abstinence. For both outcomes, adherent participants who received ET reported higher abstinence (60.5% and 44.2%) vs ST (44.7% and 27.7%), but differences in quit rates between arms were not significant for nonadherent participants (ET: 9.7% and 4.8%; ST: 12.7% and 10.9%). There were no significant differences between treatment arms on side effects, adverse and serious adverse events, and rates of high blood pressure (P's > 0.05). CONCLUSIONS: Compared with ST, ET varenicline does not increase patient risk and increases smoking cessation rates among patients who adhere to treatment. Studies are needed to identify effective methods to increase medication adherence to treat patient tobacco use effectively.

9.
J Am Heart Assoc ; 7(24): e010672, 2018 12 18.
Artículo en Inglés | MEDLINE | ID: mdl-30561252

RESUMEN

Background Diminished peak lung function in young adulthood is a risk factor for future chronic obstructive pulmonary disease. The association between lung disease and cardiovascular disease later in life is well documented. Whether peak lung function measured in young adulthood is associated with risk of future cardiovascular events is unknown. Methods and Results CARDIA (The Coronary Artery Risk Development in Young Adults) study is a prospective, multicenter, community-based, longitudinal cohort study including 4761 participants aged 18 to 30 years with lung function testing we investigated the association between lung health in young adulthood and risk of subsequent cardiovascular events. We performed Cox proportional hazards regression to test the association between baseline and years 10 and 20 pulmonary function with incident cardiovascular events. Linear and logistic regression was performed to explore the associations of lung function with development of risk factors for cardiovascular disease as well as carotid intima-media thickness and coronary artery calcified plaque. At baseline, mean age (± SD ) was 24.9±3.6 years. Baseline forced expiratory volume in 1 second (hazard ratio) per -10-unit decrement in percent predicted forced expiratory volume in 1 second (hazard ratio, 1.18; 95% CI, 1.06-1.31 [ P=0.002]) and FVC per -10-unit decrement in percent predicted FVC (hazard ratio, 1.19; 95% CI, 1.06-1.33 [ P=0.003]) were associated with future cardiovascular events independent of traditional cardiovascular risk factors. Baseline lung function was associated with heart failure and cerebrovascular events but not coronary artery disease events. Conclusions Lung function in young adulthood is independently associated with cardiovascular events into middle age. This association appears to be driven by heart failure and cerebrovascular events rather than coronary heart disease. Clinical Trial Registration URL : https://www.clinicaltrials.gov . Unique identifier: NCT 00005130.

13.
Artículo en Inglés | MEDLINE | ID: mdl-30261735

RESUMEN

RATIONALE: Chronic lower respiratory diseases (CLRD), including COPD and asthma, are the fourth leading cause-of-death. Prior studies suggest that albuminuria, a biomarker of endothelial injury, is increased in COPD patients. OBJECTIVES: To test if albuminuria was associated with lung function decline and incident CLRD. METHODS: Six US population-based cohorts were harmonized and pooled. Participants with prevalent clinical lung disease were excluded. Albuminuria (urine albumin-to-creatinine ratio) was measured in spot samples. Lung function was assessed by spirometry. Incident CLRD-related hospitalizations and deaths were classified via adjudication and/or administrative criteria. Mixed and proportional-hazards models were used to test individual-level associations adjusted for age, height, weight, sex, race/ethnicity, education, birth-year, cohort, smoking status, pack-years, renal function, hypertension, diabetes, and medications. MEASUREMENTS AND MAIN RESULTS: Among 10,961 participants with preserved lung function, mean age at albuminuria measurement was 60 years, 51% were never-smokers, median albuminuria was 5.6mg/g, and mean FEV1 decline was 31.5mL/year. For each standard deviation increase in ln-albuminuria, there was 2.81% greater FEV1 decline (95% confidence interval [CI], 0.86-4.76%; P=0.0047), 11.02% greater FEV1/FVC decline (95% CI, 4.43-17.62%; P=0.0011), and 15% increased hazard of incident spirometry-defined moderate-to-severe COPD (95% CI, 2-31%, P=0.0021). Each standard deviation ln-albuminuria increased hazards of incident COPD-related hospitalization/mortality by 26% (95% CI, 18-34%, P<0.0001) among 14,213 participants followed for events. Asthma events were not significantly associated. Associations persisted in participants without current smoking, diabetes, hypertension, or cardiovascular disease. CONCLUSIONS: Albuminuria was associated with greater lung function decline, incident spirometry-defined COPD, and incident COPD-related events in a US population-based sample.

14.
Nat Commun ; 9(1): 2976, 2018 07 30.
Artículo en Inglés | MEDLINE | ID: mdl-30061609

RESUMEN

Nearly 100 loci have been identified for pulmonary function, almost exclusively in studies of European ancestry populations. We extend previous research by meta-analyzing genome-wide association studies of 1000 Genomes imputed variants in relation to pulmonary function in a multiethnic population of 90,715 individuals of European (N = 60,552), African (N = 8429), Asian (N = 9959), and Hispanic/Latino (N = 11,775) ethnicities. We identify over 50 additional loci at genome-wide significance in ancestry-specific or multiethnic meta-analyses. Using recent fine-mapping methods incorporating functional annotation, gene expression, and differences in linkage disequilibrium between ethnicities, we further shed light on potential causal variants and genes at known and newly identified loci. Several of the novel genes encode proteins with predicted or established drug targets, including KCNK2 and CDK12. Our study highlights the utility of multiethnic and integrative genomics approaches to extend existing knowledge of the genetics of lung function and clinical relevance of implicated loci.

15.
Am J Epidemiol ; 187(11): 2265-2278, 2018 Nov 01.
Artículo en Inglés | MEDLINE | ID: mdl-29982273

RESUMEN

Chronic lower respiratory diseases (CLRDs) are the fourth leading cause of death in the United States. To support investigations into CLRD risk determinants and new approaches to primary prevention, we aimed to harmonize and pool respiratory data from US general population-based cohorts. Data were obtained from prospective cohorts that performed prebronchodilator spirometry and were harmonized following 2005 ATS/ERS standards. In cohorts conducting follow-up for noncardiovascular events, CLRD events were defined as hospitalizations/deaths adjudicated as CLRD-related or assigned relevant administrative codes. Coding and variable names were applied uniformly. The pooled sample included 65,251 adults in 9 cohorts followed-up for CLRD-related mortality over 653,380 person-years during 1983-2016. Average baseline age was 52 years; 56% were female; 49% were never-smokers; and racial/ethnic composition was 44% white, 22% black, 28% Hispanic/Latino, and 5% American Indian. Over 96% had complete data on smoking, clinical CLRD diagnoses, and dyspnea. After excluding invalid spirometry examinations (13%), there were 105,696 valid examinations (median, 2 per participant). Of 29,351 participants followed for CLRD hospitalizations, median follow-up was 14 years; only 5% were lost to follow-up at 10 years. The NHLBI Pooled Cohorts Study provides a harmonization standard applied to a large, US population-based sample that may be used to advance epidemiologic research on CLRD.

16.
Addict Behav Rep ; 8: 46-50, 2018 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-29998189

RESUMEN

Introduction: The degree to which smokers quit successfully with varenicline is strongly associated with their adherence to the medication regimen. Thus, measuring varenicline adherence to identify smokers needing additional intervention is a priority. Few studies, however, have examined the validity of self-reported varenicline adherence, using a biological assessment of adherence as a reference. No study has examined this issue among cancer patients trying to quit smoking, who may show unique patterns of adherence given their medical comorbidity. Methods: This study used data from 76 cancer patients who received varenicline and provided self-reported varenicline adherence data (pill count) and a blood sample to determine varenicline metabolites 4 weeks after initiating varenicline. Results: Receiver operating characteristic (ROC) curve analyses of plasma varenicline levels showed that 4 ng/ml was the optimal cut-point for differentiating adherence with significant (p's < 0.04) area under the curve values, ranging from 0.73-0.80 for 3-day, 7-day, and 4-week self-reported pill count; specificity values ranged from 0.63-0.78 and sensitivity values ranged from 0.82-0.94. Using this cut-point, adherence was high (88%). However, plasma varenicline levels were weakly correlated with 3-day and 4-week pill count and total pill count (12 weeks) was not correlated with plasma varenicline levels. Patients with head and neck cancer, gastrointestinal cancer, and more advanced disease showed lower varenicline adherence and lower plasma varenicline. Conclusions: Using the 4 ng/ml cut-point, this study suggests validity of short-term self-reported varenicline adherence among cancer patients undergoing tobacco dependence treatment in contrast to studies in the general population, which supported 12-week pill count.

17.
Atherosclerosis ; 275: 225-231, 2018 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-29957459

RESUMEN

BACKGROUND AND AIMS: Long-term blood pressure variability (BPV) is associated with cardiovascular events independent of mean blood pressure (BP); however, little is known about its predictors. METHODS: Using data from the CARDIA study, we investigated the association between peak lung-function and long-term BPV in 2917 individuals (mean age 24.8 years, 45.3% males, 58.6% whites) who were not taking antihypertensive medications. Lung-function was measured using forced vital capacity (FVC) and forced expiratory volume in 1-s (FEV1) at years 0, 2, 5, 10 and 20 and the maximum score attained was considered as peak lung-function. Variability independent of the mean (VIM) and coefficient of variation (CV) of BP were calculated to quantify BPV since achieving peak lung-function across 9 visits over 30 years. RESULTS: In a multivariate linear regression models, individuals in the 2nd (-0.64 mmHg; 95% CI: -1.06, -0.19), 3rd (-0.96; -1.47, -0.45), and 4th (-0.85: -1.53, -0.17) quartiles of FVC had lower VIM of systolic BP than the those in quartile 1 (p-trend = 0.005). CV of systolic BP was also lower by -0.58 (-0.98, -0.19), -0.92 (-1.42, -0.43), and -0.74 (-1.40, -0.08) percentage points, in the three progressively higher quartiles of FVC compared to quartile 1 (p-trend = 0.008). Similar findings were observed when the outcome was diastolic BPV. There was no association of FEV1 and FEV1-to-FVC ratio with BPV. CONCLUSIONS: These findings suggest that smaller lung volume or restrictive lung disease during young adulthood, which result in lower peak FVC, may independently increase the risk of higher long-term BPV during middle adulthood.

18.
Nicotine Tob Res ; 2018 Jun 28.
Artículo en Inglés | MEDLINE | ID: mdl-29955828

RESUMEN

Introduction: The degree to which smokers adhere to pharmacotherapy predicts treatment success. The development of interventions to increase adherence requires identification of predictors of treatment adherence, particularly among specific clinical populations. Methods: Using data from a 12-week open-label phase of a clinical trial of varenicline for tobacco dependence among cancer patients (N=207), we examined: 1) the relationship between self-reported varenicline adherence and verified smoking cessation; and 2) demographic and disease-related variables, and early changes in cognition, affect, withdrawal, the reinforcing effects of smoking, and medication side effects, as correlates of varenicline adherence. Results: At the end of 12 weeks, 35% of the sample had quit smoking and 52% reported taking >80% of varenicline. Varenicline adherence was associated with cessation (p <.001): 58% of participants who were adherent had quit smoking, vs. 11% of those who were not. Participants who experienced early reductions in depressed mood and satisfaction from smoking, and experienced an increase in the toxic effects of smoking, showed greater varenicline adherence (p's <.05); the relationship between greater adherence and improved cognition, reduced craving, and reduced sleep problems and vomiting approached significance (p's <.10). Conclusions: Among cancer patients treated for tobacco dependence with varenicline, adherence is associated with smoking cessation. Initial changes in depressed mood and the reinforcing effects of smoking are predictive of adherence. Implications: The benefits of varenicline for treating tobacco dependence among cancer patients may depend upon boosting adherence by addressing early signs of depression and reducing the reinforcing dimensions of cigarettes.

19.
Chest ; 154(5): 1230-1238, 2018 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-29908152

RESUMEN

Patients with both COPD and heart failure (HF) pose particularly high costs to the health-care system. These diseases arise from similar root causes, have overlapping symptoms, and share similar clinical courses. Because of these strong parallels, strategies to reduce readmissions in patients with both conditions share synergies. Here we present 10 practical tips to reduce readmissions in this challenging population: (1) diagnose the population accurately, (2) detect admissions for exacerbations early and consider risk stratification, (3) use specialist management in hospital, (4) modify the underlying disease substrate, (5) apply and intensify evidence-based therapies, (6) activate the patient and develop critical health behaviors, (7) setup feedback loops, (8) arrange an early follow-up appointment prior to discharge, (9) consider and address other comorbidities, and (10) consider ancillary support services at home. The multidisciplinary care teams needed to support these care models pose expense to the health-care system. Although these costs may more easily be recouped under financial models such as accountable care organizations and bundled payments, the opportunity cost of an admission for COPD or HF may represent an underrecognized financial lever.

20.
Nicotine Tob Res ; 2018 May 17.
Artículo en Inglés | MEDLINE | ID: mdl-29788395

RESUMEN

Introduction: Chronic obstructive pulmonary disease (COPD) is a tobacco-related disease associated with several comorbid conditions, including elevated rates of depression and anxiety. Psychological factors that commonly underlie nicotine dependence, depression, and anxiety may represent novel treatment targets, but have not yet been examined among COPD patients. We assessed three psychological factors - anxiety sensitivity (AS; fear of anxiety-related sensations), distress intolerance (DI; inability to withstand distressing states), and anhedonia (Anh; diminished sense of pleasure or interest) - in relation to smoking status, COPD symptom impact, and negative response to COPD symptoms. Methods: We conducted a single-session laboratory assessment with 37 COPD patients (17 current daily smokers and 20 former smokers). All participants completed self-report measures of psychological factors, COPD symptom impact, response to COPD symptoms, and anxiety and depression symptoms. Results: Current vs. former smokers with COPD reported higher levels of AS, DI, and Anh. In univariate regression models, AS, DI, and Anh were each associated with greater COPD symptom impact and breathlessness catastrophizing. Only AS remained a significant predictor of COPD symptom impact and breathlessness catastrophizing after adjusting for general depression and anxiety symptoms. Conclusions: Our preliminary study is the first to assess AS, DI, and Anh among COPD patients. These psychological factors were elevated among current smokers and associated with more negative disease impact, suggesting their potential utility as treatment targets within this clinical population. Implications: While elevated rates of anxiety and depression among COPD patients have been well-characterized, few studies have specifically addressed the causal, modifiable psychological factors that may underlie these disorders. Our preliminary findings demonstrate associations of three psychological factors - anxiety sensitivity, distress intolerance, and anhedonia - with smoking status, COPD symptom impact, and negative reaction to symptoms. Cognitive-behavioral interventions targeted to these psychological factors may improve smoking cessation outcomes and disease adjustment among COPD patients.

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