Analysis of trace elements in the hair of volunteers suffering from naso-pharyngeal cancer

This article describes a study where the trace elements (TEs) of four groups of volunteers were analyzed. The volunteers were divided into four groups A, B, C, and D. Group A was made up of healthy subjects, group B was made up of volunteers who had just been diagnosed as having naso-pharyngeal cancer (NPC), group C was made up of volunteers who had been diagnosed as having NPC after 3 mo of treatment, and group D was made up of volunteers who had been diagnosed as having NPC after 6 mo of treatment. In all groups, 11 trace elements in hair were analyzed. Our study shows that the concentrations of zinc (Zn), copper (Cu), manganese (Mn), and cobalt (Co) in group B are less than that of group A, whereas the concentration of titanium (Ti) in group B is higher. Our results also show that the difference in the level of TEs between group A and the other groups is dramatically decreased as the time of the treatment is increased. This may be a reflection of successful treatment.     

Investigation of Alteration in the Levels of Iron and Copper in Scalp Hair Samples of Patients Having Different Types of Viral Hepatitis

The aim of this study was to measure the alterations of copper and iron contents in scalp hair samples of hepatitis A–E patients of both genders, same age group, and socioeconomic status. For comparative study, the scalp hair samples of healthy individuals of the same age and socioeconomic status were collected. The concentrations of copper and iron were measured using an atomic absorption spectrophotometer, after microwave-assisted acid digestion. The validity and accuracy of methodology was checked using a certified reference material. The results of this study showed that the mean values of copper and iron were higher in scalp hair samples of hepatitis patients than those of age-matched control subjects, while the difference was significant in the cases of patients having viral hepatitis B, C, and D as compared to those who have viral hepatitis A and E (p?<?0.001). It was concluded that the overload of copper and iron in the human body may cause lipid peroxidation and eventually damage the hepatic system.     

Serum and hair zinc levels in epileptic children taking valproic acid

This study was performed to investigate the serum and hair zinc levels in patients having epilepsy diagnoses who were intended to be put on valproic acid (VA) monotherapy and had never ingested antiepileptics before. A total of 16 patients having normal growth, development, and nutrition was selected as Group 1, and Group 2 was made up of 10 patients who had received VA monotherapy for 2 yrs or more and had normal growth, development, and nutrition characteristics. A control group (Group 3) was formed of 15 subjects who applied to the hospital for upper respiratory tract disorders. Serum and hair samples were taken for zinc assays from the Group 1 patients on the d 0, 15, 30, 45, 60, 75, and 180. Groups 2 and 3 were sampled only once, and zinc levels were determined. We found that both serum and hair zinc levels in Group 1 were higher than those of Group 2 and control group before the beginning of VA therapy, but they returned to normal during VA treatment. There was no zinc deficiency, and zinc replacement treatment may therefore be considered as unnecessary.     

The outcome of Erb's palsy when the decision to operate is made at 4 months of age

Since the establishment of the obstetrical brachial plexus clinic in Saudi Arabia, the author has designed a prospective study in which the indication for brachial plexus surgery in infants with Erb's palsy was the lack of active elbow flexion against gravity at 4 months of age. Forty-three infants were included in the study and were distributed among four groups: group A (n = 20) included infants who had active elbow flexion at the initial assessment or at 2 months of age; group B (n = 9) included infants who had active elbow flexion at 3 months of age; group C (n = 11) included infants who had active elbow flexion at 4 months of age; and group D (n = 3) included infants who did not have active elbow flexion at 4 months of age. At the final follow-up, all children in group A demonstrated complete spontaneous recovery of the motor power of the limb. All children in group B also had satisfactory spontaneous recoveries, and none required secondary corrective procedures. Five of the 11 patients in group C had satisfactory spontaneous recoveries. The remaining six children in group C had good recovery of elbow flexion but a poor recovers of shoulder function. Finally, all three patients who did not have elbow flexion at 4 months of age (group D) underwent surgical exploration and reconstruction of the brachial plexus, using nerve grafts. The results of this prospective study are discussed, along with the controversial issue regarding the timing of primary plexus surgery in Erb's palsy.     

Increased hair selenium concentration in hyperlipidemic patients

Selenium is an essential trace element with potential anti‐atherogenic and antioxidant effects. Experimental data suggest that selenium might be beneficial in the prevention of atherosclerosis and its complications, whereas human epidemiological studies have yielded conflicting results. Data on hair selenium status in hyperlipidemic patients are still lacking. Therefore, we analysed selenium concentrations by X‐ray fluorescence in the hair of 81 statin‐naïve patients with newly diagnosed Fredrickson‐type IIa and IIb hyperlipoproteinemia and compared their data with 43 healthy volunteers. We also assessed the frequency of other classical risk factors of atherosclerosis. Hair selenium levels were found to be significantly higher in hyperlipidemic patients compared with volunteers with normal lipid levels. Also, a significantly increased number of traditional atherosclerosis risk factors were observed in hyperlipidemic patients with hair selenium concentrations above the median in contrast to those with below. Our results suggest that high hair selenium status might be associated with adverse blood lipid profile together with an increased number of traditional risk factors in a selenium‐deplete population. These findings warrant further investigations to study the impact of selenium supplementation on the incidence of cardiovascular events.     

Clinical value of the pudendal somatosensory evoked potential

The pudendal evoked potential was recorded in 126 patients who had presented with various uro-genital complaints. The patients were divided into two groups depending on whether or not there were clinical signs of neurological disease. Group I consisted of 83 patients (66%) who on clinical examination were neurologically normal. In group 11 there were 43 patients (34%) who had physical signs suggesting underlying neurological pathology. The pudendal evoked potential was abnormal in 10 patients from the group with neurological signs (group 11) but only 1 patient from group I (a man who had made an excellent recovery from previous transverse myelitis). The conclusion of this study is that the pudendal evoked potential is of no greater value than the clinical examination in the assessment of patients with uro-genital dysfunction. The recommendation that the potential should be recorded as part of the routine assessment of patients suspected of having a neurogenic disorder of the bladder and sexual function should be reconsidered.     

Incidence of AIDS and excess of mortality associated with HIV in haemophiliacs in the United Kingdom: report on behalf of the directors of haemophilia centres in the United Kingdom.

OBJECTIVE--To estimate the cumulative incidence of AIDS by time since seroconversion in haemophiliacs positive for HIV and to examine the evidence for excess mortality associated with HIV in those who had not yet been diagnosed as having AIDS. DESIGN--Analysis of data from ongoing national surveys. SETTING--Haemophilia centres in the United Kingdom. PATIENTS--A total of 1201 men with haemophilia who had lived in the United Kingdom during 1980-7 and were positive for HIV. INTERVENTION--None. END POINTS--Diagnosis of AIDS; death in those not diagnosed as having AIDS. MEASUREMENTS AND MAIN RESULTS--Estimation of cumulative incidence of AIDS and number of excess deaths in seropositive patients not diagnosed with AIDS. Median follow up after seroconversion was 5 years 2 months. Eight five patients developed AIDS. Cumulative incidence of AIDS five years after seroconversion was 4% among patients aged less than 25 at first test positive for HIV, 6% among those aged 25-44, and 19% among those aged greater than or equal to 45. There was little evidence that type or severity of haemophilia or type of factor VIII or IX that had caused HIV infection affected the rate of progression to AIDS. Mortality was increased among those who had not been diagnosed as having AIDS, especially among those with "AIDS related complex." Thirteen deaths were observed among 36 patients diagnosed as having AIDS related complex against 0.65 expected, and 34 deaths in 1080 other patients against 22.77 expected; both calculations were based on mortality rates observed in haemophiliacs in the United Kingdom in the late 1970s. CONCLUSIONS--Rate of progression to AIDS depended strongly on age. There is a substantial burden of fatal disease among patients positive for HIV who have not been formally diagnosed as having AIDS.     

Prediction of prostate cancer using hair trace element concentration and support vector machine method

A change in the normal concentration of essential trace elements in the human body might lead to major health disturbances. In this study, hair samples were collected from 115 human subject, including 55 healthy people and 60 patients with prostate cancer. The concentrations of 20 trace elements (TEs) in these samples were measured by inductively coupled plasma-mass spectrometry. A support vector machine was used to investigate the relationship between TEs and prostate cancer. It is found that, among the 20 TEs, 10 (Mg P, K, Ca, Cr, Mn, Fe. Cu, Zn, and Se) are related to the risk of prostate cancer. These 10 TEs were used to build the prediction model for prostate cancer. The model obtained can satisfactorily distinguish the healthy samples from the cancer samples. Furthermore, the cross-validation by leaving-one method proved that the prediction ability of this model reaches as high as 95.8%. It is practical to predict the risk of prostate cancer using this model in the clinics     

Elemental anomalies in hair as indicators of endocrinologic pathologies and deficiencies in calcium and bone metabolism

Analytical results obtained by ICP-MS of hair samples from a group of women from Rio de Janeiro city show that abnormal Ca and P concentrations in this compartment can be an indication of pathologies affecting the metabolism of these elements. The study was conducted initially on 900 women (outpatients, >40 years). From this group, approx. 24% showed anomalously high or low Ca concentrations in hair, in some cases correlated to anomalies of other elements. In 144 cases (16%), very high concentrations of Ca (up to 8,285 mg/kg) were measured, frequently correlated with a high concentration of P (up to 4,720 mg/kg), exceeding by far the reference intervals for this age/sex group. Follow-up studies of a few individuals from this group gave first indications that their abnormal hair compositions were related to endocrinologic pathologies affecting calcium/bone metabolism. Very low hair Ca-concentrations were observed in older women (72 cases, age >60 years) and related to senile osteoporosis. Complementary investigations of patients with recognized endocrinologic pathologies (hyperthyroidism, hyper- and hypoparathyroidism) and osteomalacia gave statistical support for the hypothesis that hair concentrations of Ca, P and various other trace elements are influenced characteristically by these diseases. In patients with hyperparathyroidism and hyperthyroidism, both elements showed significant increase in hair, whereas patients with rickets/osteomalacia had only elevated Ca concentrations, together with suspiciously high toxic levels of Cd and various other elements (Fe, Mn, Mg, Sr, Ba). Patients with hypoparathyroidism had significantly decreased Ca and P concentrations in hair. Statistical evaluation of these data by multivariant analysis (MANOVA) using a contrast matrix and by discriminant analysis showed that elemental hair anomalies can be used to diagnose correctly the above-mentioned pathologies, demonstrating the usefulness of hair analysis as a complementary tool for the detection of disturbances in calcium/bone metabolism.     

锁定钢板固定术后内侧柱支撑能力与肱骨近端骨折患者预后的相关分析

目的:研究锁定钢板固定术后内侧柱的支撑能力与肱骨近端骨折患者预后的相关关系。方法:选取107例肱骨近端骨折患者作为研究对象,根据不同内侧柱支撑重建方式将所有患者分为四组,其中A组患者48例,均接受肱骨近端内侧骨皮质解剖复位以重建内侧柱支持;B组患者20例,均使用1枚支撑螺钉置入肱骨头内下方的软骨下骨,C组患者14例,均使用2枚或2枚以上支撑螺钉置入肱骨头内下方的软骨下骨;D组患者25例,均未进行肱骨近端内侧骨皮质解剖复位亦未使用锁定螺钉固定。比较各组患者术后Constant评分、VAS(visual analogue scale)评分、骨折愈合时间、肱骨头高度丟失值、肱骨头内翻角、并发症发生情况及二次手术率。结果:与无支撑重建组相比,骨皮质解剖复位组、单枚螺钉支撑重建组以及多枚螺钉支撑重建组的VAS评分、骨折愈合时间、肱骨头高度丟失值以及肱骨头内翻角均明显降低,而Constant评分明显升高,其中骨皮质解剖复位组的变化幅度最大多枚螺钉支撑重建组次之,单枚螺钉支撑重建组变化幅度最小,差异具有统计学意义(t=23.100,22.130,7.267,68.440,47.900,均P0.001);与无支撑重建组相比,骨皮质解剖复位组、单枚螺钉支撑重建组以及多枚螺钉支撑重建组的术后总并发症发生率和二次手术率均明显降低,其中骨皮质解剖复位组的降低幅度最大,单枚螺钉支撑重建组次之,多枚螺钉支撑重建组降低幅度最小差异具有统计学意义(X~2=12.938,11.904,P=0.005,0.008)。结论:锁骨钢板固定术后内侧柱的支撑能力与肱骨近端异型解剖钢板患者预后相关,内侧柱支撑能力的越高患者术后骨折愈合、肩关节恢复越佳,而并发症发生率以及二次手术率越低。     

Diabetic Amyotrophy: A Follow-up Study

A clinical follow-up study of 12 patients with diabetic amyotrophy is reported. Re-examination after an interval indicated that improvement had occurred in all but one instance, and had been maintained over an average follow-up period of four and a half years. Improvement in the neurological syndrome appeared to follow improvement in diabetic control or institution of treatment in those whose diabetes had not previously been diagnosed.Seven patients made a good functional recovery, three no longer having any muscular weakness. Five showed significant residual disability.     

Evaluation of Essential Trace and Toxic Elements in Scalp Hair Samples of Smokers and Alcohol User Hypertensive Patients

The incidence of hypertension has been associated to cigarette smoking and consumption of alcohol. In the present study, trace and toxic elements were determined in scalp hair of patients diagnosed with hypertension who are smokers and habitual alcohol drinkers living in Dublin, Ireland. These results were compared with age- and sex-matched healthy, nonsmokers, nondrinking controls. The concentrations of trace and toxic elements were measured by inductively coupled plasma atomic emission spectrophotometer after microwave-assisted acid digestion. The validity and accuracy of the methodology were checked using certified reference material (NCS ZC 81002b) and by the conventional wet acid digestion method on the same certified reference material and on real samples. The recovery of all the studied elements was found to be in the range of 97.5%–99.7% in certified reference material. The results of this study showed that the mean values of cadmium, copper, iron, nickel and lead were significantly higher in scalp hair samples of both smoker and nonsmoker hypertensive patients than referents (P < 0.001); whereas, the concentration of zinc was lower in the scalp hair samples of hypertensive patients of both genders. The deficiency of zinc and the high exposure of trace and toxic metals as a result of cigarette smoking and alcohol consumption may be synergistic with risk factors associated with hypertension.     

Different effects of phospholipase Dζ2 and non‐specific phospholipase C4 on lipid remodeling and root hair growth in Arabidopsis response to phosphate deficiency

Phosphate (Pi) deficiency in soils is a major limiting factor for plant growth. In response to Pi deprivation, one prominent metabolic adaptation in plants is the decrease in membrane phospholipids that consume approximately one‐third cellular Pi. The level of two phospholipid‐hydrolyzing enzymes, phospholipase Dζ2 (PLDζ2) and non‐specific phospholipase C4 (NPC4), is highly induced in Pi‐deprived Arabidopsis. To determine the role of PLDζ2 and NPC4 in plant growth under Pi limitation, Arabidopsis plants deficient in both PLDζ2 and NPC4 (npc4pldζ2) were generated and characterized. Lipid remodeling in leaves and roots was analyzed at three different durations of Pi deficiency. NPC4 affected lipid changes mainly in roots at an early stage of Pi deprivation, whereas PLDζ2 exhibited a more overt effect on lipid remodeling in leaves at a later stage of Pi deprivation. Pi deficiency‐induced galactolipid increase and phospholipid decrease were impeded in pldζ2 and npc4pldζ2 plants. In addition, seedlings of npc4pldζ2 had the same root hair density as pldζ2 but shorter root hair length than pldζ2 in response to Pi deficiency. The loss of NPC4 decreased root hair length but had no effect on root hair density. These data suggest that PLDζ2 and NPC4 mediate the Pi deprivation‐induced lipid remodeling in a tissue‐ and time‐specific manner. PLDζ2 and NPC4 have distinctively different roles in root hair growth and development in response to Pi deprivation; PLDζ2 negatively modulates root hair density and length, whereas NPC4 promotes root hair elongation.     

Plasma leukocyte cell-derived chemotaxin 2 is associated with the severity of systemic inflammation in patients with sepsis

The aim of the present study was to determine the correlations between leukocyte cell-derived chemotaxin 2 (LECT2) and inflammation-related variables in human inflammatory disease. Plasma samples from 23 septic patients who had been admitted to the intensive care unit (ICU) of our institution and 31 volunteers were used. Plasma LECT2 concentrations were examined retrospectively and compared with those of various inflammatory cytokines and routine laboratory data. The LECT2 concentrations of the septic patients at the time of ICU entry (5.3 ± 4.1 ng/mL) were significantly lower than those of the volunteers (19.7 ± 3.4 ng/mL) and these concentrations had significantly increased by the time of ICU discharge. Individual analyses showed that the LECT2 concentrations of all 19 patients had increased by the time of ICU discharge. A combination of LECT2 and C-reactive protein (CRP) concentrations was capable of discriminating the acute and recovery phases of sepsis to a degree similar to those of the combinations of CRP concentration and percentage of neutrophils, CRP concentration and percentage of immature white blood cells, or CRP and interleukin-6 concentrations. Thus, the LECT2 concentration correlates with the severity of systemic inflammation in patients with sepsis. LECT2 may be a reliable diagnostic indicator of human inflammatory diseases.     

Current Status of Cancer Care for Young Patients with Nasopharyngeal Carcinoma in Jakarta,Indonesia

Background

Nasopharyngeal carcinoma (NPC) is endemic in Indonesia and 20% of the patients are diagnosed before the age of 31. This study evaluates presentation and treatment outcome of young patients in Jakarta, in a tertiary referral centre.

Methods

Forty-nine patients under the age of 31, diagnosed with NPC between July 2004 and January 2007, were evaluated. Baseline data included histological type, stage of disease and presenting symptoms. We intended to follow all patients after diagnosis to reveal treatment outcome and overall survival (OS).

Results

All but two patients had advanced stage disease (94%), 7 (14%) had distant metastasis. The median interval between start of complaints and diagnosis was 9 months. Forty-two patients were planned for curative intent treatment. Eleven patients (26%) never started treatment, 2 patients did not complete treatment and 3 patients did not return after finishing treatment. Four patients died before radiation could start. Three patients died within 4 months after treatment. Nine patients (21%) had a complete response. Due to the high number of patients who were lost to follow-up (LFU), OS was analyzed as follows: a best-case (patients censored at last contact) and a worst-case scenario (assuming that patients who did not finish treatment or had disease at last contact would have died). The 2-year OS for patients without distant metastases was 39–71%.

Conclusion

Treatment outcome for young patients with NPC in this institute was poor. Improvement can be achieved when NPC is diagnosed at an earlier stage and when there is better treatment compliance.     

SEMA3B基因在鼻咽癌组织中的表达、杂合性丢失和甲基化分析

SEMA3B基因定位于鼻咽癌高频缺失区域3p21.3上,最近被证明具有抑瘤基因的功能.分析了鼻咽癌组织中SEMA3B基因的表达、杂合性丢失(LOH)和甲基化情况.首先应用逆转录-聚合酶链式反应(RT-PCR)方法检测了33例鼻咽癌组织和15例慢性鼻咽炎组织中SEMA3B基因的表达,结果显示75.8%(25/33)鼻咽癌组织中SEMA3B基因表达缺失或下调,显著低于慢性鼻咽炎组织中的表达(P=0.001).进一步选取3个微卫星位点D3S1568、D3S1621和D3S4597分析了20例鼻咽癌组织中SEMA3B基因LOH的情况,结果表明3个位点的丢失率分别为10%、20%和15%,总的丢失率为45%,统计分析发现LOH与基因表达之间存在明显相关(P=0.023).最后,采用甲基化特异性PCR方法分析了SEMA3B基因启动子区甲基化,结果发现在100%的鼻咽癌组织和73.3%的慢性鼻咽炎组织中检测到SEMA3B基因启动子区高甲基化.由此得出结论,SEMA3B基因在鼻咽癌组织中表达缺失或下调,LOH是引起其表达异常的原因之一.     

Detection of potentially myocardial infarction susceptible individuals in Indian population

Zinc (Zn) and copper (Cu) concentrations in hair and urine of patients diagnosed and hospitalized for myocardial infarction (MI patients) and in their descendants (MI descendants) were estimated and compared with their age-matched healthy volunteers with no family history of MI (control group and control descendants). The data revealed approximately twofold higher Zn and twofold lower Cu in the urine of the patients; Zn was lower and Cu was higher in the urine of MI descendants than those of the patients (p<0.001), but Zn in hair and urine was higher and Cu in hair was lower in MI descendants compared with their control counterparts (p<0.001). The data suggested that there was a consistent rise in Zn and fall in Cu reserves in the genetically predisposed subjects (MI descendants) prior to the manifestation of clinical symptoms. Based on this, the data were subjected to logistic regression and a model was obtained to predict the susceptibility to MI (LR-MI), having impact factors values as follows: constant (C), −3.342; impact factor of body mass index, −0.776; impact factor of hair Zn, −2.449; impact factor of urine Zn, +3.441; impact factor of hair Cu, −15.077; impact factor of urine Cu, −24.153. For the equation Y=e ^x (1+e ^x ), the value of x was obtained as follows: −3.342+[BMI (kg/m²) (−0.776)]+[Hair Zn (μmol/g) (−2.449)]+[Urine Zn (μmol/L) (3.441)]+[Hair Cu (μmol/g) (−15.077)]+[Urine Cu (μmol/L) (−24.153)]. On substituting the values of BMI, hair Zn, urine Zn, hair Cu, and urine Cu in x, the response variable Y as zero for healthy controls and 0.99 or 99.9% susceptibility in MI patients were obtained. In between these two extremes, the response variable ranged between 0 and 0.99 or 99.9% susceptibility to MI in their descendants. It is envisaged that the MI patients have an operational component of a genetic disorder of ionic imbalance at a young age that can be exploited in making a prediction of susceptibility to heart stroke in individuals much before its onset and diagnosis in asymptomatic patients, particularly in genetic and epidemiological studies of MI.     

Primary ciliary dyskinesia: evaluation using cilia beat frequency assessment via spectral analysis of digital microscopy images

Ciliary beat frequency (CBF) measurements provide valuable information for diagnosing of primary ciliary dyskinesia (PCD). We developed a system for measuring CBF, used it in association with electron microscopy to diagnose PCD, and then analyzed characteristics of PCD patients. The CBF measurement system was based on power spectra measured through digital imaging. Twenty-four patients suspected of having PCD (age 1-19 yr) were selected from a group of 75 children and adolescents with pneumopathies of unknown causes. Ten healthy, nonsmoking volunteers (age ≥ 17 yr) served as a control group. Nasal brush samples were collected, and CBF and electron microscopy were performed. PCD was diagnosed in 12 patients: 5 had radial spoke defects, 3 showed absent central microtubule pairs with transposition, 2 had outer dynein arm defects, 1 had a shortened outer dynein arm, and 1 had a normal ultrastructure. Previous studies have reported that the most common cilia defects are in the dynein arm. As expected, the mean CBF was higher in the control group (P < 0.001) and patients with normal ultrastructure (P < 0.002), than in those diagnosed with cilia ultrastructural defects (i.e., PCD patients). An obstructive ventilatory pattern was observed in 70% of the PCD patients who underwent pulmonary function tests. All PCD patients presented bronchial wall thickening on chest computed tomography scans. The protocol and diagnostic techniques employed allowed us to diagnose PCD in 16% of patients in this study.     

Prevalence and Global Initiative for Chronic Obstructive Lung Disease Group Distribution of Chronic Obstructive Pulmonary Disease Detected by Preoperative Pulmonary Function Test

Background

Despite being a major public health problem, chronic obstructive pulmonary disease (COPD) remains underdiagnosed, and only 2.4% COPD patients are aware of their disease in Korea. The objective of this study was to estimate the prevalence of COPD detected by spirometry performed as a preoperative screening test and to determine the Global Initiative for Chronic Obstructive Lung Disease (GOLD) group distribution and self-awareness of COPD.

Methods

We reviewed the medical records of adults (age, ≥40 years) who had undergone spirometry during preoperative screening between April and August 2013 at a tertiary hospital in Korea. COPD was defined as a postbronchodilator forced expiratory volume in 1 s/forced vital capacity ratio of <0.7. We analyzed self-administered COPD questionnaires for the assessment of the frequency of acute exacerbation over the previous year and dyspnea severity using the modified Medical Research Council dyspnea scale and COPD assessment test.

Results

Among 3029 patients aged >40 years who had undergone spirometry as a preoperative screening test, 474 (15.6%; 404 men; median age, 70 years; range, 44–93 years) were diagnosed with COPD. Only 26 (5.5%) patients reported previous diagnosis of COPD (2.1%), emphysema (0.8%), or chronic bronchitis (2.5%). The GOLD group distribution was as follows: 63.3% in group A, 31.2% in group B, 1.7% in group C, and 3.8% in group D.

Conclusions

The prevalence of COPD diagnosed by preoperative spirometry was 15.6%, and only 5.5% patients were aware of their disease. Approximately one-third of the COPD patients belonged to GOLD groups B, C, and D, which require regular treatment.