To highlight recent publications about sleep disorders and sleep health in adult persons with HIV (PWH), with a focus on how sleep relates to comorbidities in PWH.
Sleep disorders are more common in ...PWH than in seronegative controls, especially insomnia, with four different recent studies estimating insomnia prevalence in PWH at 21-35%. Sleep apnea prevalence estimates in PWH have varied widely. Most studies suggest PWH do not have higher sleep apnea prevalence compared with controls, though definitions of sleep apnea may affect these analyses. Comorbidities recently associated with sleep in PWH include myocardial infraction (insomnia), depressive symptoms (insomnia and restless legs syndrome), and pain (insomnia). Cognition associations with sleep were inconsistent and may depend on data collection and analytic methods. Sleep health dimensions are uncommonly reported, but PWH appear to report worse sleep health dimensions and these demonstrated mixed associations with cognition and depressive symptoms in recent studies.
Sleep disorders and poor sleep health are common in PWH and are related to comorbidities. More data from longitudinal studies and clinical trials are needed. Clinical trials of insomnia interventions in PWH are especially warranted.
Summary Patients that are immunosuppressed might be at risk of serious influenza-associated complications. As a result, multiple guidelines recommend influenza vaccination for patients infected with ...HIV, who have received solid-organ transplants, who have received haemopoietic stem-cell transplants, and patients on haemodialysis. However, immunosuppression might also limit vaccine responses. To better inform policy, we reviewed the published work relevant to incidence, outcomes, and prevention of influenza infection in these patients, and in patients being treated chemotherapy and with systemic corticosteroids. Available data suggest that most immunosuppressed populations are indeed at higher risk of influenza-associated complications, have a general trend toward impaired humoral vaccine responses (although these data are mixed), and can be safely vaccinated—although longitudinal data are largely lacking. Randomised clinical trial data were limited to one study of HIV-infected patients with high vaccine efficacy. Better trial data would inform vaccination recommendations on the basis of efficacy and cost in these at-risk populations.
Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are common, associated with acute inflammation, and may increase subsequent cardiovascular disease (CVD) risk.
Determine whether ...AECOPD events are associated with increased risk of subsequent CVD.
We performed a secondary cohort analysis of the SUMMIT (Study to Understand Mortality and Morbidity) trial, a convenience sample of current/former smokers with moderate COPD from 1,368 centers in 43 countries. All had CVD or increased CVD risk. AECOPD was defined as an increase in respiratory symptoms requiring treatment with antibiotics, systemic corticosteroids, and/or hospitalization. CVD events were a composite outcome of cardiovascular death, myocardial infarction, stroke, unstable angina, and transient ischemic attack. All CVD events were adjudicated. Cox proportional hazards models compared the hazard for a CVD event before AECOPD versus after AECOPD.
Among 16,485 participants in SUMMIT, 4,704 participants had at least one AECOPD and 688 had at least one CVD event. The hazard ratio (HR) for CVD events after AECOPD was increased, particularly in the first 30 days after AECOPD (HR, 3.8; 95% confidence interval, 2.7-5.5) and was elevated up to 1 year after AECOPD. The 30-day HR after hospitalized AECOPD was more than twofold greater (HR, 9.9; 95% confidence interval, 6.6-14.9).
In patients with COPD with CVD or risk factors for CVD, exacerbations confer an increased risk of subsequent CVD events, especially in hospitalized patients and within the first 30 days after exacerbation. Patients and clinicians should have heightened vigilance for early CVD events after AECOPD. Clinical trial registered with www.clinicaltrials.gov (NCT 01313676).
To highlight recently published, clinically focused research on chronic lung disease in adult persons with human immunodeficiency virus-1 (HIV) (PWH).
Chronic lung disease was the most common ...comorbidity in hospitalized PWH in New York and second-most common condition in ambulatory PWH in Canada. The elevated risk of chronic obstructive pulmonary disease in PWH has been widely recognized, but PWH are also at higher risk for asthma and worse asthma outcomes. Expanded assessments of lung structure and function, such as single-breath diffusing capacity of carbon monoxide (DLCO), exhaled nitric oxide (FeNO), and chest computed tomography (CT) have provided new insights into HIV effects on the lungs. New biomarker analyses are emerging, but further studies are needed to validate predictive biomarkers for chronic lung disease in PWH. Clinical trials addressing chronic lung disease in PWH are few in number.
Chronic lung disease is a common and high-impact comorbidity among PWH. Future studies should collect more comprehensive lung assessments such as DLCO, FeNO, and chest CT in order to better phenotype lung derangements in HIV. Clinical trials are desperately needed to reduce the rising burden of chronic lung disease in PWH.
Acute exacerbations of chronic obstructive pulmonary disease (COPD) increase the risk of death and drive healthcare costs, but whether they accelerate loss of lung function remains controversial. ...Whether exacerbations in subjects with mild COPD or similar acute respiratory events in smokers without airflow obstruction affect lung function decline is unknown.
To determine the association between acute exacerbations of COPD (and acute respiratory events in smokers without COPD) and the change in lung function over 5 years of follow-up.
We examined data on the first 2,000 subjects who returned for a second COPDGene visit 5 years after enrollment. Baseline data included demographics, smoking history, and computed tomography emphysema. We defined exacerbations (and acute respiratory events in those without established COPD) as acute respiratory symptoms requiring either antibiotics or systemic steroids, and severe events by the need for hospitalization. Throughout the 5-year follow-up period, we collected self-reported acute respiratory event data at 6-month intervals. We used linear mixed models to fit FEV
decline based on reported exacerbations or acute respiratory events.
In subjects with COPD, exacerbations were associated with excess FEV
decline, with the greatest effect in Global Initiative for Chronic Obstructive Lung Disease stage 1, where each exacerbation was associated with an additional 23 ml/yr decline (95% confidence interval, 2-44; P = 0.03), and each severe exacerbation with an additional 87 ml/yr decline (95% confidence interval, 23-151; P = 0.008); statistically significant but smaller effects were observed in Global Initiative for Chronic Obstructive Lung Disease stage 2 and 3 subjects. In subjects without airflow obstruction, acute respiratory events were not associated with additional FEV
decline.
Exacerbations are associated with accelerated lung function loss in subjects with established COPD, particularly those with mild disease. Trials are needed to test existing and novel therapies in subjects with early/mild COPD to potentially reduce the risk of progressing to more advanced lung disease. Clinical trial registered with www.clinicaltrials.gov (NCT 00608764).
Poor oral health has been implicated as an independent risk factor for the development of COPD, but few studies have evaluated the association between oral health and COPD exacerbations. We aimed to ...determine if poor oral health is associated with COPD exacerbations and/or worse respiratory health.
We performed a case-control study of oral health among COPD exacerbators and non-exacerbators. Cases (exacerbators) had experienced ≥1 exacerbation in the previous 12 months, while controls (non-exacerbators) had no exacerbations in the previous 24 months. We excluded those with <4 teeth. We evaluated the global oral health assessment, Oral Health Impact Profile (OHIP-5), dental symptoms/habits, and St. George's Respiratory Questionnaire (SGRQ). In a subset, we performed blinded dental exams to measure bleeding on probing, probing depth, clinical attachment loss, periodontitis severity, plaque index, gingival index, and carries risk. We evaluated associations between oral health and COPD exacerbations using logistic regression. Linear regression was used to assess relationships between oral health and SGRQ scores.
Screened non-exacerbators (n=118) were significantly more likely to have <4 teeth, compared to screened exacerbators (n=100) (44% vs 30%, respectively;
=0.046). After excluding those with <4 teeth, there were 70 cases and 66 controls. Self-reported oral health and objective dental exam measures did not vary significantly between cases vs controls. However, the odds of severe COPD exacerbations requiring hospitalizations and/or emergency department visits trended higher in those with worse dental exam compared to those with better dental exam. Worse OHIP-5 was strongly associated with worse SGRQ scores.
Oral health status was not related to COPD exacerbations, but was associated with self-reported respiratory health. Non-exacerbators were more likely to be edentate or have ≤4 teeth compared to exacerbators. Larger studies are needed to address oral health as a potential method to improve respiratory health in patients with COPD.
People living with HIV have greater pulmonary function impairments and decreased health-related quality of life (HRQoL) compared to uninfected peers. We examined whether pulmonary impairment was ...associated with HRQoL or respiratory health status. Using Multicenter AIDS Cohort Study data (2017-2019), associations between outcomes HRQoL (36-Item Short Form Survey) and respiratory health status (St. George's Respiratory Questionnaire) with pulmonary impairment diffusing capacity for carbon monoxide (DL
) and forced expiratory volume in 1 s (FEV
), defined as <80% predicted for both were examined. Adjusted analyses utilized linear and zero-inflated beta regression, the latter summarized by odds ratio (OR) and quotient ratios (QRs). We also considered whether the subset of adjustment variables age, HIV serostatus, or smoking modified the relationships examined. Of 1048 men, 55% had HIV, with median age 57 interquartile range (IQR) = 48, 64 years and 1.2 (IQR = 0, 18.1) smoking pack-years. Impaired DL
, but not impaired FEV
was significantly associated with lower physical HRQoL -2.71 (-4.09, -1.33); -1.46 (-3.45, 0.54), respectively. Pulmonary impairment was associated with higher odds of any St. George's Respiratory Questionnaire (SGRQ) (total score) limitation DL
OR = 1.53 (1.15, 2.04); FEV
OR = 2.48 (1.16, 5.30) and was elevated in individuals with more severe SGRQ limitations DL
QR = 1.13 (0.94, 1.36); FEV
QR = 1.27 (0.98, 1.64). HIV did not modify any associations examined. Age modified the DL
and any respiratory limitation (SGRQ symptom score) association for every 10 mL CO/min/mmHg decrease in DL
age 30 OR = 1.03 (0.51, 2.08); age 50 OR = 1.85 (1.27, 3.85); and age 70 OR = 3.45 (2.00, 5.88). Similarly, age modified the DL
and any respiratory limitation (SGRQ total score) association. FEV
associations with SGRQ and HRQoL scores were similar across all ages. Impaired pulmonary function was associated with lower HRQoL and greater respiratory impairments. Future studies can determine if interventions aimed at preserving pulmonary function are effective in improving HRQoL and respiratory health among aging men with and without HIV.
PDF
