COPDGene® 2019: Redefining the Diagnosis of Chronic Obstructive Pulmonary Disease

Background:Chronic obstructive pulmonary disease (COPD) remains a major cause of morbidity and mortality. Present-day diagnostic criteria are largely based solely on spirometric criteria. Accumulating evidence has identified a substantial number of individuals without spirometric evidence of COPD who suffer from respiratory symptoms and/or increased morbidity and mortality. There is a clear need for an expanded definition of COPD that is linked to physiologic, structural (computed tomography [CT]) and clinical evidence of disease. Using data from the COPD Genetic Epidemiology study (COPDGene®), we hypothesized that an integrated approach that includes environmental exposure, clinical symptoms, chest CT imaging and spirometry better defines disease and captures the likelihood of progression of respiratory obstruction and mortality. Methods:Four key disease characteristics - environmental exposure (cigarette smoking), clinical symptoms (dyspnea and/or chronic bronchitis), chest CT imaging abnormalities (emphysema, gas trapping and/or airway wall thickening), and abnormal spirometry - were evaluated in a group of 8784 current and former smokers who were participants in COPDGene® Phase 1. Using these 4 disease characteristics, 8 categories of participants were identified and evaluated for odds of spirometric disease progression (FEV1 > 350 ml loss over 5 years), and the hazard ratio for all-cause mortality was examined. Results:Using smokers without symptoms, CT imaging abnormalities or airflow obstruction as the reference population, individuals were classified as Possible COPD, Probable COPD and Definite COPD. Current Global initiative for obstructive Lung Disease (GOLD) criteria would diagnose 4062 (46%) of the 8784 study participants with COPD. The proposed COPDGene® 2019 diagnostic criteria would add an additional 3144 participants. Under the new criteria, 82% of the 8784 study participants would be diagnosed with Possible, Probable or Definite COPD. These COPD groups showed increased risk of disease progression and mortality. Mortality increased in patients as the number of their COPD characteristics increased, with a maximum hazard ratio for all cause-mortality of 5.18 (95% confidence interval [CI]: 4.15-6.48) in those with all 4 disease characteristics. Conclusions:A substantial portion of smokers with respiratory symptoms and imaging abnormalities do not manifest spirometric obstruction as defined by population normals. These individuals are at significant risk of death and spirometric disease progression. We propose to redefine the diagnosis of COPD through an integrated approach using environmental exposure, clinical symptoms, CT imaging and spirometric criteria. These expanded criteria offer the potential to stimulate both current and future interventions that could slow or halt disease progression in patients before disability or irreversible lung structural changes develop

The Talking Cure as Action: Freud's Theory of Ritual Revisited

Freud made creative use of late Victorian theories of ritual as empty modes of behavior, using the idea of seemingly meaningless ritual to offer a compelling comparison with obsessive behavior. However, analytic hours, with their repetitive frame and repetition of unconscious conflicts, have stronger links with rituals than Freud admitted. Recent theories highlight the extensive power of rituals to organize and instantiate models of effective action, especially in terms of the multifunctionality of language. These new theories of ritual offer in turn new tools for understanding the therapeutic action of analytic hours. © 2011 Association for the Advancement of Psychoanalysis

Novel subtypes of pulmonary emphysema based on spatially-informed lung texture learning: the multi-ethnic study of atherosclerosis (MESA) COPD study.

Pulmonary emphysema overlaps considerably with chronic obstructive pulmonary disease (COPD), and is traditionally subcategorized into three subtypes previously identified on autopsy. Unsupervised learning of emphysema subtypes on computed tomography (CT) opens the way to new definitions of emphysema subtypes and eliminates the need of thorough manual labeling. However, CT-based emphysema subtypes have been limited to texture-based patterns without considering spatial location. In this work, we introduce a standardized spatial mapping of the lung for quantitative study of lung texture location and propose a novel framework for combining spatial and texture information to discover spatially-informed lung texture patterns (sLTPs) that represent novel emphysema subtype candidates. Exploiting two cohorts of full-lung CT scans from the MESA COPD (n=317) and EMCAP (n=22) studies, we first show that our spatial mapping enables population-wide study of emphysema spatial location. We then evaluate the characteristics of the sLTPs discovered on MESA COPD, and show that they are reproducible, able to encode standard emphysema subtypes, and associated with physiological symptoms

The ECORS-Truc Vert’08 nearshore field experiment: Presentation of a three-dimensional morphologic system in a macro-tidal environment during consecutive extreme storm conditions

A large multi-institutional nearshore field experiment was conducted at Truc Vert, on the Atlantic coast of France in early 2008. Truc Vert’08 was designed to measure beach change on a long, sandy stretch of coast without engineering works with emphasis on large winter waves (offshore significant wave height up to 8 m), a three-dimensional morphology, and macro-tidal conditions. Nearshore wave transformation, circulation and bathymetric changes involve coupled processes at many spatial and temporal scales thus implying the need to improve our knowledge for the full spectrum of scales to achieve a comprehensive view of the natural system. This experiment is unique when compared with existing experiments because of the simultaneous investigation of processes at different scales, both spatially (from ripples to sand banks) and temporally (from single swash events to several spring-neap tidal cycles, including a major storm event). The purpose of this paper is to provide background information on the experiment by providing detailed presentation of the instrument layout and snapshots of preliminary results.Hydraulic EngineeringCivil Engineering and Geoscience