Hypermethylation of Anti-oncogenic MicroRNA 7 is Increased in Emphysema Patients

IntroductionMicroRNA-7 (miR-7) has a suppressive role in lung cancer and alterations in its DNA methylation may contribute to tumorigenesis. As COPD patients with emphysema have a higher risk of lung cancer than other COPD phenotypes, we compared the miR-7 methylation status among smoker subjects and patients with various COPD phenotypes to identify its main determinants.Methods30 smoker subjects without airflow limitation and 136 COPD patients without evidence of cancer were recruited in a prospective study. Clinical and functional characteristics were assessed and patients were classified into: frequent exacerbator, emphysema, chronic bronchitis and asthma COPD overlap (ACO). DNA collected from buccal epithelial samples was isolated and bisulfite modified. miR-7 methylation status was evaluated by quantitative methylation-specific polymerase chain reaction (qMSP).ResultsmiR-7 Methylated levels were higher in COPD patients than in smokers without airflow limitation (23.7 ± 12.4 vs. 18.5 ± 8.8%, p = 0.018). Among COPD patients, those with emphysema had higher values of methylated miR-7 (27.1 ± 10.2%) than those with exacerbator (19.4 ± 9.9%, p = 0.004), chronic bronchitis (17.3 ± 9.0%, p = 0.002) or ACO phenotypes (16.0 ± 7.2%, p = 0.010). After adjusting for clinical parameters, differences between emphysematous patients and those with other phenotypes were retained. In COPD patients, advanced age, mild-moderate airflow limitation, reduced diffusing capacity and increased functional residual capacity were identified as independent predictors of methylated miR-7 levels.ConclusionThe increase of miR-7 methylation levels experienced by COPD patients occurs mainly at the expense of the emphysema phenotype, which might contribute to explain the higher incidence of lung cancer in these patients.     

Anesthesia for bariatric surgery: 8-Year retrospective study: Are our patients now easier to manage?

ObjectivesTo review the perioperative management of patients who had undergone bariatric surgery in our institution during an 8-year period, with the aim of identifying variables that correlated with improved clinical outcomes and changes in perioperative practice.MethodsThis was a retrospective observational study of 437 patients who had undergone bariatric surgery from January 2005 to June 2013. Of these patients, 163 had undergone open or laparoscopic biliopancreatic diversion (Group 1), and 274 had been managed according to a Tailored Laparoscopic Approach Program (TLAP) (Group 2). We analyzed major cardiocirculatory, pulmonary, and surgery-related complications, mortality rate, intensive care unit (ICU) admissions, post-anesthetic care unit (PACU) length of stay, and perioperative management standards, throughout the study period.ResultsChanges were observed in anesthetic patterns and perioperative care standards during the study period: 25% of patients had combined epidural anesthesia in 2005, compared with none at present; ICU admissions decreased from 28.6% in 2005 to 3.1% at present; and time in PACU declined from a median of 23 h in 2005 to 5.12 h at present. Duration of postoperative opioid therapy was also significantly reduced (from 48 h to 6 h). Group 2 had a significantly lower mortality rate than Group 1 (0.37% versus 4.3%, respectively, P = 0.004).ConclusionsIn our institution, adoption of a TLAP for bariatric surgery has led to changes in perioperative care standards that have been followed by clear improvements according to morbidity, mortality and management indicators.     

Classification of Chronic Obstructive Pulmonary Disease Severity According to the New Global Initiative for Chronic Obstructive Lung Disease 2011 Guidelines: COPD Assessment Test Versus Modified Medical Research Council Scale

IntroductionThe GOLD 2011 revision proposes to stratify patients with chronic obstructive pulmonary disease (COPD) by measuring the impact of the disease using the modified Medical Research Council (mMRC) scale or COPD assessment test (CAT). Our aim was to determine whether both methods are equivalent.Patients and methodsObservational study on a cohort of 283 patients diagnosed with COPD. We analyzed the demographic and lung function results. Patients were assessed by CAT and mMRC on the same day by the same interviewer, and divided into GOLD 2011 categories according to the result of the evaluation. The degree of concordance and Spearman correlation were determined. We used ANOVA on the clinical and functional variables of the four GOLD 2011 categories.ResultsOn assessing the classification of patients according to the method used, an overall correlation of ρ = 0.613 and a degree of concordance of κ = 0.63 (moderate) were obtained. κ = 0.44 was obtained for the 152 patients in categories A and B (moderate-low), and at 0.38 for the 131 patients in categories C and D (low). Differences were observed between the categories in terms of functional parameters.ConclusionsThe classification of patients with COPD using the assessment proposed by GOLD 2011 varies according to the method used (CAT or mMRC); more than 25% of patients were reclassified into different categories, implying differences in the recommended therapeutic strategy. Longitudinal studies are needed to appraise which method does better classification of the patients, according to its prognostic ability.     

Presence or Absence of Skeletal Muscle Dysfunction in Chronic Obstructive Pulmonary Disease is Associated With Distinct Phenotypes

IntroductionReduced skeletal muscle function and cognitive performance are common extrapulmonary features in Chronic Obstructive Pulmonary Disease (COPD) but their connection remains unclear. Whether presence or absence of skeletal muscle dysfunction in COPD patients is linked to a specific phenotype consisting of reduced cognitive performance, comorbidities and nutritional and metabolic disturbances needs further investigation.MethodsThirty-seven patients with COPD (grade II–IV) were divided into two phenotypic cohorts based on the presence (COPD dysfunctional, n = 25) or absence (COPD functional, n = 12) of muscle dysfunction. These cohorts were compared to 28 healthy, age matched controls. Muscle strength (dynamometry), cognitive performance (Trail Making Test and STROOP Test), body composition (Dual-energy X-Ray Absorptiometry), habitual physical activity, comorbidities and mood status (questionnaires) were measured. Pulse administration of stable amino acid tracers was performed to measure whole body production rates.ResultsPresence of muscle dysfunction in COPD was independent of muscle mass or severity of airflow obstruction but associated with impaired STROOP Test performance (p = 0.04), reduced resting O₂ saturation (p = 0.003) and physical inactivity (p = 0.01), and specific amino acid metabolic disturbances (enhanced leucine (p = 0.02) and arginine (p = 0.06) production). In contrast, COPD patients with normal muscle function presented with anxiety, increased fat mass, plasma glucose concentration, and metabolic syndrome related comorbidities (hypertension and dyslipidemia).ConclusionCOPD patients with muscle dysfunction show characteristics of a cognitive – metabolic impairment phenotype, influenced by the presence of hypoxia, whereas those with normal muscle function present a phenotype of metabolic syndrome and mood disturbances.     

Home Intervention and Predictor Variables for Rehospitalization in Chronic Obstructive Pulmonary Disease Exacerbations

BackgroundChronic obstructive pulmonary disease (COPD) exacerbation increases mortality and resources used associated with hospitalization. We studied whether early home monitoring reduces the rate of readmission and if there are any predictor variables.Patients and methodsWe performed a prospective, controlled, parallel-group study in patients who were hospitalized for COPD. Patients whose residence was within less than 15 km from the hospital were assigned to an interventional group (home visits by nurses about 48–72 h after discharge), the remaining patients were assigned to a conventional care group. The rate of rehospitalization within the first month was compared between the 2 groups, as well as those variables that showed a predictive capability.ResultsSeventy-one patients were included: 35 in the conventional care group and 36 in the interventional group. In the latter, the treatment was modified in 13 patients (36%). The hospital readmission rate was 17%, which was similar in both groups (P=.50). For every 5-year increase in age, the risk for readmission was 2.54 (95%CI 1.06–5.07) and for each increase of 10 mmHg in PaCO₂, the risk of readmission was 8.34 (95%CI 2.43–18.55).ConclusionsEarly home monitoring did not decrease the readmission rate during the first month. Older age and high PaCO₂ are factors that identify the group with a high risk for rehospitalization.     

COPD Exacerbation: Mortality Prognosis Factors in a Respiratory Care Unit

ObjectiveThe aim of our study was to determine the predictive factors for mortality during hospitalization for chronic obstructive pulmonary disease (COPD) exacerbation in a Spanish intermediate respiratory care unit (IRCU).Patients and methodsOurs is a 2-year prospective observational study including all patients with acute COPD exacerbation and hypercapnic respiratory failure admitted to an IRCU. We analyzed different sociodemographic, functional and clinical variables as well as physical activity.ResultsWe collected data from 102 consecutive cases admitted to IRCU (90.1% men). Mean age was 69.4 ± 10.6. Mean APACHE II was 19.6 ± 5.0 and 9.5% presented failure of another non-respiratory organ. Noninvasive mechanical ventilation was applied in 75.3% of the episodes, and this treatment failed in 11.6%. Mean IRCU stay was 3.5 ± 2.1 days, and mean hospitalization was 8.0 ± 5.3 days. Mortality rate during hospitalization was 6.9%, and 12.7% 90 days after discharge. In order to predict hospital mortality, multivariate statistics identified a predictive model with an AUC of 0.867, based on 3 variables: the number of hospitalizations for COPD exacerbation in the previous year (p = 0.048), the respiratory rate (RR) 2 hours after admittance to the IRCU (p = 0.0484) and the severity of the disease established with ADO score (p = 0.0241).ConclusionsThe number of hospitalizations for COPD exacerbation in the previous year, the respiratory rate two hours after being admitted to the IRCU and the severity of the disease established with the multidimensional ADO score allowed us to identify which patients were susceptible to death during hospitalization in IRCU for decompensated COPD.     

Factors Associated With Hospital Admission for Exacerbation of Chronic Obstructive Pulmonary Disease

IntroductionExacerbations of Chronic Obstructive Pulmonary Disease (COPD) that require hospital admission have a major impact on the progression of disease and generate high health costs.MethodA multi-center, cross-sectional, observational study was conducted with the aim to identify factors associated with hospital admission in patients with COPD. We obtained data of socio-demographic and anthropometric characteristics, quality of life, respiratory symptoms, anxiety and depression, physical activity and pulmonary function tests. We analyzed their association with hospital admission with a multivariate analysis using a logistic regression model.ResultsWe analyzed 127 patients, 50 (39%) of whom had been hospitalized. 93.7% were men, mean age 67 years (SD=9) and a FEV1 of 41.9% (SD=15.3). In the first model obtained, the baseline SpO₂, the BODE index and emergency room (ER) visits were associated with hospital admission and the area under the ROC curve (AUC) was 0.809. In a second model we included only variables readily available (without the 6 min walking test) and only the SpO₂ and previous visits to the ER were significant with an AUC ROC 0.783.ConclusionsHospital admission for exacerbation of COPD is associated with poor SpO₂, higher BODE index score and a greater number of visits to the ER. In case you do not have the 6 min walking test, the other two variables offer a similar discriminative ability.     

Patterns of Physical Activity Progression in Patients With COPD

IntroductionAlthough mean physical activity in COPD patients declines by 400?500 steps/day annually, it is unknown whether the natural progression is the same for all patients. We aimed to identify distinct physical activity progression patterns using a hypothesis-free approach and to assess their determinants.MethodsWe pooled data from two cohorts (usual care arm of Urban Training [NCT01897298] and PROactive initial validation [NCT01388218] studies) measuring physical activity at baseline and 12 months (Dynaport MoveMonitor). We identified clusters (patterns) of physical activity progression (based on levels and changes of steps/day) using k-means, and compared baseline sociodemographic, interpersonal, environmental, clinical and psychological characteristics across patterns.ResultsIn 291 COPD patients (mean ± SD 68 ± 8 years, 81% male, FEV₁ 59 ± 19%_pred) we identified three distinct physical activity progression patterns: Inactive (n = 173 [59%], baseline: 4621 ± 1757 steps/day, 12-month change (?): ∧487 ± 1201 steps/day), Active Improvers (n = 49 [17%], baseline: 7727 ± 3275 steps/day, ?: + 3378 ± 2203 steps/day) and Active Decliners (n = 69 [24%], baseline: 11 267 ± 3009 steps/day, ?: ∧2217 ± 2085 steps/day). After adjustment in a mixed multinomial logistic regression model using Active Decliners as reference pattern, a lower 6-min walking distance (RRR [95% CI] 0.94 [0.90?0.98] per 10 m, P = .001) and a higher mMRC dyspnea score (1.71 [1.12?2.60] per 1 point, P = .012) were independently related with being Inactive. No baseline variable was independently associated with being an Active Improver.ConclusionsThe natural progression in physical activity over time in COPD patients is heterogeneous. While Inactive patients relate to worse scores for clinical COPD characteristics, Active Improvers and Decliners cannot be predicted at baseline.     

Similar outcomes after newly implemented rats approach compared to standard vats for anatomical lung resection. A propensity-score matched analysis

IntroductionOutcomes after the introduction of surgical innovations can be impaired by learning periods. The aim of this study is to compare the short-term outcomes of a recently implemented RATS approach to a standard VATS program for anatomical lung resections.MethodsRetrospective review of consecutive patients undergoing pulmonary anatomical resection through a minimally invasive approach since RATS approach was applied in our department (June 01, 2018, to November 30, 2019). Propensity score matching was performed according to patients’ age, gender, ppoFEV1, cardiac comorbidity, type of malignancy, and type of resection. Outcome evaluation includes: overall morbidity, significant complications (cardiac arrhythmia, pneumonia, prolonged air leak, and reoperation), 30-day mortality, and length of hospital stay. Data were compared by two-sided chi-square or Fisher's exact test for categorical and Mann–Whitney U test for continuous variables.ResultsA total of 273 patients (206 VATS, 67 RATS) were included in the study. After propensity score matching, data of 132 patients were analyzed. The thirty-days mortality was nil. Overall morbidity (RATS: 22.4%, VATS: 29.2%; p = 0.369), major complications (RATS: 9% vs VATS: 9.2%; p = 0.956) and the rates of specific major complications (cardiac arrhythmia RATS: 4.5%, VATS: 4.6%, p = 1; pneumonia RATS:0%, VATS:4.6%, p = 0.117; prolonged air leak RATS: 7.5%; VATS: 4.6%, p = 0.718) and reoperation (RATS: 3%, VATS: 1.5%, p = 1) were comparable between both groups. The median length of stay was 3 days in both groups (p = 0.101).ConclusionsA RATS program for anatomical lung resection can be implemented safely by experienced VATS surgeons without increasing morbidity rates.     

Inpatient burden and resource utilization of polymyositis and dermatomyositis: A 10-year Study of National Inpatient Sample

ObjectivesTo characterize inpatient prevalence and resource utilization of patients with polymyositis (PM) and dermatomyositis (DM).MethodsPatients with PM/DM were identified from the Nationwide Inpatient Sample (NIS) database from the year 2005 to 2014 using ICD-9 diagnostic codes. The primary outcome of this study was inpatient prevalence of PM/DM in the United States across the span of 10 years. Secondary outcomes included reason for hospitalization, inpatient mortality, morbidity, hospital length of stay (LOS), utilization of specialized procedures/tests and expenditures. A cohort of patients without PM/DM was also identified from the same database to serve as comparators. Multivariate regression analysis was used to adjust for age, sex, ethnicity, comorbidities and hospital characteristics.ResultsA total of 160,528 admissions of patients with a diagnosis of PM/DM occurred in the study period, corresponding to the inpatient prevalence of 41.9 cases per 100,000 discharges. During admission, patients with PM/DM died more frequently than patients without PM/DM with an adjusted odds ratio (aOR) of 2.22 (P < 0.01). A significantly higher inpatient morbidity among patients with PM/DM was also observed as indicated by a significantly higher risk of shock (aOR 2.33; P < 0.01), acute kidney injury (aOR 1.12; P < 0.01), multi-organ failure (aOR 1.83; P < 0.01) and need for admission to intensive care unit (aOR 1.94; P < 0.01). Patients in the PM/DM had an average of 1.7 more days of LOS (P < 0.01). The mean hospital costs and total hospitalization charges for patients with PM/DM were significantly higher than patients without PM/DM with additional adjusted mean of $4,217 and $13,531, respectively, in the multivariate model. Patients with PM/DM underwent computerized tomography scan (aOR 1.90; P < 0.01), magnetic resonance imaging (aOR 1.68; P < 0.01) and angiography (aOR 1.15; P < 0.01) more often than comparators.ConclusionsInpatient prevalence of PM/DM was higher than what would be expected from the overall incidence. Hospitalizations of patients with PM/DM were associated with significantly higher rate of mortality, morbidity and resource utilization.     

Influence of the CYP2J2 Gene Polymorphisms on Chronic Obstructive Pulmonary Disease Risk in the Chinese Han Population

IntroductionCytochrome P450 (CYP) 2J2 is a major enzyme that controls epoxyeicosatrienoic acids biosynthesis, which may play a role in chronic obstructive pulmonary disease (COPD) development. In this study, we aimed to assess the influence of CYP2J2 polymorphisms with COPD susceptibility.Material and methodsA case–control study enrolled 313 COPD cases and 508 controls was to investigate the association between CYP2J2 polymorphisms and COPD risk. Agena MassARRAY platform was used to genotype CYP2J2 polymorphisms. Odds ratios (OR) and 95% confidence intervals (CI) were calculated to evaluate the association between CYP2J2 polymorphisms and COPD risk.ResultsWe observed rs11207535 (homozygote: OR = 0.08, 95%CI = 0.01–0.96, p = 0.047; recessive: OR = 0.08, 95%CI = 0.01–0.94, p = 0.044), rs10889159 (homozygote: OR = 0.08, 95%CI = 0.01–0.92, p = 0.043; recessive: OR = 0.08, 95%CI = 0.01–0.90, p = 0.040) and rs1155002 (heterozygote: OR = 1.63, 95%CI = 1.13–2.36, p = 0.009; dominant: OR = 1.64, 95%CI = 1.15–2.35, p = 0.006; additive: OR = 1.45, 95%CI = 1.09–1.92, p = 0.011) were significantly associated with COPD risk. Allelic tests showed T allele of rs2280274 was related to a decreased risk of COPD and T allele of rs1155002 was associated with an increased COPD risk. Stratified analyses indicated the effects of CYP2J2 polymorphisms and COPD risk were dependent on gender and smoking status (p < 0.05). Additionally, two haplotypes (A_rs11207535C_rs10889159T_rs1155002 and A_rs11207535C_rs10889159C_rs1155002) significantly decreased COPD risk.ConclusionIt suggested CYP2J2 polymorphisms were associated with COPD susceptibility in the Chinese Han population.     

Management of polytrauma patients in the UK: Is there a ‘weekend effect’?

Background/purposeIt has been suggested that hospital admission during weekends poses a risk for adverse outcomes and increased patient mortality, the so-called ‘weekend effect’. We undertook an evaluation of the impact of weekend admissions to the management of polytraumatised patients, in a Level I Major Trauma Centre (MTC) in the UK.Materials and methodsA retrospective review of prospectively documented data of polytrauma patients (injury severity score (ISS) > 15), admitted between April 2013 and August 2015 was performed. Exclusion criteria included patients initially assessed in other institutions. All patients were initially managed at the emergency department (ED) according to ATLS^® principles and underwent a trauma computed tomography (CT) scan, unless requiring immediate surgical intervention.ResultsDuring the study period 1735 patients (pts) were admitted under the care of the MTC. Four hundred and five pts were excluded as they were transferred from other institutions and 300 pts were excluded as their ISS was less than 16. Overall 1030 patients met the inclusion criteria, out of which 731 were males. Comparing the two groups (Group A: weekday admissions (670), Group B: weekend admissions (360)), there was no difference in pts gender, mechanism of injury, GCS at presentation, need for intubation and time to CT. Patients admitted over the weekend were younger (p < 0.01) and presented with haemodynamic instability more frequently (p = 0.02). Time to operating room was also lower during the weekend, but this did not reach statistical significance (p = 0.08). Mortality was lower in Group B: 39/360 pts (10.8%) compared to Group A: 100/670 pts (14.9%) (p = 0.07). The relative risk (RR) of weekend mortality was calculated as 0.726 (95% CI: 0.513–1.027).Discussion/conclusionWeekend polytrauma patients appear to be younger, more severely injured and present with a higher incidence of haemodynamic instability (shock). Overall, we failed to identify a “weekend effect” in relation to mortality, time to CT and time to operating room. On the contrary, a lower risk of mortality was noted for patents admitted during the weekend.     

Hospital Mortality and Effect of Adjusting PaO2/FiO2 According to Altitude Above the Sea Level in Acclimatized Patients Undergoing Invasive Mechanical Ventilation. A Multicenter Study

Objective(i) Analyze the effect of altitude above the sea level on the mortality rate in patients undergoing invasive mechanical ventilation. (ii) Validate the traditional equation for adjusting PaO₂/FiO₂ according to the altitude.DesignA prospective, observational, multicenter and international study conducted during August 2016.PatientsInclusion criteria: (i) age between 18 and 90 years old, (ii) admitted to intensive care unit (ICU) situated at the same altitude above the sea level (AASL) in which the patients has stayed, at least, during the previous 40 days and (iii) received invasive MV for at least 12 h.Material and methodsAll variables were registered the day of intubation (day 0). Patients were followed until death, ICU discharge or day 28. PaO₂/FiO₂ ratio was adjusted by the AASL according to: PaO₂/FiO₂ * (barometric pressure/760). Categorical variables were compared with χ² and Cochran–Mantel–Haenszel test. Continuous variables with Mann–Whitney. Correlation between continuous variables was analyzed graphically and analytically. Logistic regression model was constructed to identify factors associated to mortality. Kapplan–Meier method was used to estimate the probability of survival according to the altitude. A 2-side p value <0.05 was consider significant.Results249 patients (<1500 m n = 55; 1500 to <2500 m n = 20; 2500 to <3500 m n = 155 and ≥3500 m n = 19) were included. Adjusted and non-adjusted PaO₂/FiO₂ were correlated with several respiratory and non respiratory variables. None discordances between non adjusted and adjusted PaO₂/FiO₂ were identified. However, several correlations were appreciated only in patients situated <1500 m or in >1500 m. Seventy-nine patients died during the ICU stayed (32%). The mortality curve was not affected by the altitude above the sea level. Variables independently associated to mortality are: PEEP, age, systolic arterial blood pressure, and platelet count. AUROC: 0.72.ConclusionIn acclimatized patients undergoing invasive mechanical ventilation, the traditional equation for adjusting PaO₂/FiO₂ according the elevation above the sea level seems to be inaccurate and the altitude above the sea level does not affect the mortality risk.     

Single-visit surgery: An evaluation from an institutional perspective

Background/PurposeElective ambulatory surgical care traditionally involves three independent visits. Single-Visit Surgery (SVS) is an alternative surgical model that consolidates care into one visit. Evaluation of the effect of this novel program on hospital operations is limited. The objective of this study was to analyze SVS from an institutional perspective.MethodsWe retrospectively reviewed patients scheduled for SVS at a freestanding children’s hospital between January 2016 and August 2017. Data collected included clinic “no show” rates, operating room (OR) utilization, reimbursement rates, and postoperative visits.ResultsThere were 89 patients scheduled for SVS, of which 63% (n = 56) were male, and the median age was 6 years [IQR, 4–9]. The SVS clinic “no show” rate was 2% (n = 2) compared to the pediatric surgery clinic “no show” rate of 11% (p = 0.01). The SVS OR block utilization rate was 90%. Payment was received from third-party payors for 92% of consultations and 100% of operative procedures without securing prior authorization. Postoperatively 25% (n = 17) of patients presented to clinic for follow-up, and one child presented to the emergency department for vomiting. There were no hospital admissions.ConclusionSingle-Visit Surgery is an alternative model of ambulatory surgical care that improves institutional efficiency while also enhancing the patient experience.Type of studyRetrospective cohort reviewLevel of evidenceIII     

Variation in patterns of hospitalization and associated resource use among children with spinal cord injury in the U.S.

IntroductionTrauma is a leading cause of mortality and morbidity among children in the U.S. There is paucity of data on the triage of children with spinal cord injury (SCI) to definitive trauma care, and it is unknown if clinical outcomes and resource utilization for children hospitalized with SCI vary according to the settings where trauma care is provided. The study was conducted to describe recent patterns of emergency department (ED) evaluation for paediatric SCI in the U.S., and to characterize outcomes and resource use for children hospitalized at non-trauma centres versus trauma centres.Materials and methodsSecondary analysis of a national database on injured children 0–20 years evaluated at U.S. EDs and either hospitalized or released, in 2009–2012. In-hospital mortality, duration of stay, and overall charges, were compared according to trauma centre status of the treating hospital.ResultsOf an estimated 67 million annual paediatric visits to the ED for trauma evaluation nationally in 2009–2012, 2317 had SCI. Majority (87%) of children evaluated for SCI were under 6 years of age, and boys comprised 73% of the visits. Injuries were caused mainly by motor vehicle accidents, falls, non-transport-related accidents, and firearms. The South census region had the most ED visits and hospitalizations. Majority (92%) of the most severely injured was evaluated at trauma centres, and more visits to trauma centres (81% vs. 18%, p = 0.022) resulted in hospitalization. Among an estimated 1570 hospitalizations of children with SCI from the ED nationally, children at trauma centres were more likely to have major injuries (67% vs. 44%, p = 0.001), similar mortality, longer average hospital stay, and higher charges, compared with children hospitalized at non-trauma centres.ConclusionSignificant demographic and geographical variation exists in national patterns of hospital care for paediatric SCI. Higher severity of patient injury was associated with concomitantly higher hospital resource use at trauma centres.     

Psoas Muscle Density Evaluated by Chest CT and Long-Term Mortality in COPD Patients

RationalePoor muscle quality in COPD patients relates to exercise intolerance and mortality. Muscle quality can be estimated on computed tomography (CT) by estimating psoas density (PsD). We tested the hypothesis that PsD is lower in COPD patients than in controls and relates to all-cause mortality.MethodsAt baseline, PsD was measured using axial low-dose chest CT images in 220 COPD patients, 80% men, who were 65 ± 8 years old with mild to severe airflow limitation and in a control group of 58 subjects matched by age, sex, body mass index (BMI) and body surface area (BSA). COPD patients were prospectively followed for 76.5 (48–119) months. Anthropometrics, smoking history, BMI, dyspnoea, lung function, exercise capacity, BODE index and exacerbations history were recorded. Cox proportional risk analysis determined the factors more strongly associated with long-term mortality.ResultsPsD was lower in COPD patients than in controls (40.5 vs 42.5, p = 0.045). During the follow-up, 54 (24.5%) deaths occurred in the COPD group. PsD as well as age, sex, pack-year history, FEV₁%, 6MWD, mMRC, BODE index, were independently associated with mortality. Multivariate analysis showed that age (HR 1.06; 95% CI 1.02–1.12, p = 0.006) and CT-assessed PsD (HR 0.97; 95%CI 0.94–0.99, p = 0.023) were the variables independently associated with all-cause mortality.ConclusionsIn COPD patients with mild to severe airflow limitation, chest CT-assessed psoas muscle density was lower than in matched controls and independently associated with long-term mortality. Muscle quality using the easy to evaluate psoas muscle density from chest CT may provide clinicians with important prognostic information in COPD.     

Serum Levels of Alpha1-antitrypsin and Their Relationship With COPD in the General Spanish Population

BackgroundLow plasma level of alpha1-antitrypsin (AAT) is an established risk factor for early-onset chronic obstructive lung disease (COPD). However, less attention is given to the levels of AAT in the general population.MethodsThis is a part of a multicentre, population-based study conducted at 11 sites throughout Spain. Plasma levels of AAT were available for 837 persons with a mean (SD) age of 58.05 (11.3) years: 328-smokers, 272-ex-smokers and 237 non-smokers. Out of 837, 303 (36.2%) had a diagnosis of COPD, 222 (26.5%) had respiratory symptoms but no COPD, and 312 (37.3%) were healthy controls.ResultsIn the whole cohort, the mean level of plasma AAT was 1.51 (0.47) g/L. Levels were higher in COPD patients [1.55 (0.45) g/L] and individuals with respiratory symptoms [1.57 (0.47) g/L] than in controls [1.43 (0.47) g/L], p < 0.001, a finding which persisted after correction for age and CRP. Plasma AAT levels were negatively associated with FEV1/FVC ratio, after adjustment for age, sex, smoking status, CRP, TNFα, fibrinogen and albumin. The risk for COPD was significantly associated with higher AAT levels in univariate and multivariate models, with odds ratios of 1.8 and 1.5, respectively. In the univariate and multivariate models smoking status, gender, and CRP levels were also associated with COPD probability, demonstrating that they act independently.ConclusionIncreased circulating levels of AAT, similarly to CRP and other markers of systemic inflammation, is an important feature of COPD. Our results highlight a complex interrelationship between levels of AAT and health of respiratory system.     

Assessment of Induced Sputum Cellularity in COPD Patients Belonging to Two Different Classes of Air Pollution Exposure

IntroductionSeveral studies have previously demonstrated that long-term exposure to outdoor pollution present airway inflammation in term of an increase of sputum neutrophils.Aim and methodsThe aim of our study was to evaluate the level of airway inflammation by induced sputum in a group of 15 non-professionally exposed population of well-characterized COPD patients, residing in urban areas with high rate of outdoor pollution, compared to a control group of 13 individuals with COPD, living in rural areas with a low pollution rate. All participants underwent spirometry and sputum induction.ResultsA statistically significant increase in the percentage of neutrophil cell count was found among the residents in urban areas compared to those living in rural regions (89.1 vs 79.0, p < 0.05)ConclusionsIn conclusion, we showed that non-professionally exposed patients with COPD residing in highly-polluted urban areas had greater airway inflammation in terms of sputum neutrophils compared to a population with very similar characteristics, living in rural areas with lower outdoor pollution. The results of this pilot study may be relevant for the long term effect of environmental outdoor pollution in vulnerable patients like those with COPD.     

Process of Care Partly Explains the Variation in Mortality Between Hospitals After Peripheral Vascular Surgery

ObjectivesThe aim of this study is to investigate whether variation in mortality at hospital level reflects differences in quality of care of peripheral vascular surgery patients.DesignObservational study.MaterialsIn 11 hospitals in the Netherlands, 711 consecutive vascular surgery patients were enrolled.MethodsMultilevel logistic regression models were used to relate patient characteristics, structure and process of care to mortality at 1 year. The models were constructed by consecutively adding age, sex and Lee index, then remaining risk factors, followed by structural measures for quality of care and finally, selected process of care parameters.ResultsTotal 1-year mortality was 11%, ranging from 6% to 26% in different hospitals. Large differences in patient characteristics and quality indicators were observed between hospitals (e.g., age > 70 years: 28–58%; beta-blocker therapy: 39–87%). Adjusted analyses showed that a large part of variation in mortality was explained by age, sex and the Lee index (Akaike’s information criterion (AIC) = 59, p < 0.001). Another substantial part of the variation was explained by process of care (AIC = 5, p = 0.001).ConclusionsDifferences between hospitals exist in patient characteristics, structure of care, process of care and mortality. Even after adjusting for the patient population at risk, a substantial part of the variation in mortality can be explained by differences in process measures of quality of care.