WEEK 11 COMOBIDITIES CONTINUED Flashcards
What conditions do people have if they are at increased risk of getting covid-19?
- Heart failure. CID, cardiomyopathies
- COPD
- Obesity
- Other chronic diseases.
What conditions do people have that means they MAY be at increased risk of getting covid-19?
- Overweight
- Have asthma
- Hypotensive.
- Have a neurological conditions such as dementia.
What percentage of countries have no mental health legislation?
- 25%
What % of countries have no mental health policy or no mental health program respectively?
- More than 40% with no mental health policy and over 30% with no mental health programme.
What % of countries surveyed have indicated that the COVID-19 pandemic has disrupted mental health serives?
- 93%
Over the COVID-19 lockdown period in Australia, how had mental health problems changed in prevalence (nationwide survey), and what types of people was this worse for?
- Mental health problems Dubbo with and prevalence compared to normal Lockdown periods.
- This was due to anxiety, depression and irritability attributed to restrictions
- Worse for those who:
- Lost jobs
- Caring for children and other family members
- Lived alone
- Had fewer resources
Would extending Telehealth be suitable for all people in lockdown?
- NO
- ## This is because some people are from low socioeconomic areas and there may be less privacy at home.
In a study by Stanton et al., what was decreased and increased in terms of changes linked to higher anxiety in the first lockdown period for COVID-19?
- A decrease in physical activity
- Increase in alcohol use
- Increase in smoking
- Increase in Psychological distress
- These changes are ALL linked to higher depression and anxiety
What 4 other factors were seen in those who had higher psychological distress as part of the Stanton et al study. (W11 L1)?
- More females compared to males
- Singled compared to partnered
- Lower incomes
- Increase in chronic illness
With a study conducted via the Kids helpline (aged 18-25), what were the 5 top concerns across the age range from Jan-April 2020?
- Mental health
- Social isolation
- Impacts on education.
- Impact on family life.
- Changes to plans and activities.
- Greater burden to carers looking after autistic people
What 3 things is Australia doing to improve mental health services from 2020 onwards?
- Launched a mental health and well-being plan in May 2020. (Additional $48 million mental health funding)
- Increased access to Medicare subsidized psychological sessions (Up to 20 from 10) in Oct 2020
- Additional, mental health clinics in Victoria (Sept 2020)
Do many people with autism like structure and routine?
- YES
Even though every autistic person is different what three things can autism be a company by in terms of behaviours?
- Anxiety
- Irritability
- Agression
In an Italian survey of parents of young children with autism, what was the biggest request coming out of life in covid lockdown?
- Request for in home healthcare support (30%) and Centre-based healthcare support (10.5%)
What was a concern and thus suggestion made for people with autism regarding the COVID-19 pandemic?
- To have a home testing kit
- This is because they don’t understand the concept of wearing a mask and also difficult if they have to go into emergency without carers.
What does an Autistic person find it hard to do in terms of tasks?
- They find it hard to switch tasks and so need time to process
Is Asthma more prevalent in boys or girls aged 0 to 14?
- More prevalent in boys aged 0-14
Is asthma more prevalent in males or females age 15 and over?
- More prevalent in females aged 15 and over
What is the estimated cost of asthma in Aus?
- $27.9 billion (as of 2015) - 3.3B in economic costs + 24.7 in “burden of disease”
What is the prevalence of asthma in australia?
- 1/10 Aussies
What is the estimated healthcare costs of obesity?
-27.9 billion (as of 2017)
Who is the 13th fattest country in the world?
- Australia
What % of children are classified as overweight?
- 25%
How many Aussies are overweight and obese respectively?
- > 6M overweight and >5.2M obese
What are the comorbidities that come with Obesity?
- hypertension
- diabetes
- GERD
- OSA
- Asthma
What is the most common type of Asthma?
- Allergic asthma (T2 type asthma)
What are the two different types of asthma umbrellas?
- T2-type asthma (allergic and exercise induced)
- Non-T2 type asthma (obesity associated, smoking related etc)
Does obesity increase the risk of asthma occurring?
- YES
Is the obesity and asthma relationship a dose dependent response?
- YES
e. g. Increasing BMI is associated with increasing odds of asthma (e.g. 40% higher risk of developing asthma if you are OVERWEIGHT AND 90% higher risk with obese etc. )
How can obesity both cause and complicate asthma?
- It can worsen the asthma consequent to obesity and can also cause Non-T2 type asthma, which is also worsened by obesity.
- Allergic asthma is also worsened by obesity
Which is the main immune cell infiltration in T2-Type asthma?
- Eosinophils
Which is the main immune cell infiltration in Non-T2 type asthma?
- Neutrophils
What are the 4 common features of asthma fitting under the inflammation and remodeling umbrella?
- Inflammatory cell infiltration. (eosinophils- T2, neutrophils- Non-T2)
- Excessive mucus (obstruction and barrier to inhaler therapy)
- Basement membrane thickening (fibrosis)
- More smooth muscle (increased contraction)
Which two factors lead to the airways contracting “too easily and too much” in terms of airway hyperresponsiveness?
- The influence of inflammatory mediators
- Increased bulk of “sensitised” muscle
How is AHR (Airway hyperresponsiveness) quantified?
- Need to find a dose of bronchoconstrictor that causes a 20% increase in airway resistance (methylcholine challenge).
- Don’t want to push someone too much.
- The lower the PC20 value is (graph), the more severe someone’s asthma is, and the more hyper-responsive their airways are.
What does a low PC20 value mean?
- that a person’s asthma is more severe and the more hyperresponsive their airways are
What are the factors that Th2 cells release in terms of allergic asthma and causing T2 immune deviation to aeroallergens?
-IL-5, IL-4 and IL-13
What are the factors that Eosinophils cells release in terms of allergic asthma and causing T2 immune deviation to aeroallergens?
- Leukotrienes
- Cytokines
What are the factors that Plasma cells and mast cells release in terms of allergic asthma and causing T2 immune deviation to aeroallergens?
- IgE
- Histamine, Leukotrienes and cytokines
What are the three main types of immune cells/mediators in Obese asthma (known as T1 immune deviation or ‘non T2)?
- Increased adipose tissue - adipokines (more leptin-pro inflamm, and less adiponectin- antiinflamm)
- Increase in macrophages
- Increase in neutrophils (TNFa, IL-6, and IL-17)
Are relievers or preventers used for obese (non T2) type asthma, which phase of asthma do they target, and what do they relieve?
- Relievers are used as it is non allergic asthma
- They target the immediate (acute) phase of asthma
- They relieve airway smooth muscle spasm
What are examples of relievers used to treat Obese asthma?
- B2 adrenoceptor agonists
- PDE inhibitors
- Muscarinic receptor antagonists
What is an example of a B2 adrenoceptor agonist (1st line treatment for non T2/obese type asthma and what is its mechanism of action?
- SABA- Salbutamol , (LABA-fromoterol)
- This mimics adrenaline
- Increases cAMP synthesis
What is an example of a PDE inhibitor treatment for non T2/obese type asthma and what is its mechanism of action?
- Theophylline
- Decreases the cAMP breakdown
What is an example of a muscarinic receptor antagonist for non T2/obese type asthma and what is its mechanism of action?
- SAMA- ipratropium, LAMA-tiotropium
- Block Ach (PNS)
- Decrease calcium signaling
What are the limitations with relievers, specifically B2 adrenoceptor agonists (1st line treatment)?
- Efficacy reduced if airway contraction is INCREASED (functional antagonism) or if B2 adrenoceptor expression is reduced
What is an example of preventers and their mechanism of action?
- Example is Inhaled corticosteroids (fluticasone, budesonise (regulate gene transcription)
- For TRANSACTIVATION: bind to GREs, increase anti-inflammatory proteins (annexin A1)
- For TRANSREPRESSION: bind to TFs and decrease pro inflammatory proteins e.g. COX-2, IL-1 and TNFa
Are preventers (i.e. inhaled corticosteroids) helpful in non-T2 Asthma (Obese asthma) and why is/isn’t this the case?
- NO
- This is the case as the main cells in non-T2 type asthma are neutrophils, TNFa and IL-17 (compared to eosinophils, Th2 cytokines)
Can preventers (i.e. inhaled corticosteroids) be used in combination with a LABA for long-term bronchodilation, and if so, are there any limitations?
- Yes it may be used
- BUT the dilator efficacy may be reduced (like SABA) if the contraction is increased (functional antagonism) and B2 adrenoceptor expression is reduced
What are the three main mechanisms of obese asthma?
- Decreased lung function.
- Inflammation
- Oxidative stress
What is included in decreased lung function in terms of asthma and obesity mechanisms?
- Reduced FRC and ERV due to abdominal adiposity (adipodisity linked)
What are three components of inflammation that occurs in obese (non-T2 type) asthma?
- Th1 related inflammation in the airways
- Increased Leptin in the airways, reduced adiponectin
- IL-17 associated inflammation in the airways
What is one component of oxidative stress that occurs in obese (non-T2 type) asthma?
- Low L-arginine ADMA ratio and increased oxidative stress and lower NO
Does obesity impair lung function?
- YES
How does obesity impair lung function?
- Decreases the tidal volume (TV) (increased rate) which contributes an increase in airway stiffness (because they are not relaxing and contracting to their full capacity, making it harder to breathe). This then leads to an increase in airway contraction and increase in airway narrowing.
- So:
DECREASED TITAL VOLUME
INCREASED AIRWAY STIFFNESS
INCREASED AIRWAY CONTRACTION
INCREASED AIRWAY NARROWING
As Obesity impairs lung function, does it impact on the airway obstruction, and what does this mean?
- NO it does NOT impact on airway obstruction. This means that the FEV1/FVC are preserved (not changed)
How does obesity cause systemic inflammation (i.e. what are the factors that are released?)
- Increased Prime lemon tree leptin decrease anti-inflammatory adiponectin.
- Macrophages infiltrate adipose and release tissue release TNF-a and IL-6.
How does obesity cause lung inflammation (i.e. what are the three things that occur) ?
- Decreased airway eosinophils (lumen. sputum)
- Increased airway neutrophils
- Predominately Th-1 and potential IL-17 related inflammation
Via which pathway is interrupted to allow for inflammation and bronchodilation?
- L-arginine to cNOS (activates NO)
- NO + L-citrulline causes inhibition of inflammation bronchodilation
- BUT in Obesity asthma, something happens to the cNOS enzyme and there is no more inhibition of inflammation bronchodilation
- Obesity REDUCES NO-
Are there increased levels of ADMA in obesity, and if so, what is the mechanism and result of this?
- YES there are
- ADMA- assymetric di-methyl arginine that is an endogenous inhibitor of NOS enzymes that produce NO -
- It increases and INHIBITS THE cNOS enzyme wihch causes NO production (therefore loss of protection) to cause inflammation, increased contractility and cytotoxicity.
What is ADMA?
- Asymmetric di-methyl arginine
- Endogenous inhibitor of NOS enzymes that produce NO
Are there increased levels of iNOS in obesity and if so, how dos this contribute to the increased oxidative stress?
- YES
- iNOS produces O2- which combines with NO and Citrulline to form a powerful oxidant that causes inflammation, increased contractility and cytotoxicity much like ROS does
Are there increased levels of Arginase I in obesity, and if so, what is the mechanism of action?
- YES (this is the enzyme that breaks arginine down)
- Increased Arginase, leads to urrea and L-orthinine
- This leads to polyamines and L-proline being produced.
1. Polyamines lead to airway smooth muscle proliferation which leads to airway remodelling
2. L-proline leads to collagen production which also leads to airway remodelling (via fibrosis)
What are the three main mechanisms of obese asthma and what are the details of these?
- IMPAIRED LUNG FUNCTION:
- Increase abdominal fat, decrease tidal volume–] airway narrowing - INFLAMMATION
- Increased leptin, decreased adiponectin
- increased non T2 inflammation- neutrophils, TNF-a, IL-6 and IL-17 - OXIDATIVE STRESS
- Increased ADMA (cNOS inhibitor), arginase –> decreased NO& L-Arg, increased ROS –> decreased bronchodilation, increased inflammation and remodeling
What may be 5 additional factors contributing to asthma and obesity?
- Genetic susceptibility
- Birth weights – low or high?
- Prenatal, maternal and paternal nutrition, postnatal diet
- Gender?
- Comorbidities (obstructive sleep apnea).
What did a study find in relation to males, weight and asthma risk, and what may be the implications?
- They found that if the males gained the weight in their childhood it increased the risk of their offspring in the future becoming asthmatic as adults.
- Therefore may want to think about being healthy in long term.
Is there conclusive evidence that gender contributes to obese asthma?
- NO
- One study did not find any major differences between the sexes