Pub Date : 2024-11-19DOI: 10.1016/j.rmed.2024.107861
Javier Errasti Viader , Miguel Ángel Martínez González , Arantza Campo Ezquibela , Maira Bes-Rastrollo
Objective
We conducted a systematic review and meta-analysis of published prospective cohort studies and randomized controlled trials (RCT) assessing the association between a healthy dietary pattern and adult-onset asthma following the PRISMA and MOOSE guidelines.
Methods
Inclusion criteria were RCT or cohort studies evaluating a dietary pattern and their association with asthma incidence in adults. We searched two databases, Medline (PubMed) and ISI Web of Science until November 2023. Two independent reviewers assessed the quality of the included studies. Risk of bias was assessed using the Newcastle-Ottawa Scale (NOS).
Results
Ten cohort studies were included in the systematic review and seven of them were assessed in a quantitative random-effects meta-analysis. They included a total of 597,909 participants with 10,988 asthma events. Dietary patterns or indexes were most frequently measured with validated food frequency questionnaires. Follow-up ranged between 5 and 16 years. When we pooled all the included studies, no significant reduction in asthma risk was associated with higher adherence to a high-quality dietary pattern (relative risk [RR]: 0.91; 95 % confidence interval [CI]: 0.81 to 1.02). However, there was a substantial between-study heterogeneity (I2 = 81.8 %, p < 0.001) and potential sources of heterogeneity were identified.
Discussion
Differences between studies in measuring the incidence of asthma, as well as, in assessing dietary patterns are likely to be potential sources of heterogeneity. Nevertheless, with the currently available evidence a beneficial association between adherence to a healthy dietary pattern and lower risk of adult-onset asthma cannot be supported.
{"title":"Dietary patterns and asthma incidence in adult population. Systematic review and meta-analysis","authors":"Javier Errasti Viader , Miguel Ángel Martínez González , Arantza Campo Ezquibela , Maira Bes-Rastrollo","doi":"10.1016/j.rmed.2024.107861","DOIUrl":"10.1016/j.rmed.2024.107861","url":null,"abstract":"<div><h3>Objective</h3><div>We conducted a systematic review and meta-analysis of published prospective cohort studies and randomized controlled trials (RCT) assessing the association between a healthy dietary pattern and adult-onset asthma following the PRISMA and MOOSE guidelines.</div></div><div><h3>Methods</h3><div>Inclusion criteria were RCT or cohort studies evaluating a dietary pattern and their association with asthma incidence in adults. We searched two databases, Medline (PubMed) and ISI Web of Science until November 2023. Two independent reviewers assessed the quality of the included studies. Risk of bias was assessed using the Newcastle-Ottawa Scale (NOS).</div></div><div><h3>Results</h3><div>Ten cohort studies were included in the systematic review and seven of them were assessed in a quantitative random-effects meta-analysis. They included a total of 597,909 participants with 10,988 asthma events. Dietary patterns or indexes were most frequently measured with validated food frequency questionnaires. Follow-up ranged between 5 and 16 years. When we pooled all the included studies, no significant reduction in asthma risk was associated with higher adherence to a high-quality dietary pattern (relative risk [RR]: 0.91; 95 % confidence interval [CI]: 0.81 to 1.02). However, there was a substantial between-study heterogeneity (I<sup>2</sup> = 81.8 %, p < 0.001) and potential sources of heterogeneity were identified.</div></div><div><h3>Discussion</h3><div>Differences between studies in measuring the incidence of asthma, as well as, in assessing dietary patterns are likely to be potential sources of heterogeneity. Nevertheless, with the currently available evidence a beneficial association between adherence to a healthy dietary pattern and lower risk of adult-onset asthma cannot be supported.</div></div>","PeriodicalId":21057,"journal":{"name":"Respiratory medicine","volume":"236 ","pages":"Article 107861"},"PeriodicalIF":3.5,"publicationDate":"2024-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142688673","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-18DOI: 10.1016/j.rmed.2024.107864
Alexandra Hodge , Helena Wickham , Katia Florman , Gemma Barrowcliffe , Aoife Tynan , Anant Patel , Simon Brill , James Brown
Introduction
Increasing the proportion of low-carbon inhalers prescribed within the NHS forms a central part of net-zero policy. Yet, the patients’ perspective on this strategy has not been determined. We aimed to establish if environmental issues are important to respiratory patients and whether this may influence inhaler choice.
Methods
We conducted a survey of 61 respiratory patients at the Royal Free NHS Foundation Trust, London to establish their perspective on the environmental impact of inhalers.
Results
We identified that 70.5 % (43/61) of patients did not know that inhalers could contribute to climate change. Furthermore, 85.3 % (52/61) of patients felt it was ‘quite’ or ‘very important’ to reduce their own contribution to climate change. Importantly, 59 % (36/61) of patients would actively want to change inhalers and 26.2 % (16/61) would consider changing inhalers based on this information. There was no significant difference based on age (< or ≥ 60 years) (Chi2 = 1.2, p = 0.28) or gender (Chi2 = 0.88, p = 0.77).
Discussion
These findings demonstrate that environmental issues are important to respiratory patients. Despite this, the environmental impact of inhalers is not routinely discussed with patients. Once provided with this information patients actively want to change to low-carbon inhalers. Hence, the environmental impact of inhalers should be shared with patients to help us to achieve a net-zero NHS.
{"title":"The patient perspective on the environmental impact of inhalers","authors":"Alexandra Hodge , Helena Wickham , Katia Florman , Gemma Barrowcliffe , Aoife Tynan , Anant Patel , Simon Brill , James Brown","doi":"10.1016/j.rmed.2024.107864","DOIUrl":"10.1016/j.rmed.2024.107864","url":null,"abstract":"<div><h3>Introduction</h3><div>Increasing the proportion of low-carbon inhalers prescribed within the NHS forms a central part of net-zero policy. Yet, the patients’ perspective on this strategy has not been determined. We aimed to establish if environmental issues are important to respiratory patients and whether this may influence inhaler choice.</div></div><div><h3>Methods</h3><div>We conducted a survey of 61 respiratory patients at the Royal Free NHS Foundation Trust, London to establish their perspective on the environmental impact of inhalers.</div></div><div><h3>Results</h3><div>We identified that 70.5 % (43/61) of patients did not know that inhalers could contribute to climate change. Furthermore, 85.3 % (52/61) of patients felt it was ‘quite’ or ‘very important’ to reduce their own contribution to climate change. Importantly, 59 % (36/61) of patients would actively want to change inhalers and 26.2 % (16/61) would consider changing inhalers based on this information. There was no significant difference based on age (< or ≥ 60 years) (Chi<sup>2</sup> = 1.2, p = 0.28) or gender (Chi<sup>2</sup> = 0.88, p = 0.77).</div></div><div><h3>Discussion</h3><div>These findings demonstrate that environmental issues are important to respiratory patients. Despite this, the environmental impact of inhalers is not routinely discussed with patients. Once provided with this information patients actively want to change to low-carbon inhalers. Hence, the environmental impact of inhalers should be shared with patients to help us to achieve a net-zero NHS.</div></div>","PeriodicalId":21057,"journal":{"name":"Respiratory medicine","volume":"235 ","pages":"Article 107864"},"PeriodicalIF":3.5,"publicationDate":"2024-11-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142682466","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-16DOI: 10.1016/j.rmed.2024.107867
Nilesh Seshadri , Walter Faig , Lisa R. Young , David A. Hill
Background and objectives
Children with severe persistent asthma managed by subspecialists represent a unique patient population. The factors predisposing these children to hospital admission are poorly understood. This study aimed to identify factors associated with future emergency department (ED) visits and hospitalization in this group.
Methods
A chart review was conducted for children with severe persistent asthma evaluated by a pulmonologist between January 1, 2021 and June 30, 2022. Asthma-related ED visits and hospitalizations were recorded from electronic medical records. Chi-square testing, mixed effects modeling, and logistic regression were used to analyze associations between patient characteristics and hospitalization. A secondary analysis evaluated factors contributing to ED visits.
Results
We identified 244 unique patients with 487 pulmonary clinic visits. Of these, 56 % were black, 58 % had public insurance, and 32 % had a history of ICU admission for asthma. In the 12 months following a clinic visit, 84 (34 %) patients had an ED visit, and 46 (19 %) had at least one hospitalization. Secondhand smoke exposure (OR 2.74, 95 % CI 1.16–6.45), public insurance (OR 3.37, 95 % CI 1.46–7.82), and prior ICU admission (OR 2.29, 95 % CI 1.09–4.79) were positively associated with hospitalization for asthma exacerbation. Among hospitalized patients, bronchopulmonary dysplasia (BPD) and gastroesophageal reflux disease (GERD) were linked to shorter time to admission.
Conclusions
Despite subspecialty care, children with severe persistent asthma exposed to cigarette smoke, with prior ICU admission, or with public insurance are at higher risk of subsequent ED visits and hospitalization. These findings will inform targeted interventions to prevent hospitalization in this patient population.
{"title":"Risk factors for hospitalization in subspecialty patients with severe persistent asthma","authors":"Nilesh Seshadri , Walter Faig , Lisa R. Young , David A. Hill","doi":"10.1016/j.rmed.2024.107867","DOIUrl":"10.1016/j.rmed.2024.107867","url":null,"abstract":"<div><h3>Background and objectives</h3><div>Children with severe persistent asthma managed by subspecialists represent a unique patient population. The factors predisposing these children to hospital admission are poorly understood. This study aimed to identify factors associated with future emergency department (ED) visits and hospitalization in this group.</div></div><div><h3>Methods</h3><div>A chart review was conducted for children with severe persistent asthma evaluated by a pulmonologist between January 1, 2021 and June 30, 2022. Asthma-related ED visits and hospitalizations were recorded from electronic medical records. Chi-square testing, mixed effects modeling, and logistic regression were used to analyze associations between patient characteristics and hospitalization. A secondary analysis evaluated factors contributing to ED visits.</div></div><div><h3>Results</h3><div>We identified 244 unique patients with 487 pulmonary clinic visits. Of these, 56 % were black, 58 % had public insurance, and 32 % had a history of ICU admission for asthma. In the 12 months following a clinic visit, 84 (34 %) patients had an ED visit, and 46 (19 %) had at least one hospitalization. Secondhand smoke exposure (OR 2.74, 95 % CI 1.16–6.45), public insurance (OR 3.37, 95 % CI 1.46–7.82), and prior ICU admission (OR 2.29, 95 % CI 1.09–4.79) were positively associated with hospitalization for asthma exacerbation. Among hospitalized patients, bronchopulmonary dysplasia (BPD) and gastroesophageal reflux disease (GERD) were linked to shorter time to admission.</div></div><div><h3>Conclusions</h3><div>Despite subspecialty care, children with severe persistent asthma exposed to cigarette smoke, with prior ICU admission, or with public insurance are at higher risk of subsequent ED visits and hospitalization. These findings will inform targeted interventions to prevent hospitalization in this patient population.</div></div>","PeriodicalId":21057,"journal":{"name":"Respiratory medicine","volume":"235 ","pages":"Article 107867"},"PeriodicalIF":3.5,"publicationDate":"2024-11-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142648972","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-16DOI: 10.1016/j.rmed.2024.107860
Andrew J. Gangemi , Chandra A. Dass , Huaqing Zhao , Maulin Patel , Nathaniel Marchetti , Gerard J. Criner , Parag Desai
Purpose
Point of Care Ultrasound (POCUS) is widely used to evaluate pleural apposition in acute disease; however, the prevalence of abnormal findings among emphysematous patients is unknown. The aim of the study was to characterize POCUS findings in advanced emphysema and correlate parenchymal and spirometric changes with abnormal POCUS results.
Materials and methods
We retrospectively evaluated POCUS images obtained in hyperinflated COPD patients. Images were obtained in the 2nd intercostal space (upper lobes) and above diaphragm insertion (lower lobes). Pleural sliding was graded as “present” or “absent,” and M-mode images graded as “seashore,” “barcode,” or “hybrid” patterns; patients were then assigned to four groups based on the combination of findings. Differences between pulmonary function testing and high-resolution CT were made by Chi Square or ANOVA testing, and association by Spearman's correlation. Agreement among three scorers (two pulmonologists and one radiologist) was assessed using Kappa statistics.
Results
Our study included 48 patients with 159 lobes imaged. We found a substantial percentage of lobes had either barcode M-mode appearance (13.8 %) or indeterminate/absent lung sliding (20.3 %). We identified 87 lobes (54.7 %) that did not fit any typical definition for M-mode ultrasound findings. There was no strong association of abnormal ultrasound patterns with airflow obstruction or emphysema percentage. There was wide interrater variability among B-mode (0.20–0.611) and M-mode (0.24-0.049) among the three graders.
Conclusions
Hyperinflated patients often show abnormal pleural sliding appearance on POCUS, with a high false positive rate of barcode pattern. This should be considered when interpretation of POCUS drives therapeutic decisions.
{"title":"Advanced emphysema leads to high false positivity rate for pneumothorax in point of care ultrasound","authors":"Andrew J. Gangemi , Chandra A. Dass , Huaqing Zhao , Maulin Patel , Nathaniel Marchetti , Gerard J. Criner , Parag Desai","doi":"10.1016/j.rmed.2024.107860","DOIUrl":"10.1016/j.rmed.2024.107860","url":null,"abstract":"<div><h3>Purpose</h3><div>Point of Care Ultrasound (POCUS) is widely used to evaluate pleural apposition in acute disease; however, the prevalence of abnormal findings among emphysematous patients is unknown. The aim of the study was to characterize POCUS findings in advanced emphysema and correlate parenchymal and spirometric changes with abnormal POCUS results.</div></div><div><h3>Materials and methods</h3><div>We retrospectively evaluated POCUS images obtained in hyperinflated COPD patients. Images were obtained in the 2nd intercostal space (upper lobes) and above diaphragm insertion (lower lobes). Pleural sliding was graded as “present” or “absent,” and M-mode images graded as “seashore,” “barcode,” or “hybrid” patterns; patients were then assigned to four groups based on the combination of findings. Differences between pulmonary function testing and high-resolution CT were made by Chi Square or ANOVA testing, and association by Spearman's correlation. Agreement among three scorers (two pulmonologists and one radiologist) was assessed using Kappa statistics.</div></div><div><h3>Results</h3><div>Our study included 48 patients with 159 lobes imaged. We found a substantial percentage of lobes had either barcode M-mode appearance (13.8 %) or indeterminate/absent lung sliding (20.3 %). We identified 87 lobes (54.7 %) that did not fit any typical definition for M-mode ultrasound findings. There was no strong association of abnormal ultrasound patterns with airflow obstruction or emphysema percentage. There was wide interrater variability among B-mode (0.20–0.611) and M-mode (0.24-0.049) among the three graders.</div></div><div><h3>Conclusions</h3><div>Hyperinflated patients often show abnormal pleural sliding appearance on POCUS, with a high false positive rate of barcode pattern. This should be considered when interpretation of POCUS drives therapeutic decisions.</div></div>","PeriodicalId":21057,"journal":{"name":"Respiratory medicine","volume":"235 ","pages":"Article 107860"},"PeriodicalIF":3.5,"publicationDate":"2024-11-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142668814","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-15DOI: 10.1016/j.rmed.2024.107866
Hansheng Wang , Wenya Han , Chengqing Yang , Hongling Hu , Yulan Zheng , Li He , Miaojuan Zhu , Qiujie Tu , Lulu Nan , Fuying Hu , Wentian Li , Yijun Tang , Meifang Wang
Background and objective
We aimed to evaluate clinical characteristics and therapeutic efficacy of pulmonary cryptococcosis (PC) in patients with different immune status in a large multicenter population to support appropriate clinical management of this public health threat.
Methods
We retrospectively investigated the medical records of 510 patients with PC from January 2014 to June 2023 in 10 representative regional tertiary teaching hospitals in Hubei province of China, and clinical data of these patients were then stratified by different immune statuses.
Results
Immunocompetent (IC) patients accounted for 68.8 % (351/510), mild-to-moderate immunodeficiency (MID) patients accounted for 16.7 % (85/510), and severe immunodeficiency (SID) patients accounted for 14.5 % (74/510). PC patients in the MID and SID groups had a higher incidence of central nervous system (CNS) involvement than that in the IC group [4.7 % (MID) vs. 8.1 % (SID) vs. 1.1 % (IC), p = 0.002]. Patients with fever in SID group (35.1 %, 26/74) was more common (p < 0.01). Solitary nodule/mass were more common in the IC group than the MID and SID groups (p < 0.05); in contrast, diffuse nodules in MID or SID groups was significantly greater than that in IC groups (p < 0.01). The follow-up showed that the overall treatment improvement rate for PC showed a significant difference between the 3 groups [90.3 % (IC) vs. 75.3 % (MID) vs. 54.1 % (SID), p = 0.00].
Conclusion
The incidence of PC is increasing in Central China, especially for the immunocompetent PC population. In addition, there are significant differences in age, systemic symptoms, certain radiographic characteristics and some laboratory results between immunosuppressed and immunocompetent PC hosts. And finally, limited nodules/masses and mild symptoms in patients with PC often lead to misdiagnosis and unnecessary pulmonary resection, but CrAg assay contributes to early noninvasive diagnosis.
背景和目的：我们旨在评估肺隐球菌病（PC）在大型多中心人群中不同免疫状态患者的临床特征和疗效，以支持对这一公共卫生威胁的适当临床管理：我们回顾性调查了2014年1月至2023年6月期间中国湖北省10家具有代表性的区域性三级教学医院的510例PC患者的病历，然后按照不同的免疫状态对这些患者的临床数据进行分层：免疫功能正常（IC）患者占68.8%（351/510），轻中度免疫缺陷（MID）患者占16.7%（85/510），重度免疫缺陷（SID）患者占14.5%（74/510）。MID组和SID组PC患者中枢神经系统（CNS）受累的发生率高于IC组[4.7%（MID） vs. 8.1%（SID） vs. 1.1%（IC），P = 0.002]。发热患者在 SID 组（35.1%，26/74）中更为常见（P=0.002）：PC在华中地区的发病率正在上升，尤其是免疫功能正常的PC人群。此外，免疫抑制和免疫功能健全的 PC 患者在年龄、全身症状、某些影像学特征和某些实验室结果方面存在显著差异。最后，PC 患者的局限性结节/肿块和轻微症状常常导致误诊和不必要的肺切除，而 CrAg 检测有助于早期无创诊断。
{"title":"Clinical characteristics of pulmonary cryptococcosis patients with different immune statuses: A 10-year multicenter retrospective study in China","authors":"Hansheng Wang , Wenya Han , Chengqing Yang , Hongling Hu , Yulan Zheng , Li He , Miaojuan Zhu , Qiujie Tu , Lulu Nan , Fuying Hu , Wentian Li , Yijun Tang , Meifang Wang","doi":"10.1016/j.rmed.2024.107866","DOIUrl":"10.1016/j.rmed.2024.107866","url":null,"abstract":"<div><h3>Background and objective</h3><div>We aimed to evaluate clinical characteristics and therapeutic efficacy of pulmonary cryptococcosis (PC) in patients with different immune status in a large multicenter population to support appropriate clinical management of this public health threat.</div></div><div><h3>Methods</h3><div>We retrospectively investigated the medical records of 510 patients with PC from January 2014 to June 2023 in 10 representative regional tertiary teaching hospitals in Hubei province of China, and clinical data of these patients were then stratified by different immune statuses.</div></div><div><h3>Results</h3><div>Immunocompetent (IC) patients accounted for 68.8 % (351/510), mild-to-moderate immunodeficiency (MID) patients accounted for 16.7 % (85/510), and severe immunodeficiency (SID) patients accounted for 14.5 % (74/510). PC patients in the MID and SID groups had a higher incidence of central nervous system (CNS) involvement than that in the IC group [4.7 % (MID) <em>vs.</em> 8.1 % (SID) <em>vs.</em> 1.1 % (IC), <em>p</em> = 0.002]. Patients with fever in SID group (35.1 %, 26/74) was more common (<em>p</em> < 0.01). Solitary nodule/mass were more common in the IC group than the MID and SID groups (<em>p</em> < 0.05); in contrast, diffuse nodules in MID or SID groups was significantly greater than that in IC groups (<em>p</em> < 0.01). The follow-up showed that the overall treatment improvement rate for PC showed a significant difference between the 3 groups [90.3 % (IC) <em>vs</em>. 75.3 % (MID) <em>vs</em>. 54.1 % (SID), <em>p</em> = 0.00].</div></div><div><h3>Conclusion</h3><div>The incidence of PC is increasing in Central China, especially for the immunocompetent PC population. In addition, there are significant differences in age, systemic symptoms, certain radiographic characteristics and some laboratory results between immunosuppressed and immunocompetent PC hosts. And finally, limited nodules/masses and mild symptoms in patients with PC often lead to misdiagnosis and unnecessary pulmonary resection, but CrAg assay contributes to early noninvasive diagnosis.</div></div>","PeriodicalId":21057,"journal":{"name":"Respiratory medicine","volume":"235 ","pages":"Article 107866"},"PeriodicalIF":3.5,"publicationDate":"2024-11-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142648955","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-15DOI: 10.1016/j.rmed.2024.107865
Giulia Scioscia , Federico Baraldi , Tommaso Bigoni , Alberto Papi , Alessandro Vatrella , Claudio Micheletto , Maria Pia Foschino Barbaro
Chronic obstructive pulmonary disease (COPD) is a progressive lung condition and a leading cause of physical decline and death. COPD prevalence is expected to increase steadily in the coming years, and as a result, the healthcare and social burden of this condition will intensify. In this scenario, a patient-centric approach, the treatable trait (TT) strategy, based on the identification of traits that are clinically relevant, identifiable, monitorable and treatable, has emerged. The TT strategy, which considers behavioral/risk factors, as well as pulmonary and extrapulmonary traits, has shown to be a promising strategy in COPD management. This work reviews the TT strategy in COPD, giving special attention to the most relevant pulmonary traits, such as frequent productive cough, chronic bronchitis, type 2 inflammation, neutrophilic inflammation, lung hyperinflation, bronchiectasis, exacerbations and non‐reversible airflow limitation. N-acetylcysteine (NAC), a widely used mucolytic agent, might be a major player in this strategy. Indeed, through a thorough review of the literature, it has been possible to highlight that, besides being essential in the treatment of frequent productive cough, NAC could bring benefits in case of airflow limitations, airways inflammation, exacerbations and bronchiectasis.
A clinical case in which the TT strategy was able to reduce symptoms and improve lung function and quality of life, minimizing unnecessary medication and side effects, is also presented. The identification of TTs and their proper treatment through personalized medicine remarkably ameliorates COPD management. Of note, the mucolytic, antioxidant, and anti-inflammatory activities of NAC might have beneficial effects on several TTs.
{"title":"The precision medicine strategy to treat COPD pulmonary traits in clinical practice: The role of N-acetylcysteine","authors":"Giulia Scioscia , Federico Baraldi , Tommaso Bigoni , Alberto Papi , Alessandro Vatrella , Claudio Micheletto , Maria Pia Foschino Barbaro","doi":"10.1016/j.rmed.2024.107865","DOIUrl":"10.1016/j.rmed.2024.107865","url":null,"abstract":"<div><div>Chronic obstructive pulmonary disease (COPD) is a progressive lung condition and a leading cause of physical decline and death. COPD prevalence is expected to increase steadily in the coming years, and as a result, the healthcare and social burden of this condition will intensify. In this scenario, a patient-centric approach, the treatable trait (TT) strategy, based on the identification of traits that are clinically relevant, identifiable, monitorable and treatable, has emerged. The TT strategy, which considers behavioral/risk factors, as well as pulmonary and extrapulmonary traits, has shown to be a promising strategy in COPD management. This work reviews the TT strategy in COPD, giving special attention to the most relevant pulmonary traits, such as frequent productive cough, chronic bronchitis, type 2 inflammation, neutrophilic inflammation, lung hyperinflation, bronchiectasis, exacerbations and non‐reversible airflow limitation. N-acetylcysteine (NAC), a widely used mucolytic agent, might be a major player in this strategy. Indeed, through a thorough review of the literature, it has been possible to highlight that, besides being essential in the treatment of frequent productive cough, NAC could bring benefits in case of airflow limitations, airways inflammation, exacerbations and bronchiectasis.</div><div>A clinical case in which the TT strategy was able to reduce symptoms and improve lung function and quality of life, minimizing unnecessary medication and side effects, is also presented. The identification of TTs and their proper treatment through personalized medicine remarkably ameliorates COPD management. Of note, the mucolytic, antioxidant, and anti-inflammatory activities of NAC might have beneficial effects on several TTs.</div></div>","PeriodicalId":21057,"journal":{"name":"Respiratory medicine","volume":"235 ","pages":"Article 107865"},"PeriodicalIF":3.5,"publicationDate":"2024-11-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142644693","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-14DOI: 10.1016/j.rmed.2024.107858
Mehnaz Rahman , Avaneesh Jakkoju , Ala M. Mohsen , Anjali Vaidya , Stephen C. Mathai , Monica Mukherjee , Matthew R. Lammi
Background
Interventricular septal (IVS) flattening is a key echocardiographic feature of pulmonary hypertension (PH) that is associated with worse outcomes. The accuracy and interobserver reliability of visual and quantitative measures of IVS in PH patients are poorly described.
Methods
This single-center, retrospective analysis included 173 PH patients. All echocardiograms were independently interpreted by two board-certified echocardiographers, and IVS flattening was judged to be present visually and by calculating the eccentricity index (EI). A receiver operating characteristics analysis was conducted to determine the EI with the highest combination of sensitivity and specificity for visual IVS flattening. The agreement between the two echocardiographers for calculation of EI was assessed using Bland-Altman analysis.
Results
The overall percent agreement for visual IVS flattening was 72 % with a Kappa coefficient of 0.27. Agreement was highest for patients with pre-capillary PH and lowest for those with isolated post-capillary PH. An EI cut-off of 1.5 had the highest combination of specificity (80 %) and sensitivity (32 %) to distinguish visual septal flattening. Bland-Altman analysis showed wide 95 % limits of agreement between echocardiographers for EI measured during systole and diastole.
Interpretation
There was a fair degree of agreement between two echo readers for the presence or absence of IVS flattening, which differed based on the hemodynamic subgroup of PH. Compared to the quantitative measure EI, visual assessment had a moderately high specificity but very low sensitivity for the presence of IVS flattening. Automated measures of IVS flattening should be considered to improve the accuracy and reliability of this key metric.
{"title":"Interobserver reliability and accuracy of the visual assessment of interventricular septal flattening in pulmonary hypertension","authors":"Mehnaz Rahman , Avaneesh Jakkoju , Ala M. Mohsen , Anjali Vaidya , Stephen C. Mathai , Monica Mukherjee , Matthew R. Lammi","doi":"10.1016/j.rmed.2024.107858","DOIUrl":"10.1016/j.rmed.2024.107858","url":null,"abstract":"<div><h3>Background</h3><div>Interventricular septal (IVS) flattening is a key echocardiographic feature of pulmonary hypertension (PH) that is associated with worse outcomes. The accuracy and interobserver reliability of visual and quantitative measures of IVS in PH patients are poorly described.</div></div><div><h3>Methods</h3><div>This single-center, retrospective analysis included 173 PH patients. All echocardiograms were independently interpreted by two board-certified echocardiographers, and IVS flattening was judged to be present visually and by calculating the eccentricity index (EI). A receiver operating characteristics analysis was conducted to determine the EI with the highest combination of sensitivity and specificity for visual IVS flattening. The agreement between the two echocardiographers for calculation of EI was assessed using Bland-Altman analysis.</div></div><div><h3>Results</h3><div>The overall percent agreement for visual IVS flattening was 72 % with a Kappa coefficient of 0.27. Agreement was highest for patients with pre-capillary PH and lowest for those with isolated post-capillary PH. An EI cut-off of 1.5 had the highest combination of specificity (80 %) and sensitivity (32 %) to distinguish visual septal flattening. Bland-Altman analysis showed wide 95 % limits of agreement between echocardiographers for EI measured during systole and diastole.</div></div><div><h3>Interpretation</h3><div>There was a fair degree of agreement between two echo readers for the presence or absence of IVS flattening, which differed based on the hemodynamic subgroup of PH. Compared to the quantitative measure EI, visual assessment had a moderately high specificity but very low sensitivity for the presence of IVS flattening. Automated measures of IVS flattening should be considered to improve the accuracy and reliability of this key metric.</div></div>","PeriodicalId":21057,"journal":{"name":"Respiratory medicine","volume":"235 ","pages":"Article 107858"},"PeriodicalIF":3.5,"publicationDate":"2024-11-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142639676","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-12DOI: 10.1016/j.rmed.2024.107857
Han Na Lee , Ho Cheol Kim , Jung Bok Lee , Jae Seung Lee , Dae-Hee Kim , Jong-Min Song , June-Goo Lee , Joon-Won Kang , Dong Hyun Yang , Hyun Jung Koo
Introduction
Idiopathic pulmonary arterial hypertension (IPAH) is a severe condition characterized by a poor prognosis, rapid deterioration, and high mortality in the absence of lung transplantation. However, non-invasive prognostic markers in assessing IPAH remain uncertain. We aimed to investigate the prognostic significance of chest CT and alterations in heart contours on chest radiography (CXR) in predicting adverse outcomes in IPAH patients.
Methods
A retrospective study analyzed medical records of IPAH patients who underwent right heart catheterization and chest CT at a tertiary center between 2001 and 2023. Clinical, hemodynamic, and CT findings, and changes (Δ) in heart contours on CXR were assessed. Adverse events were defined as IPAH-related death or lung transplantation. Cox regression models evaluated the predictive power of these parameters.
Results
In 80 patients with IPAH (mean age 42.6 years; 75 % females), the 3- and 5-year survival rates were 65.8 % and 55.1 %, respectively. Adverse events were associated with a history of cardiac arrest (Hazard ratio [HR], 11.67, p = 0.02), mean pulmonary artery pressure (HR, 1.04, p = 0.001), creatinine (HR, 4.12, p < 0.001), 6-min walk distance (HR, 0.997, p = 0.03), CT-derived right atrial (RA) volume index (HR, 1.01, p = 0.02), and ΔRA contour on CXR (HR, 1.27, p < 0.001). Combined clinical, CT, and CXR findings showed a 3-year event-free survival predictive accuracy of 82.2 % (95 % CI, 69.8–94.7), outperforming clinical factors alone.
Conclusion
Rapid increases in RA contour on CXR and CT-derived RA volume index were associated with adverse outcomes in IPAH. Assessing these parameters may be helpful in identifying patients who require proactive treatments.
{"title":"Prognostic significance of right atrial volume and interval changes in patients with idiopathic pulmonary arterial hypertension","authors":"Han Na Lee , Ho Cheol Kim , Jung Bok Lee , Jae Seung Lee , Dae-Hee Kim , Jong-Min Song , June-Goo Lee , Joon-Won Kang , Dong Hyun Yang , Hyun Jung Koo","doi":"10.1016/j.rmed.2024.107857","DOIUrl":"10.1016/j.rmed.2024.107857","url":null,"abstract":"<div><h3>Introduction</h3><div>Idiopathic pulmonary arterial hypertension (IPAH) is a severe condition characterized by a poor prognosis, rapid deterioration, and high mortality in the absence of lung transplantation. However, non-invasive prognostic markers in assessing IPAH remain uncertain. We aimed to investigate the prognostic significance of chest CT and alterations in heart contours on chest radiography (CXR) in predicting adverse outcomes in IPAH patients.</div></div><div><h3>Methods</h3><div>A retrospective study analyzed medical records of IPAH patients who underwent right heart catheterization and chest CT at a tertiary center between 2001 and 2023. Clinical, hemodynamic, and CT findings, and changes (Δ) in heart contours on CXR were assessed. Adverse events were defined as IPAH-related death or lung transplantation. Cox regression models evaluated the predictive power of these parameters.</div></div><div><h3>Results</h3><div>In 80 patients with IPAH (mean age 42.6 years; 75 % females), the 3- and 5-year survival rates were 65.8 % and 55.1 %, respectively. Adverse events were associated with a history of cardiac arrest (Hazard ratio [HR], 11.67, p = 0.02), mean pulmonary artery pressure (HR, 1.04, p = 0.001), creatinine (HR, 4.12, p < 0.001), 6-min walk distance (HR, 0.997, p = 0.03), CT-derived right atrial (RA) volume index (HR, 1.01, p = 0.02), and ΔRA contour on CXR (HR, 1.27, p < 0.001). Combined clinical, CT, and CXR findings showed a 3-year event-free survival predictive accuracy of 82.2 % (95 % CI, 69.8–94.7), outperforming clinical factors alone.</div></div><div><h3>Conclusion</h3><div>Rapid increases in RA contour on CXR and CT-derived RA volume index were associated with adverse outcomes in IPAH. Assessing these parameters may be helpful in identifying patients who require proactive treatments.</div></div>","PeriodicalId":21057,"journal":{"name":"Respiratory medicine","volume":"235 ","pages":"Article 107857"},"PeriodicalIF":3.5,"publicationDate":"2024-11-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142626368","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-12DOI: 10.1016/j.rmed.2024.107859
Odil Garrido Campos de Andrade , Luiz Claudio Gonçalves de Castro , Veronica Moreira Amado
<div><div>This study aimed to evaluate the prevalence of thyroid, glycemic, lipid and metabolic bone disorders among adult patients with pulmonary arterial hypertension (PAH).</div></div><div><h3>Methods</h3><div>This was an observational cross-sectional clinical study with patients with PAH, matched by sex and age with a control group without PAH. All individuals were enrolled into a clinical assessment, metabolic workup, thyroid ultrasound, and bone densitometry protocol.</div></div><div><h3>Results</h3><div>The PAH group included 35 participants (34 females, 46 ± 15.5 years), and the control group, 40 (39 females, 41.8 ± 13.1 years). There was no difference in body mass index (BMI) between PAH and control group (27.5 ± 5.9 and 26.9 ± 4.3 kg/m<sup>2</sup>, respectively, p = 0.63; 95 % CI: −1.8, 2.94), neither in physical activity time per week (60.3 ± 103.3 and 98.9 ± 137.6, respectively, p = 0.17; 95 % CI: −95.23, 18.06). Although there was no difference in the prevalence of insulin resistance between the PAH (51.4 %) and the control group (47.5 %), p = 0.74, patients with PAH had a higher median of glycated hemoglobin (A1c) than the control group (6.1 % and 5.57 %, respectively, p = 0.006; 95 % CI: −0.14, 1.22). PAH group presented lower mean total <strong>c</strong>holesterol (170.46 ± 35.51 mg/dL) and median LDL-cholesterol [105 (83–129) mg/dL, median (P25–P75)] levels than the control group [192.1 ± 34.44 mg/dL, p = 0.009; 95 % CI = −37.76, 5.52 and 121.6 (97–145) mg/dL, p = 0.012; 95 % CI: −34.08, 0.77, respectively]. It was found a higher prevalence of hypothyroidism (22.9 %) in PAH group than in control group (2.5 %), p = 0.007. We found hyperparathyroidism (HPT) among 8 patients of PAH group (23 %), but none in the control group. Considering bone mineral density disorders, 12 patients from PAH group presented low bone mass, osteopenia, or osteoporosis (34 %), and 8 individuals in the control group (20 %), p = 0.032, which represented a 2.13 higher relative risk for those conditions for the former group. The patients with HPT presented a higher creatinine level (0.98 ± 0.12 mg/dL) than the PAH patients with normal parathyroid hormone (0.76 ± 0.14 mg/dL), p = 0.0004; 95 % CI: 0.12, 0.33. The PAH group also presented lower total hip (-0.15 ± 1.25) and femoral neck (−0.14 ± 1.07) bone mineral density (BMD) Z-scores than the control group (0.50 ± 1.13, p = 0.021; 95 % CI: −0.18, −0.027 and 0.35 ± 0.94, p = 0.038; 95 % CI: −0.16, −0.01, respectively).</div></div><div><h3>Conclusion</h3><div>In this cohort, the findings of higher A1c levels, hypothyroidism prevalence, lower LDL and total cholesterol levels, and a higher prevalence of hyperparathyroidism, as well as lower total hip and femoral neck BMD Z-scores in the PAH group, compared to the control group and highlighting the dysregulation of various metabolic pathways in patients with HAP, suggesting the need for targeted interventions to enhance patient care. Additionally, they underscore
{"title":"Unveiling the metabolic challenges in pulmonary arterial hypertension: Insights into thyroid, glycemic, lipid, and bone disorders","authors":"Odil Garrido Campos de Andrade , Luiz Claudio Gonçalves de Castro , Veronica Moreira Amado","doi":"10.1016/j.rmed.2024.107859","DOIUrl":"10.1016/j.rmed.2024.107859","url":null,"abstract":"<div><div>This study aimed to evaluate the prevalence of thyroid, glycemic, lipid and metabolic bone disorders among adult patients with pulmonary arterial hypertension (PAH).</div></div><div><h3>Methods</h3><div>This was an observational cross-sectional clinical study with patients with PAH, matched by sex and age with a control group without PAH. All individuals were enrolled into a clinical assessment, metabolic workup, thyroid ultrasound, and bone densitometry protocol.</div></div><div><h3>Results</h3><div>The PAH group included 35 participants (34 females, 46 ± 15.5 years), and the control group, 40 (39 females, 41.8 ± 13.1 years). There was no difference in body mass index (BMI) between PAH and control group (27.5 ± 5.9 and 26.9 ± 4.3 kg/m<sup>2</sup>, respectively, p = 0.63; 95 % CI: −1.8, 2.94), neither in physical activity time per week (60.3 ± 103.3 and 98.9 ± 137.6, respectively, p = 0.17; 95 % CI: −95.23, 18.06). Although there was no difference in the prevalence of insulin resistance between the PAH (51.4 %) and the control group (47.5 %), p = 0.74, patients with PAH had a higher median of glycated hemoglobin (A1c) than the control group (6.1 % and 5.57 %, respectively, p = 0.006; 95 % CI: −0.14, 1.22). PAH group presented lower mean total <strong>c</strong>holesterol (170.46 ± 35.51 mg/dL) and median LDL-cholesterol [105 (83–129) mg/dL, median (P25–P75)] levels than the control group [192.1 ± 34.44 mg/dL, p = 0.009; 95 % CI = −37.76, 5.52 and 121.6 (97–145) mg/dL, p = 0.012; 95 % CI: −34.08, 0.77, respectively]. It was found a higher prevalence of hypothyroidism (22.9 %) in PAH group than in control group (2.5 %), p = 0.007. We found hyperparathyroidism (HPT) among 8 patients of PAH group (23 %), but none in the control group. Considering bone mineral density disorders, 12 patients from PAH group presented low bone mass, osteopenia, or osteoporosis (34 %), and 8 individuals in the control group (20 %), p = 0.032, which represented a 2.13 higher relative risk for those conditions for the former group. The patients with HPT presented a higher creatinine level (0.98 ± 0.12 mg/dL) than the PAH patients with normal parathyroid hormone (0.76 ± 0.14 mg/dL), p = 0.0004; 95 % CI: 0.12, 0.33. The PAH group also presented lower total hip (-0.15 ± 1.25) and femoral neck (−0.14 ± 1.07) bone mineral density (BMD) Z-scores than the control group (0.50 ± 1.13, p = 0.021; 95 % CI: −0.18, −0.027 and 0.35 ± 0.94, p = 0.038; 95 % CI: −0.16, −0.01, respectively).</div></div><div><h3>Conclusion</h3><div>In this cohort, the findings of higher A1c levels, hypothyroidism prevalence, lower LDL and total cholesterol levels, and a higher prevalence of hyperparathyroidism, as well as lower total hip and femoral neck BMD Z-scores in the PAH group, compared to the control group and highlighting the dysregulation of various metabolic pathways in patients with HAP, suggesting the need for targeted interventions to enhance patient care. Additionally, they underscore","PeriodicalId":21057,"journal":{"name":"Respiratory medicine","volume":"235 ","pages":"Article 107859"},"PeriodicalIF":3.5,"publicationDate":"2024-11-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142626486","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Cardiometabolic risk factors (CMRFs) play a crucial role in the occurrence and development of cardiovascular diseases. Obstructive sleep apnea (OSA) causes abnormalities of CMRFs. Continuous positive airway pressure (CPAP) is a widely used treatment for OSA. This systematic review and meta-analysis aimed to investigate the effect of CPAP on CMRFs in patients with OSA.
Methods
A search of PubMed, Cochrane Library, Scopus, Web of Science, and Embase was conducted to find randomized controlled trials up to December 3, 2023. The quality of the studies included was evaluated using the Cochrane Bias Risk Tool 2.0, and a meta-analysis was carried out using Stata15.1 software. The effect sizes for this meta-analysis were represented as the weighted mean difference (WMD) and 95 % confidence interval (CI).
Results
A total of 52 studies with 10,104 participants were analyzed. The results showed that CPAP significantly lowered systolic blood pressure (WMD: −2.04 mmHg; 95%CI: −3.56 to −0.51), diastolic blood pressure (WMD: −1.40 mmHg; 95%CI: −2.36 to −0.44), total cholesterol (WMD: −0.27 mmol/L; 95%CI: −0.51 to −0.04), triglycerides (WMD: −0.02 mmol/L; 95%CI: −0.03 to −0.01), and fasting blood glucose (WMD: −0.15 mmol/L; 95%CI: −0.16 to −0.13) in patients with OSA. However, there was no significant change in low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, waist circumference, or body mass index after CPAP.
Conclusion
In summary, this meta-analysis demonstrated that CPAP effectively reduced certain CMRFs in patients with OSA, offering new insights for cardiovascular disease prevention.
{"title":"Effect of continuous positive airway pressure on cardiometabolic risk factors in patients with obstructive sleep apnea: A systematic review and meta-analysis","authors":"Mengjiao Lv , Jing Mao , Saikun Wang , Changyue Zhang , Chunting Qian , Ruiting Zhu , Sikun Xiong , Yong Zhang , Lirong Guo","doi":"10.1016/j.rmed.2024.107852","DOIUrl":"10.1016/j.rmed.2024.107852","url":null,"abstract":"<div><h3>Objective</h3><div>Cardiometabolic risk factors (CMRFs) play a crucial role in the occurrence and development of cardiovascular diseases. Obstructive sleep apnea (OSA) causes abnormalities of CMRFs. Continuous positive airway pressure (CPAP) is a widely used treatment for OSA. This systematic review and meta-analysis aimed to investigate the effect of CPAP on CMRFs in patients with OSA.</div></div><div><h3>Methods</h3><div>A search of PubMed, Cochrane Library, Scopus, Web of Science, and Embase was conducted to find randomized controlled trials up to December 3, 2023. The quality of the studies included was evaluated using the Cochrane Bias Risk Tool 2.0, and a meta-analysis was carried out using Stata15.1 software. The effect sizes for this meta-analysis were represented as the weighted mean difference (WMD) and 95 % confidence interval (CI).</div></div><div><h3>Results</h3><div>A total of 52 studies with 10,104 participants were analyzed. The results showed that CPAP significantly lowered systolic blood pressure (WMD: −2.04 mmHg; 95%CI: −3.56 to −0.51), diastolic blood pressure (WMD: −1.40 mmHg; 95%CI: −2.36 to −0.44), total cholesterol (WMD: −0.27 mmol/L; 95%CI: −0.51 to −0.04), triglycerides (WMD: −0.02 mmol/L; 95%CI: −0.03 to −0.01), and fasting blood glucose (WMD: −0.15 mmol/L; 95%CI: −0.16 to −0.13) in patients with OSA. However, there was no significant change in low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, waist circumference, or body mass index after CPAP.</div></div><div><h3>Conclusion</h3><div>In summary, this meta-analysis demonstrated that CPAP effectively reduced certain CMRFs in patients with OSA, offering new insights for cardiovascular disease prevention.</div></div><div><h3>Systematic review registration</h3><div>PROSPERO, identifier CRD42023456380.</div></div>","PeriodicalId":21057,"journal":{"name":"Respiratory medicine","volume":"235 ","pages":"Article 107852"},"PeriodicalIF":3.5,"publicationDate":"2024-11-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142626363","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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