Special Issue: Respiratory Diseases
Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2023 Report) (GOLD 2023) maintains the basic framework of GOLD 2022, but with major revisions in the definition, assessment, initial therapy and follow-up management of chronic obstructive lung disease (COPD) as follow: (1) Chapter 1: The definition and overview section was rewritten to propose a new definition of COPD, incorporating new background information, therapeutic strategies and classifications for COPD, with the addition of content on chronic bronchitis; (2) Chapter 2: Content on screening and case-finding of COPD has been included, the ABCD assessment tool has been revised to the ABE assessment tool (no further grouping of high-risk population of acute exacerbation of COPD based on symptom levels), information on imaging and computed tomography scans (CT) has been included in the diagnosis and assessment section; (3) Chapter 3: Recommendations for Streptococcus pneumoniae vaccination have been updated, information on therapeutic interventions to reduce COPD mortality has been included, issues related to inhalation delivery have been updated, content on inhaled medications adherence and remote rehabilitation has been included, information on interventional and surgical therapies of COPD has been expanded in the prevention and maintenance treatment section; (4) Chapter 4: Information on the selection of inhalation devices has been included, information on initial drug therapy and follow-up drug therapy has been updated in the management of stable COPD section; (5) Chapter 5: A new definition of and set of acute exacerbation of COPD assessment parameters have been proposed, information on differential diagnoses of acute exacerbation of COPD has been expanded in the acute exacerbation of COPD section management; (6) Chapter 6 and 7: Updating content on COPD and complications (Chapter 6), COPD (Chapter 7) and COVID-19 based on the latest evidence. The above updates will be an important guide to the clinical management of COPD.
Interpretation of Global Strategy for the Diagnosis，Treatment，Management and Prevention of Chronic Obstructive Pulmonary Disease 2022 Report
Global initiative for chronic obstructive lung disease (GOLD) 2022 report was released on November 15, 2021. In general, chronic obstructive pulmonary disease (COPD) diagnosis, assessment and individualized therapy are the same as GOLD 2021, with corresponding content added in ten aspects. The article introduces and interprets the new content.
China has attached importance to the prevention and treatment of chronic obstructive pulmonary disease (COPD) , a major chronic respiratory disease. An in-depth discussion of the immunopathogenesis of COPD and intervening the identified key targets may be new ideas for the prevention and treatment of COPD. Based on the relevant evidence of commonly used immunomodulatory agents for COPD, and the status and trend of development of immunomodulators for COPD, the Writing Group for the Expert Consensus of Immunemodulatory Therapies for Chronic Obstructive Pulmonary Disease proposed the following four recommendations for treating COPD with immunomodulatory therapies: (1) bacterial lysates, phosphodiesterase inhibitors, macrolides and other biological and chemical agents have immunomodulatory efects on COPD by enhancing immune function and immune cell activity; (2) vaccination against influenza and pneumococcal infection could reduce the probability of acute exacerbation of COPD and mortality; (3) statins and vitamin D may be partially effective in COPD owing to their immunomodulatory actions, but need to be verified further due to quite insufficient relevant evidence and reported adverse reactions; (4) Chinese medicine compound and Cordyceps preparations may improve the quality of life and reduce the probability of acute exacerbationsin patients with stable COPD by regulating immune function and improving immune cell activity.The main purpose of this consensus is to greatly promote the clinical treatment of COPD using immunomodulatory therapies in China.
Chronic obstructive pulmonary disease (COPD) is a common, chronic heterogeneous airway disease. Although recent years have witnessed growing advances in both COPD research and management, there are still many difficulties need to be solved urgently. In view of this, the Lancet published Towards the Elimination of Chronic Obstructive Pulmonary Disease in September 2022, a document in which new ideas on the recognition, diagnosis, assessment and individualized treatment of COPD and relevant clinical guidance were proposed. This article focuses on the introduction and interpretation of the classification, diagnostic criteria and diagnostic recommendations of COPD in this document, the acute exacerbation of COPD and the move towards elimination of COPD, hoping to provide insights into COPD research and management conducted by Chinese clinical workers.
Chronic obstructive pulmonary disease (COPD) is one of the major chronic disease seriously affecting the health of Chinese residents. There are national and international guidelines and consensus on the diagnosis, treatment and management of COPD. However, there is no expert consensus on integrated traditional Chinese and western medicine management for COPD by now. Therefore, Chinese and western medicine experts with rich experience in the diagnosis and treatment of COPD in China were invited to formulate this consensus based on relevant domestic and foreign guidelines, consensus and personal experience, which includes early recognition and diagnosis of COPD, disease assessment, integrated traditional Chinese and western medicine treatment for stable COPD, evaluation, intervention measures of traditional Chinese and modern medicine, follow-up and management of acute exacerbation of COPD, so as to further improve the level of diagnosis, treatment and management of COPD in China.
The global initiative for chronic obstructive lung disease (GOLD) 2025 report, released on November 11th, 2024, marks the second update since GOLD 2023. Overall, this version maintains similar definition, diagnosis, assessment, and treatment for COPD as in GOLD 2024, but with revisions and expansions in 12 specific areas. These include: added explanations and references on lung function trajectories, expanded content on dysbiosis, updates and additions to spirometry, revised cardiovascular risk information for COPD patients, updated guidance on CT imaging for COPD, new insights into the impact of climate change on COPD, updated vaccination recommendations, updated follow-up pharmacological treatments, new guidance for delivery of pulmonary rehabilitation, revised recommendations on ICS withdrawal in patients on LABA+ICS therapy, updated information on PDE3 and PDE4 inhibitors and other exacerbation-reducing medications, and additional content on pulmonary hypertension. The article introduces and interprets the new contents.
In China, a country with relatively serious burden of chronic obstructive pulmonary disease (COPD) , COPD is the third leading cause of death, and ranks third among all diseases in terms of disability adjusted life years (DALYs) . Effective prediction of the burden of COPD based on its prevalence, mortality and DALYs rate will provide theoretical support for the formulation of prevention and control measures.
To describe and analyze the burden of COPD and its temporal trends from 1990 to 2019, and to forecast the COPD burden between 2020 and 2024 in China, provide a basis for scientific prevention and control of COPD in China.
In December 2021, data about indicators measuring the burden of COPD in China from 1990—2019, including COPD prevalence, mortality and DALYs rates, were extracted from the Global Burden of Disease 2019. The average annual percentage change was used to measure the temporal trend of COPD prevalence, mortality and DALYs rates over the period. Autoregressive moving average (ARIMA) and neural network autoregressive (NNAR) models for COPD prevalence, mortality and DALYs rates were constructed based on data from 1990-2016 (training set) , and their predictive performance was tested using data from 2017—2019 (test set) . The relative error, mean absolute percentage error (MAPE) , mean absolute error (MAE) and root mean square error (RMSE) between predicted and actual values of these two models were calculated for comparing their goodness of fit and predictive performance. And the better model was used to estimate the COPD disease burden from 2020 to 2024.
COPD prevalence, mortality and DALYs rates in China during 1990—2019: (1) The prevalence of COPD in the whole population increased from 2 344.40/100 000 to 3 175.37/100 000, with an average annual growth rate of 1.04%. And the average annual growth rates of COPD prevalence were 0.92% and 1.13% for men and women, respectively. (2) The mortality rate of COPD in the whole population decreased from 105.09/100 000 to 72.94/100 000, with an average annual rate of decrease of 1.29%. And the mortality rates in both men and women showed a decreasing trend, with average annual rates of decrease of 0.83% and 1.83%, respectively. (3) The rate of COPD DALYs in the whole Chinese population decreased from 2 206.55/100 000 to 1 400.71 /100 000, with an average annual rate of decrease of 1.56%. And the rates of DALYs in both men and women showed a decreasing trend, with average annual rates of decrease of 1.37% and 1.86%, respectively. The predicted values of the trends by both ARIMA and NNAR models were basically consistent with the actual values of trends, but the ARIMA model had smaller relative error, MAPE, MAE and RMSE, indicating that it may have better prediction accuracy. And by the ARIMA model, the predicted COPD prevalence in 2020—2024 was 3 229.77/100 000, 3 262.44/100 000, 3 292.38/100 000, 3 322.31/100 000, and 3 352.25/100 000, respectively; the predicted mortality rates were 74.50/100 000, 75.49/100 000, 76.11/100 000, 76.50/100 000, and 76.75/100 000, respectively; the predicted DALYs rates were 1 429.56/100 000, 1 452.07/100 000, 1 469.64/100 000, 1 483.35/100 000, and 1 494.05/100 000, respectively.
The trend of burden of COPD in China was predicted to be increased from 2020 to 2024 by the ARIMA model. Owing to the high goodness of fit and predictive accuracy demonstrated in the prediction, the ARIMA model may be used as a tool for predicting short-term burden of COPD.
Chronic obstructive pulmonary disease (COPD) is a global public health problem with increasing incidence and mortality. Fatigue is a common complaint of COPD patients, which seriously impairs the quality of life.
To conduct a scoping review of current research status and tools about fatigue as well as fatigue-related factors in COPD, providing ideas for the development of relevant individualized intervention schemes.
Methodological framework was used. Studies on fatigue in COPD were searched from databases of Web of Science, PubMed, EmBase, CINAHL, ProQuest, the Cochrane Library, CNKI, WanFang, CQVIP, and SinoMed from inception to July 2022, and enrolled according to the inclusion and exclusion criteria. Relevant data were extracted, collected, summarized and reported.
A total of 52 studies were included. Taken overall, a wide variety of assessment tools for fatigue in COPD featured by lack of multidimensionality and specificity were used, among which common were the Functional Assessment of Chronic Illness Therapy and the Fatigue Severity Scale. There were certain disparities in the incidence, duration, and severity of fatigue in COPD across studies. The main influencing factors of fatigue include sociodemographic factors, COPD-related factors, somatic factors, and psychological factors.
As fatigue is a major symptom that seriously declines the quality of life in COPD patients, clinical care providers need to use specific tools to accurately assess fatigue, and to develop individualized interventions to improve fatigue according to its influencing factors.
Severe pneumonia is a common critical respiratory illness with high mortality and heavy social burden. Early and accurate assessment of the condition and prognosis of patients with severe pneumonia contributes to clinical decision-making. The Sequential Organ Failure Assessment (SOFA), CURB-65 score, and Pneumonia Severity Index (PSI) score can reflect the severity of pneumonia in different aspects, but there is no consensus on which one of them has the highest performance in predicting the prognosis of severe pneumonia.
To explore the predictive efficacy of SOFA, CURB-65 and PSI scores for short-term prognosis of patients with severe pneumonia.
This was a multicenter, prospective observational study. Inpatients with severe pneumonia were selected from the ICU and department of respiratory and critical medicine of 11 hospitals (including the First Affiliated Hospital of Henan University of Traditional Chinese Medicine and other 10 hospitals) from December 2017 to March 2022. The patients were divided into survival group and death group according to the 28-day mortality after diagnosis to compare clinical characteristics and SOFA, CURB-65 and PSI scores assessed on the day of hospitalization. The receiver operating characteristic (ROC) curve was used to assess the performance of three risk scores for predicting the 28-day mortality. The predictive efficacy of the risk scores was evaluated using the Hosmer-Lemeshow test and calibration plot. Optimal risk scores were stratified using X-tile 3.6 to determine the optimal threshold. Kaplan-Meier survival curves of the patients were plotted and compared using the Log-rank test.
A total of 240 patients were included, among whom 57 (23.8%) died within 28 days after diagnosis. Compared with the survival group, the death group had greater average age and lower average platelet count (P<0.05). And the SOFA, CURB-65 and PSI scores in the death group were higher (P<0.05). ROC analysis demonstrated that the values of AUC of SOFA score, CURB-65 score and PSI score were 0.741〔95%CI (0.663, 0.820) 〕, 0.627〔95%CI (0.544, 0.710) 〕, and 0.621〔95%CI (0.539, 0.703) 〕, respectively, all were greater than 0.6, indicating that the three scores had good predictive value for 28-day mortality in severe pneumonia (P<0.001), and the AUC of SOFA score was higher than that of CURB-65 score (Z=2.492, P=0.013) or PSI score (Z=2.775, P=0.006). Both the Hosmer-Lemeshow test and calibration plot suggested that the SOFA score was more accurate. Kaplan-Meier survival analysis showed that 28-day mortalities in low-risk (0-5), moderate-risk (6-8), and high-risk (9-18) patients stratified by SOFA score using the X-tile 3.6 were 12.0% (17/142), 28.8% (19/66), and 65.6% (21/32) respectively (χ2=37.93, P<0.001) .
SOFA, CURB-65 and PSI score are all suitable for predicting 28-day mortality of patients with severe pneumonia, with SOFA score being more valuable for clinical application.
Analysis of Non-pharmacological Management Strategies for Stable Chronic Obstructive Pulmonary Disease Based on 2021 GOLD's Global Strategy for the Diagnosis，Management，and Prevention of Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease (COPD) is now the third leading cause of death in the world, after ischemic heart disease and stroke. However, in the face of this preventable and curable major public health problem, there are still many problems in clinical diagnosis and treatment in China, such as insufficient health education, missing follow-up data, and non-standardized clinical management, which may be important causes of the deterioration of conditions, leading to increased difficulties in treating and higher possibility of poor outcome after late treatment as well as increased social and economic burden of COPD. Therefore, it is of great practical significance to accelerate the standardization of prevention, diagnosis and management of COPD to improve the accuracy and effectiveness of diagnosis and treatment of COPD. To provide a reference for emergency and respiratory clinicians to better treat COPD patients clinically, in view of domestic diagnosis, treatment and studies regarding COPD, we comprehensively analyzed the non-pharmacological treatment of stable COPD based on the updated GOLD's Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, mainly including pulmonary function measurement and assessment, smoking cessation, pulmonary rehabilitation, oxygen therapy, ventilatory support and surgical interventions.
The number of chronic obstructive pulmonary disease (COPD) patients in China is huge, and respiratory rehabilitation training, as an important part of the management of COPD patients in the stabilization period, can effectively improve their lung function and quality of life, as well as reduce the burden on their families and society. Current data from Europe and the United States have shown that the implementation of respiratory rehabilitation under telemedicine management can improve the lung function and QOL of patients, however, there is a lack of relevant practice in China, especially in the west.
To assess the impact of respiratory rehabilitation training via telemedicine management in combination with conventional therapy on improving ventilatory capacity and lung function in elderly patients with moderate-to-severe COPD.
This study was a prospective randomized controlled study, enrolling consecutive COPD patients who attended the Fourth People's Hospital of Sichuan Province and five joint community clinics from June 2021 to June 2022. The included patients were randomly divided into the experimental group and control group by simple randomized grouping method using random number table. The control group received traditional long-term regular inhalation bronchodilator and oral medication, and the experimental group was guided by telemedicine on the basis of the treatment plan of the control group. A six-month study was conducted on two groups of patients, lung function, Borg score, 6MWT, and quality of life score (QOL score) were recorded at 1 month before and 1, 3, 6 months after intervention.
The study subjects were divided into 72 cases in the control group and 73 cases in the experimental group, and there was no significant difference in gender, age and lung function at baseline [the forced expiratory volume in one second/predicted value ratio (FEV1%pred) , and the ratio of the forced expiratory volume in one second to the forced vital capacity (FEV1/FVC) ] between the two groups (P>0.05) . There was an interaction between time and group for dyspnea and mood in FEV1%pred, FEV1/FVC, 6MWT level and QOL score (P<0.05) . After 1, 3, and 6 months of intervention, FEV1%pred, FEV1/FVC, 6MWT, Borg score, and QOL score of the experimental group were better than those of the control group (P<0.05) ; FEV1%pred, FEV1/FVC, Borg score, 6MWT, and QOL scores at 3 and 6 months post-intervention were better than those at 1 month post-intervention in the experimental group (P<0.05) .
The use of telemedicine technology for respiratory rehabilitation of elderly moderate-to-severe COPD patients in the stable stage can effectively improve the pulmonary function, quality of life and the quality of survival of this group of patients after 3, 6-months intervention.
Chronic obstructive pulmonary disease (COPD) is a common chronic disease of the respiratory system that has high morbidity and mortality across the world. Like other chronic diseases, the development of COPD is a long process, and its prognosis could be improved significantly by early prevention and intervention. As the understanding of COPD in the international academic community gradually deepens, the 2022 Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) report first proposed the concept of pre-COPD. We reviewed the development of pre-COPD, analyzed its definition and diagnostic criteria, and summarized the significance of early identification of pre-COPD patients. Pre-COPD results from the widening and deepening of the existing concept of COPD prevention and treatment. A full understanding of pre-COPD will contribute to guiding the direction of COPD pathogenesis research and basic COPD research, and to improving the awareness of primary prevention of COPD in clinical practice, thereby reducing the prevalence and mortality of COPD and the burden of COPD on families and society.
Inexpensive and convenient early screening for chronic obstructive pulmonary disease (COPD) is of great significance to identify individuals at high risk of COPD. There are many kinds of COPD screening tools with various diagnostic accuracies, but which one is superior to others has not been identified by evidence-based studies.
To evaluate the diagnostic accuracies of common COPD screening tools using a network meta-analysis.
PubMed, the Cochrane Library, Embase, Web of Science, CNKI, Wanfang Data and VIP databases were searched for diagnostic studies related to COPD screening and tools for early diagnosis COPD included from database establishment to December 31, 2021. Two researchers independently conducted literature screening, quality evaluation and data extraction. Meta-disc 1.4 and Stata 15.0 were used for network meta-analysis.
A total of 46 studies were enrolled, involving seven screening tools: the Lung Function Questionnaire (IFQ) , COPD Diagnostic Questionnaire (CDQ) , COPD Screening Questionnaire (COPD-SQ) , Self-Scored COPD Population Screener Questionnaire (COPD-PS) , spirometer, peak flow meter, questionnaire+peak flow meter. The results of meta-analysis demonstrated combined sensitivity values of the aforementioned seven screening tools for COPD were as follows: 0.79〔95%CI (0.75, 0.83) 〕, 0.85〔95%CI (0.83, 0.86) 〕, 0.68〔95%CI (0.65, 0.70) 〕, 0.60〔95%CI (0.56, 0.63) 〕, 0.58〔95%CI (0.54, 0.61) 〕, 0.86〔95%CI (0.84, 0.88) 〕, and 0.68〔95%CI (0.65, 0.71) 〕. And combined specificity values of them were: 0.67〔95%CI (0.65, 0.68) 〕, 0.59〔95%CI (0.58, 0.59) 〕, 0.81〔95%CI (0.80, 0.82) 〕, 0.84〔95%CI (0.83, 0.85) 〕, 0.88〔95%CI (0.87, 0.89) 〕, 0.86〔95%CI (0.84, 0.88) 〕, and 0.85〔95%CI (0.84, 0.86) 〕. The surface under the cumulative ranking curve (SUCRA) values of the tools ranked in terms of combined sensitivity from highest to lowest were: peak flow meter (72.7%) >CDQ (70.1%) >LFQ (61.8%) >questionnaire+peak flow meter (45.3%) >COPD-SQ (28.5%) >COPD-PS (13.2%) >spirometer (9.1%) . And the SUCRA values of these tools ranked in terms of combined specificity from highest to lowest were: spirometer (76.8%) >questionnaire+peak flow meter (66.7%) >COPD-SQ (46.7%) >peak flow meter (45.8%) >COPD-PS (39.2%) >LFQ (11.9%) >CDQ (8.2%) .
Among the seven commonly used tools, peak flow meter has higher sensitivity, and spirometer has higher specificity. But this conclusion still needs to be further confirmed by more multicenter, large-sample studies.
Low attenuation area ratio (LAA%) and pectoral major parameters are in elderly patients with COPD related to pulmonary ventilation function, but there are few studies at home and abroad.
To analyze the correlation of LAA% and pectoral major parameters with impaired pulmonary ventilation function in elderly patients with COPD, and to explore the predictive value of LAA% and PMcsa in the severity of airflow restriction, in order to provide clinical basis for the early detection and diagnosis of COPD.
A total of 270 elderly patients with stable COPD who underwent chest CT and lung function examination in North Jiangsu People's Hospital affiliated to Yangzhou University from December 2019 to June 2021 were selected and divided into GOLDⅠgroup (FEVl%pred≥80%, n=47) , GOLD Ⅱgroup (50%≤FEVl%pred<80%, n=88) , GOLD Ⅲ group (30%≤FEVl%pred<50%, n=84) and GOLD Ⅳ group (FEVl%pred<30%, n=51) according to GOLD classification with their general information and CT quantitative indexes recorded. Pearson correlation analysis and multiple linear regression analysis were used to explore the relationship between LAA%, pectoralis major areas (PMcsa) and lung function. The receiver operating characteristic curve (ROC curve) was used to evaluate the predictive value of LAA% and PMcsa for FEV1%pred<50% and FEV1%pred<80%.
BMI and PMD in GOLDⅠgroup were higher than those in GOLD Ⅲ group and GOLD Ⅳ group (P<0.05) , and the BMI in GOLD Ⅱgroup and GOLD Ⅲ group was higher than that in GOLD Ⅳ group (P<0.05) . PMcsa, PMI, FEV1%pred, FEV1 and FVC in GOLD Ⅰgroup were higher than those in GOLD Ⅱ group, GOLD Ⅲ group and GOLD Ⅳ group (P<0.05) . PMcsa, PMI, FEV1%pred, FEV1 and FVC in GOLD Ⅱ group were higher than those in GOLD Ⅲ group and GOLD Ⅳ group (P<0.05) . PMcsa, PMI , FEV1%pred, FEV1 and FVC in GOLD Ⅲ group were higher than those in GOLD Ⅳ group (P<0.05) . Left lung LAA%, right lung LAA% and total lung LAA% in GOLD Ⅰ group were lower than those in GOLD Ⅱ group, GOLD Ⅲ group and GOLD Ⅳ group (P<0.05) . Left lung LAA%, right lung LAA% and total lung LAA% in GOLD Ⅱ group were lower than those in GOLDⅢ group and GOLD Ⅳ group (P<0.05) . Left lung LAA%, right lung LAA% and total lung LAA% in GOLD Ⅲ group were lower than those in GOLD Ⅳ group (P<0.05) . FEV1%pred, FEV1 and FVC were positively correlated with PMcsa, PMI and PMD (P<0.05) . Both FEV1%pred and FEV1 were negatively correlated with low attenuation area ratio (right LAA%, left LAA%, total LAA%) (P<0.05) . Multiple linear regression analysis show that gender, total LAA% and PMcsa were independent influencing factors of FEV1%pred. The area under ROC curve of right lung LAA%, left lung LAA%, total lung LAA% and PMcsa predicting FEV1%pred<50% in male patients were 0.832, 0.827, 0.834, 0.809, respectively. The area under ROC curve of right lung LAA%, left lung LAA%, total lung LAA% and PMcsa predicting FEV1%pred<50% in female patientswere 0.844, 0.801, 0.845, 0.839, respectively. The area under ROC curve of right lung LAA%, Left lung LAA%, total lung LAA% and PMcsa predicting FEV1%pred<80% in male patients were 0.830, 0.815, 0.831, 0.844, respectively. The area under ROC curve of right lung LAA%, left lung LAA%, total lung LAA% and PMcsa predicting FEV1%pred<80% in female patients were 0.805, 0.817, 0.807, 0.846, respectively.
The low attenuation area ratio and PMcsa can assess the severity of airflow restriction in elderly patients with COPD, and can be used as an important tool for early screening and severity assessment of COPD.
Chronic obstructive pulmonary disease (COPD) is a common respiratory disease that is associated with high risk of disability and mortality. Although evidence suggests that fatigue may induce acute exacerbation in COPD, it needs to be further tested.
To explore the relationship between fatigue and the acute exacerbation in COPD.
By use of convenient sampling, a total of 597 COPD patients were selected from the First Affiliated Hospital of Bengbu Medical College, the Second Affiliated Hospital of Bengbu Medical College and the Third People's Hospital of Bengbu to establish a cohort study population between March 2019 and October 2020. During the hospitalization, general information such as gender, age, educational level, marital status, living style, comorbidities, smoking history, and monthly family income were collected from patients. Fatigue Scale-14 was used to measure the fatigue status, BODE index was used to predict the severity and prognosis, Anxiety and depression were assessed by the Anxiety Scale (HADS-A) and the Depression Scale (HADS-D) in the Hospital Anxiety and Depression Scale (HADS) . The patients were followed up for 1 year after discharge, recorded the occurrence of acute exacerbation in COPD, and assessed the quality of life with COPD Assessment Test (CAT) . Univariate analysis and multivariate Cox regression analysis were performed to identity factors possibly associated with the acute exacerbation in COPD. ROC curve analysis was used to measure the performance of fatigue in predicting acute exacerbation in COPD.
The lost cases were screened and eliminated according to the corresponding inclusion criteria and exclusion criteria, five hundred and fifty cases were finally included for analysis, 416 of them had fatigue, and other 134 did not. Patients with and without fatigue had significant differences in smoking prevalence, mean number of acute exacerbations in a year, BODE index, HADS-A score, and CAT score (P<0.05) . Multivariate Cox regression analysis showed that FS-14 score, BODE index and CAT score are risk factors for acute exacerbation in COPD (P<0.05) . ROC curve analysis showed that the area under the curve of fatigue in predicting the acute exacerbation in COPD was 0.826, with 85.2% sensitivity, 65.4% specificity, and 0.506 Youden's index.
Fatigue increases the risk of acute exacerbation in COPD to a certain extent. So clinical delivery of targeted preventive interventions may be beneficial to the reduction of acute exacerbation in COPD.
The Availability of Essential Medicines and Diagnostic Devices for Chronic Obstructive Pulmonary Disease in Primary Care
China has seen a significantly increased prevalence of chronic obstructive pulmonary disease (COPD) recently. But primary care institutions, the main "battlefield" for containing COPD, have shown relatively weak capabilities for the diagnosis and treatment of disease. As there are relatively few large-scale investigations and studies on medicines and diagnostic devices for COPD in primary care, we conducted this study to further understand the weaknesses of current COPD containment in primary care, by which the gap in related research may be made up.
To understand the allocation and availability rate of essential medicines for COPD, and availability rate of spirometer as well as the implementation of pulmonary function tests in primary care.
From February to March 2021, a multi-stage cluster sampling was adopted to select 8 176 community (township) health centers from 31 provinces of China to attend a survey. The rates of availability and allocation of each of the 16 essential medicines for COPD in the 2018 National Essential Medicines List were calculated to estimate the categories and number of these medicines in primary care institutions. The rate of availability of spirometer in these institutions was estimated. And the rate of implementation of pulmonary function tests in these institutions was estimated.
Altogether, 7 458 (91.22%) institutions who gave effective responses to the survey were included for analysis, including 5 901 (79.12%) township health centers, and 1 557 (20.88%) community health centers. Among the 16 essential medicines for COPD, less than 8 were available in 6 538 (87.66%) institutions, at least 1 inhaled antiasthmatic medicines were available in 4 992 (66.00%) institutions, and long-acting inhaled antiasthmatic medicines were available in 814 (10.91%) institutions. The average availability rate of 16 essential medicines for COPD was 33.30%. The highest ranked three medicines in terms of availability rate were ambroxol〔85.28% (6 360/7 458) 〕, aminophylline〔81.17% (6 054/7 458) 〕 and compound licorice〔74.48% (5 555/7 458) 〕. And the relatively low-ranked three were fluticasone propionate 〔4.89% (365/7 458) 〕, tiotropium bromide〔6.25% (466/7 458) 〕, budesonide forterol〔8.61% (642/7 458) 〕. The average availability rate of 6 inhaled antiasthmatic medicines in community health centers was 28.31%, and that in township health centers was 4.81%. The average availability rate of 2 long-acting inhaled antiasthmatic medicines in community health centers was 16.18%, and that in township health centers was 5.12%. The average availability rate of spirometers in primary care institutions was 8.94% (667/7 458) . The average availability rate of spirometers in community health centers was higher than that of township health centers〔18.56% (289/1 557) vs 6.41% (378/5 901) , P<0.05〕. Pulmonary function tests were implemented in 10.82% (807/7 458) of the institutions. The rate of community health centers was higher than that of township health centers in terms of offering pulmonary function testing services〔13.81% (215/1 557) vs 10.03% (592/5 901) , P<0.05〕.
The available essential medicines for COPD in these primary care institutions were insufficient with unbalanced distribution. Most of available medicines were oral preparations, and inhaled antiasthmatic medicines, especially long-acting inhaled antiasthmatic medicines, were poorly available. Moreover, the availability rate of spirometers and the implementation rate of pulmonary function tests were both relatively low. All these factors negatively influence early screening for and management of COPD in primary care. In view of this, it is recommended that increasing the availability levels of inhaled antiasthmatic medicines and portable spirometers, and the application of pulmonary function tests in primary care, as well as primary care physicians asompetencies and initiatives for the prevention, diagnosis, treatment and rehabilitation of COPD with the delivery of the national essential publish health services for COPD as the starting point of enhancement trainings.
Roles of Primary Care in Response to the COVID-19 Pandemic Defined in Policy Documents
The major promise for promoting primary care intuitions to take the initiative to play an active role in containing the COVID-19 pandemic is defining the duties and roles that they should undertake.
To review the policy documents related to COVID-19 issued by China's health administrative departments to make a systematic summary of the responsibilities and duties that should be undertaken by primary care institutions, offering guidance for COVID-19 containment in various regions of China.
In August 2021, we searched the official websites of the National Health Commission of the People's Republic of China (PRC) and its subordinate institutions for policy documents related to COVID-19 using "primary careinstitutions" "prevention and control at the community level" "COVID-19" and "COVID-19 prevention and control" as the main search terms. The policy documents containing "COVID-19 prevention and control" and "primary careinstitutions" were sorted out in chronological order of publication, and their contents were intensively reviewed, organized, summarized and analyzed.
Thirty-four policy documents extracted from the official websites of the National Health Commission of the PRC and its three subordinate institutions (Department of Primary Health, the former Bureau of Medical Administration and the former Bureau of Disease Prevention and Control) were finally enrolled. They were mainly formulated by the Joint Prevention and Control Mechanism of the State Council in Response to the COVID-19, General Office and Department of Primary Health of the National Health Commission of the PRC. According to these policy documents, the major responsibilities of primary care institutions in containing COVID-19 include: early detection and reporting the suspected COVID-19 cases; receiving trainings regarding knowledge related to COVID-19 containment and emergency preparedness drills for coping with the pandemic; strengthening nosocomial COVID-19 infection containment and personal protection against the pandemic; cooperating with the community in fighting the COVID-19 pandemic; implementing health education about COVID-19 containmentusing a scientific approach; health management of priority populations; collecting and submitting nucleic acid samples; COVID vaccination.
Primary care institutions play a vital role in containing COVID-19 in China. The local governments should follow policy guidelines, and take measures according to the local conditions to facilitate the primary care in stitutions to better their performance in response to COVID-19 as frontline responders.
Acute exacerbation is an important cause for the significant decline of lung function in patients with chronic airway disease, which seriously affects the health and quality of life of patients, and significantly increases the medical and economic burden of the disease. Early identification of different inflammatory phenotypes in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and asthma-COPD overlap (ACO) and timely and precise treatment are important in reducing the occurrence of exacerbations, controlling disease progression, and improving quality of life.
To compare the clinical characteristics of AECOPD with different inflammatory phenotypes and ACO patients and their response to glucocorticoid therapy, and to provide a reference for further guiding the application of glucocorticoids.
The basic clinical data of AECOPD and ACO patients hospitalized in respiratory and critical care Medicine Department of the Second Hospital of Hebei Medical University from January 2018 to December 2020 were collected. The basic clinical data were collected, and the peripheral blood eosinophils (EOS) percentage (2%) was used as the critical value, EOS%≥2% was defined as EOS group, EOS%<2% was defined as non-EOS group, and ACO patients were defined as ACO group. The clinical characteristics and response to glucocorticoids of the three groups were analyzed.
High-sensitivity C-reactive protein (hs-CRP) , absolute value of peripheral blood neutrophils (NE) , neutrophil/lymphocyte ratio (NLR) , fibrinogen/serum albumin (FAR) , lung and the use rate of systemic hormones, total hormone application, hormone treatment course, and hospitalization time of AECOPD patients in the EOS group were lower than those in the non-EOS group (P<0.05) . ALB of AECOPD patients in EOS group was higher than that in non-EOS group (P<0.05) . Body mass index (BMI) , FEV1%pred, severity of pulmonary function, absolute value of NE, NLR, utilization rate of pulmonary and systemic hormones, total hormone application, and hormone treatment course of AECOPD patients in the EOS group were lower than those in ACO group (P<0.05) . The age, hospitalization time, male prevalence rate, smoking rate, and EOS%≥2% of AECOPD patients in EOS group were higher than those in ACO group (P<0.05) .
EOS may be used as an important indicator to evaluate the severity of AECOPD and guide glucocorticoid therapy. The causes of acute exacerbations of COPD patients in the EOS group were mostly considered to be caused by non-infectious factors, and the treatment of antibiotics may be more prudent. AECOPD patients in EOS group have different clinical characteristics, and it is of positive significance to grasp their unique clinical characteristics for the early identification of chronic airway disease and accurate treatment decision.
The Effectiveness Satisfaction Questionnaire for COPD (ESQ-COPD) previously developed by us based on classical test theory has proven to have some limitations. The combination use of classical test theory and item response theory may achieve complementary advantages, which may be a theoretical basis and methodological support for the development or revision of instruments.
To develop a modified ESQ-COPD (mESQ-COPD) based on the combination of disease and syndrome, and to evaluate its psychometric properties.
By predefining basic characteristics of the instrument, normalizing the essential concepts and terminologies, revising the conceptual framework, generating an item pool, and reviewing the items, the draft of the mESQ-COPD was developed by our revision group. Then the draft was improved to be a mESQ-COPD by screening items based on the results of a pretest conducted during October 2017 to February 2018 with a convenience sample of 265 stable COPD patients from the respiratory clinic of 10 grade A tertiary hospitals in China, in combination with item screening using the classical test theory and item response theory. After that, the psychometric properties of the mESQ-COPD were tested using an onsite investigation carried out in a convenience sample of 365 stable COPD patients from the respiratory clinic of six grade A tertiary hospitals in China from November 2018 to February 2019.
The final mESQ-COPD includes four domains (clinical symptoms, capabilities for work and life, ability of environmental adaptation, and therapeutic effect) and 19 items. The Cronbach's α of the questionnaire was 0.949, and that of the four domains was 0.943, 0.869, 0.829, and 0.767, respectively. The correlation coefficient between the domain of clinical symptoms, capabilities for work and life, ability of environmental adaptation, or therapeutic effect and its component items ranged from 0.667 to 0.798, 0.855 to 0.882, 0.795 to 0.907, or 0.857 to 0.934, respectively. Confirmatory factor analysis showed that the comparative fit index, incremental fit index, non-normed fit index, standardized root mean square residual, and root mean square error of approximation measuring the construct validity of the mESQ-COPD were 0.94, 0.94, 0.93, 0.07, and 0.16, respectively. The correlation coefficients of the mESQ-COPD and its domains with COPD assessment test ranged from 0.371 to 0.538, while those of the mESQ-COPD and its domains with the modified Medical Research Council scale ranged from 0.329 to 0.564. The differences in the total score and domain scores of the mESQ-COPD between mild/moderate and severe/extremely severe COPD patients were both statistically significant (P<0.01). The acceptance rate of the mESQ-COPD was 99.5%, and the completion rate was 99.2%, with a mean completion time of (6.13±4.59) min.
The 19-item mESQ-COPD (consists of four domains: clinical symptoms, ability of work and life, capability for environmental adaptation, and therapeutic effect) has good reliability, validity, and applicability, which could be used to support the efficacy evaluation in COPD.
Our previous study showed that Yifei moxibustion has good effect on chronic obstructive pulmonary disease (COPD) in stable stage, but the effect could be enhanced according to the suggestions of an expert questionnaire survey. It is of great significance to carry out clinical research on the relationship of moxibustion duration with clinical efficacy and suitability in COPD.
To study and optimize the appropriate duration of moxibustion treatment in COPD, and to evaluate its clinical efficacy and suitability.
One hundred and twenty patients with stable COPD were recruited from the First Affiliated Hospital of Henan University of Chinese Medicine from June to July 2017, and randomly divided into groups A and B with SAS software. Both groups received routine western medicine treatment and one course of Yifei moxibustion treatment (1.5 h each time for group A, and 2 h each time for group B, once every 15 days, for a total of six times in three months) . The primary outcome index was the number of colds during treatment, and the secondary outcome indices included clinical symptoms and signs scores, COPD Assessment Test (CAT) , pulmonary function, suitability evaluation〔using the Visual Analogue Scale (VAS) 〕, and the safety was evaluated.
Except 29 dropouts, 91 cases (47 in group A and 44 in group B) were included in the Per Protocol Set and analyzed with full data set analysis. The results of repeated measures ANOVA showed that the main effects on the number of colds, score of chest tightness, CAT score and VAS score were significant between groups (P<0.05) . There were significant intergroup differences in the number of colds, the total score of clinical symptoms and signs, the score of each of the clinical symptoms and signs, the score of each of the clinical symptoms and signs, CAT score and VAS score at different time points (P<0.05) . No adverse events occurred in both groups.
Both types of Yifei moxibustion could reduce the number of colds, improve the cough, chest tightness and other clinical symptoms as well as the quality of life in stable COPD patients. But the efficacy of Yifei moxibustion lasting for 1.5 h each time was better, and was more applicable.
Analysis of the Prevalence and Influencing Factors of Chronic Obstructive Pulmonary Disease in Elderly Hospitalized Patients：a Study Based on a Comprehensive Geriatric Assessment System in Yunnan Province
Current studies on chronic obstructive pulmonary disease (hereinafter referred to as COPD) mostly focus on the lung itself, while studies on the extrapulmonary manifestations of COPD are still lacking. Many studies in China and at abroad have shown that COPD is closely related to geriatric syndrome, but it has not been further confirmed.
To investigate the prevalence of COPD in senile inpatients in several hospitals in Yunnan Province in the past three years, and to explore the influencing factors of elderly COPD from the aspect of geriatric syndrome.
A total of 2 182 newly admitted elderly patients (≥60 years old) in several hospitals of Yunnan Province from September 2018 to June 2021 were selected as the research objects and divided into COPD group and non-COPD group according to whether the patients had COPD. The software platform of "Comprehensive Geriatric Assessment System" independently developed by the Geriatrics Department of the First People's Hospital of Yunnan Province was used to collect general data from the patients. At the same time, the scales in the system were used to conduct a comprehensive geriatric evaluation of the patients, including the assessment of anxiety and depression by 15-item geriatric depression scale (GDS-15) , the assessment of insomnia situation by athens insomnia scale (AIS) , the assessment of family support by PAGAR scale, the assessment of fall risk by Morse fall scale, the assessment of cognitive function by mini-mental state examination (MMSE) , the assessment of nutrition status by mini nutritional assessment scale, the assessment of the patients' daily living ability by the basic activities of daily living (BADL) scale, the assessment of frailty state by the Fried Scale, the assessment of swallowing (choking) by swallowing function assessment scale, the assessment of urinary incontinence by incontinence questionnaire simple form (ICI-Q-SF) , the assessment of constipation by Roma Ⅲ scale, the assessment of pain by visual analogue scale (VAS) . The influencing factors of COPD in the elderly hospitalized patients were analyzed by binary Logistic regression.
There were 1 558 cases (71.4%) in the non-COPD group and 624 cases (28.6%) in the COPD group. The results of binary Logistic regression analysis showed that age ≥75 and <85 years, age≥85 years old, male, anxiety and depression, potential malnutrition, malnutrition, pre-frailty, frailty were independent influencing factors of COPD (P<0.05) .
Elderly hospitalized patients aged ≥60 years have a higher prevalence of COPD and are closely associated with geriatric syndrome.
Ginkgo biloba extract (GBE) has been found to be effective in inhibiting the airway and systemic inflammatory response and improve airway remodeling in rat models of chronic obstructive pulmonary disease (COPD) , but the mechanism remains unclear.
To discuss the mechanism of GBE regulating alveolar macrophage autophagy through phosphatidylinositol 3-kinase (PI3K) /protein kinase B (Akt) /mammalian target of rapamycin (mTOR) signaling pathways to prevent and treat COPD.
A total of 90 SPF male Wistar rats were equally randomized into normal control group, COPD model group, GBE group, bicalutamide group, rapamycin group, and Taselisib group. The normal control group were normally fed except that normal saline was injected into their trachea on the 1st and 14th days of intervention, the other 5 groups were treated with exposure to cigarette smoking combined with intratracheal injection of lipopolysaccharide (LPS) to establish rat models of COPD. The GBE group received intraperitoneal injection of Shuxuening injection from the 15th day to the 28th day of the experiment, while bicalutamide, rapamycin, and Taselisib groups were given bicalutamide, rapamycin, and taselisib, respectively, from the 29th day to the 42nd day of the experiment. HE staining was used to observe alveolar pathological changes and airway remodeling. ELISA was used to detect the levels of interleukin -6 (IL-6) and interleukin -8 (IL-8) in alveolar lavage fluid (BALF) and the serum. The number of alveolar macrophages was counted under microscope. The ultrastructure of alveolar macrophages was observed by transmission electron microscope. Western blotting was used to measure the expression levels of autophagy-related proteins in alveolar macrophages. The ratio of microtubule-associated protein light chain 3 (LC3) -Ⅱ/LC3-Ⅰwas calculated subsequently.
As of the models being successfully established, the rats in normal control, COPD model, GBE, bicalutamide, rapamycin, and Taselisib groups numbered 12, 11, 12, 12, 12, and 11, respectively. H&E staining showed that the degree of alveolar injury in COPD model group was more severe than that of GBE, bicalutamide, rapamycin, or Taselisib group (P<0.05) . COPD model group had larger mean linear intercept and mean alveolar area as well as less mean alveolar number than GBE, bicalutamide, rapamycin, or Taselisib group (P<0.05) . Moreover, COPD model group had less complete bronchial wall structure than GBE, bicalutamide, rapamycin, or Taselisib group. The levels of BALF and serum IL-6 and IL-8 in COPD model group were higher than those of each of other five groups (P<0.05) . Among all groups, the number of macrophages in the normal control group was the lowest, while that of COPD model group was the highest (P<0.05) .Transmission electron microscopy showed that COPD model group had less autophagolysosomes in alveolar macrophages than GBE, bicalutamide, rapamycin, or Taselisib group. The normal control group had higher expression levels of PI3Kp110α, Akt, p-Ak, mTOR and p-mTOR and lower ratio of LC3-II/LC3-I than each of other five groups (P<0.05) . COPD model group had higher expression levels of PI3Kp110α, Akt, p-Akt, mTOR and p-mTOR, and lower ratio of LC3-Ⅱ/LC3-Ⅰ compared with GBE, bicalutamide, rapamycin or Taselisib group (P<0.05) .
GBE maintained the autophagy function of alveolar macrophages, reduced macrophage infiltration, inhibited the inflammatory response and alveolar damage, and improved airway remodeling in model rats of COPD through regulating the PI3K/Akt/mTOR signaling pathway.
Analysis and Research on the Characteristics of COVID-19 Epidemic in Urban Village and Its Prevention and Control Strategies in Primary Care Institutions
For a period of time, the outbreak of the COVID-19 outbreak in many urban villages in our country had caused concern. The dense and complex population structure of urban villages, with their inter-regional mobility, posed a challenge to the prevention and control of the epidemic.
Urban village areasare more prone to regional outbreaks of infectious diseases because of their spatial environment, demographic characteristics, cross-regional mobility and the characteristics of residents' medical treatment behavior. The purpose of this study was tounderstand the characteristics of the COVID-19 epidemic situation in urban villages and the current situation and difficulties of primary care institutions in carrying out COVID-19 epidemic prevention and control measures, in order to provide references for primary care institutions to deal with normalized prevention and control, social dynamic clearing work and future infectious disease prevention and control.
By using public opinion analysis, literature retrieval, online interviews with epidemic prevention and control personnel and experts in urban village, the epidemic situation, prevention and control status of urban village were summarized, and the existing weak links and important loopholes were analyzed.
Based on the relevant information, a total of six points of concern were extracted: (1) The number of mapping and screening objects was large, which was the focus and difficulty of epidemic prevention and control work in urban villages. (2) There was not strict closed-loop management lead to virus carriers who were not timely controlled, which caused a risk of spreading the epidemic. (3) The prevention and control of nosocomial infection in primary care institutions was not in place. (4) There were loopholes in the inspection of close contacts in the principle of territorial management; close contacts who did not live and work in the same administrative area but only screened in their living places, which may lead to the spread of the epidemic in workplaces where secondary close contacts may be at risk of infection were not screened in a timely manner. (5) Overload had become the norm, highlighting the large gap in primary health care manpower. (6) During the normalization of epidemic prevention and control, residents were paralyzed and careless, and the phenomenon of not wearing masks in public places and crowd gathering was common. Health education still needs to be strengthened and emphasized that residents were the first responsible for their own health.
Primary care providers played an important role in the prevention and control of COVID-19 in urban village by undertaking community management, outpatient treatment, public health services, health education, vaccination, quarantine hotel stationing, joint prevention and control, etc. It was recommended that additional fever sentinel clinics be set up for early detection and isolation to avoid further spread of the epidemic, rental houses be requisitioned to meet the demand for isolated medical observation, primary care institutions be strengthened for hospitalization and prevention, green relief channels be opened to protect special groups from medical treatment, volunteers be organized to reinforce primary care institutions, and health education emphasized that residents were the first to be responsible for maintaining their own health and raised personal awareness of the risk of COVID-19 prevention and control.
Using Machine Learning to Build an Early Warning Model for the Risk of Severe Airflow Limitation in Patients with Chronic Obstructive Pulmonary Disease
The degree of airflow limitation is a key indicator of the progression degree in COPD patients. However, problems such as contraindications to testing and compliance make it difficult for some patients to undergo the relevant tests and evaluate the severity of the disease.
To develop and evaluate a machine learning algorithm-based early warning model for the risk of severe airflow limitation in COPD patients.
A cross-sectional design was used to investigate COPD inpatients in a tertiary hospital in Sichuan Province from 2019-01 to 2020-06. General clinical indexes and pulmonary function test data were collected. The data were randomly divided into training and test sets in the ratio of 8∶2, and 216 risk warning models were constructed in the training set using four missing value filling methods, three feature screening methods, 17 machine learning and one integrated learning algorithm. The area under the ROC curve (AUC) , accuracy, precision, recall and F1 score were used to evaluate the predictive performance of the model; and the ten-fold cross-validation method and Bootstrapping were used for internal and external validation, respectively. The test set data was used for model testing and selection, the posterior method was used for sample size verification.
A total of 418 patients were included, of which 212 (50.7%) patients were at risk of severe airflow limitation. After four missing value treatments and three feature filters, a total of 12 processed datasets and the importance ranking of 12 factors affecting airflow limitation were obtained, and the results showed that modified medical research council dyspnea scale grade (mMRC) , age, body mass index (BMI) , smoking history (yes, no) , chronic obstructive pulmonary disease assessment test (CAT) score, and dyspnea (yes, no) were at the forefront inthe ranking of variable features and were key indicators for constructing the model, which had an important role in predicting the outcome. Using unfilled, Lasso screening, mMRC grade, smoking history (yes, no) , and dyspnea (yes, no) were the top 3 predictors, with mMRC grade accounting for 54.15% of feature importance. In which, using unfilled, Boruta screening, CAT score, age, and mMRC class were the top 3 predictors, and CAT score accounted for 26.64% of feature importance. A total of 216 prediction models were obtained using 17 machine learning algorithms and 1 integrated learning for each of the 12 datasets. 17 machine learning algorithms with 10-fold cross-validation showed that the differences were statistically significant (P<0.05) when comparing the prediction performance of different algorithms, and the average AUC of the stochastic gradient descent algorithm was maximum (0.738±0.089) . The results of external validation of the test set using the Bootstrapping algorithm showed that the differences were statistically significant (P<0.05) when comparing the prediction performance of the models obtained by different algorithms, and the average AUC of the integrated learning algorithm was maximum (0.757±0.057) . Evaluation of the prediction performance of four missing value treatments and three feature filters using the Bootstrapping algorithm showed that the performance of the model was improved when no padding and Lasso filtering were applied, with a statistically significant difference (P<0.05) . Using the test set data for 216 machine learning models, the best model had an AUC of 0.790 9, accuracy of 75.90%, precision of 75.00%, recall of 78.57%, and F1 value of 0.767 4. The sample size validation results suggested that the study sample size can meet the modeling needs.
In this study, a risk warning model for severe airflow limitation in COPD patients was developed and evaluated. mMRC class, age, BMI, CAT score, presence of smoking history and dyspnea were the key indicators affecting airflow limitation. The model has good predictive effect and has potential clinical application.
Correlation of Malnutrition，25-hydroxy Vitamin D and Interleukin-1β with Chronic Obstructive Pulmonary Disease in Elderly Inpatients
The specific pathogenesis of chronic obstructive pulmonary disease (COPD) is still not very clear so far, clinical interventions mainly focus on the control of pulmonary symptoms with drugs, however, the influence of extrapulmonary related factors of COPD has not caused enough attention.
To explore the correlation of malnutrition, 25-hydroxy vitamin D and interleukin-1β with COPD in elderly inpatients.
A total of 305 inpatients (≥60 years old) were recruited from Department of Geriatrics, the First People's Hospital of Yunnan Province from November 2020 to August 2021, and divided into COPD group (n=89) and non-COPD group (n=216) according to the incidence of COPD. General information and comprehensive geriatric assessment results were compared between the two groups; binary Logistic regression analysis was used to analyze the influencing factors of COPD in elderly inpatients, and Spearman rank correlation analysis was used to analyze the correlation of malnutrition, 25-hydroxy vitamin D and interleukin-1β with COPD.
There were significant differences in age, gender, current smoking rate, nutritional status, cognitive function, incidence of anxiety and depression, incidence of disability, sleeping status, frailty status, proportion of multiple drugs, kinds of drugs used, platelet count, C-reactive protein, total protein, albumin, thyroxine, 25-hydroxy vitamin D, estradiol, testosterone, prothrombin time, D-dimer, interleukin-6 and interleukin-1β between the two groups (P<0.05) . The results of binary Logistic regression analysis showed that, current smoking〔OR=2.351, 95%CI (1.053, 5.249) 〕, underlying malnutrition〔OR=2.429, 95%CI (1.118, 5.276) 〕, malnutrition〔OR=3.936, 95%CI (1.355, 11.439) 〕, sleeplessness〔OR=2.584, 95%CI (1.094, 6.102) 〕, C-reactive protein〔OR=0.988, 95%CI (0.978, 0.999) 〕, 25-hydroxy vitamin D〔OR=0.929, 95%CI (0.880, 0.981) 〕and interleukin-1β〔OR=1.025, 95%CI (1.003, 1.047) 〕were independent influencing factors of COPD in elderly inpatients (P<0.05) . The results of Spearman rank correlation analysis showed that, malnutrition (rs=0.280, P<0.001) and interleukin-1β (rs=0.145, P=0.011) were positively correlated with the incidence of COPD in elderly inpatients, while 25-hydroxy vitamin D was negatively correlated with the incidence of COPD (rs=-0.264, P<0.001) .
Malnutrition, 25-hydroxy vitamin D and interleukin-1β are independent influencing factors of COPD in elderly inpatients. Among them, malnutrition and interleukin-1β are positively correlated with the incidence of COPD, while 25-hydroxy vitamin D is negatively correlated with the incidence of COPD.
Respiratory virus infection is an important trigger of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) . China has adopted a series of containment measures assisting to curb COVID-19 transmission since the outbreak of the pandemic. Several studies showed a decrease in hospitalizations for AECOPD during the COVID-19 pandemic. However, there has been a relative lack of studies investigating the effects of preventive measures on the frequency and severity of exacerbations.
To explore the impact of the COVID-19 pandemic on the frequency of AECOPD with or without medical attention.
The subjects were from a prospective COPD cohort study conducted in the First Affiliated Hospital of Guangzhou Medical University, which began recruiting patients in early 2016, with visits every 3 months to collect demographic and clinical data, including those who were followed up during June to August 2017 (group 1) , June to August 2018 (group 2) , June to August 2019 (group 3) , and June to August 2020 (group 4) . Basic clinical data (including the frequency of AECOPD, sex, age, symptom score and so on) were collected from group 1 from October 2016 to May 2017, group 2 from October 2017 to May 2018, group 3 from October 2018 to May 2019, and group 4 from October 2019 to May 2020 (during which the periods from October 2019 to January 2020, and from February to May 2020 were defined as pre-COVID-19 period, and post-COVID-19 period, respectively) . The frequency of AECOPD during October to May next year in group 4 was compared with that of the other three groups. The changes in the frequency of AECOPD between pre- and post-COVID-19 periods were analyzed.
There were 162 patients in group 1, 157 in group 2, 167 in group 3, and 159 in group 4. Group 1 had a higher frequency of AECOPD in February to May than in October to January next year (P=0.013) , so did group 2 (P=0.016) . In contrast, group 4 had a higher frequency of AECOPD in October to January next year than in February to May (P=0.001) . The frequency of AECOPD during October to December in group 4 was similar to that of the other three groups (P>0.05) . But the frequency of AECOPD from February to April in group 4 was lower than that in groups 1-3 (P<0.05) . There was no significant difference in the monthly frequency of AECOPD without medical attention in group 4 compared with that of groups 1-3 (P>0.05) . The frequency of AECOPD with medical attention from October to December in group 4 was similar to that of groups 1-3 (P>0.05) . but it from February to April in group 4 was lower than that in groups 1-3 (P<0.05) .
Prevention and control measures targeting COVID-19 may be contributive to reducing the frequency of AECOPD. It is suggested that COPD patients should reduce gathering activities, maintain social distance, wear masks when going out, and wash hands frequently even after the COVID-19.
Expert Advice on Community-based Grid Containment of COVID-19 Pandemic by the General Practice Network & Regional Medical Consortium
The COVID-19 containment has become a top global public health concern. China has obtained a phased achievement in containing COVID-19 pandemic, during the process, primary medical institutions and general practitioner teams in regional medical consortiums have played a key role. To better guide and standardize the development of regional medical consortiums, give full play to the bridge role and grid management of general medicine in COVID-19 pandemic containment, and consolidate the achievements of COVID-19 pandemic containment further, we invited a group of related experts to develop the Expert Advice on Community-based Grid Containment of COVID-19 Pandemic by the General Practice Network & Regional Medical Consortium (the First Version for Trial Implementation) (hereinafter referred to as the Expert Advice) following in-depth analysis and thorough consideration of literature review results, suggestions extensively collected and practical evidence, which mainly includes the following aspects: the essential characters of the general practice network & regional medical consortium, organizational structure, contents and separation of responsibilities and duties, operation mechanism, content of the work, workflow, training and assessment. We hope the Expert Advice will contribute to the construction and operation of the general practice network & regional medical consortium in various regions for COVID-19 containment.
The Value of Handheld COPD-6 Spirometry for Early COPD Detection in High Risk Elderly Population in Community
Chronic obstructive pulmonary disease (COPD) is a common chronic disease of the respiratory tract, and lung function is necessary for the diagnosis of COPD. However, conventional pulmonary function meters are not suitable for a large number of physical examinations in the community. In recent years, it is recommended to use spirometry for COPD screening and management both at home and abroad. However, there is still a lack of relevant data on its consistency and effectiveness with conventional lung function.
To explore the value of handheld COPD-6 spirometry for early COPD detection in high risk elderly population in community.
From January 2018 to December 2019 at Dongshan Community Health Service Center, Jiangning District, Nanjing City, a free physical examination was performed on the elder population over 60 years who had high risk factors of COPD. Handheld COPD-6 spirometry was performed pre- and post-bronchodilator, the forced expiratory volume in one second (FEV1) , the forced expiratory volume in one second as a percentage of the predicted value (FEV1%prep) , the forced expiratory volume in six second (FEV6) , the percentage of forced expiratory volume in six second to the predicted value (FEV6%prep) , and the value of FEV1/FEV6 were evaluated and recorded. With FEV1/FEV6<80% as the initial screening positive pre-bronchodilator, retests were performed both with handheld COPD-6 spirometry and confirmatory spirometry after inhaling bronchodilator. Using FEV1/Forced vital capacity (FVC) <70% as the gold standard by confirmatory spirometry, receiver-operator characteristic (ROC) curve analysis was used to obtain the best diagnostic threshold of FEV1/FEV6. Sensitivity, specificity, positive predictive value, and negative predictive value were used to evaluate the diagnostic value of the handheld COPD-6 spirometer.
Out of the 382 participants, COPD was confirmed in 75 according to FEV1/FVC<70% post-bronchodilator. There was no statistically significant difference between FEV1%pred pre- and post-bronchodilator by handheld COPD-6 spirometry (t=-0.971, P=0.703) ; There was no statistically significant difference among FEV1%pred in two tests (t=-2.352, -1.429; P=0.396, 0.058) . The FEV1%pred detected by handheld COPD-6 spirometry post-bronchodilation was positively correlated with confirmatory spirometry (r=0.969, P<0.05) . Compared with FVC%pred and FEV6%pred post-bronchodilation, the difference was statistically significant (t=-3.170, P=0.005) ; and the FEV6%pred was positively correlated with the FVC%pred (r=0.653, P<0.05) . There was no statistically significant difference between FEV1/FEV6 and FEV1/FVC post-bronchodilation (t=1.735, P=0.084) ; and there was substantial agreement between the two diagnostic (r=0.871, P<0.05) . The FEV1/FEV6 cut-off with the greatest sum of sensitivity and specificity was 71% pre-bronchodilator, the sensitivity, specificity, positive and negative predictive values were 80.0%, 79.2%, 90.6% and 48.5% respectively. The greatest sum of sensitivity and specificity was 75% post-bronchodilator, the sensitivity, specificity, positive and negative predictive values were 80.0%, 98.8%, 98.4% and 58.3% respectively.
It is feasible to use FEV1/FEV6 as an indicator to screen COPD patients in elderly high-risk populations. It is recommended to use FEV1/FEV6<71% before bronchodilation and FEV1/FEV6<75% after diastole as the screening criteria.
Meta-analysis and Trial Sequential Analysis of the Effects of Bilevel Positive Pressure Ventilation in the Acute Exacerbation of Chronic Obstructive Pulmonary Disease Complicated with TypeⅡ Respiratory Failure
Patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) have a significantly increased risk of developing type Ⅱ respiratory failure. In clinical treatment, BiPAP is widely used in this kind of patients to correct respiratory acidosis and delay the deterioration of lung function, but the therapeutic effect of BiPAP in this kind of patients is still controversial.
To systematically review the effect of BiPAP intervention on the treatment of patients with AECOPD complicated with type Ⅱrespiratory failure.
CNKI, Wanfang Database, CQVIP, CBM, PubMed, The Cochrane Library, Springer, Medline, and Web of Science were retrived by computer for the RCTs published from inception to October 2020 regarding the application of BiPAP in patients with AECOPD complicated with type Ⅱ respiratory failure. Two researchers independently screened the retrieved documents, extracted data and evaluated the quality. The first author, country, population characteristics, age, sample size, intervention methods of the experimental group and control group, frequency and duration of intervention of the experimental group, outcome indicators〔pH, partial pressure of carbon dioxide (PaCO2) , partial pressure of oxygen (PaO2) , respiratory frequency (RR) , tracheal intubation rate, incidence of adverse reactions〕 and other information were extracted. The Review Manager 5.4 software was used to conduct a meta-analysis of the included literature, and the TSA v0.9 developed by the Copenhagen Clinical Trial Center was used to complete the trial sequential analysis.
A total of 10 RCTs were included, of which 4 were of high quality and 6 were of medium quality. The experimental group could improve the pH value of patients with acute COPD and type Ⅱ respiratory failure 〔MD=0.04, 95%CI (0.03, 0.04) , P<0.05〕, PaCO2〔MD=-7.22, 95%CI (-8.20, -6.24) , P<0.05〕, PaO2〔MD=6.23, 95%CI (5.31, 7.14) , P<0.05〕, could improve the RR of patients with acute COPD onset and type Ⅱ respiratory failure within 24 h and after 24 h of intervention 〔MD=-3.85, 95%CI (-4.36, -3.35) , P<0.05〕, tracheal intubation rate〔RR=0.50, 95%CI (0.32, 0.78) , P<0.05〕 are better than the control group. The incidence of abdominal distension〔RR=5.95, 95%CI (1.79, 19.77) , P<0.05〕, facial skin damage〔RR=8.04, 95%CI (1.92, 33.76) , P<0.05〕are higher than the control group. The results of trial sequential analysis showed that BiPAP treatment could significantly improve the outcomes of pH, PaCO2, PaO2, RR and intubation rate in patients with typeⅡ respiratory failure due to acute exacerbation of COPD.
BiPAP therapy in patients with type Ⅱ respiratory failure due to acute exacerbation of COPD can improve patients' conditions of respiratory acidosis and hypoxia, and reduce intubation rate. However, BiPAP treatment may increase the incidence of adverse reactions such as abdominal distension and facial skin damage.
Prediction Methods of Exercise Induced Desaturation Detected by Six-minute Walk Test in Patients with Stable Chronic Obstructive Pulmonary Disease
Exercise-induced desaturation (EID) is highly prevalent, and associated with the prognosis in patients with chronic obstructive pulmonary disease (COPD) . Current predicators of EID mostly depend on pulmonary function, and the assessment for their values is different.
To explore simple, and accurate methods suitably used in primary care to predict EID by six-minute walk test (6MWT) in patients with stable COPD.
A retrospective study was conducted. Participants were 67 stable COPD patients with respiratory clinic follow-ups selected from China-Japan Friendship Hospital from 2019 to 2020. Data were collected, including assessment results of pulmonary function test, 6MWT, modified Medical Research Council (mMRC) , and COPD Assessment Test (CAT) , as well as calculated BODE index. EID in 6MWT was defined as the difference between minimum oxygen saturation in 6MWT and resting oxygen saturation at the beginning of 6MWT (ΔSpO2) ≥4%. mMRC score, CAT score and BODE index were compared between patients with and without EID in 6MWT to estimate the association of ΔSpO2 in 6MWT with mMRC score, CAT score and BODE index. ROC analysis was used to estimate the predictive value of mMRC score, CAT score and BODE index for inducible hypoxia in 6MWT.
The ΔSpO2 in 6MWT was significantly negatively correlated with mMRC score (r=-0.492, P<0.001) , CAT score (r=-0.447, P<0.001) , and BODE index (r=-0.415, P<0.001) . The AUC of mMRC score in predicting EID in 6MWT was 0.683 (with 2 as the optimal cut-off value) , and that for CAT score was 0.765 (with 14 as the optimal cut-off value) , for BODE index was 0.711 (with 2 as the optimal cut-off value) .
All of mMRC score, CAT score and BODE index can be used to predict EID in 6MWT in patients with stable COPD.
Non-communicable disease (NCD) managers are the main force in the prevention and treatment of chronic obstructive pulmonary disease (COPD) . Understanding the perceptions of COPD among NCD managers in primary care in rural areas can provide a scientific basis for enhancing future prevention and management of COPD in primary care.
To investigate the perceptions of COPD in NCD managers in rural primary care, offering a scientific basis for the improvement of COPD prevention and management in primary care.
In June 2021, random sampling method was used to select 20 township hospitals in Zigong, Sichuan Province, and from which NCD managers〔including general practitioners (GPs) , public health workers and rural doctors〕were selected by use of cluster sampling. A survey was conducted with them using a self-developed questionnaire (consisting of two parts: general demographics and COPD-related knowledge) for understanding their perceptions of COPD.
All the cases (n=474) who participated in the survey returned responsive questionnaires, achieving a response rate of 100.0%, including 68 GPs (14.4%) , 177 public health workers (37.3%) , and 229 rural doctors (48.3%) . With regards to answering the questions of comprehensive COPD knowledge, GPs had statistically significant higher pass rate than rural doctors〔35.3% (24/68) vs 7.4% (17/229) 〕 (P<0.017) , and public health workers also had statistically notably higher pass rate than rural doctors〔31.6% (56/177) vs 7.4% (17/229) 〕 (P<0.017) . In terms of answering the questions about risk factors of COPD, GPs had statistically significant higher pass rate than rural doctors〔73.5% (50/68) vs 46.3% (106/229) 〕 (P<0.017) , and so did public health workers〔66.7% (118/177) vs 46.3% (106/229) 〕 (P<0.017) . In terms of answering the questions about diagnosis and evaluation of COPD, GPs had statistically significant higher pass rate〔38.2% (26/68) 〕than public health workers〔20.3% (36/177) 〕or rural doctors〔3.9% (9/229) 〕 (P<0.017) , and the pass rate of public health workers was statistically significant higher than that of rural doctors (P<0.017) . In terms of answering the questions about treatment strategies for COPD, GPs had statistically significant higher pass rate than rural doctors〔30.9% (21/68) vs 6.6% (15/229) 〕 (P<0.017) , and so did public health workers〔19.2% (34/177) vs 6.5% (15/229) 〕 (P<0.017) . In terms of answering the questions regarding follow-up management for COPD, public health workers had statistically significant higher pass rate than GPs〔46.9% (83/177) vs 29.4% (20/68) 〕and rural doctors〔46.9% (83/177) vs 14.4% (33/229) 〕 (P<0.017) . And GPs had statistically significant higher pass rate than rural doctors (P<0.017) .
The NCD managers in primary care in rural areas of Sichuan's Zigong have insufficient knowledge of COPD, especially its diagnosis, evaluation, treatment strategies and follow-up management. NCD managers from different positions have different perceptions of COPD, among them rural doctors have the lowest level of perception. In view of the above problems, we need to take targeted measures to improve the level of general prevention and management of COPD in rural primary care.
Special Issue: Respiratory Diseases
