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Introduction: Autonomic dysfunction is common in chronic obstructive pulmonary disease (COPD), and worse autonomic function may be a marker of risk for acute exacerbations of COPD (AECOPD). Heart rate variability (HRV) is a measure of autonomic function. Our objective was to test whether lower (worse) HRV is a risk factor for AECOPD. Methods: We measured standard deviation of normal RR intervals (SDNN) and root mean square of successive RR interval differences (RMSSD) on 10-second electrocardiograms (ECGs) performed at screening and day 42 in participants in the Beta Blockers for the Prevention of Acute Exacerbations of COPD trial ( BLOCK-COPD), a placebo-controlled trial of metoprolol for prevention of AECOPD. We used Cox-proportional hazards models to test if these HRV measures were associated with risk of any AECOPD, and separately, hospitalized AECOPD. We tested associations using baseline HRV measures and incorporating HRV measures from day 42 as a time-varying covariate. We also tested for interactions with metoprolol assignment. Results: Of 532 trial participants, 529 (forced expiratory volume in 1 second [FEV(1) ]41 ± 16.3 % predicted) were included in this analysis. We did not find a significant association between HRV measures and risk of AECOPD when all participants were analyzed together. There was a significant interaction between RMSSD and assignment to metoprolol on time to first hospitalized AECOPD; in the placebo group greater RMSSD was associated with a lower risk of hospitalized AECOPD (adjusted hazard ratio0.71, 95% confidence interval: 0.52 to 0.96, per 10 ms increase) but there was no association in the metoprolol group. Conclusions: Autonomic dysfunction as measured by HRV may be a risk factor for AECOPD. Future studies should analyze longer HRV recordings and their performance in broader samples of people with COPD, including those on beta-blockers.

RATIONALE: The chronotropic index quantifies the proportion of the expected heart rate increase that is attained during exercise. The relationship between the chronotropic index and acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) has not been evaluated. OBJECTIVES: To determine whether a higher chronotropic index during a 6-minute walk (CI-6MW) is associated with lower risk of AECOPD and whether the CI-6MW is a marker of susceptibility to adverse effects of metoprolol in chronic obstructive pulmonary disease (COPD). METHODS: We analyzed data from the BLOCK COPD (Beta-Blockers for the Prevention of AECOPDs) trial. We used Cox proportional hazards models to investigate the relationship between the CI-6MW and the time to AECOPDs. We also tested for interactions between study group assignment (metoprolol vs. placebo) and the CI-6MW on the time to AECOPDs. RESULTS: Four hundred seventy-seven participants with exacerbation-prone COPD (mean forced expiratory volume in 1 second, 41% of predicted) were included in this analysis. A higher CI-6MW was independently associated with a decreased risk of AECOPDs of any severity (adjusted hazard ratio per 0.1 increase in CI-6MW of 0.88; 95% confidence interval, 0.80–0.96) but was not independently associated with AECOPDs requiring hospitalization (adjusted hazard ratio, 0.94; 95% confidence interval, 0.81–1.05). There was a significant interaction by treatment assignment, and in a stratified analysis, the protective effects of a higher CI-6MW on AECOPDs were negated by metoprolol use. CONCLUSIONS: A higher CI-6MW is associated with a decreased risk of AECOPDs and may be an indicator of susceptibility to the adverse effects of metoprolol.

BackgroundSARS-CoV-2 viral entry may disrupt angiotensin II (Ang II) homeostasis in part via ACE2 downregulation, potentially contributing to COVID-19 induced lung injury. Preclinical models of viral pneumonias that utilize ACE2 demonstrate Ang II type 1 receptor (AT1R) blockade mitigates lung injury, though observational COVID-19 data addressing the effect of AT1R blockade remain mixed.MethodsMulticenter, blinded, placebo-controlled randomized trial of losartan (50 mg PO twice daily for 10 days) versus placebo. Hospitalized patients with COVID-19 and a respiratory sequential organ failure assessment score of at least 1 and not already taking a renin-angiotensin-aldosterone system (RAAS) inhibitor were eligible. The primary outcome was the imputed partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) ratio at 7 days. Secondary outcomes included ordinal COVID-19 severity, oxygen, ventilator, and vasopressor-free days, and mortality. Losartan pharmacokinetics (PK) and RAAS components [Ang II, angiotensin-(1–7) (Ang-(1–7)), ACE, ACE2] were measured in a subgroup of participants.FindingsFrom April 2020 - February 2021, 205 participants were randomized, 101 to losartan and 104 to placebo. Compared to placebo, losartan did not significantly affect PaO2/FiO2 ratio at 7 days [difference of -24.8 (95% -55.6 to 6.1; p=0.12)]. Losartan did not improve any secondary clinical outcome, but worsened vasopressor-free days. PK data were consistent with appropriate steady-state concentrations, but we observed no significant effect of losartan on RAAS components.InterpretationInitiation of orally administered losartan to hospitalized patients with COVID-19 and acute lung injury does not improve PaO2 / FiO2 ratio at 7 days. These data may have implications for ongoing clinical trials.Trial RegistrationLosartan for Patients With COVID-19 Requiring Hospitalization (NCT04312009), https://clinicaltrials.gov/ct2/show/NCT04312009

Background The SARS-CoV-2 virus enters cells via Angiotensin-converting enzyme 2 (ACE2), disrupting the renin-angiotensin-aldosterone axis, potentially contributing to lung injury. Treatment with angiotensin receptor blockers (ARBs), such as losartan, may mitigate these effects, though induction of ACE2 could increase viral entry, replication, and worsen disease. Methods This study represents a placebo-controlled blinded randomized clinical trial (RCT) to test the efficacy of losartan on outpatients with COVID-19 across three hospital systems with numerous community sites in Minnesota, U.S. Participants included symptomatic outpatients with COVID-19 not already taking ACE-inhibitors or ARBs, enrolled within 7 days of symptom onset. Patients were randomized to 1:1 losartan (25 mg orally twice daily unless estimated glomerular filtration rate, eGFR, was reduced, when dosing was reduced to once daily) versus placebo for 10 days, and all patients and outcome assesors were blinded. The primary outcome was all-cause hospitalization within 15 days. Secondary outcomes included functional status, dyspnea, temperature, and viral load. (clinicatrials.gov, NCT04311177, closed to new participants) Findings From April to November 2020, 117 participants were randomized 58 to losartan and 59 to placebo, and all were analyzed under intent to treat principles. The primary outcome did not differ significantly between the two arms based on Barnard's test [losartan arm: 3 events (5.2% 95% CI 1.1, 14.4%) versus placebo arm: 1 event (1.7%; 95% CI 0.0, 9.1%)]; proportion difference -3.5% (95% CI -13.2, 4.8%); p = 0.32]. Viral loads were not statistically different between treatment groups at any time point. Adverse events per 10 patient days did not differ signifcantly [0.33 (95% CI 0.22–0.49) for losartan vs. 0.37 (95% CI 0.25–0.55) for placebo]. Due to a lower than expected hospitalization rate and low likelihood of a clinically important treatment effect, the trial was terminated early. Interpretation In this multicenter blinded RCT for outpatients with mild symptomatic COVID-19 disease, losartan did not reduce hospitalizations, though assessment was limited by low event rate. Importantly, viral load was not statistically affected by treatment. This study does not support initiation of losartan for low-risk outpatients. Funding This study was supported by Minnesota Partnership for Biotechnology and Medical Genomics (CON000000076883).

Background: The SARS-CoV-2 virus enters cells via the ACE2 receptor, disrupting the renin-angiotensin-aldosterone axis, potentially contributing to lung injury. Treatment with angiotensin receptor blockers(ARBs) may mitigate these effects, though induction of ACE2 expression could increase viral entry, replication, and worsen disease. Methods: This study represents a placebo-controlled blinded randomized clinical trial (RCT) to test the efficacy of losartan on outpatients with COVID-19 across three hospital systems in Minnesota, U.S. Participants included symptomatic outpatients with COVID-19 not already taking ACE-inhibitors or ARBs, enrolled within 7 days of symptom onset. Patients were randomized to losartan versus placebo for 10 days. The primary outcome was all-cause hospitalization within 15 days. Secondary outcomes included functional status, dyspnea, temperature, and viral load. Findings: From April-November 2020, 117 participants were randomized 58 to losartan and 59 to placebo. The primary outcome did not differ significantly between the two arms based on Barnard’s test [losartan arm: 3 events (5.2%; 95% CI 1.8-14.1%) versus placebo arm: 1 event (1.7% 95% CI 0.01-9.0%); proportion difference -3.5% (95% CI -12.7-4.5%); p=0.32]. Functional status, self-reported dyspnea, maximum daily temperatures, and viral load were not significantly different between treatment groups. Due to a lower than expected hospitalization rate and low likelihood of a clinically important treatment effect, the trial was terminated early. Interpretation: In this multicenter blinded RCT for outpatients with mild symptomatic COVID-19 disease, losartan did not significantly reduce hospitalizations, affect functional status or assessment of dyspnea. Viral load was not significantly affected by treatment. This study does not support initiation of losartan for low-risk outpatients. Trial Registration: The trial was conducted under the authority of the Food and Drug Administration (IND 148365), was registered on clinicaltrials.gov prior to study initialization (NCT04311177). Funding Statement: This study was supported by Minnesota Partnership for Biotechnology and Medical Genomics (CON000000076883) Declaration of Interests: The authors have no financial conflicts of interest to disclose. MAP, MHN, TWS, and CJT have received additional funding from the Bill and Melinda Gates Foundation to conduct a clinical trial of losartan in inpatients with COVID-19. Ethics Approval Statement: The protocol was approved by a central institutional review board and underwent local context review. The study was conducted following good clinical practice guidelines under the oversight of an independent data safety monitoring board (DSMB).

Rationale Acute exacerbations negatively impact quality of life in patients with chronic obstructive pulmonary disease (COPD), but the impact of hospitalized exacerbations on quality of life is not clear. We hypothesized that patients with hospitalized exacerbations would benefit from hospitalization and experience improvement in general and disease-specific quality of life (as measured by the St. George's respiratory questionnaire (SGRQ) and the medical outcomes study 36-item short form health survey (SF-36)) compared to those without exacerbations, or with non-hospitalized acute exacerbations. Methods 1219 COPD patients enrolled in either the simvastatin for the prevention of exacerbations in moderate-to severe COPD Trial (STATCOPE) or azithromycin for prevention of exacerbations of COPD trial (MACRO) were analyzed. Demographic information, spirometry, and symptom scores were noted at baseline. Exacerbation events and changes in quality of life scores were assessed over a mean of 538 days of follow-up. Results Of patients studied, 25.6% were hospitalized, 44.0% had at least one outpatient exacerbation, and 30.4% had no exacerbation. Baseline SGRQ and SF-36 scores were severely impaired in all groups studied. Over time, SF-36 scores did not change significantly between groups. SGRQ symptom domain scores improved in other groups but did not improve in those hospitalized for a COPD exacerbation. Conclusions At baseline, patients hospitalized for acute exacerbations of COPD had more impaired quality of life scores. Over time, SGRQ symptom domain scores improved in other groups but did not in those who were hospitalized. Other measurements of quality of life were not improved by hospitalization for COPD.

Background No evidence-based guidelines exist for preventive dental care before radiation therapy (RT) in patients with head and neck cancer (HNC). An ongoing multicenter, prospective cohort study, Clinical Registry of Dental Outcomes in Head and Neck Cancer Patients (OraRad), is addressing this knowledge gap. The authors evaluated the level of dental disease before RT in the OraRad cohort, factors associated with dental disease, and dental treatment recommendations made before RT. Methods As part of OraRad, the authors assessed caries, periodontal disease, dental recommendations, and dental interventions performed before RT. Results Baseline measures were reported for 356 participants (77% men) with mean (standard deviation) age of 59.9 (11.0) years. Measures included mean number of teeth (22.9), participants with at least 1 tooth with caries (37.2%), and participants with at least 1 tooth with probing depth 5 millimeters or greater (47.4%). Factors associated with less extensive dental disease before RT included having at least a high school diploma, having dental insurance, history of routine dental care, and a smaller tumor size (T1 or T2). Based on the dental examination before RT, 163 (49.5%) participants had dental treatment recommended before RT, with extractions recommended most frequently. Conclusion Many patients with HNC require dental treatment before RT; more than one-third require extractions. Practical Implications Most patients have some level of dental disease at the start of RT, indicating the importance of dental evaluation before RT. By observing dental outcomes after RT, OraRad has the potential to determine the best dental treatment recommendations for patients with HNC.

BackgroundObservational studies suggest that beta-blockers may reduce the risk of exacerbations and death in patients with moderate or severe chronic obstructive pulmonary disease (COPD), but these findings have not been confirmed in randomized trials.MethodsIn this prospective, randomized trial, we assigned patients between the ages of 40 and 85 years who had COPD to receive either a beta-blocker (extended-release metoprolol) or placebo. All the patients had a clinical history of COPD, along with moderate airflow limitation and an increased risk of exacerbations, as evidenced by a history of exacerbations during the previous year or the prescribed use of supplemental oxygen. We excluded patients who were already taking a beta-blocker or who had an established indication for the use of such drugs. The primary end point was the time until the first exacerbation of COPD during the treatment period, which ranged from 336 to 350 days, depending on the adjusted dose of metoprolol.ResultsA total of 532 patients underwent randomization. The mean (±SD) age of the patients was 65.0±7.8 years; the mean forced expiratory volume in 1 second (FEV1) was 41.1±16.3% of the predicted value. The trial was stopped early because of futility with respect to the primary end point and safety concerns. There was no significant between-group difference in the median time until the first exacerbation, which was 202 days in the metoprolol group and 222 days in the placebo group (hazard ratio for metoprolol vs. placebo, 1.05; 95% confidence interval [CI], 0.84 to 1.32; P = 0.66). Metoprolol was associated with a higher risk of exacerbation leading to hospitalization (hazard ratio, 1.91; 95% CI, 1.29 to 2.83). The frequency of side effects that were possibly related to metoprolol was similar in the two groups, as was the overall rate of nonrespiratory serious adverse events. During the treatment period, there were 11 deaths in the metoprolol group and 5 in the placebo group.ConclusionsAmong patients with moderate or severe COPD who did not have an established indication for beta-blocker use, the time until the first COPD exacerbation was similar in the metoprolol group and the placebo group. Hospitalization for exacerbation was more common among the patients treated with metoprolol. (Funded by the Department of Defense; BLOCK COPD ClinicalTrials.gov number, NCT02587351.).

Rationale: Colder temperatures have been shown to increase hospitalization and mortality rates in adults with chronic obstructive pulmonary disease (COPD) and cardiac disease. Seasonal influences on exacerbation rates in adults with severe COPD but without significant cardiovascular disease are unclear. In addition, regional variations in COPD exacerbations in North America have not yet been explored. Objectives: In this study, we sought to determine the seasonal and regional variability in exacerbation rates in those with COPD but without significant cardiovascular risk factors. Methods: We studied adults without cardiovascular risk factors from STATCOPE (Simvastatin in the Prevention of COPD Exacerbations) and placebo arm of MACRO (Azithromycin for the Prevention of Exacerbations of COPD) studies. Forty-five study sites were divided into climate regions in Canada and the United States; seasons were defined as winter, spring, summer, and fall. The primary outcome was the rate of COPD exacerbation. Secondary outcomes included time to first exacerbation, severity of exacerbations, all-cause mortality, and antibiotic and steroid use. Results: We analyzed 1,175 subjects with a mean age of 63.3 ± 8.6 years, forced expiratory volume in 1 second of 41.5 ± 17.1% predicted, and 53.6 ± 29.4 pack-years of smoking history. The COPD exacerbation rate was higher in winter (0.13 exacerbations/person-month) than in spring, summer, and fall (0.11, 0.079, and 0.10 exacerbations/person-month, respectively) (P

Patients with Chronic Obstructive Pulmonary Disease (COPD) frequently experience unplanned hospital readmissions leading to increased morbidity [1]. The European Union COPD audit found that 35% of patients admitted with acute exacerbation of COPD (AECOPD) were readmitted within 90 days [2]. In the United States, 22% of patients admitted with AECOPD experienced a 30-day readmission, motivating financial policies to incentivize readmission reduction [1]. Footnotes This manuscript has recently been accepted for publication in the European Respiratory Journal . It is published here in its accepted form prior to copyediting and typesetting by our production team. After these production processes are complete and the authors have approved the resulting proofs, the article will move to the latest issue of the ERJ online. Please open or download the PDF to view this article. Conflict of interest: Dr. Krishnan reports grants from NHLBI/NIH, during the conduct of the study. Conflict of interest: Ms. Voelker has nothing to disclose. Conflict of interest: Dr. Connett has nothing to disclose. Conflict of interest: Dr. Niewoehner reports grants from National Institute of Health, during the conduct of the study; personal fees from Boehringer Ingelheim, personal fees from Astrazeneca, personal fees from GlaxoSmithKline, outside the submitted work. Conflict of interest: Dr. Albert has nothing to disclose. Conflict of interest: Dr. Scanlon reports grants from National Heart Lung and Blood Institute, during the conduct of the study; grants from Astra Zeneca, grants from Boehringer Ingelheim, grants from Forest Pharmaceuticals, grants from GlaxoSmithKline, grants from Novartis, grants from Pearl Therapeutics, other from Boehringer Ingelheim, other from GlaxoSmithKline, outside the submitted work. Conflict of interest: Dr. Dransfield reports grants from NHLBI, during the conduct of the study; grants from Department of Defense , personal fees and other from Boehringer Ingeheim, personal fees and other from GlaxoSmithKline, other from Novartis, personal fees and other from AstraZeneca, other from Yungjin, other from PneumRx/BTG, other from Pulmonx, personal fees from Genentech, personal fees and other from Boston Scientific , outside the submitted work. Conflict of interest: Dr. Han reports personal fees from BI, personal fees from GSK, personal fees from AZ, non-financial support from Novartis, non-financial support from Sunovion, outside the submitted work. Conflict of interest: Dr. Martinez reports non-financial support from GlaxoSmithKline, during the conduct of the study; personal fees from Continuing Education, personal fees from Forest Laboratories, other from Janssen, personal fees from GlaxoSmithKline, personal fees from Nycomed/Takeda, personal fees from AstraZeneca, personal fees from Boehringer Ingelheim, personal fees from Bellerophon (formerly Ikaria), personal fees from Genentech, personal fees from Novartis, personal fees from Pearl, personal fees from Roche, personal fees from Sunovion, personal fees from Theravance, personal fees from CME Incite, personal fees from Annenberg Center for Health Sciences at Eisenhower, personal fees from Integritas, personal fees from InThought, personal fees from National Association for Continuing Education, personal fees from Paradigm Medical Communications, LLC, personal fees from PeerVoice, personal fees from UpToDate, personal fees from Haymarket Communications, personal fees from Western Society of Allergy and Immunology, from Proterixbio (formerly Bioscale), personal fees from Unity Biotechnology, personal fees from ConCert Pharmaceuticals, personal fees from Lucid, personal fees from Methodist Hospital, personal fees from Columbia University, personal fees from Prime Healthcare Ltd, personal fees from WebMD, personal fees from PeerView Network, personal fees from California Society of Allergy and Immunology, personal fees from Chiesi, personal fees from Puerto Rico Thoracic Society, outside the submitted work. Conflict of interest: Dr. Criner reports grants from Boehringer- Ingelheim, grants from Novartis, grants from Astra Zeneca, grants from Respironics, grants from MedImmune, grants from Actelion, grants from Forest, grants from Pearl , grants from Ikaria , grants from Aeris , grants from PneumRx, grants from Pulmonx , other from HGE Health Care Solutions, Inc, other from Amirall, other from Boehringer- Ingelheim, other from Holaira, outside the submitted work.

No evidence-based guidelines exist for preventive dental care before radiation therapy (RT) in patients with head and neck cancer (HNC). An ongoing multicenter, prospective cohort study, Clinical Registry of Dental Outcomes in Head and Neck Cancer Patients (OraRad), is addressing this knowledge gap. The authors evaluated the level of dental disease before RT in the OraRad cohort, factors associated with dental disease, and dental treatment recommendations made before RT.As part of OraRad, the authors assessed caries, periodontal disease, dental recommendations, and dental interventions performed before RT.Baseline measures were reported for 356 participants (77% men) with mean (standard deviation) age of 59.9 (11.0) years. Measures included mean number of teeth (22.9), participants with at least 1 tooth with caries (37.2%), and participants with at least 1 tooth with probing depth 5 millimeters or greater (47.4%). Factors associated with less extensive dental disease before RT included having at least a high school diploma, having dental insurance, history of routine dental care, and a smaller tumor size (T1 or T2). Based on the dental examination before RT, 163 (49.5%) participants had dental treatment recommended before RT, with extractions recommended most frequently.Many patients with HCN require dental treatment before RT; more than one-third require extractions.Most patients have some level of dental disease at the start of RT, indicating the importance of dental evaluation before RT. By observing dental outcomes after RT, OraRad has the potential to determine the best dental treatment recommendations for patients with HCN.

BACKGROUND Retrospective studies have shown that statins decrease the rate and severity of exacerbations, the rate of hospitalization, and mortality in chronic obstructive pulmonary disease (COPD). We prospectively studied the efficacy of simvastatin in preventing exacerbations in a large, multicenter, randomized trial. METHODS We designed the Prospective Randomized Placebo-Controlled Trial of Simvastatin in the Prevention of COPD Exacerbations (STATCOPE) as a randomized, controlled trial of simvastatin (at a daily dose of 40 mg) versus placebo, with annual exacerbation rates as the primary outcome. Patients were eligible if they were 40 to 80 years of age, had COPD (defined by a forced expiratory volume in 1 second [FEV1] of less than 80% and a ratio of FEV1 to forced vital capacity of less than 70%), and had a smoking history of 10 or more pack-years, were receiving supplemental oxygen or treatment with glucocorticoids or antibiotic agents, or had had an emergency department visit or hospitalization for COPD within the past year. Patients with diabetes or cardiovascular disease and those who were taking statins or who required statins on the basis of Adult Treatment Panel III criteria were excluded. Participants were treated from 12 to 36 months at 45 centers. RESULTS A total of 885 participants with COPD were enrolled for approximately 641 days; 44% of the patients were women. The patients had a mean (±SD) age of 62.2±8.4 years, an FEV 1 that was 41.6±17.7% of the predicted value, and a smoking history of 50.6±27.4 pack-years. At the time of study closeout, the low-density lipoprotein cholesterol levels were lower in the simvastatin-treated patients than in those who received placebo. The mean number of exacerbations per person-year was similar in the simvastatin and placebo groups: 1.36±1.61 exacerbations and 1.39±1.73 exacerbations, respectively (P = 0.54). The median number of days to the first exacerbation was also similar: 223 days (95% confidence interval [CI], 195 to 275) and 231 days (95% CI, 193 to 303), respectively (P = 0.34). The number of nonfatal serious adverse events per person-year was similar, as well: 0.63 events with simvastatin and 0.62 events with placebo. There were 30 deaths in the placebo group and 28 in the simvastatin group (P = 0.89). CONCLUSIONS Simvastatin at a daily dose of 40 mg did not affect exacerbation rates or the time to a first exacerbation in patients with COPD who were at high risk for exacerbations. (Funded by the National Heart, Lung, and Blood Institute and the Canadian Institutes of Health Research; STATCOPE ClinicalTrials.gov number, NCT01061671.)

The Lung Health Study enrolled 3,923 participants in a smoking cessation intervention program, and followed them for 5 years. The study provided intensive group interventions for participants who had relapsed. The purpose of this analysis was to describe and evaluate these Restart programs. Among 1,004 relapsed participants, the percent not smoking at 5th year was higher for men who had used Restart (47) compared to those who had not (28), but not for women (42 vs. 33). Overall, there was equivocal evidence of the impact of the Restart programs due to limitations in the evaluation design. Because relapse is a common feature of efforts to quit smoking, relapse intervention programs need further study and more rigorous evaluation.

To the Editor: We recently found that azithromycin taken daily for 1 year reduced the frequency of acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) in subjects who were selected as having an increased risk of exacerbations [1]. Since azithromycin has potentially adverse effects, identifying patients most likely to benefit might be useful for targeting therapy. Accordingly, we included a substudy in our trial that was prospectively designed to determine whether plasma levels at entry, or a change in levels at 3 months of any of four blood biomarkers, were associated with improved clinical response to azithromycin as compared to placebo. We chose to study biomarkers of inflammatory pathways likely to be relevant to chronic obstructive pulmonary disease (COPD) including C-reactive protein (CRP), interleukin (IL)-6, IL-8 and soluble tumour necrosis factor receptor 75 (sTNFR75). The parent trial comprised 1142 subjects with COPD randomised to receive azithromycin (250 mg orally each day) or placebo (1:1) for 12 months (ClinicalTrials.gov NCT00325897) [1]. To enrich our population for subjects more likely to have an AECOPDs, we required that subjects used either systemic corticosteroids, visited an emergency room or were hospitalised for AECOPD in the preceding 12 months or were using continuous supplemental oxygen [2]. We required subjects to be free of AECOPDs or other acute illness for ≥4 weeks prior to enrolment and excluded subjects with known congestive heart failure (CHF) and those with clinically defined bronchiectasis. The primary outcome was time to first AECOPD defined as “a complex of respiratory symptoms (increased or new onset) of more than one of the following: cough, sputum, wheezing, dyspnoea, or chest tightness with a duration of at least 3 days requiring treatment with antibiotics or systemic steroids” [2]. We monitored participants for AECOPDs at follow-up clinic visits …

Although use of cigarettes and alcohol is positively related, there is a lack of evidence whether changes in smoking are followed by changes in drinking. The Lung Health Study recruited 5,887 adult smokers and randomized 2/3 to a smoking cessation intervention and 1/3 to a control group. "Heavy drinkers" were excluded from the sample. After a year in the study, 42% of the intervention participants reported that they had stopped smoking, compared to 11% of the controls. There was no corresponding difference between intervention and control participants in the use of alcohol after one year, although the study provided a high level of power to detect such a difference.

Introduction A substantial majority of chronic obstructive pulmonary disease (COPD)-related morbidity, mortality and healthcare costs are due to acute exacerbations, but existing medications have only a modest effect on reducing their frequency, even when used in combination. Observational studies suggest β-blockers may reduce the risk of COPD exacerbations; thus, we will conduct a randomised, placebo-controlled trial to definitively assess the impact of metoprolol succinate on the rate of COPD exacerbations. Methods and analyses This is a multicentre, placebo-controlled, double-blind, prospective randomised trial that will enrol 1028 patients with at least moderately severe COPD over a 3-year period. Participants with at least moderate COPD will be randomised in a 1:1 fashion to receive metoprolol or placebo; the cohort will be enriched for patients at high risk for exacerbations. Patients will be screened and then randomised over a 2-week period and will then undergo a dose titration period for the following 6 weeks. Thereafter, patients will be followed for 42 additional weeks on their target dose of metoprolol or placebo followed by a 4-week washout period. The primary end point is time to first occurrence of an acute exacerbation during the treatment period. Secondary end points include rates and severity of COPD exacerbations; rate of major cardiovascular events; all-cause mortality; lung function (forced expiratory volume in 1 s (FEV 1 )); dyspnoea; quality of life; exercise capacity; markers of cardiac stretch (pro-NT brain natriuretic peptide) and systemic inflammation (high-sensitivity C reactive protein and fibrinogen). Analyses will be performed on an intent-to-treat basis. Ethics and dissemination The study protocol has been approved by the Department of Defense Human Protection Research Office and will be approved by the institutional review board of all participating centres. Study findings will be disseminated through presentations at national and international conferences and publications in peer-reviewed journals. Trial registration number NCT02587351; Pre-results.

Background. Reported alcohol intake has an inverse association with body weight in women but is related to greater weight or no differences in weight in men. However, the relationship of alcohol consumption to weight appears to be less reliable in cigarette smokers and may be modified by the pattern of alcohol intake. The objective of this investigation was to examine the relationship of both aggregate alcohol intake and daily modal intake to body mass index (BMI) in male and female cigarette smokers. Methods. Cigarette smoking habits, body weight, and alcohol intake were assessed during screening for a clinical trial of early intervention for chronic obstructive pulmonary disease. Analyses are based on 3616 men and 2141 women cigarette smokers between 35 and 60 years of age. Results. There were no significant differences in BMI between alcohol drinkers and abstainers in either men or women. However, following regression adjustment for age, education, and cigarettes/day, total weekly alcohol intake was related to a lower BMI in both men and women, whereas a greater modal intake (drinks on a day alcohol is consumed) was related to a greater BMI in both men and women. Conclusions. The association of alcohol use to BMI in moderate to heavy cigarette smokers appears to be modified by the pattern of intake. Although the factors underlying this association are unclear, increased modal alcohol intake may serve as a marker for dietary or behavioural factors linked to greater body weight in cigarette smokers.

The extent and predictors of weight change were assessed among sustained nonsmoking special intervention participants in the Lung Health Study. The intervention included a 12-session group program and 2-mg nicotine gum. At 12 months, female sustained quitters (SQs; n = 248) had gained a mean of 8.4% (5.3 kg) of their baseline weight, whereas male SQs (n = 443) had gained 6.7% (5.5 kg). By 24 months, female SQs had gained 9.8% of their baseline weight compared with 6.9% for men. Nicotine gum usage delayed a portion of the weight gain. Multiple regression analysis showed that weight gain at 12 months was associated with a higher baseline salivary cotinine level, a lower baseline body mass index, drinking less alcohol per week, and a lower cotinine level at 12 months (indicating less or no nicotine gum use). We conclude that moderate weight gain is a long-term consequence of smoking cessation--a portion of which can be delayed with 2-mg nicotine gum.

Background The major marker utilized to monitor COPD patients is forced expiratory volume in one second (FEV1). However, asingle measurement of FEV1 cannot reliably predict subsequent decline. Recent studies indicate that T lymphocytes and eosinophils are important determinants of disease stability in COPD. We therefore measured cytokine levels in the lung lavage fluid and plasma of COPD patients in order to determine if the levels of T cell or eosinophil related cytokines were predictive of the future course of the disease. Methods Baseline lung lavage and plasma samples were collected from COPD subjects with moderately severe airway obstruction and emphysematous changes on chest CT. The study participants were former smokers who had not had a disease exacerbation within the past six months or used steroids within the past two months. Those subjects who demonstrated stable disease over the following six months (ΔFEV1 % predicted = 4.7 ± 7.2; N = 34) were retrospectively compared with study participants who experienced a rapid decline in lung function (ΔFEV1 % predicted = -16.0 ± 6.0; N = 16) during the same time period and with normal controls (N = 11). Plasma and lung lavage cytokines were measured from clinical samples using the Luminex multiplex kit which enabled the simultaneous measurement of several T cell and eosinophil related cytokines. Results and Discussion Stable COPD participants had significantly higher plasma IL-2 levels compared to participants with rapidly progressive COPD (p = 0.04). In contrast, plasma eotaxin-1 levels were significantly lower in stable COPD subjects compared to normal controls (p < 0.03). In addition, lung lavage eotaxin-1 levels were significantly higher in rapidly progressive COPD participants compared to both normal controls (p < 0.02) and stable COPD participants (p < 0.05). Conclusion These findings indicate that IL-2 and eotaxin-1 levels may be important markers of disease stability in advanced emphysema patients. Prospective studies will need to confirm whether measuring IL-2 or eotaxin-1 can identify patients at risk for rapid disease progression.

Cross-sectional studies have associated cigarette smoking in men with elevated androstenedione and little net effect on other sex steroids. However, it is not clear if such findings reflect the impact of nicotine exposure or if sex hormone levels change following smoking cessation. The relationship of the reported number of cigarettes smoked per day and salivary cotinine to salivary testosterone and androstenedione was examined in 221 men aged 35 to 59 years at baseline and 1 year following randomization into a clinical trial including a smoking-cessation intervention. At baseline, salivary cotinine was related to increased salivary androstenedione and testosterone following control for age, body mass, alcohol intake, and time of day of specimen collection (partial r = +.14 and +.30 P < .05 and .01, respectively). The reported number of cigarettes smoked per day was unrelated to either hormone. At the first annual visit, there was a significant decrease in the salivary androstenedione of men who had quite smoking and were currently using nicotine gum (94 v 60 pg/mL, P < .05, n = 34) and of men who had quit smoking and were not exposed to nicotine (86 v 56 pg/mL, P < .05, n = 48), whereas the salivary androstenedione of men who remained smokers at the first annual visit was unchanged (83 v 85 pg/mL, n = 139). Salivary testosterone levels were not significantly affected by a change in smoking status.(ABSTRACT TRUNCATED AT 250 WORDS)

This study investigates the relation of salivary cotinine and of the reported number of cigarettes smoked per day to body mass index among middle-aged male (n = 3,538) and female (n = 2,096) cigarette smokers participating in screening for entry to a clinical trial of early intervention in chronic obstructive pulmonary disease (Lung Health Study) from 1986 to 1989. Both before and after controlling for age, education, and alcohol intake, the number of cigarettes smoked per day was positively related to body mass index among both men and women, whereas salivary cotinine levels were negatively related to body mass index among both men and women. The opposite relation of salivary cotinine and of reported number of cigarettes smoked per day to body mass index is discussed with regard to nicotine metabolism, energy intake, and measurement issues in the assessment of cigarette smoke exposure.