Dependence in performing activities as a predictor of mortality following hospitalization for chronic obstructive pulmonary disease exacerbation

IntroductionScant evidence is available on whether dependency for basic (BADL) or instrumental (IADL) activities of daily living can be predictors of mortality after severe COPD exacerbation (COPDE). In addition, it is as yet unclear whether the inclusion of this parameter in a multidimensional score can improve the prediction of mortality.MethodologyProspective cohort study, with follow-up of patients discharged after COPDE and multivariate analysis of clinical-demographic and dependency variables (Barthel and Lawton and Brody indices) as predictors of mortality. Three scores were generated (including or not including dependency for BADL and IADL) that were compared with each other and with other commonly used multidimensional indices (BODEx, ADO, DOSE, CODEx).ResultsIn total, 247 patients were included, 112 (45%, 3); and 195 (72.4%) had some dependency for BADL and IADL. Survival was 631.7 (258.8) days, 95% confidence interval (95% CI), 60–912 days. Fifty-four (21.9%, 95% CI 17–27) patients died. Age > 60 years, FEV1 < 50% and Charlson score ≥ 3 were independent predictors in the 3 models generated. Dependency for BADL and IADL were predictors in each of the models in which they were included. The score that included the dependency for BADL presented the best predictive capacity (area under the curve 0.818, 95% CI 0.757–0.879). Stratification into tertiles differentiated groups with a higher risk of death from the beginning of the follow-up (P < .01).ConclusionsDependence for activities of daily living, especially the most elementary ones, is an independent predictor of mortality after a severe COPDE that is comparable to clinical variables. Its inclusion in multidimensional scores clearly improves predictive capacity.     

Frequency of Osteoporosis and Vertebral Fractures in Chronic Obstructive Pulmonary Disease (COPD) Patients

BackgroundOsteoporosis is a systemic skeletal disease characterized by low bone mass and/or microarchitectural deterioration of bone. Osteoporosis is a risk factor for fractures specially in patients with advanced COPD. The aim of this cross-sectional study was to determine the frequency of osteoporosis and vertebral fracture in COPD patients.MethodsWe evaluated 91 COPD patients and compared to 82 healthy subjects (control group) matched for gender and age. We measured the bone mineral density by means of dual energy X-ray absorptiometry (DXA), evaluating the lumbar vertebra (L1–L4), proximal femur and total femur and evaluated vertebral fractures in thoracic and lumbar spine using X-ray. We questioned patients whether they had had any fall that resulted in any fracture in the past five years.ResultsMales comprised 60.4% of COPD group and 57.3% of the control group. Mean age was 66.2 ± 9.2 years for COPD group and 64.2 ± 8.8 for the control group. The frequency of osteoporosis in the COPD group was 29.7% and 18.3% in control group (p = 0.007). The frequency of vertebral fractures was 18.6% in the COPD group and 9.0% in control group (p = 0.06). The frequency of reported falls at resulting in any fracture was 36.3% in the COPD group and 7.3% in control group (p = 0.001).ConclusionsOur data indicate that COPD patients present a high frequency of osteoporosis and falls seem to be an important factor for vertebral fracture.     

Creation of the SAQ-COPD Questionnaire to Determine Physical Activity in COPD Patients in Clinical Practice

Introduction

Physical activity (PA) is a significant clinical dimension in COPD, but no useful tools are available to determine this variable in routine clinical practice.

Implementation of an Integrated Care Model for Frequent-Exacerbator COPD Patients: A Controlled Prospective Study

IntroductionFrequent-exacerbator COPD (fe-COPD) associated with frequent hospital admissions have high morbidity, mortality and use of health resources. These patients should be managed in personalized integrated care models (ICM). Accordingly, we aimed to evaluate the long-term effectiveness of a fe-COPD ICM on emergency room (ER) visits, hospital admissions, days of hospitalization, mortality and improvement of health status.MethodsProspective-controlled study with analysis of a cohort of fe-COPD patients assigned to ICM and followed-up for maximally 7 years that were compared to a parallel cohort who received standard care. All patients had a confirmed diagnosis of COPD with a history of ≥2 hospital admissions due to exacerbations in the year before enrollment. The change in CAT score and mMRC dyspnea scale, hospital admissions, ER visits, days of hospitalization, and mortality were analyzed.Results141 patients included in the ICM were compared to 132 patients who received standard care. The ICM reduced hospitalizations by 38.2% and ER visits by 69.7%, with reduction of hospitalizations for COPD exacerbation, ER visits and days of hospitalization (p < 0.05) compared to standard care. Further, health status improved among the ICM group after 1 year of follow-up (p = 0.001), effect sustained over 3 years. However, mortality was not different between groups (p = 0.117). Last follow-up CAT score > 17 was the strongest independent risk factor for mortality and hospitalization among ICM patients.ConclusionsAn ICM for fe-COPD patients effectively decreases ER and hospital admissions and improves health status, but not mortality.     

Eosinophilic COPD Patients Display a Distinctive Serum miRNA Profile From Asthma and Non-eosinophilic COPD

BackgroundAsthma and chronic obstructive pulmonary disease (COPD) are common chronic airway diseases that may overlap in some individuals. Asthma COPD overlap (ACO) is a heterogeneous conditions that includes smoking-asthma (SA) and COPD with eosinophilia (COPDe). MicroRNAs (miRNA) are regulators of gene expression with a great potential as biomarkers.ObjectivesThe objective of this study was to identify distinctive miRNA signatures in patients from the whole spectrum of chronic obstructive bronchial disease (SA, COPDe, non-smoking asthmatics (NSA), and COPD) that could serve as diagnostic biomarkers or describe differential molecular mechanisms with potential therapeutic implications.MethodsFrom a previously characterized cohort of ACO, COPD and asthma patients, we selected a discovery group of 40 patients for miRNA expression profiling by means of microarray technology. Differential expression of miRNAs were validated by quantitative PCR in the complete cohort (n = 274).ResultsThirty differentially expressed miRNAs (eBAYES p < 0.05, fold change ≥2) were found among the different groups of patients regarding COPDe: 19 COPD-vs-COPDe, 13 NSA-vs-COPDe, 11 SA-vs-COPDe. A characteristic down-regulated miRNA expression pattern was identified in COPDe patients. Differential expression of miR-619-5p and miR-4486 in COPDe patients were validated in the complete cohort (n = 274).ConclusionsWe postulate that COPDe patients show a characteristic expression profile of miRNAs distinctive from asthma and COPD. Also that SA and COPDe patients, which have been typically clustered in the ACO group, display distinct molecular events.     

Association of Reduction in Bone Mineral Density with Mortality in Male Hemodialysis Patients

In the present study we examined the relationship of bone mineral density (BMD) reduction with increased mortality in hemodialysis patients. A single-center prospective observational study was conducted on 269 male hemodialysis patients. The BMD in the distal third of the radius (DR1/3) and in the ultradistal radius (UR), which are enriched with cortical and cancellous bone, respectively, was measured twice using dual-energy X-ray absorptiometry (DXA) with a 1-year interval. Subjects were divided into two groups based on the presence or absence of BMD reduction. Survival was followed for 61.0 months, after which time 104 patients (39%) had died. A significant BMD reduction at the UR and DR1/3 occurred in 182 (68%) and 195 (72%) patients, respectively. Patients with BMD reduction in the UR, in contrast to the DR1/3, had a significantly lower survival rate than those without BMD reduction (P = 0.01). In Cox regression analysis, the rate of BMD change at the UR, in addition to patient age, diabetes mellitus, and serum albumin, emerged as an independent predictor for increased mortality (HR = 0.970, 95% CI 0.945–0.996). Our results suggest that BMD reduction at the UR might be a clinically relevant marker that predicts an increased risk of mortality in male hemodialysis patients.     

Characteristics of COPD Patients Managed in Respiratory Medicine Departments in Spain,According to GOLD Groups and GesEPOC Clinical Phenotypes

Introduction

The objective of this study was to analyze the clinical characteristics of COPD patients attending general respiratory clinics, adherence to clinical guidelines, classification accuracy, and therapeutic management.

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.     

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.     

Prevalence and Determinants of COPD in Spain: EPISCAN II

BackgroundTwo previous national epidemiological studies, IBERPOC in 1997 and EPISCAN in 2007, determined the COPD burden in Spain. Changes in demographics and exposure to risk factors demand the periodic update of COPD prevalence and its determinants.MethodsEPISCAN II aimed to estimate the prevalence of COPD in the general population aged 40 years or older in all 17 regions of Spain. A random population screening sample, requiring 600 participants per region performed a questionnaire plus post-bronchodilator (post-BD) spirometry.ResultsA total of 12,825 subjects were initially contacted, and 9433 (73.6%) agreed to participate, of whom 9092 performed a valid spirometry. Baseline characteristics were: 52.6% women, mean ± SD age 60 ± 11 years, 19.8% current- and 34.2% former-smokers. The prevalence of COPD measured by post-BD fixed ratio FEV₁/FVC < 0.7 was 11.8% (95% C.I. 11.2–12.5) with a high variability by region (2.4-fold). Prevalence was 14.6% (95% C.I. 13.5–15.7) in males and 9.4% (95% C.I. 8.6–10.2) in females; according to the lower limit of normal (LLN) was 6.0% (95% C.I. 5.5–6.5) overall, by sex being 7.1% (95% C.I. 6.4–8.0) in males and 4.9% (95% C.I. 4.3–5.6) in females. Underdiagnosis of COPD was 74.7%. Cases with COPD were a mean of seven years older, more frequently male, of lower attained education, and with more smokers than the non-COPD population (p < 0.001). However, the number of cigarettes and pack-years in non-COPD participants was substantial, as it was the reported use of e-cigarettes (7.0% vs. 5.5%) (p = 0.045). There were also significant social and clinical differences including living alone, previous respiratory diagnoses, more comorbidities measured with the Charlson index, greater BODE and COTE scores, cognitive impairment, and depression (all p < 0.001).ConclusionsCOPD remains prevalent in Spain and frequently underdiagnosed.     

Geriatric Assessment and Prognostic Factors of Mortality in Very Elderly Patients With Community-Acquired Pneumonia

IntroductionTo assess the relationship between the parameters obtained in the geriatric assessment and mortality in elderly people with community-acquired pneumonia in an acute care geriatric unit.MethodsFour hundred fifty-six patients (≥75 years). Variables: age, sex, referral source, background, consciousness level, heart rate, breathing rate, blood pressure, laboratory data, pleural effusion, multilobar infiltrates, functional status (activities of daily living) prior to admission [Lawton index (LI), Barthel index (BIp)] prior to and at admission (BIa), cognitive status [Pfeiffer test (PT)], comorbidity [Charlson index (ChI)] and nutrition (total protein, albumin).ResultsA hundred ten patients died (24.2%) during hospitalization. These patients were older (86.6±6.4 vs 85.1±6.4, P<.04), had more comorbidity (ChI 2.35±1.61 vs 2.08±1.38; P<.083), worse functional impairment [(LI: 0.49±1.15 vs 1.45±2.32, P<.001) (BIp: 34.6±32.9 vs 54.0±34.1, P<.001) (BIa: 5.79±12.5 vs 20.5±22.9, P<.001)], a higher percentage of functional loss at admission (85.9±23.2 vs 66.4±28.6; P<.0001), worse cognitive impairment (PT: 7.20±3.73 vs 5.10±3.69, P<.001) and malnutrition (albumin 2.67±0.54 vs 2.99±0.49, P<.001). Mortality was higher with impaired consciousness [49.2% (P<.01)], tachypnea [33.3% (P<.01)], tachycardia [44.4% (P<.002), high urea levels [31.8 (P<.001)], anemia [44.7% (P<.02)], pleural effusion [42.9% (P<.002)], and multilobar infiltrates [43.2% (P<.001)]. In the multivariate analysis, variables associated with mortality were: age≥90 years [OR: 3.11 (95% CI: 1.31–7.36)], impaired consciousness [3.19 (1.66–6.15)], hematocrit<30% [2.87 (1.19–6.94)], pleural effusion [3.77 (1.69–8.39)] and multilobar infiltrates [2.76 (1.48–5.16)]. Female sex and a preserved functional status prior (LI≥5) and during admission (BIa≥40) were protective of mortality [0.40 (0.22–0.70), 0.09 (0.01–0.81) and 0.11 (0.02–0.51)].ConclusionsGeriatric assessment parameters and routine clinical variables were associated with mortality.     

Changes in Control Status of COPD Over Time and Their Consequences: A Prospective International Study

IntroductionControl status may be a useful tool to assess response to treatment at each clinical visit in COPD. Control status has demonstrated to have long-term predictive value for exacerbations, but there is no information about the short-term predictive value of the lack of control and changes in control status over time.MethodProspective, international, multicenter study aimed at describing the short-term (6 months) prognostic value of control status in patients with COPD. Patients with COPD were classified as controlled/uncontrolled at baseline and at 3,6-month follow-up visits using previously validated criteria of control. Moderate and severe exacerbation rates were compared between controlled and uncontrolled visits and between patients persistently controlled, uncontrolled and those changing control status over follow-up.ResultsA total of 267 patients were analyzed: 80 (29.8%) were persistently controlled, 43 (16%) persistently uncontrolled and 144 (53.7%) changed control status during follow-up. Persistently controlled patients were more frequently men, with lower (not increased) body mass index and higher FEV₁(%). During the 6 months following an uncontrolled patient visit the odds ratio (OR) for presenting a moderate exacerbation was 3.41 (95% confidence interval (CI) 2.47–4.69) and OR = 4.25 (95%CI 2.48–7.27) for hospitalization compared with a controlled patient visit.ConclusionsEvaluation of control status at each clinical visit provides relevant prognostic information about the risk of exacerbation in the next 6 months. Lack of control is a warning signal that should prompt investigation and action in order to achieve control status.     

Treatment Pathways Before and After Triple Therapy in COPD: A Population-based Study in Primary Care in Spain

BackgroundRecent data from real world clinical practices on the use of Triple Therapy (TT) in patients with COPD are scarce.MethodsObservational population-based study with longitudinal follow-up in patients with COPD identified in a primary care electronic medical records database in Catalonia, covering 80% of the general population. The aims were to characterize COPD patients who initiated TT and to describe treatment pathways before and after TT initiation. Time to and probability of step down or complete discontinuation of TT was described using restricted mean survival time and Kaplan?Meier analysis.ResultsA total of 34,018 COPD patients initiated TT during the study period. Of them, 23,867 (70.1%) were GOLD A/B. 18,453 (54.2%) were non-exacerbators, 9931 (29.2%) infrequent exacerbators, 5634 (16.5%) frequent exacerbators and 1923 (5.6%) had asthma-COPD overlap. Drugs most frequently used prior to initiation of TT were long-acting antimuscarinics (22.5%) and combination of long-acting beta2 agonists/inhaled corticosteroids (15.2%). A total of 11,666 (34.3%) stepped down and 1091 (3.2%) discontinued TT during follow-up. Step down following TT was more likely in patients with severe COPD, especially during the first year; however, discontinuation was more common among patients with mild COPD.ConclusionMost patients initiating treatment with TT were non exacerbators and continued on the same treatment over time regardless severity of disease. Stepping down was more frequent in severe patients, while discontinuation was more common among mild patients. Overall, it appears that TT is extensively used in primary care for treatment of patients with COPD.     

Factors Affecting Morbidity and Mortality in Patients Who Underwent Emergency Operation for Incarcerated Abdominal Wall Hernia

Patients with incarcerated abdominal wall hernias (AWHs) are often encountered in emergency care units. Despite advances in anesthesia, antisepsis, antibiotic therapy, and fluid therapy, the morbidity and mortality rates for these patients remain high. Between 2006 and 2011, we retrospectively analyzed the cases of 131 patients who underwent emergency surgery for incarcerated abdominal wall hernias. Of these, there were 70 women (53.4%) and 61 men (46.6%) with an average age of 63.3 ± 17.4 years (range, 17–91 years). Morbidity was observed in 28 patients (21.4%), and the mortality rate was 2.3%. Intestinal resection, presence of concomitant disease, and general anesthesia were the independent variants that affected morbidity of patients with incarcerated abdominal wall hernias.     

Preoperative Body Weight and Albumin Predict Survival in Patients With Resectable Lung Neoplasms: Role of COPD

IntroductionThe impact of preoperative nutritional status on survival in lung cancer (LC) patients with underlying chronic obstructive pulmonary disease (COPD) is still unclear. We hypothesized that presurgical nutritional assessment may differentially predict mortality in patients with resectable LC with moderate COPD and relatively well-preserved nutritional status.MethodsNutritional assessment [body mass index (BMI), blood parameters including albumin and protein levels, and body weight loss], and other clinical parameters [cigarette smoking (CS) history, LC staging and histological subtypes, COPD severity, lung function, and adjuvant therapy] were evaluated in 125 patients from the LC Mar Prospective Cohort: 87 LC-COPD patients and 38 LC patients without COPD before thoracotomy. Ten-year overall survival (OS) was analyzed in all patients.ResultsPrior to thoracotomy, in LC-COPD patients compared to LC, BMI and albumin declined relatively, low levels of the parameters BMI, albumin, and total proteins were associated with poorer 10-year survival, especially in the LC-COPD. CS burden also correlated with impaired survival. COPD per se worsened the prognosis in LC patients.ConclusionsIn the present cohort of LC patients with resectable tumors and relatively well-preserved nutritional status, the parameters BMI and blood albumin and protein levels measured prior to thoracotomy predicted OS, especially in those with COPD. These are clinically relevant findings, since values of those nutritional parameters were within the normal ranges in the majority of the analyzed patients. A thorough nutritional preoperative assessment should be included in the study of patients with resectable LC, particularly in those with chronic airway obstruction.     

Exercise Capacity and Activities of Daily Living are Related in Patients With Chronic Obstructive Pulmonary Disease

IntroductionThe knowledge of the relationship between exercise capacity and activities of daily living (ADLs) is important to minimize the negative outcomes in ADLs resulting from reduced exercise capacity in patients with chronic obstructive pulmonary disease (COPD). There is a limited study about the association between exercise capacity and ADLs in patients with COPD. This study aimed to investigate the relationship between maximal exercise capacity and ADLs in patients with GOLD stage II–III COPD.MethodsTwenty-seven clinically stable GOLD stage II–III COPD patients were included (mean age = 58.59 ± 9.63 years and mean FEV₁ = 50.6 ± 13.7%) in this cross-sectional study. Maximal and submaximal exercise capacity were evaluated using an incremental shuttle walk test (ISWT) and 6-min walk test (6MWT), respectively. Activities of daily living were assessed using Glittre-ADL test.ResultsThe ISWT distance was significantly correlated with Glittre-ADL test time (r = −0.517, p = 0.006). There was also a negative correlation between 6MWT distance and Glittre-ADL test time (r = −0.506, p = 0.007).ConclusionA moderate relationship was found between maximal exercise capacity and general activities of daily living performance. The reduction in exercise capacity increases the negative influences in ADLs and strengthens our beliefs that exercise interventions in pulmonary rehabilitation could influence activities of daily living positively.     

Occupational and Biomass Exposure in COPD: Results of a Cross-Sectional Analysis of the On-Sint Study

Background

Although tobacco smoke is the main risk factor for chronic obstructive pulmonary disease (COPD), other inhaled toxics have also been associated with the disease. The present study analyzes data from exposure to these substances in a cohort of patients with COPD and assesses their impact on the clinical presentation of the disease.

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.