BACKGROUND: Integrating non-communicable disease (NCD) screening into TB household contact investigations may identify undiagnosed NCDs and reduce the burden of both conditions. However, evidence on the costs and cost-effectiveness of this approach is limited. METHOD: We conducted a cross-sectional study in South Africa to assess patient and provider costs for NCD screening (hypertension, diabetes, chronic kidney disease, dyslipidaemia). Incremental costs per NCD case identified were calculated. Using a decision tree model, we estimated incremental costs per disability-adjusted life year (DALY) averted over 10 years from a healthcare perspective, with cardiovascular disease (CVD) risk estimated using the WHO prediction model. RESULTS: The incremental cost was USD72.3 per contact screened and USD334.0 per NCD case identified. Integrated screening reduced mean 10-year CVD risk from 5.7% to 2.7% among contacts with NCDs. The incremental cost-effectiveness ratio (ICER) was USD27,043.6 per DALY averted, exceeding South Africa’s threshold of USD3,708. Management of identified NCDs, mainly drug costs, comprised over 80% of total incremental costs. The ICER decreased in populations with a high risk for NCDs. CONCLUSION: Integrated NCD screening was not cost-effective, mainly due to subsequent care costs. Prioritising individuals at high risk for NCDs can improve cost-effectiveness.
Rebecca Kummer, Aahd Kubbara, Katelyn M. Tessier
et al.
Abstract Background Interstitial lung diseases (ILD) are relatively rare fibrotic lung diseases that can cause significant morbidity and mortality. Early diagnosis of ILDs is crucial to improve patient survival. Incidental radiologic findings of interstitial lung disease may provide an opportunity for early diagnosis. We sought to estimate the incidence of incidental interstitial lung disease findings on CT scans ordered for other reasons and quantify the time to pulmonary function test or pulmonary referral. Methods In this retrospective cohort study performed at a large metropolitan health system, radiology reports from CT scans of the neck, chest, abdomen/pelvis, and coronary arteries of adult patients were reviewed for documentation of ILD findings based on the pre-defined search terms. We also descriptively examined time from CT scan to pulmonary function testing or pulmonology referral. The main outcomes were incidence of ILD findings on CT scans and frequency of follow up testing. Results Of the 239,535 scans that were included, there were 25,219 initial scans with ILD findings (10.8%). Of those patients, only 16.1% had pulmonary function testing or pulmonary referral at one year, and 23.9% at 5 years. Follow up testing was more common if interstitial lung disease findings were present on CT chest compared to other scan types. The median time to PFT for all scan types was 59 days and the median time to pulmonary referral was 112 days. Conclusion In conclusion, incidental findings of interstitial lung disease are common on many different types of CT scans but infrequently lead to follow up pulmonary function testing or referral to a pulmonary specialist. Significant delays in time were noted for pulmonary referrals. This study raises awareness of delay in diagnosing ILD.
ABSTRACT Pulmonary arterial hypertension (PAH) requires lifelong medication, with patients taking an average of 12 tablets/day. Several chronic diseases can be treated with a fixed‐dose combination (FDC) tablet, decreasing patient pill burden and increasing adherence. This exploratory research, conducted via focus groups, asked 13 patients with PAH for their insights about the use of FDC (2 PAH treatments in a single tablet), its potential benefits, and challenges to its use. At the time of the focus groups (July 2023), no FDC medications were available for PAH and the discussions were therefore hypothetical. Focus group transcripts were analyzed by a qualitative research specialist to identify key themes. Most participants were unfamiliar with FDC prior to taking part in the focus groups; however, during the engagement, 12/13 participants expressed interest in taking FDC as single‐tablet therapy for their PAH. In general, participants saw the potential benefits as improved convenience, less time spent navigating insurance coverage, and improved adherence. Participants felt that reducing their tablet count by just one tablet would be meaningful to them. Concerns were raised about the potential difficulty with medication titration and challenges distinguishing between the side effects of two combined medications. This exploratory research provides insight into the perceptions of US patients on the utility of FDC in PAH and highlights an unmet need for patient education on medication adherence in PAH.
Diseases of the circulatory (Cardiovascular) system, Diseases of the respiratory system
Cystic Fibrosis leads to liver complications, including cystic fibrosis liver disease but hyperbilirubinemia in CF patients on CFTR modulators is less understood. This article describes two pediatric CF patients on Elexacaftor/Tezacaftor/Ivacaftor therapy with elevated bilirubin, ultimately diagnosed with Gilbert syndrome, highlighting the importance of fractionated bilirubin testing for early diagnosis and management.
The nationwide claims data lake for sleep apnoea (ALASKA)—real-life data for understanding and increasing obstructive sleep apnea (OSA) quality of care study—investigated long-term continuous positive airway pressure (CPAP) termination rates, focusing on the contribution of comorbidities. The French national health insurance reimbursement system data for new CPAP users aged ≥18 years were analyzed. Innovative algorithms were used to determine the presence of specific comorbidities (hypertension, diabetes and chronic obstructive pulmonary disease (COPD)). Therapy termination was defined as cessation of CPAP reimbursements. A total of 480,000 patients were included (mean age 59.3 ± 13.6 years, 65.4% male). An amount of 50.7, 24.4 and 4.3% of patients, respectively, had hypertension, diabetes and COPD. Overall CPAP termination rates after 1, 2 and 3 years were 23.1, 37.1 and 47.7%, respectively. On multivariable analysis, age categories, female sex (1.09 (1.08–1.10) and COPD (1.12 (1.10–1.13)) and diabetes (1.18 (1.16–1.19)) were significantly associated with higher CPAP termination risk; patients with hypertension were more likely to continue using CPAP (hazard ratio 0.96 (95% confidence interval 0.95–0.97)). Therapy termination rates were highest in younger or older patients with ≥1 comorbidity. Comorbidities have an important influence on long-term CPAP continuation in patients with OSA.
Nontuberculous mycobacterial pulmonary disease (NTM-PD) results from the exposure of susceptible hosts to a diverse group of environmental mycobacteria. The emphasis on nonpharmacological strategies is motivated by the widespread presence of NTM in various environments, and the inconsistent success rates of pharmacological treatments. Modifiable factors contributing to NTM-PD development include impaired airway clearance, low body mass index, gastroesophageal reflux disease, and exposure to NTM habitats. This suggests that lifestyle and environmental modifications could affect disease development and progression. The review highlights several modalities that can modify the risk factors. Airway clearance techniques, informed by the “gel-on-brush” model of the bronchial epithelium, aim to enhance mucociliary clearance, and have the potential to alleviate symptoms and improve lung function. The impact of nutritional status is also examined, with a lower body mass index linked to an increased risk and progression of NTM-PD, indicating the importance of targeted nutritional support. Additionally, the theoretical and epidemiological links between gastroesophageal reflux disease and NTM-PD advocate careful management of reflux episodes. Understanding the risk of NTM transmission through environmental exposure to contaminated water and soil is also crucial. Strategies to mitigate this risk, including effective water management and minimizing soil contact, are presented as vital preventive measures. The review supports the inclusion of nonpharmacological treatments within a comprehensive NTM-PD management strategy, alongside conventional pharmacological therapies. This integrated approach seeks to improve the overall understanding and handling of NTM-PD.
P. V. da Silva-Neto, Valéria B. do Valle, C. Fuzo
et al.
Patients with COVID-19 predominantly have a respiratory tract infection and acute lung failure is the most severe complication. While the molecular basis of SARS-CoV-2 immunopathology is still unknown, it is well established that lung infection is associated with hyper-inflammation and tissue damage. Matrix metalloproteinases (MMPs) contribute to tissue destruction in many pathological situations, and the activity of MMPs in the lung leads to the release of bioactive mediators with inflammatory properties. We sought to characterize a scenario in which MMPs could influence the lung pathogenesis of COVID-19. Although we observed high diversity of MMPs in lung tissue from COVID-19 patients by proteomics, we specified the expression and enzyme activity of MMP-2 in tracheal-aspirate fluid (TAF) samples from intubated COVID-19 and non-COVID-19 patients. Moreover, the expression of MMP-8 was positively correlated with MMP-2 levels and possible shedding of the immunosuppression mediator sHLA-G and sTREM-1. Together, overexpression of the MMP-2/MMP-8 axis, in addition to neutrophil infiltration and products, such as reactive oxygen species (ROS), increased lipid peroxidation that could promote intensive destruction of lung tissue in severe COVID-19. Thus, the inhibition of MMPs can be a novel target and promising treatment strategy in severe COVID-19.
The clinical evolution of patients infected with the Severe Acute Respiratory Coronavirus type 2 (SARS-CoV-2) depends on the complex interplay between viral and host factors. The evolution to less aggressive but better-transmitted viral variants, and the presence of immune memory responses in a growing number of vaccinated and/or virus-exposed individuals, has caused the pandemic to slowly wane in virulence. However, there are still patients with risk factors or comorbidities that put them at risk of poor outcomes in the event of having the coronavirus infectious disease 2019 (COVID-19). Among the different treatment options for patients with COVID-19, virus-targeted measures include antiviral drugs or monoclonal antibodies that may be provided in the early days of infection. The present expert consensus is based on a review of all the literature published between 1 July 2021 and 15 February 2022 that was carried out to establish the characteristics of patients, in terms of presence of risk factors or comorbidities, that may make them candidates for receiving any of the virus-targeted measures available in order to prevent a fatal outcome, such as severe disease or death. A total of 119 studies were included from the review of the literature and 159 were from the additional independent review carried out by the panelists a posteriori. Conditions found related to strong recommendation of the use of virus-targeted measures in the first days of COVID-19 were age above 80 years, or above 65 years with another risk factor; antineoplastic chemotherapy or active malignancy; HIV infection with CD4+ cell counts < 200/mm3; and treatment with anti-CD20 immunosuppressive drugs. There is also a strong recommendation against using the studied interventions in HIV-infected patients with a CD4+ nadir <200/mm3 or treatment with other immunosuppressants. Indications of therapies against SARS-CoV-2, regardless of vaccination status or history of infection, may still exist for some populations, even after COVID-19 has been declared to no longer be a global health emergency by the WHO.
Purpose: To develop the concept of an automated system for the prevention of acute respiratory disease Covid 19 and other respiratory diseases at the enterprise. Methodology: Analysis of legal documents and scientific and technical literature - for update the scientific problem and formulate the research task; the system analysis methods - for build the overall structure of the system and establish relationships between all its elements; simulation modeling methods - for the development of algorithms for the functioning and interaction of sensors and executing devices of the corresponding subsystem; the decision theory methods and data mining - for the development of training programs and testing the knowledge of employees in matters of epidemic safety. Conclusions. It has been developed the concept of an automated system for the prevention of acute respiratory disease Сovid 19 and other respiratory diseases. The system, due to the connection of functionally independent elements according to the certain scheme, allows minimizing the risk of infection of employees with the relevant viruses. It also becomes possible increasing their protection against the occurrence of infectious diseases that are transmitted by airborne droplets, through the contact of a healthy person's body with contaminated surfaces. This is ensured as a result of the implementation anti-epidemic measures set, as well as the provision and constant support of the quarantine regime at the enterprise in accordance with WHO recommendations. Research limitations: The number of system elements may vary (increase/decrease) depending on the number of workplaces, as well as areas requiring control. Value: The introduction of the proposed system makes it possible to increase the level of economic stability of the enterprise in a difficult epidemiological situation by introducing a full range of anti-epidemiological measures at the enterprise and ensuring that employees constantly comply with the quarantine regime established at the enterprise. Originality: For the first time, the concept of the automated system for the prevention of acute respiratory disease Covid 19 and other respiratory diseases was developed and proposed for use in enterprises. This system, unlike others, makes it possible to ensure that employees comply with the established quarantine regime by constantly managing the modes of sanitary and epidemiological access control to the enterprise, disinfection of surfaces, ventilation and air disinfection, etc.
Accurate assessment of particulate matter (PM) dose and respiratory deposition is essential to better understand the risks of exposure to PM and, consequently, to develop the respective risk-control strategies. In homes, this is especially relevant in regards to ultrafine particles (UFP; <0.1 μm) which origin in these environments is mostly due to indoor sources. Thus, this study aimed to estimate inhalation doses for different PM mass/number size fractions (i.e., PM10, PM2.5 and UFP) in indoor air of residential homes and to quantify the deposition (total, regional and lobar) in human respiratory tract for both newborn children and mothers. Indoor real-time measurements of PM10, PM2.5 and UFP were conducted in 65 residential homes situated in Oporto metropolitan area (Portugal). Inhalation doses were estimated based on the physical characteristics of individual subjects and their activity patterns. The multi-path particle dosimetry model was used to quantify age-specific depositions in human respiratory tract. The results showed that 3-month old infants exhibited 4-fold higher inhalation doses than their mothers. PM10 were primarily deposited in the head region (87%), while PM2.5 and UFP depositions mainly occurred in the pulmonary area (39% and 43%, respectively). Subject age affected the pulmonary region and the total lung deposition; higher deposition being observed among the newborns. Similarly, lower lobes (left lobe: 37% and right lobe: 30%) received higher PM deposition than upper and middle lobes; right lobes lung are prone to be more susceptible to respiratory problems, since asymmetric deposition was observed. Considering that PM-related diseases occur at specific sites of respiratory system, quantification of site-specific particle deposition should be predicted in order to better evidence the respective health outcomes resulting from inhaled PM.
Usharani Bhimavarapu, M. Sreedevi, Nalini Chintalapudi
et al.
The immune system can be compromised when humans inhale excessive cooling. Physical activity helps a person’s immune system, and influenza seasonally affects immunity and respiratory tract illness when there is no physical activity during the day. Whenever people chill excessively, they become more susceptible to pathogens because they require more energy to maintain a healthy body temperature. There is no doubt that exercise improves the immune system and an individual’s fitness. According to an individual’s health history, lifestyle, and preferences, the physical activity framework also includes exercises to improve the immune system. This study developed a framework for predicting physical activity based on information about health status, preferences, calorie intake, race, and gender. Using information about comorbidities, regions, and exercise/eating habits, the proposed recommendation system recommends exercises based on the user’s preferences.
Pulmonary thromboembolism (PTE) has been associated with tuberculosis (TB), but the true incidence is unknown. The aim of our study was to retrospectively evaluate the PTE prevalence in TB patients hospitalized at the National Institute for Infectious Diseases L. Spallanzani during the January 2016–December 2021 period. Retrospective data collection and evaluation were conducted. Among 1801 TB patients, 29 (1.61%) exhibited PTE. Twenty (69%) had comorbidities; eleven (37.9%) had predisposing factors for PTE. Nineteen (65.5%) had extensive TB disease. The commonest respiratory symptoms were cough (37.9%), dyspnea (31%), chest pain (10.3%), and hemoptysis (6.9%). Twenty-five (86.2%) had elevated serum D-dimer levels. An increased prevalence of PTE from 0.6% in the pre-COVID-19 pandemic period to 4.6% in the pandemic period was found. Acute respiratory failure and extensive TB disease increased significantly in the pandemic period. The increase in PTE could be explained by the increased severity of TB in patients in the pandemic period and by increased clinical suspicion and, consequently, increased requests for D-dimer testing, including in patients with non-COVID-19 pneumonia. Patients with extensive pulmonary disease are at high risk of developing PTE. Clinicians should be aware of this potentially life-threatening complication of TB, and patients should receive a thromboembolism risk assessment.
The use of secondary hospital-based clinical data and electronical health records (EHR) represent a cost-efficient alternative to investigate chronic conditions. We present the Clinical Network Big Data and Personalised Health project, which collects EHRs for patients accessing hospitals in Central-Southern Italy, through an integrated digital platform to create a digital hub for the collection, management and analysis of personal, clinical and environmental information for patients, associated with a biobank to perform multi-omic analyses. A total of 12,864 participants (61.7% women, mean age 52.6 ± 17.6 years) signed a written informed consent to allow access to their EHRs. The majority of hospital access was in obstetrics and gynaecology (36.3%), while the main reason for hospitalization was represented by diseases of the circulatory system (21.2%). Participants had a secondary education (63.5%), were mostly retired (25.45%), reported low levels of physical activity (59.6%), had low adherence to the Mediterranean diet and were smokers (30.2%). A large percentage (35.8%) were overweight and the prevalence of hypertension, diabetes and hyperlipidemia was 36.4%, 11.1% and 19.6%, respectively. Blood samples were retrieved for 8686 patients (67.5%). This project is aimed at creating a digital hub for the collection, management and analysis of personal, clinical, diagnostic and environmental information for patients, and is associated with a biobank to perform multi-omic analyses.
Michael Bogart,1 Yuhang Liu,2 Todd Oakland,2 Marjorie Stiegler1,3 1Value Evidence and Outcomes, GlaxoSmithKline, Research Triangle Park, NC, USA; 2GNS Healthcare, Somerville, MA, USA; 3University of North Carolina Chapel Hill, Chapel Hill, NC, USACorrespondence: Michael Bogart, GlaxoSmithKline, Five Moore Drive, PO Box 13398, Research Triangle Park, NC, 27709-3398, USA, Tel +19198897413, Email michael.r.bogart@gsk.comPurpose: Inhaled triple therapy (TT) comprising a long-acting muscarinic antagonist, long-acting β2 agonist, and inhaled corticosteroid is recommended for symptomatic chronic obstructive pulmonary disease (COPD) patients, or those at risk of exacerbation. However, it is not well understood which patient characteristics contribute most to future exacerbation risk. This study assessed patient predictors associated with future exacerbation time following initiation of TT.Patients and Methods: This retrospective cohort study used data from the Optum™ Clinformatics™ Data Mart, a large health claims database in the United States. COPD patients who initiated TT between January 2008 and March 2018 (index) were eligible. Patients were required to be aged ≥ 18 years at index and have continuous enrollment for the 12 months prior to index (baseline) and the 12 months following index (follow-up). Patients who had received TT during baseline were excluded. Data from eligible patients were analyzed using a reverse engineering forward simulation machine learning platform to predict future COPD exacerbation time.Results: Data from 73,625 patients were included. The model found that prior exacerbation was largely correlated with post-index exacerbation time; patients who had ≥ 4 exacerbation episodes during baseline had an average increase of 32.4 days post-index exacerbation, compared with patients with no exacerbations during baseline. Likewise, ≥ 2 inpatient visits (effect size 27.1 days), the use of xanthines (effect size 11.5 days), or rheumatoid arthritis (effect size 6.4 days) during baseline were associated with increased exacerbation time. Conversely, diagnosis of anemia (effect size – 5.68 days), or oral corticosteroids in the past month (effect size – 3.43 days) were associated with reduced exacerbation time.Conclusion: Frequent prior exacerbations, healthcare resource utilization, xanthine use, and rheumatoid arthritis were the strongest factors predicting the future increase of exacerbations. These results improve our understanding of exacerbation risk among COPD patients initiating triple therapy.Keywords: Bayesian modeling, chronic obstructive pulmonary disease, exacerbation, triple therapy, predictive modeling
The COVID-19 pandemic and phased nationwide lockdown have impacted negatively on individuals with tuberculosis (TB) and routine TB services. Through a literature review and the perspective of members of a national TB Think Tank task team, we describe the impact of the pandemic and lockdown on TB patients and services as well as the potential long-term setback to TB control in South Africa (SA). Strategies to mitigate risk and impact are explored, together with opportunities to leverage synergies from both diseases to the benefit of the National TB Programme (NTP). With the emergence of COVID-19, activities to address this new pandemic have been prioritised across all sectors. Within the health system, the health workforce and resources have been redirected away from routine services towards the new disease priority. The social determinants of health have deteriorated during the lockdown, potentially increasing progression to TB disease and impacting negatively on people with TB and their households, resulting in additional barriers to accessing TB care, with early reports of a decline in TB testing rates. Fewer TB diagnoses, less attention to adherence and support during TB treatment, poorer treatment outcomes and consequent increased transmission will increase the TB burden and TB-related mortality. People with TB or a history of TB are likely to be vulnerable to COVID-19. Modifications to current treatment practices are suggested to reduce visits to health facilities and minimise the risks of COVID-19 exposure. The COVID-19 pandemic has the potential to negatively impact on TB control in TB-endemic settings such as SA. However, there are COVID-19-related health systems-strengthening developments that may help the NTP mitigate the impact of the pandemic on TB control. By integrating TB case finding into the advanced screening, testing, tracing and monitoring systems established for COVID-19, TB case finding and linkage to care could increase, with many more TB patients starting treatment. Similarly, integrating knowledge and awareness of TB into the increased healthcare worker and community education on infectious respiratory diseases, behavioural practices around infection prevention and control, and cough etiquette, including destigmatisation of mask use, may contribute to reducing TB transmission. However, these potential gains could be overwhelmed by the impact of increasing poverty and other social determinants of health on the burden of TB.