BMJ Open Respiratory Research最新文献

Background: People who smoke are at increased risk of unfavourable tuberculosis treatment outcomes compared with those who do not, but the pathways that explain this disparity are unclear.

Objective: To estimate the difference in a successful end-of-treatment outcome by smoking status among people with multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB) and to examine if this difference changes if people who smoked had the same retention in treatment as those who did not smoke.

Design and methods: Using data from the prospective endTB Observational Study, we estimated the difference in treatment success by cigarette smoking status, adjusting for baseline confounders including demographics, social history and comorbidities. To examine how this difference changed if everyone was retained in treatment, we censored participants who were lost to follow-up and applied inverse probability of censoring weights to simulate this scenario.

Results: Among 1786 participants in 12 countries, 539 (30.2%) reported smoking at least one cigarette daily. People who smoked were more frequently found in post-Soviet countries and had a complex social history (eg, incarceration and substance use) and infectious comorbidities (eg, hepatitis C). At the end of treatment, 73.5% of people who smoked and 80.3% of people who did not smoke had treatment success (risk difference in percentage points: -6.8, 95% CI -11.1 to -2.6). After adjusting for baseline confounders, the risk difference was similar (-5.2 percentage points), but the 95% CI was less precise (-14.1 to 3.2). When simulating a scenario in which everyone was retained in treatment, the risk difference was attenuated (-1.9 percentage points; 95% CI -11.1 to 4.7).

Conclusion: People who smoked had a lower frequency of MDR/RR-TB treatment success than those who did not smoke. Eliminating loss to follow-up reduced this difference by smoking status, suggesting that pathways related to retention in treatment were a major driver of this disparity.

Introduction: Progressive pulmonary fibrosis (PPF) is a debilitating progression of pulmonary fibrosis in patients with interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF). Oral pirfenidone has been studied in non-IPF ILDs, but in smaller academic studies, it did not achieve a statistically significant change in the primary endpoint. Increased systemic exposure with oral administration may lead to substantial adverse events and limit its utility. Clinical data support inhaled pirfenidone for the treatment of PPF with improved tolerability compared with orally administered pirfenidone.

Methods and analysis: Approximately 300 patients with PPF will be randomised 2:1:2 to one of three treatment arms: AP01 100 mg two times per day, AP01 50 mg two times per day or placebo two times per day by oral inhalation using the investigational eFlow Nebuliser System (PARI Pharma GmbH, Germany). The primary endpoint is the change from baseline in forced vital capacity at week 52. The main secondary endpoints are change in quality of life measurements from baseline to 52 weeks, time to disease progression and change in lung fibrosis scores based on high-resolution CT from baseline to 52 weeks.

Trial registration number: NCT06329401.

Background: This study characterised the use and perceptions of cannabis and vaping in people with cystic fibrosis (CF) and CF transmembrane conductance regulator (CFTR)-related disorder followed by a large Canadian adult CF clinic. It also aimed to assess whether cannabis legalisation in Canada affected perceived benefits and harms, and whether media attention regarding e-cigarette or vaping product use-associated lung injury (EVALI) affected perceptions of vaping.

Methods: An electronic questionnaire was emailed to all clinic patients on 23 April 2021, and remained open until 28 October 2021.

Results: 110 individuals completed the questionnaire, of whom 43% identified as a current user of cannabis. As a result of legalisation, 14% of respondents reported change in their perceptions of cannabis, primarily related to decreased stigma and increased awareness of medical indications and potential side effects. Cannabis was reported as being used medically for 85% of current users, with stress, insomnia/lack of sleep, and anxiety being the most common symptoms treated; the majority reported it to be somewhat or very effective to manage symptoms. Overall, 33% of respondents had tried vaping, but only 7% considered themselves current vapers. For 45% of respondents, the 2019 EVALI epidemic was reported to have changed perceptions of potential short-term and long-term effects associated with vaping, with increased awareness of potential harms.

Conclusions: Cannabis use was common, with a reported increase since its legalisation in this population. EVALI media attention was reported to increase awareness for potential harms associated with vaping. CF healthcare providers are well positioned to provide education and support so patients can make informed decisions about cannabis use and vaping.

Introduction: A significant proportion of patients with asthma remain uncontrolled despite treatment with inhaled corticosteroids and bronchodilators. Multiple reasons exist for this. Suboptimal inhaler adherence, inadequate inhaler technique and continuous exposure to allergens are often found to contribute to poor asthma control. Additionally, symptoms from some comorbid conditions, such as obesity, GORD and deconditioning, may be perceived as arising from asthma. The first priority should always be to confirm if asthma is the cause of the patients' current symptoms.

Methods & analysis: In this protocol paper, we describe the design of a prospective cohort replicate study. We will test the hypothesis that digitally acquired data on lung function and medication use can better establish that asthma is the cause of symptoms, rather than guideline-recommended practice. Patients with clinician-diagnosed asthma who remain uncontrolled despite inhaled corticosteroid treatment will be enrolled. Over 26 weeks and five visits, lung function, markers of T2 inflammation and symptoms will be repeatedly assessed. The 'ground truth' diagnosis for each patient will be established using a multimodal template comprised of lung function, T2 inflammation data, response to treatment, assessment of alternative diagnoses and patient outcome over time.The primary aim of this study is to compare guideline-recommended methods to diagnose asthma with a novel metric derived from digitally measured lung function in combination with T2 inflammation, which has been developed in an independent cohort of patients with severe asthma and a healthy control group. In secondary analysis, we will assess the direct costs and cost-effectiveness of this approach.

Ethics & dissemination: The trial was approved by the Beaumont Hospital's Research & Ethics Committee, REC number 21/89. Participants completed an informed, written consent form. Data will be analysed, anonymised and reported in relevant peer-reviewed journals and at national and international conferences. Data will be anonymised prior to publication.

Trial registration number: NCT05357274.

Background: Interstitial lung diseases (ILDs) comprise a group of more than 200 different subtypes. They vary widely in terms of incidence, prognosis and treatment, yet real-life data from Germany are sparse.

Methods: The prospective Exploring Clinical and Epidemiological Characteristics of Interstitial Lung Diseases (EXCITING)-ILD registry included patients with all different ILD subtypes from different healthcare settings. Follow-up ranged from 36 months to 5 years. Data were analysed descriptively. Baseline characteristics, diagnostic and treatment information are presented as absolute numbers and percentages. The Wilcoxon signed-rank sum test was used to quantify differences between groups. Line plots and bar plots were used for graphical presentation.

Results: A total of 601 patients (60.7% men, mean age 64.3 years) from 32 centres were included in the EXCITING-ILD registry. The most common subtypes were sarcoidosis with 26.6% (n=160) and idiopathic pulmonary fibrosis (IPF) with 25.3% (n=152). Pulmonary hypertension was present in 8.7% of patients (n=52), with high incidences in connective tissue disease-associated ILD (16.3%) and pneumoconiosis (27.3%). The mean forced vital capacity was 76.4% predicted, and the mean DLCO-SB (diffusing capacity for carbon monoxide) was 54.1% predicted. The mean time to diagnosis was 38.8 months (SD 64.4) and was significantly shorter when the diagnosis was made after multidisciplinary discussion (31.6 vs 49.2 months, p<0.001). The frequency of surgical lung biopsies decreased over time in the registry, whereas the proportion of cryobiopsies showed a notable increase. In IPF, the number of patients treated with antifibrotics increased from 35.2% before 2015 to 48.4% in 2019.

Conclusion: The EXCITING-ILD registry describes the frequency of ILD subtypes, ILD-related impairments, selected comorbidities and diagnostic and treatment patterns in a representative German population.

Background: Chronic obstructive pulmonary disease (COPD) is linked to an increased risk of falls, however, there is no accurate method for predicting falls in this population. This study aimed to develop and internally validate a clinical prediction model for falls in individuals with COPD.

Methods: A secondary analysis was conducted using data from a recent fall prevention trial. Participants with COPD who reported a 12-month history of falls, concerns with balance or recent near falls were tracked for falls over 12 months prospectively. Baseline data included demographics and measures of balance, mobility and health status. A predictive model was developed using backward-selected multivariate logistic regression with fall status (no falls versus ≥1 fall) as the dependent variable and 17 baseline candidate predictors as independent variables. Using the bootstrap resampling method for internal validation, model performance was assessed for discrimination by the concordance (c) statistic and calibration by the expected to observed (E:O) ratio, calibration in the large (CITL) and calibration slope. The final model was adjusted for optimism using the bootstrap shrinkage factor.

Results: Of 178 participants (mean age 73±9 years; 83 females), 74 (42%) reported ≥1 fall over 12 months, totalling 188 falls. The predictive model identified three factors associated with 12-month future falls: reporting a 12-month history of ≥2 falls (OR=3.59, CI (1.65 to 7.82)), more chronic conditions (OR=1.14, CI (1.01 to 1.28)) and worse Timed Up and Go Dual-Task test scores (OR=1.04, CI (1.00 to 1.09)). The final prediction model achieved acceptable discrimination (c-statistic=0.69, CI (0.61 to 0.78)) and calibration (E:O ratio=1.01, CITL=-0.01 and calibration slope=0.93).

Conclusions: A history of ≥2 falls, having more chronic conditions and impaired mobility under cognitive demand predicts future falls in individuals with COPD. The prediction model showed acceptable internal validation. External validation is needed to confirm these findings.

Trial registration number: NCT02995681; clinicaltrials.gov.

Background: The prevalence of infection with non-tuberculous mycobacteria (NTM) has been increasing in people with cystic fibrosis (pwCF) over the past 30 years. Emerging reports of beneficial effects of CFTR modulators, particularly elexacaftor/tezacaftor/ivacaftor (ETI), on the rates of NTM acquisition and persistence are encouraging. In this observational study, we evaluate the impact of the introduction of ETI on the prevalence of NTM infection within a cohort of pwCF living in sub-tropical Queensland, Australia.

Methods: We examined the impact of ETI introduction on rates of NTM isolation in pwCF attending an adult CF centre and two large regional clinics providing CF care. Data on NTM infection were collected for a minimum of 2 years pre- and post-initiation of ETI.

Results: In total, 271 (84.2%) were commenced on ETI with 33 (12.2%) of these pwCF isolating an NTM species on one or more occasion. The number of pwCF isolating Mycobacterium abscessus (Mabs) remained static across the 4-year period of analysis. However, there was a trend towards declining numbers of pwCF isolating either Mycobacterium intracellulare or other NTM species across the surveillance period.

Conclusions: ETI therapy was not associated with reduced rates of NTM isolation from sputum over the first 2 years of treatment. However, at a species level, two distinct patterns of change were seen with a trend towards a reduction in the isolation of M. intracellulare, while the rates of Mabs isolation remained unchanged. The reasons for this remain unclear at present but highlight the need for ongoing vigilance with screening for NTM in the setting of ETI therapy.

Introduction: The COVID-19 pandemic significantly impacted primary healthcare for chronic disease patients, including those with chronic obstructive pulmonary disease (COPD). Information about whether virtual or remote consultations were effective or acceptable to patients with COPD is sparse. E-consultation and telephone triage strategies were deployed, with the vast majority of triaged consultations taking place over the phone or through video calls. This study explored the views of patients with COPD and providers on the effects of the pandemic on their health and healthcare, and barriers to/enablers of remote consultations.

Methods: 12 semi-structured interviews with open-ended questions were conducted via telephone/Zoom among patients with COPD and healthcare professionals (HCPs) in the West Midlands, UK. Patients with COPD were recruited from the Birmingham Lung Improvement StudieS (BLISS) cohort. HCPs were approached via an advert distributed through general practitioner practices that were part of the BLISS cohort; brief adverts were disseminated to several professional organisations throughout the West Midlands area and social media. Interviews were analysed using Braun and Clarke's six steps of thematic analysis.

Results: Three major themes around coping and life adjustment, NHS service accessibility and healthcare inequalities related to e-health literacy.

Conclusion: Post-pandemic priorities should include enhancing remote consultation training for providers, with a focus on rapport-building and care delivery. Equally important are providing flexible healthcare access, continuity of care and targeted support for vulnerable patients with COPD to maintain essential services during crises.

The British Thoracic Society responded to a call from the pleural community to establish a new Training Standard for pleural procedures, relevant to all health care professionals. This should be seen as an enhancement to aspects of existing curricula and be supportive in giving clarity to learners and trainers about expectations for training and practice in pleural procedures.

Introduction: An increase in airway isolates of non-tuberculous mycobacteria (NTM) has been observed, particularly in patients with previous lung damage. Inhaled corticosteroids may increase the risk of NTM lung disease. NTM isolation is of therapeutic importance, especially when macrolides are used. There are few data on the actual prevalence of NTM isolation in patients with chronic obstructive pulmonary disease (COPD).

Objective: To determine the prevalence of NTM isolation and NTM pulmonary disease according to the ATS/ERS/IDSA 2020 criteria in patients with high-risk COPD. As a secondary objective, we sought to identify risk factors for NTM isolation and developing NTM pulmonary disease in patients with COPD.

Methods: Prospective multicentre observational study based on the collection of three sputum samples in a year, for standard, mycobacteria and fungi cultures, in patients with high-risk COPD (postbronchodilator forced expiratory volume in 1 s<50% and/or ≥2 exacerbations in the previous year), with a 12-month follow-up. Patients with at least two good-quality samples were included.

Results: 305 patients were initially selected, of which only 258 had at least two valid samples. NTM was isolated in 15% of patients (n=39), though only 8 (3%) met the ATS 2020 criteria for NTM disease. The most commonly isolated species was mycobacterium avium complex (MAC). Multivariate analysis identified the following risk factors for NTM isolation: low body weight, alpha-1 antitrypsin (AAT) deficiency, inhaled corticosteroids and cancer. NTM disease was only associated with body mass index <21.

Conclusions: NTM isolation is more common than expected in patients with COPD and may have implications for treatment. It is associated with low body weight, AAT deficiency, inhaled corticosteroid use and cancer.