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.     

T2 Biomarkers as Predictors of Exacerbations of Chronic Obstructive Pulmonary Disease

IntroductionType 2 (T2) biomarkers such as blood eosinophil count (BEC) and FeNO have been related to a higher risk of exacerbations in COPD. It is unknown whether combining these biomarkers could be useful in forecasting COPD exacerbations.MethodsCOPD patients were enrolled in this prospective, multicenter, observational study and followed up for 1 year, during which BEC were analysed at baseline (V0) while FeNO analyses were performed at baseline (V0), 6 months (V1) and 12 months (V2). The risk of moderate or severe exacerbation during follow up was assessed by Cox regression analysis, and the predictive capacity of both measurements was assessed by ROC curves and the DeLong test. Statistical significance was assumed at P < .05.ResultsOf the 322 COPD patients initially recruited, 287 were followed up. At baseline, 28.0% were active smokers, and experienced moderate airflow limitation (mean FEV₁ 56.4% ± 17.0% predicted). Patients with at least one elevated T2 biomarker (n = 125, 42.5%) were at increased risk of COPD exacerbation (HR 1.75, 95% CI 1.25–2.45, P = .001) and of shorter time to first COPD exacerbation. There was no difference between BEC and FeNO regarding the predictive capacity for moderate to severe exacerbation (AUC 0.584 vs 0.576, P = .183) but FeNO predicted severe episodes more accurately than BEC (AUC 0.607 vs 0.539, P < .05). Combining the two biomarkers enhanced the detection of moderate and severe COPD exacerbations.ConclusionsBoth eosinophil count and FeNO have limited utility for predicting COPD exacerbations. Combining these T2 biomarkers could enhance the detection of future COPD exacerbations.     

C-reactive protein velocity following antibiotics in patients with chronic obstructive pulmonary disease exacerbation and community acquired pneumonia

IntroductionDistinguishing community acquired pneumonia (CAP) from chronic obstructive pulmonary disease (COPD) exacerbation is a challenging task, since fever, productive cough, dyspnea, and leukocytosis are all common features of both conditions. Moreover, chest X-ray might not be sensitive enough. It is therefore quite common for physicians to prescribe unnecessary antibiotics for COPD exacerbation, leading to resistant bacteria and other related adverse affects.AimTo study whether CRP levels upon admission and the delta in CRP levels following initiation of antibacterial treatment, could provide an efficient tool for distinguishing CAP from COPD exacerbation.MethodsThe study group included 36 COPD exacerbation and 49 CAP patients, admitted to a single Internal Medicine department during the years 2004–2006. All patients were treated with cephalosporins and macrolides upon admission.ResultsCRP levels upon admission were significantly higher among CAP patients than among COPD exacerbation patients (111.5 ± 104.4 vs. 34.9 ± 28.6 mg/l, p < 0.0001). CRP levels on the second day of hospitalization, following antibiotic administration to all patients, made a sharp incline in 36.7% of CAP patients compared to only 5.9% of COPD exacerbation patients (p = 0.005), and remained unchanged in 61.8% of COPD patients compared to 16.3% of CAP patients (p = 0.0006).ConclusionsCRP levels upon admission and the delta in CRP levels following initiation of antibacterial treatment could provide an efficient tool for distinguishing CAP from COPD exacerbation.     

Impact of a Home Telehealth Program After a Hospitalized COPD Exacerbation: A Propensity Score Analysis

IntroductionCurrently there is lack of data regarding the impact of a home telehealth program on readmissions and mortality rate after a COPD exacerbation-related hospitalization.ObjectiveTo demonstrate if a tele-monitoring system after a COPD exacerbation admission could have a favorable effect in 1-year readmissions and mortality in a real-world setting.MethodsThis is an observational study where we compared an intervention group of COPD patients treated after hospitalization that conveyed a telehealth program with a followance period of 1 year with a control group of patients evaluated during one year before the intervention began. A propensity-score analyses was developed to control for confounders. The main clinical outcome was 1-year all-cause mortality or COPD-related readmission.ResultsThe analysis comprised 351 telemonitoring patients and 495 patients in the control group. The intervention resulted in less mortality or readmission after 12 months (35.2% vs. 45.2%; hazard ratio [HR] 0.71 [95% CI = 0.56–0.91]; p = 0.007). This benefit was maintained after the propensity score analysis (HR = 0.66 [95% CI = 0.51–0.84]). This benefit, which was seen from the first month of the study and during its whole duration, is maintained when mortality (HR = 0.54; 95% CI = [0.36–0.82]) or readmission (subdistribution hazard ratio [SHR] 0.66; 95% CI = [0.50–0.86]) are analyzed separately.ConclusionTelemonitoring after a severe COPD exacerbation is associated with less mortality or readmissions at 12 months in a real world clinical setting.     

Acute exacerbation of chronic hepatitis B virus infection in renal transplant patients

IntroductionThere is scarce information regarding clinical evolution of HBV infection in renal transplant patients.AimsTo evaluate the prevalence of acute exacerbation in HBV-infected renal transplant patients and its association with the time after transplantation, presence of viral replication, clinical evolution, and use of antiviral prophylaxis.Materials and methodsHBV infected renal transplant patients who underwent regular follow-up visits at 6-month intervals were included in the study. The criteria adopted to characterize exacerbation were: ALT >5× ULN and/or >3× baseline level. Predictive factors of exacerbation evaluated were age, gender, time on dialysis, type of donor, post-transplant time, ALT, HBeAg, HBV-DNA, HCV-RNA, immunosuppressive therapy, and use of antiviral prophylaxis.Results140 HBV-infected renal transplant patients were included (71% males; age 46 ± 10 years; post-renal transplant time 8 ± 5 years). During follow-up, 25% (35/140) of the patients presented exacerbation within 3.4 ± 3 years after renal transplant. Viral replication was observed in all patients with exacerbation. Clinical and/or laboratory signs of hepatic insufficiency were present in 17% (6/35) of the patients. Three patients died as a consequence of liver failure. In univariate analysis variables associated with exacerbation were less frequent use of prophylactic/preemptive lamivudine and of mycophenolate mofetil. Lamivudine use was the only variable independently associated with exacerbation, with a protective effect.ConclusionsAcute exacerbation was a frequent and severe event in HBV-infected renal transplant patients. Prophylactic/preemptive therapy with antiviral drugs should be indicated for all HBsAg-positive renal transplant patients.     

Facteurs associés à un mauvais contrôle tensionnel chez 253 hypertendus traités

IntroductionHypertension is a major public health problem throughout the world. The blood pressure control and the decrease of global cardiovascular risk are two main goals of the treatment of hypertension. The purpose of this study was to determine the proportion and associated factors of uncontrolled hypertension in hypertensive patients followed by private cardiologists in Oran.Materials and methodsThis study included 253 hypertensive patients followed by 7 private cardiologists in Oran. Was regarded as uncontrolled high blood pressure, a systolic blood pressure (SBP) superior or equal to 140 mmHg and/, or a diastolic blood pressure (DBP) superior or equal to 90 mmHg. A logistic regression analysis was performed to determine the associated factors with poor blood pressure control.ResultsThe proportion of uncontrolled hypertension was 69.6 % (75.8 % of men and 65.8 % of women). Using multivariate analysis, poor blood pressure control was found to be associated with salt consumption (OR_a = 2.71; CI 95 % = [1.42–5.18]).ConclusionNutritional actions are required for better blood pressure control.     

Factors that influence improvement for patients with poorly controlled type 2 diabetes

ObjectiveAssess reasons for improved control for patients with initially poorly controlled diabetes.Research design and methodsPatients in seven practices with type 2 diabetes were selected if within a 6-month period they had two glycosylated hemoglobin (HbA1c) levels of at least 8.0%. Patient factors that may influence control were compared for patients grouped according to their last two HbA1c levels.ResultsReview of 643 medical records of diabetic patients treated by 29 clinicians identified 69 study patients. After at least 1 year of follow-up 26 patients became well controlled, 14 had intermediate control, and 29 remained in poor control. Becoming controlled was not significantly associated with gender, age, duration of diabetes, BMI, or HbA1c levels prior to baseline. It was inversely associated with greater use of medications (P = 0.04), and positively associated with understanding of diabetes (P = 0.03), adherence to recommendations for meal plan (P = 0.001), and glucose monitoring (P = 0.02). Thirty-one percent of patients who became controlled had a change in life circumstances. Reasons for not advancing medications were probably justified for 69% of patients who remained uncontrolled.ConclusionImproved control depends largely on patient self-care behaviors.     

Effectiveness of Treatment With Dual Bronchodilation (LABA/LAMA) Compared With Combination Therapy (LABA/ICS) for Patients With COPD: A Population-Based Study

BackgroundInitiation of treatment of COPD with a combination of a long-acting beta-agonist (LABA) and an inhaled corticosteroid (ICS) is frequent irrespective of the risk of exacerbations.MethodWe performed a retrospective, population-based, observational study aimed at comparing the effectiveness of a LABA/long-acting antimuscarinic agent (LAMA) and LABA/ICS in patients with COPD over a one-year follow-up. Data were obtained from an administrative healthcare claims database. The primary outcome was the risk of first exacerbation. A sensitivity analysis was conducted in a propensity-score matched population.ResultsThe population consisted of 14,046 COPD patients; 11,329 (80.6%) initiated LABA/ICS and 2717 (19.4%) LABA/LAMA. The matched population included 1650 patients in each arm. During follow-up, 69.6% patients in the LABA/ICS group and 64.4% in the LABA/LAMA group presented an exacerbation. The mean time to the first exacerbation was 6.03 months (95% confidence interval (CI): 5.94–6.12) for LABA/ICS and 6.4 months (95%CI: 6.21–6.59) for LABA/LAMA; p < 0.001. The time to scalation to triple therapy was also significantly prolonged in LABA/LAMA. Similar results were obtained in the matched population. LABA/LAMA was associated with a significantly lower risk of exacerbations and escalation to triple therapy compared to LABA/ICS, except in patients with frequent exacerbations and high blood eosinophils in which no differences were observed in the time to first exacerbation.ConclusionInitiation of treatment with LABA/LAMA was associated with a lower risk of exacerbation and escalation to triple therapy compared to LABA/ICS in the majority of patients with COPD in primary care.     

Pegvisomant treatment in acromegaly in clinical practice: Final results of the French ACROSTUDY (312 patients)

ObjectiveWe report the final analysis of the French ACROSTUDY, using data revised and enriched since the 2013 interim analysis. Our objective was to validate the use of pegvisomant (PEGV) in the treatment of acromegaly and to determine efficacy and safety.Patients and methodsPatients with acromegaly treated with PEGV and followed up for at least 5 years were included. Eighty-eight investigators from 62 clinical centers in France included patients from April 2007 to April 2014. PEGV dose and administration frequency were determined by the physicians, based on their clinical evaluation and local habits. No additional examinations beyond those performed in normal follow-up were required. Minimum recommended follow-up included check-ups at treatment initiation, 6 months, 12 months and then annually.ResultsIn total, 312 patients were enrolled. Mean age was 46.1 ± 14.3 years at introduction of PEGV. Median PEGV treatment duration was 6.3 years and median follow-up was 5.6 years. Median dose at initiation was 10 mg/day. The percentages of patients with IGF-1 ≤ ULN (upper limit of normal) were 10% (n = 300) at baseline, 54% at 6 months (n = 278), and 61.7% (n = 253) at 2 years, then stabilizing at 64.4% (n = 180) at 5 years. Mean PEGV dose was 17.4 ± 11.7 mg in patients with controlled disease versus 21.1 ± 17.3 mg in those without control at 5 years. At 5 years, 21.8% of patients (54/248) were receiving >30 mg PEGV per day. In patients with at least one pituitary imaging procedure during the 5-year follow-up (n = 292), the most recent image showed stable tumor volume in 212 subjects (72.6%), increased volume in 13 (4.5%), and decreased volume in 30 (10.3%). No PEGV treatments were permanently discontinued due to transaminase elevation. There were no cases of liver failure.ConclusionThe French ACROSTUDY showed normalization of IGF-1 levels in 64.4% of a real-life cohort of patients, mostly with uncontrolled disease despite multiple prior therapies. Long-term follow-up showed a sustained effectiveness and good long-term safety.     

Blood Eosinophil Counts and Their Variability and Risk of Exacerbations in COPD: A Population-Based Study

BackgroundThere is controversy regarding the role of blood eosinophil levels as a biomarker of exacerbation risk in chronic obstructive pulmonary disease (COPD). Our aim was to quantify blood eosinophil levels and determine the risk of exacerbations associated with these levels and their variability.MethodsObservational, retrospective, population-based study with longitudinal follow-up in patients with COPD identified in a primary care electronic medical record database in Catalonia, Spain, covering 80% of the general population. Patients were classified into 4 groups using the following cut-offs: (a) <150 cells/μl; (b) ≥150 and <300 cells/μl; (c) ≥300 and <500 cells/μl; (d) ≥500 cells/μl.ResultsA total of 57,209 patients were identified with a mean age of 70.2 years, a mean FEV1(% predicted) of 64.1% and 51.6% had at least one exacerbation the previous year. The number of exacerbations in the previous year was higher in patients with the lowest and the highest eosinophil levels compared with the intermediate groups. During follow-up the number of exacerbations was slightly higher in the group with the lowest blood eosinophil levels and in those with higher variability in eosinophil counts, but ROC curves did not identify a reliable threshold of blood eosinophilia to discriminate an increased risk of exacerbations.ConclusionsOur results do not support the use of blood eosinophil count as a reliable biomarker of the risk of exacerbation in COPD in a predominantly non-exacerbating population. Of note was that the small group of patients with the highest variability in blood eosinophils more frequently presented exacerbations.     

Características clínicas y riesgo de agudizaciones asociados con diferentes criterios diagnósticos del solapamiento asma-EPOC

IntroductionThere is currently no universally accepted definition of asthma-COPD overlap (ACO).ObjectiveTo compare the prevalence of ACO in patients with asthma or COPD, and to assess their clinical characteristics and the capacity of the different definitions to predict the risk of exacerbation.MethodProspective observational study with a 12-month follow-up in an asthma cohort and a COPD cohort. Four diagnostic criteria were compared: A) the Spanish 2012 consensus; B) the 2016 international consensus; C) the 2017 consensus between the Spanish COPD guidelines (GesEPOC) and GEMA asthma guidelines; and D) the single criterion of ≥ 300 eosinophils/μL, proposed by GOLD 2019. The risk of exacerbations was evaluated in each group.ResultsA total of 345 patients were included, 233 (67.5%) with COPD and 112 (32.5%) with asthma, aged 63 ± 14 years, 70.4% men. Fifteen (4.3%) patients met the criteria for ACO according to the criteria described under A above; 30 (8.7%) with the criteria of B; 118 (34.2%) with the criteria of C; and 97 (28.1%), with the D criterion. The ACO-COPD subtype were older, had worse lung function, and an increased risk of exacerbation compared with the ACO-asthma group. Of all the definitions evaluated, those which distinguished a higher risk of exacerbations were the GesEPOC-GEMA consensus and the GOLD proposal.ConclusionsThe prevalence of ACO varies enormously depending on the diagnostic criteria used. The ACO population is heterogeneous, and the ACO-COPD subtype is very different from the ACO-asthma subtype. The definitions that include eosinophilia identify ACO patients with a greater risk of exacerbation.     

Long-term azithromycin use in patients with chronic obstructive pulmonary disease and tracheostomy

Patients with Chronic Obstructive Pulmonary Disease (COPD) and tracheostomy are at high risk for exacerbations and hospitalizations. Macrolide treatment has shown to reduce exacerbations in moderate-to-severe COPD. To evaluate the safety and the efficacy of long-term azithromycin use in outpatients with severe COPD and tracheostomy.A multicenter, randomized, uncontrolled, pilot trial evaluating the safety and the efficacy of azithromycin 500 mg three day-a-week for 6 months (AZI) vs. standard of care (SC) in severe COPD outpatients with tracheostomy. Patients were monitored for six months of treatment plus six months of follow up. The primary outcome was the reduction in the number of exacerbations and hospitalizations.A total of 22 patients was randomized (11 to SC and 11 to AZI). Patients in AZI had a significant lower cumulative number of exacerbations after the first 3 months of treatment when compared to patients in SC (p = 0.001), as well as hospitalizations (p = 0.02). Kaplan–Meier survival curves for time to first exacerbation showed a significant reduction in AZI of the rates of first exacerbation when compared to SC (log rank test = 12.14, p < 0.001), as well as to first hospitalization (log-rank = 4.09, p = 0.04). Azithromycin significantly improved the quality of life in comparison to SC. No serious adverse events in the AZI group were reported.Long-term azithromycin treatment seems to be safe and effective in severe COPD outpatients with tracheostomy in reducing exacerbations, hospitalizations, as well as in improving quality of life.     

Screening for frailty in community-dwelling elderly subjects: Predictive validity of the modified SEGA instrument

AimsTo study the capacity of the SEGAm instrument to predict loss of independence among elderly community-dwelling subjects.MethodsThe study was performed in four French departments (Ardennes, Marne, Meurthe-et-Moselle, Meuse). Subjects aged 65 years or more, living at home, who could read and understand French, with a degree of autonomy corresponding to groups 5 or 6 in the AGGIR autonomy evaluation scale were included. Assessment included demographic characteristics, comprehensive geriatric assessment, and the SEGAm instrument at baseline. Subjects had follow-up visits at home at 6 and 12 months. During follow-up, vital status and level of independence were recorded. Logistic regression was used to study predictive validity of the SEGAm instrument.ResultsAmong the 116 subjects with complete follow-up, 84 (72.4%) were classed as not very frail at baseline, 23 (19.8%) as frail, and 9 (7.8%) as very frail; 63 (54.3%) suffered loss of at least one ADL or IADL at 12 months. By multivariable analysis, frailty status at baseline was significantly associated with loss of independence during the 12 months of follow-up (OR = 4.52, 95% CI = 1.40-14.68; p = 0.01). We previously validated the SEGAm instrument in terms of feasibility, acceptability, internal structure validity, reliability, and discriminant validity.ConclusionsThis instrument appears to be a suitable tool for screening frailty among community-dwelling elderly subjects, and could be used as a basis to plan early targeted interventions for subjects at risk of adverse outcome.     

Phenotype properties and status of corticosteroid resistance among patients with uncontrolled asthma

BackgroundControl cannot be achieved in some asthmatics although optimal monitoring and treatment is administered. Glucocorticoid (GC) resistance is one of the reasons of poor asthma control. We aimed to investigate GC resistance by lymphocyte proliferation suppression test (LPST) in uncontrolled asthmatics.MethodsAfter assessing asthma control level of 77 asthmatics their treatment was adjusted upon GINA guidelines. They were followed-up for three to six months and the patients who remained uncontrolled were accepted as uncontrolled patients. Steroid resistance test (SRT) was applied to them (7–14 days oral prednisolone) and the patients who were still uncontrolled and/or had a FEV1 increase <15% after SRT were assessed as the “case group” while the remaining composed the “control group”. Optimal treatment was adjusted and at the end of a follow-up period LPST was performed to both groups.ResultsFourteen of the case (n = 22) and four (n = 8) of the control groups could be evaluated by LPST. Proliferated lymphocytes were observed to be significantly suppressed in all dexamethasone concentrations in the control group (p = 0.001). However, in the case group LPST was positive only at 10^?6 and 10^?4 concentrations although statistically not significant (p = 0.147). There was no significant relationship between clinically GC resistance and LPST positivity (p = 0.405).ConclusionWe determined that in vitro responses to the GCs were significantly declined in the uncontrolled asthma cases. An SRT alone does not seem to be very sensitive for evaluating GC sensitivity, LPST may be performed for demonstrating GC responsiveness in asthmatic patients in addition to SRT.     

Choose your outcomes: From the mean to the personalized assessment of outcomes in COPD. An exploratory pragmatic survey

BackgroundPatient's expectations and needs may influence adherence in chronic obstructive pulmonary disease (COPD). The objectives of this survey were to assess the specific outcomes that patients expected their COPD treatment to improve (patient's personal outcome [PPO]) and to evaluate how the ongoing therapy was able to reach this objective.MethodsWe performed an exploratory pragmatic survey of COPD patients attending 2 university hospitals for scheduled follow-up visits. Patients had to indicate their PPO, the effect of ongoing treatment on the PPO, the symptom COPD of they expected treatment to improve and how this symptom is currently bothering them. Patients also underwent assessment of lung function and completed the COPD assessment test (CAT).ResultsWe analyzed data from 144 consecutive patients, (62.5% males; age range 54–94; mean age 73.88 ± 8.33). A total of 23 different PPOs were scored, and 44.5% of patients reported an improvement ≥ 6 (mean 4.93 ± 2.27 on a 0–10 points scale) due to ongoing treatment. The correlation between perceived improvement in PPO and CAT score was weak and negative (r = − 0.13, p = 0.11), whereas it was high and significant with FEV1 (r = .35, p = 0.007). The clinical features patients most expected their ongoing treatment to improve were breathlessness (64.6% of patients), cough (13.9%), sputum production (11%) and episodes of exacerbation (8.3%), for which their scores were, respectively, 7.12 ± 1.99, 6.8 ± 2.24, 6.63 ± 2.13, and 8.0 ± 0.94.ConclusionAppropriate assessment of PPO could lead to better long-term management of COPD.     

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.     

Oral tacrolimus as maintenance therapy for refractory ulcerative colitis—an analysis of outcomes in two London tertiary centres

BackgroundThe medical management of refractory ulcerative colitis (UC) remains a significant challenge. Two randomised controlled studies have demonstrated tacrolimus therapy is effective for the induction of remission of moderate to severe UC. However, the long term outcomes of UC patients treated with tacrolimus as maintenance therapy are not certain.AimsThis study aims to assess the efficacy of tacrolimus maintenance therapy for refractory UC.MethodsA retrospective review of patients with UC treated with tacrolimus at two London tertiary centres was performed. Clinical outcomes were assessed at six months, at the end of tacrolimus treatment, or at the last follow-up for patients continuing tacrolimus treatment. Modified Truelove–Witts score (mTW) and Mayo endoscopy subscores were calculated.Results25 patients with UC, treated with oral tacrolimus between 2005 and 2011, were identified. The median duration of tacrolimus treatment was 9 months (IQR 3.7–18.2 months). The median duration of follow-up was 27 months (range 3–66 months). At six months thirteen (52%) patients had achieved and maintained clinical response and eleven (44%) were in clinical remission. The mean mTW score decreased from 10 +/− 0.5 before therapy, to 5.8 +/− 0.8 (p ≤ 0.001 95% CI 2.7–5.8) at cessation of treatment or last follow-up. Mayo endoscopy subscore decreased from 2.6 +/− 0.1 to 1.2 +/− 0.2 (p ≤ 0.001 mean reduction 1.4, 95% CI 0.8–1.9). Eight patients (32%) subsequently underwent a colectomy within a mean time of 17 months (range 2–45 months).ConclusionTacrolimus is effective for the maintenance of refractory UC and can deliver sustained improvement in mucosal inflammation.     

Low Inspiratory Capacity to Total Lung Capacity Ratio Is a Risk Factor for Chronic Obstructive Pulmonary Disease Exacerbation

IntroductionAir trapping because of chronic obstructive pulmonary disease (COPD) leads to a reduction in inspiratory capacity/total lung capacity (IC/TLC) ratio. We hypothesize that COPD patients with a low IC/TLC ratio suffer more frequent COPD exacerbations.MethodsRetrospective cohort study of patients with COPD, aged 30 years or older with forced expiratory volume in 1 second <70% predicted and forced expiratory volume in 1 second/forced expiratory volume (FEV1/FVC) ratio <70% treated in our ambulatory care clinic for 3 years (2003–2006). Patients were divided in 2 groups, either IC/TLC ratio less than or greater than 25%.ResultsCharts of 350 patients with COPD were reviewed. Of the 77 patients who met inclusion criteria, 28 patients (20 women and 8 men) had IC/TLC ratio <25% (low group) and 49 patients (25 women and 24 men) had IC/TLC ratio >25% (high group). Average number of exacerbations per person in the low group was 3.5 (0–10), significantly higher than in the high group, which was 2.2 (0–10; P = 0.01). Visits for COPD exacerbations were analyzed based on treatment site namely, office, emergency room (ER), and hospital. The per person office visits were 1.96 (0–10) in the low group and 0.80 (0–3) in the high group (P = 0.002). ER visits were similar, 0.57 (0–3) in the low group and 0.38 (0–3) in the high group (P = 0.15), as were hospital visits, 0.96 (0–8) in the low group and 1.06 (0–5) in the high group (P = 0.81).ConclusionCOPD patients in the low group experienced significantly more unscheduled office visits because of exacerbations, suggesting they need early identification and closely monitored therapy.     

HEPACONTROL. A program that reduces early readmissions,mortality at 60 days,and healthcare costs in decompensated cirrhosis

Background & aimsDecompensated cirrhosis patients have an elevated incidence of early readmission, mortality and economic burden. The aims of HEPACONTROL were to reduce early readmission and to evaluate its impact on mortality and emergency department visits.Patients and methodsQuasi-experimental study with control group which compared two cohorts of patients discharged after being admitted for cirrhosis-related complications. A prospective cohort (n = 80), who followed the HEPACONTROL program, which began with a follow-up examination seven days after discharge at the Hepatology Unit Day Hospital and a retrospective cohort of patients (n = 112), who had been given a standard follow-up. Outcome variables that were compared between both groups were early readmission rates, the number of emergency department visits post-discharge, financial costs and mortality.ResultsThe rate of early readmission was lower in the group with HEPACONTROL (11.3% vs 29.5%; P = .003). Also, the mean number of visits to the emergency department post-discharge (1.10 ± 1.64 vs 1.71 ± 2.36; P = .035), mortality at 60 days (3.8% vs 14.3%; P = .016), and the cost of early readmission were all lower compared with the group with standard follow-up (P = .029).ConclusionsHEPACONTROL decreases the incidence of early readmission the rate of emergency department visits and mortality at 60 days in patients with decompensated cirrhosis, and it is cost-effective.     

Quarterly individual outpatients lifestyle counseling after initial inpatients education on type 2 diabetes: the REDIA Prev-2 randomized controlled trial in Reunion Island

AimsThis study aimed to describe the 1-year evolution of type 2 diabetes (T2D) patients who attended inpatients education, and to assess whether quarterly outpatients counseling visits by nurses and dietitians can improve metabolic control and health-related behaviours.MethodsFollowing in-hospital educational sessions, 398 adult T2D patients were randomized to either attend quarterly individual lifestyle counseling visits by a nurse and a dietitian (intervention group), or receive the usual care (control group). Primary (HbA_1c) and secondary endpoints (fasting blood glucose, lipids, body mass index, waist circumference, fat mass, blood pressure, diet, physical activity) were assessed at baseline and at 12 months.ResultsHbA_1c changes from baseline to 12 months were ? 1.74 ± 2.64% (P < 0.0001) for the intervention group and ? 2.02 ± 2.57% (P < 0.0001) for the control group. There was no statistically significant difference between the intervention group (n = 153) and the controls (n = 166) for any of the clinical and biological outcomes. In both groups, total energy and fat intakes decreased significantly from baseline levels. Also, no difference was found between the groups for any dietary outcome. A slight enhancement in sports activity was observed in the intervention group, but the difference between the two groups did not reach statistical significance, and no difference was found concerning any other physical activity scores.ConclusionIn this study of adults with T2D, patients significantly improved their metabolic control, and dietary and exercise habits, 1 year after receiving intensive inpatients education, whereas subsequent quarterly outpatients counseling visits with nurses and dietitians have not demonstrated any superiority compared with the usual care.