Chest. 2010 May;137(5):1116-21 Hannink JD, van Helvoort HA, Dekhuijzen PN, Heijdra YF. Department of Pulmonary Diseases, Radboud University Nijmegen Medical Centre, P. O. Box 9101, Nijmegen, 6500 HB, The Netherlands.

BACKGROUND: One of the contributors to exercise limitation in COPD is dynamic hyperinflation. Although dynamic hyperinflation appears to occur during several exercise protocols in COPD and seems to increase with increasing disease severity, it is unknown whether dynamic hyperinflation occurs at different severity stages according to the Global initiative for chronic Obstructive Lung Disease (GOLD) in daily life. The present study, therefore, aimed to compare dynamic hyperinflation between COPD GOLD stages II-IV during daily activities.

METHODS: Thirty-two clinically stable patients with COPD GOLD II (n = 10), III (n = 12), and IV (n = 10) participated in this study. Respiratory physiology during a daily activity was measured at patients' homes with Oxycon Mobile. Inspiratory capacity maneuvers were performed at rest, at 2-min intervals during the activity, and at the end of the activity. Change in inspiratory capacity is commonly used to reflect change in end-expiratory lung volume (DeltaEELV) and, therefore, dynamic hyperinflation. The combination of static and dynamic hyperinflation was reflected by inspiratory reserve volume (IRV) during the activity.

RESULTS: Overall, increase in EELV occurred in GOLD II-IV without significant difference between the groups. There was a tendency for a smaller DeltaEELV in GOLD IV. DeltaEELV was inversely related to static hyperinflation. IRV during the daily activity was related to the level of airflow obstruction.

CONCLUSIONS: Dynamic hyperinflation occurs independent of GOLD stage during real-life daily activities. The combination of static and dynamic hyperinflation, however, increases with increasing airflow obstruction.

Do symptoms predict COPD in smokers?

Chest. 2010 Jun;137(6):1345-53 Ohar JA, Sadeghnejad A, Meyers DA, Donohue JF, Bleecker ER. Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA

BACKGROUND: The US Preventive Services Task Force recommends against spirometry in the absence of symptoms. However, as much as 50% of COPD cases in the United States remain undiagnosed.

METHODS: Report of symptoms, smoking history, and spirometric data were collected from subjects screened for a work-related medical evaluation (N = 3,955). Prevalence of airflow obstruction and respiratory symptoms were assessed. Sensitivity, specificity, positive and negative predictive values, and relative risks of predicting symptoms and smoking history for COPD were calculated.

RESULTS: Forty-four percent of smokers in our sample had airways obstruction (AO). Of these, 36% reported a diagnosis of or treatment for COPD. Odds ratio (95% CI) for AO with smoking (> or = 20 pack-years) was 3.73 (3.12- 4.45), 1.98 (1.73-2.27) for cough, 1.79 (1.55-2.08) for dyspnea, 1.95 (1.70-2.34) for sputum, and 2.59 (2.26-2.97) for wheeze. Respiratory symptoms were reported by 92% of smokers with AO, 86% smokers with restriction, 76% smokers with normal spirometry, and 73% of nonsmokers. Sensitivity (92% vs 90%), specificity (19% vs 22%), positive (47% vs 40%) and negative (75% vs 80%) predictive values for the presence of one or more symptoms were similar between smokers and all subjects.

CONCLUSIONS: COPD is underdiagnosed in the United States. Symptoms are frequent in subjects with AO and increase their risk for COPD, but add little beyond age and smoking history to the predictive value of spirometry. In view of the high prevalence of symptoms and their poor predictive value, a simpler and more effective approach would be to screen older smokers.

COPD in England: a comparison of expected, model-based prevalence and observed prevalence from general practice data.

J Public Health (Oxf). 2010 Jun 3 Nacul L, Soljak M, Samarasundera E, Hopkinson NS, Lacerda E, Indulkar T, Flowers J, Walford H, Majeed A. Foundation for Genomics and Population Health, Cambridge CB1 8RN, UK.

BACKGROUND: Primary care data show that 765 000 people in England have a general practice (GP) diagnosis of chronic obstructive pulmonary disease (COPD). We hypothesized that this underestimates actual prevalence, and compared expected prevalence of COPD for English local authority areas with prevalence of diagnosed COPD.

METHODS: Cross-sectional comparison of GP observed and model-based prevalence estimates (using spirometry data without clinical diagnosis) from the Health Survey for England. Local underdiagnosis of COPD was estimated as the ratio of observed to expected cases. We investigated geographical patterns using classical and geographically weighted regression analysis.

RESULTS: Both observed and expected prevalence of COPD varied widely between areas. There was evidence of a 'north-south' divide, with both observed and modelled prevalence higher in the north. The ratio of diagnosed to expected prevalence varied from 0.20 to 0.95, with a mean of 0.52. Underdiagnosis was more pronounced in urban areas, and is particularly severe in London. The inclusion of GP numbers in the analysis yielded a stronger regression relationship, suggesting primary care supply affects diagnosis.

CONCLUSION: Both observed and modelled COPD prevalence varies considerably across England. Cost-effective case-finding strategies should be evaluated, especially in areas where the ratio of observed to expected cases is low.

Resistance training prevents deterioration in quadriceps muscle function during acute exacerbations of chronic obstructive pulmonary disease.

Am J Respir Crit Care Med. 2010 May 15;181(10):1072-7 Troosters T, Probst VS, Crul T, Pitta F, Gayan-Ramirez G, Decramer M, Gosselink R. Respiratory Rehabilitation and Respiratory Division, UZ Gasthuisberg, Herestraat 49, Leuven, Belgium.

RATIONALE: Exacerbations of chronic obstructive pulmonary disease (COPD) acutely reduce skeletal muscle strength and result in long-term loss of functional capacity.

OBJECTIVES: To investigate whether resistance training is feasible and safe and can prevent deteriorating muscle function during exacerbations of COPD.

METHODS: Forty patients (FEV(1) 49 +/- 17% predicted) hospitalized with a severe COPD exacerbation were randomized to receive usual care or an additional resistance training program during the hospital admission. Patients were followed up for 1 month after discharge. Primary outcomes were quadriceps force and systemic inflammation. A muscle biopsy was taken in a subgroup of patients to assess anabolic and catabolic pathways.

MEASUREMENTS AND MAIN RESULTS: Resistance training did not yield higher systemic inflammation as indicated by C-reactive protein levels and could be completed uneventfully. Enhanced quadriceps force was seen at discharge (+9.7 +/- 16% in the training group; -1 +/- 13% in control subjects; P = 0.05) and at 1 month follow-up in the patients who trained. The 6-minute walking distance improved after discharge only in the group who received resistance training (median 34; interquartile range, 14-61 m; P = 0.002). In a subgroup of patients a muscle biopsy showed a more anabolic status of skeletal muscle in patients who followed training. Myostatin was lower (P = 0.03) and the myogenin/MyoD ratio tended to be higher (P = 0.08) in the training group compared with control subjects.

CONCLUSIONS: Resistance training is safe, successfully counteracts skeletal muscle dysfunction during acute exacerbations of COPD, and may up-regulate the anabolic milieu in the skeletal muscle.

Vitamin D deficiency is highly prevalent in COPD and correlates with variants in the vitamin D-binding gene.

Thorax. 2010 Mar;65(3):215-20. Janssens W, Bouillon R, Claes B, Carremans C, Lehouck A, Buysschaert I, Coolen J, Mathieu C, Decramer M, Lambrechts D Respiratory Division, University Hospital Gasthuisberg, KUL Herestraat 49, 3000 Leuven, Belgium.

INTRODUCTION: Vitamin D deficiency has been associated with many chronic illnesses, but little is known about its relationship with chronic obstructive pulmonary disease (COPD).

OBJECTIVES: Serum 25-hydroxyvitamin D (25-OHD) levels were measured in 414 (ex)-smokers older than 50 years and the link between vitamin D status and presence of COPD was assessed. The rs7041 and rs4588 variants in the vitamin D-binding gene (GC) were genotyped and their effects on 25-OHD levels were tested.

RESULTS: In patients with COPD, 25-OHD levels correlated significantly with forced expiratory volume in 1 s (FEV(1)) (r=0.28, p<0.0001). Compared with 31% of the smokers with normal lung function, as many as 60% and 77% of patients with GOLD (Global Initiative for Obstructive Lung Disease) stage 3 and 4 exhibited deficient 25-OHD levels <20 ng/ml (p<0.0001). Additionally, 25-OHD levels were reduced by 25% in homozygous carriers of the rs7041 at-risk T allele (p<0.0001). This correlation was found to be independent of COPD severity, smoking history, age, gender, body mass index, corticosteroid intake, seasonal variation and rs4588 (p<0.0001). Notably, 76% and 100% of patients with GOLD stage 3 and 4 homozygous for the rs7041 T allele exhibited 25-OHD levels <20 ng/ml. Logistic regression corrected for age, gender and smoking history further revealed that homozygous carriers of the rs7041 T allele exhibited an increased risk for COPD (OR 2.11; 95% CI 1.20 to 3.71; p=0.009).

CONCLUSION: Vitamin D deficiency occurs frequently in COPD and correlates with severity of COPD. The data warrant vitamin D supplementation in patients with severe COPD, especially in those carrying at-risk rs7041 variants

COPD and chronic bronchitis risk of indoor air pollution from solid fuel: a systematic review and meta-analysis.

Thorax. 2010 Mar;65(3):221-8. Kurmi OP, Semple S, Simkhada P, Smith WC, Ayres JG. Institute of Occupational and Environmental Medicine, School of Population and Health Sciences, University of Birmingham, Birmingham B15 2TT, UK

BACKGROUND: Over half the world is exposed daily to the smoke from combustion of solid fuels. Chronic obstructive pulmonary disease (COPD) is one of the main contributors to the global burden of disease and can be caused by biomass smoke exposure. However, studies of biomass exposure and COPD show a wide range of effect sizes. The aim of this systematic review was to quantify the impact of biomass smoke on the development of COPD and define reasons for differences in the reported effect sizes.

METHODS: A systematic review was conducted of studies with sufficient statistical power to calculate the health risk of COPD from the use of solid fuel, which followed standardised criteria for the diagnosis of COPD and which dealt with confounding factors. The results were pooled by fuel type and country to produce summary estimates using a random effects model. Publication bias was also estimated.

RESULTS: There were positive associations between the use of solid fuels and COPD (OR=2.80, 95% CI 1.85 to 4.0) and chronic bronchitis (OR=2.32, 95% CI 1.92 to 2.80). Pooled estimates for different types of fuel show that exposure to wood smoke while performing domestic work presents a greater risk of development of COPD and chronic bronchitis than other fuels.

CONCLUSION: Despite heterogeneity across the selected studies, exposure to solid fuel smoke is consistently associated with COPD and chronic bronchitis. Efforts should be made to reduce exposure to solid fuel by using either cleaner fuel or relatively cleaner technology while performing domestic work.

Influence of anxiety on health outcomes in COPD.

Thorax. 2010 Mar;65(3):229-34. Eisner MD, Blanc PD, Yelin EH, Katz PP, Sanchez G, Iribarren C, Omachi TA Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, CA 94143-0111, USA.

BACKGROUND: Psychological functioning is an important determinant of health outcomes in chronic lung disease. To better define the role of anxiety in chronic obstructive pulmonary disease (COPD), a study was conducted of the inter-relations between anxiety and COPD in a large cohort of subjects with COPD and a matched control group.

METHODS: Data were used from the FLOW (Function, Living, Outcomes, and Work) cohort of patients with COPD (n=1202) and matched controls without COPD (n=302). Anxiety was measured using the Anxiety subscale of the Hospital Anxiety and Depression Scale.

RESULTS: COPD was associated with a greater risk of anxiety in multivariable analysis (OR 1.85; 95% CI 1.072 to 3.18). Among patients with COPD, anxiety was related to poorer health outcomes including worse submaximal exercise performance (less distance walked during the 6-min walk test: -66.3 feet for anxious vs non-anxious groups; 95% CI -127.3 to -5.36) and a greater risk of self-reported functional limitations (OR 2.41; 95% CI 1.71 to 3.41). Subjects with COPD with anxiety had a higher longitudinal risk of COPD exacerbation in Cox proportional hazards analysis after controlling for covariates (HR 1.39; 95% CI 1.007 to 1.90).

CONCLUSION: COPD is associated with a higher risk of anxiety. Once anxiety develops among patients with COPD, it is related to poorer health outcomes. Further research is needed to determine whether systematic screening and treatment of anxiety in COPD will improve health outcomes and prevent functional decline and disability.

Systemic impairment in relation to disease burden in patients with moderate COPD eligible for a lifestyle program. Findings from the INTERCOM trial.

Int J Chron Obstruct Pulmon Dis. 2008;3(3):443-51. van Wetering CR, van Nooten FE, Mol SJ, Hoogendoorn M, Rutten-Van Mölken MP, Schols AM. Department of Physiotherapy, Máxima Medical Centre,Veldhoven, The Netherlands.

INTRODUCTION: In contrast with the frequency distribution of chronic obstructive pulmonary disease (COPD) stages in the population, in which the majority of the patients is classified as GOLD 2, much less information is available on the prevalence and implications of systemic manifestations in less severe patients relative to GOLD 3 and 4.

AIM: To characterize local and systemic impairment in relation to disease burden in a group of GOLD 2 COPD patients (n = 127, forced expiratory volume in one second (SD): 67 (11)% pred) that were eligible for the Interdisciplinary Community-based COPD management (INTERCOM) trial.

METHODS: Patients were included for this lifestyle program based on a peak exercise capacity (Wmax) < 70% of predicted. Metabolic and ventilatory response to incremental cycle ergometry, 6 minute walking distance (6MWD), constant work rate test (CWR), lung function, maximal inspiratory pressure (Pimax), quadriceps force (QF), quadriceps average power (QP) (isokinetic dynamometry), handgrip force (HGF) and body composition were measured. Quality of life (QoL) was assessed by the St. George's Respiratory Questionnaire (SGRQ) and dyspnea by the modified Medical Research Council (MRC) dyspnea scale. Exacerbations and COPD-associated hospital admissions in 12 months prior to the start of the study were recorded. Burden of disease was defined in terms of exercise capacity, QoL, hospitalization, and exacerbation frequency. GOLD 2 patients were compared with reference values and with GOLD 3 patients who were also included in the trial.

RESULTS: HGF (77.7 (18.8) % pred) and Pimax (67.1 (22.5)% pred) were impaired in GOLD 2, while QF (93.5 (22.5)% pred) was only modestly decreased. Depletion of FFM was present in 15% of weight stable GOLD 2 patients while only 2% had experienced recent involuntary weight loss. In contrast to Wmax, submaximal exercise capacity, muscle function, and body composition were not significantly different between GOLD 2 and 3 subgroups. Body mass index and fat-free mass index were significantly lower in smokers compared to ex-smokers. In multivariate analysis, QF and diffusing capacity (DLco) were independently associated with Wmax and 6 MWD in GOLD 2 while only 6 MWD was identified as an independent determinant of health-related QoL. HGF was an independent predictor of hospitalization.

CONCLUSIONS: This study shows that also in patients with moderate COPD, eligible for a lifestyle program based on a decreased exercise capacity, systemic impairment is an important determinant of disease burden and that smoking affects body composition.

Early life origins of chronic obstructive pulmonary disease

Thorax. 2010 Jan;65(1):14-20. Svanes C, Sunyer J, Plana E, Dharmage S, Heinrich J, Jarvis D, de Marco R, Norbäck D, Raherison C, Villani S, Wjst M, Svanes K, Antó JM. Section of Thoracic Medicine, Institute of Medicine, University of Bergen, Norway.

BACKGROUND: Early life development may influence subsequent respiratory morbidity. The impact of factors determined in childhood on adult lung function, decline in lung function and chronic obstructive pulmonary disease (COPD) was investigated.

METHODS: European Community Respiratory Health Survey participants aged 20-45 years randomly selected from general populations in 29 centres underwent spirometry in 1991-3 (n = 13 359) and 9 years later (n = 7738). Associations of early life factors with adult forced expiratory volume in 1 s (FEV(1)), FEV(1) decline and COPD (FEV(1)/FVC ratio <70% and FEV(1) <80% predicted) were analysed with generalised estimating equation models and random effects linear models.

RESULTS: Maternal asthma, paternal asthma, childhood asthma, maternal smoking and childhood respiratory infections were significantly associated with lower FEV(1) and defined as "childhood disadvantage factors"; 40% had one or more childhood disadvantage factors which were associated with lower FEV(1) (men: adjusted difference 95 ml (95% CI 67 to 124); women: adjusted difference 60 ml (95% CI 40 to 80)). FEV(1) decreased with increasing number of childhood disadvantage factors (> or =3 factors, men: 274 ml (95% CI 154 to 395), women: 208 ml (95% CI 124 to 292)). Childhood disadvantage was associated with a larger FEV(1) decline (1 factor: 2.0 ml (95% CI 0.4 to 3.6) per year; 2 factors: 3.8 ml (95% CI 1.0 to 6.6); > or =3 factors: 2.2 ml (95% CI -4.8 to 9.2)). COPD increased with increasing childhood disadvantage (1 factor, men: OR 1.7 (95% CI 1.1 to 2.6), women: OR 1.6 (95% CI 1.01 to 2.6); > or =3 factors, men: OR 6.3 (95% CI 2.4 to 17), women: OR 7.2 (95% CI 2.8 to 19)). These findings were consistent between centres and when subjects with asthma were excluded.

CONCLUSIONS: People with early life disadvantage have permanently lower lung function, no catch-up with age but a slightly larger decline in lung function and a substantially increased COPD risk. The impact of childhood disadvantage was as large as that of heavy smoking. Increased focus on the early life environment may contribute to the prevention of COPD.

Short- and long-term efficacy of a community-based COPD management programme in less advanced COPD: a randomised controlled trial.

Thorax. 2010 Jan;65(1):7-13 van Wetering CR, Hoogendoorn M, Mol SJ, Rutten-van Mölken MP, Schols AM. Department of Respiratory Medicine, Máxima Medical Centre, Veldhoven, The Netherlands.

BACKGROUND: The effectiveness of pulmonary rehabilitation in advanced COPD is well established, but few data are available in less advanced disease.

METHODS: In a 2 year randomised controlled trial, 199 patients with an average moderate airflow obstruction but impaired exercise capacity (mean (SD) forced expiratory volume in 1 s (FEV(1)) 60 (16)%, peak work load (Wmax) <70%) were randomised to the INTERdisciplinary COMmunity-based COPD management programme (INTERCOM) or usual care. Intervention consisted of 4 months multidisciplinary rehabilitation followed by a 20-month maintenance phase. Outcomes (4, 12, 24 months): health-related quality of life (St George's Respiratory Questionnaire (SGRQ)), exacerbation frequency, MRC dyspnoea score, cycle endurance time (CET), 6-minute walking distance (6MWD), skeletal muscle strength and patients' and caregivers' perceived effectiveness.

RESULTS: Between-group comparison after 4 months revealed the following mean (SE) significant differences in favour of INTERCOM: SGRQ total score 4.06 (1.39), p = 0.004; activity and impact subscores, p<0.01; MRC score 0.33 (0.13), p = 0.01; Wmax 6.0 (2.3) Watt, p = 0.02; CET 221 (104) s, p = 0.04; 6MWD 13 (6) m, p = 0.02; hand grip force 4.3 (1.5) lb, p<0.01; and fat-free mass index 0.34 (0.13) kg/m(2), p = 0.01. Between-group differences over 2 years were as follows: SGRQ 2.60 (1.3), p = 0.04; MRC score 0.21 (0.10), p = 0.048; CET 253 (104) s, p = 0.0156; 6MWD 18 (8) m, p = 0.0155. Exacerbation frequency was not different (RR 1.29 (95% CI 0.89 to 1.87)). Patients' and caregivers' perceived effectiveness significantly favoured the INTERCOM programme (p<0.01).

CONCLUSIONS: This study shows that a multidisciplinary community-based disease management programme is also effective in patients with COPD with exercise impairment but less advanced airflow obstruction.

Home telehealth for chronic obstructive pulmonary disease: a systematic review and meta-analysis

J Telemed Telecare 2010;16:120-127 Julie Polisena * , Khai Tran *, Karen Cimon *, Brian Hutton *, Sarah McGill *, Krisan Palmer {dagger} and Richard E Scott {ddagger} * Canadian Agency for Drugs and Technologies in Health (CADTH), Ottawa; {dagger}Atlantic Health Sciences Corporation, Saint John; {ddagger}Centre for Innovation in Health Technology, Faculty of Medicine, University of Calgary, Calgary, Canada

We conducted a systematic review of the literature about home telehealth for chronic obstructive pulmonary disease (COPD) compared with usual care. An electronic literature search identified 6241 citations. From these, nine original studies (10 references) relating to 858 patients were selected for inclusion in the review. Four studies compared home telemonitoring with usual care, and six randomized controlled trials compared telephone support with usual care. Clinical heterogeneity was present in many of the outcomes measured. Home telehealth (home telemonitoring and telephone support) was found to reduce rates of hospitalization and emergency department visits, while findings for hospital bed days of care varied between studies. However, the mortality rate was greater in the telephone-support group compared with usual care (risk ratio = 1.21; 95% CI: 0.84 to 1.75).

Home telehealth interventions were similar or better than usual care for quality of life and patient satisfaction outcomes.

Prevalence and underdiagnosis of chronic obstructive pulmonary disease among patients at risk in primary care

Kylie Hill, BSc(PT) PhD, Roger S. Goldstein, MB ChB, Gordon H. Guyatt, MD MSc, Maria Blouin, RRT, Wan C. Tan, MBBS MD, Lori L. Davis, BSc, Diane M. Heels-Ansdell, MSc, Marko Erak, Pauline J. Bragaglia, BMedSc MD, Itamar E. Tamari, MD, Richard Hodder, MSc MD and Matthew B. Stanbrook, MD PhD

Background: People with known risk factors for chronic obstructive pulmonary disease (COPD) are important targets for screening and early intervention. We sought to measure the prevalence of COPD among such individuals visiting a primary care practitioner for any reason. We also evaluated the accuracy of prior diagnosis or nondiagnosis of COPD and identified associated clinical characteristics.

Methods: We recruited patients from three primary care sites who were 40 years or older and had a smoking history of at least 20 pack-years. Participants were asked about respiratory symptoms and underwent postbronchodilator spirometry. COPD was defined as a ratio of forced expiratory volume in the first second of expiration to forced vital capacity (FEV1/FVC) of less than 0.7 and an FEV1 of less than 80% predicted.

Results: Of the 1459 patients who met the study criteria, 1003 (68.7%) completed spirometry testing. Of these, 208 were found to have COPD, for a prevalence of 20.7% (95% confidence interval 18.3%–23.4%). Of the 205 participants with COPD who completed the interview about respiratory symptoms before spirometry, only 67 (32.7%) were aware of their diagnosis before the study. Compared with patients in whom COPD had been correctly diagnosed before the study, those in whom COPD had been over-diagnosed or undiagnosed were similar in terms of age, sex, current smoking status and number of visits to a primary care practitioner because of a respiratory problem.

Interpretation: Among adult patients visiting a primary care practitioner, as many as one in five with known risk factors met spirometric criteria for COPD. Underdiagnosis of COPD was frequent, which suggests a need for greater screening of at-risk individuals. Knowledge of the prevalence of COPD will help plan strategies for disease management.

CPAP and survival in moderate-to-severe obstructive sleep apnoea syndrome and hypoxaemic COPD.

Eur Respir J. 2010 Jan;35(1):132-7. Machado MC, Vollmer WM, Togeiro SM, Bilderback AL, Oliveira MV, Leitão FS, Queiroga F Jr, Lorenzi-Filho G, Krishnan JA Division of Respiratory Diseases, Federal University of São Paulo, Paulista School of Medicine, São Paulo, Brazil.

Obstructive sleep apnoea syndrome (OSAS) often coexists in patients with chronic obstructive pulmonary disease (COPD). The present prospective cohort study tested the effect of OSAS treatment with continuous positive airway pressure (CPAP) on the survival of hypoxaemic COPD patients. It was hypothesised that CPAP treatment would be associated with higher survival in patients with moderate-to-severe OSAS and hypoxaemic COPD receiving long-term oxygen therapy (LTOT). Prospective study participants attended two outpatient advanced lung disease LTOT clinics in São Paulo, Brazil, between January 1996 and July 2006. Of 603 hypoxaemic COPD patients receiving LTOT, 95 were diagnosed with moderate-to-severe OSAS. Of this OSAS group, 61 (64%) patients accepted and were adherent to CPAP treatment, and 34 did not accept or were not adherent and were considered not treated. The 5-yr survival estimate was 71% (95% confidence interval 53-83%) and 26% (12-43%) in the CPAP-treated and nontreated groups, respectively (p<0.01). After adjusting for several confounders, patients treated with CPAP showed a significantly lower risk of death (hazard ratio of death versus nontreated 0.19 (0.08-0.48)).

The present study found that CPAP treatment was associated with higher survival in patients with moderate-to-severe OSAS and hypoxaemic COPD receiving LTOT.

Is INTERdisciplinary COMmunity-based COPD management (INTERCOM) cost-effective?

Eur Respir J. 2010 Jan;35(1):79-87. Hoogendoorn M et al. Institute for Medical Technology Assessment (IMTA), Erasmus MC, Rotterdam, The Netherlands.

The study aimed to estimate the cost-effectiveness of interdisciplinary community-based chronic obstructive pulmonary disease (COPD) management in patients with COPD. We conducted a cost-effectiveness analysis alongside a 2-yr randomised controlled trial, in which 199 patients with less advanced airflow obstruction and impaired exercise capacity were assigned to the INTERCOM programme or usual care. The INTERCOM programme consisted of exercise training, education, nutritional therapy and smoking cessation counselling offered by community-based physiotherapists and dieticians and hospital-based respiratory nurses. All-cause resource use during 2 yrs was obtained by self-report and from hospital and pharmacy records. Health outcomes were the St George's Respiratory Questionnaire (SGRQ), exacerbations and quality-adjusted life years (QALYs). The INTERCOM group had 30% (95% CI 3-56%) more patients with a clinically relevant improvement in SGRQ total score, 0.08 (95% CI -0.01-0.18) more QALYs per patient, but a higher mean number of exacerbations, 0.84 (95% CI -0.07-1.78). Mean total 2-yr costs were euro2,751 (95% CI -euro632-euro6,372) higher for INTERCOM than for usual care, which resulted in an incremental cost-effectiveness ratio of euro9,078 per additional patient with a relevant improvement in SGRQ or euro32,425 per QALY.

INTERCOM significantly improved disease-specific quality of life, but did not affect exacerbation rate. The cost per QALY ratio was moderate, but within the range of that generally considered to be acceptable.

COPD and the risk of depression.

Chest. 2010 Feb;137(2):341-7. Schneider C, Jick SS, Bothner U, Meier CR. Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University Basel, Switzerland.

BACKGROUND: Chronic comorbidities are often associated with depression. Most previous studies exploring the association between COPD and depression were rather small and based on a cross-sectional study design. We conducted a large population-based study on the risk of developing an incident depression diagnosis in association with a previous COPD diagnosis.

METHODS: We used the UK-based General Practice Research Database to assess and compare the prevalence of a history of depression and to quantify the risk of developing incident depression in patients with COPD and patients without COPD between 1995 and 2005. We conducted a nested case-control analysis, matching up to four patients who did not develop depression for each case patient with depression, to further analyze the impact of COPD severity.

RESULTS: In a study population of 35,722 patients with COPD and 35,722 patients without COPD, the prevalence of diagnosed depression prior to the first COPD diagnosis was higher in the population with COPD (23.1%) than among patients without COPD (16.8%). The incidence rate of a new-onset diagnosis of depression after the first COPD diagnosis was 16.2/1,000 person-years (py) in the COPD group, whereas it was only 9.4/1,000 py in the COPD-free comparison group. In the nested case-control analysis, patients with severe COPD had the highest risk of developing depression (odds ratio, 2.01; 95% CI, 1.45-2.78).

CONCLUSION: This large observational study provides further evidence that patients with COPD are at an increased risk of developing depression.

Resistance training prevents deterioration in quadriceps muscle function during acute exacerbations of chronic obstructive pulmonary disease.

Am J Respir Crit Care Med. 2010 May 15;181(10):1072-7. Troosters T, Probst VS, Crul T, Pitta F, Gayan-Ramirez G, Decramer M, Gosselink R. Respiratory Rehabilitation and Respiratory Division, UZ Gasthuisberg, Herestraat 49, Leuven, Belgium.

The impact of home-based physiotherapy interventions on breathlessness during activities of daily living in severe COPD: a systematic review.

Physiotherapy. 2010 Jun;96(2):108-19. Thomas MJ, Simpson J, Riley R, Grant E. University of Liverpool, Directorate of Physiotherapy, The Quadrangle, Brownlow Hill, Liverpool L69 3BG, UK.

OBJECTIVES: To conduct a systematic review and meta-analysis to determine the impact of home-based physiotherapy interventions on breathlessness during activities of daily living (ADL) in severe chronic obstructive disease (COPD).

DATA SOURCES: The electronic databases AMED, CINAHL, Cochrane Central Register of Controlled Trials, Embase, Medline and Physiotherapy Evidence Database (PEDro) were searched from their inception to Week 20 2008. Bibliographies of all potentially relevant retrieved studies, identified relevant systematic reviews and international guidelines were searched by hand.

REVIEW METHODS: Inclusion criteria consisted of individuals over 18 years of age with severe COPD (defined as forced expiratory volume in 1 second < or = 50% predicted) without cardiovascular co-morbidities, home-based interventions and valid, reliable breathlessness ADL outcome measures. The PEDro scale assessed methodological quality. Data extraction included baseline characteristics, treatment intervention, frequency of training, level of supervision, breathlessness ADL outcome measure and results. Where possible, a random-effects meta-analysis was applied to appropriate trial data to produce overall quantitative results.

RESULTS: Seven studies, providing nine data sets, met the inclusion criteria. Trial PEDro scores ranged from 4 to 7 out of 10. Studies were homogenous at baseline regarding age and COPD severity, although subjects were predominantly male. Five studies investigated inspiratory or expiratory muscle training, and two studies investigated exercises. Statistically significant breathlessness ADL outcome improvements were reported for all interventions except expiratory muscle training. Five studies demonstrated clinical significance (four for inspiratory muscle training and one for exercise). However, due to heterogeneity among study interventions and outcomes, meta-analysis was only considered clinically appropriate on one occasion to pool three inspiratory muscle training studies in relation to breathlessness score. The random-effects meta-analysis indicated that, on average, inspiratory muscle training improved the breathlessness score significantly by 2.36 (95% confidence interval 0.76 to 3.96) compared with controls.

CONCLUSION: Inspiratory muscle training and exercise are home-based physiotherapy interventions that may improve breathlessness during ADL in severe COPD. Administration can only be advocated tentatively in outpatient services and primary care at this stage because further higher quality, more homogeneous research with larger sample sizes is required to substantiate the current findings.

GOLD stage 0 is associated with excess FEV1 decline in a representative population sample.

Chest. 2010 Apr 23. Brito-Mutunayagam R, Appleton SL, Wilson DH, Ruffin RE, Adams RJ; on behalf of the North West Adelaide Cohort Health Study Team.. 1 Department of Medicine, Rockhampton Base Hospital, Rockhampton, Queensland, Australia.

BACKGROUND: The Global Initiative for Obstructive Lung Disease (GOLD) guideline removed stage-0 (chronic cough and sputum without airflow obstruction, GOLD-0) due to poor prognostic value. Preventative intervention may be relevant for those with chronic symptoms, therefore, we assessed the stability of, morbidity and FEV(1) decline associated with GOLD stage-0 in a representative adult population cohort.

METHODS: Baseline (n=4060) and follow-up (n=3206, mean 3.5 years) clinic assessment of the North West Adelaide Health Study included post-bronchodilator spirometry, anthropometry, and measures of doctor-diagnosed asthma, respiratory symptoms, smoking status, quality of life, and depression.

RESULTS: Baseline GOLD-0 prevalence was 17.0% (n=584). At follow-up (n=420), 39.8% remained stable, 1.4% progressed to GOLD stage 1-2 and 58.8% resolved to no symptoms. Persistent GOLD-0 at follow-up was associated with persistent smoking (males: OR=11.9, 95%CI: 6.4-22.1, females: OR=4.0, 2.1-7.4), depressive symptoms (males: OR=3.8, 1.9-7.6; females: OR=3.2, 1.7-5.9) and with highest quartile of FEV(1) decline/year (OR=2.1 1.2-3.7), the metabolic syndrome (OR=1.7, 1.01-3.0) in males, and in females, with older age. These associations generally held in smokers and never-smokers. Resolving GOLD-0 was associated with smoking cessation (OR=13.7, 4.6-40.1), FEV(1) decline/year below the median (OR=2.0, 1.1-3.5), normal BMI, and younger age groups. Sensitivity analyses based upon the presence of sputum did not change the observed associations.

CONCLUSION: Persistent GOLD-0 identified people with physical and psychological morbidity in both smokers and non-smokers. Identification of those with persistent respiratory symptoms is therefore important. Excess FEV(1) decline in men suggests GOLD-0 may identify a group at risk to progress to COPD over time.

Co-existence of COPD and left ventricular dysfunction in vascular surgery patients.

Respir Med. 2010 May;104(5):690-6. Flu WJ, van Gestel YR, van Kuijk JP, Hoeks SE, Kuiper R, Verhagen HJ, Bax JJ, Sin DD, Poldermans D. Department of Anaesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands.

BACKGROUND: The co-existence between chronic obstructive pulmonary disease (COPD) and heart failure has been previously described. However, the co-existence between COPD and subclinical left ventricular (LV) dysfunction, without the presence of heart failure symptoms, is less well understood. This study determined the relationship and clinical relevance of COPD and subclinical LV dysfunction in vascular surgery patients.

METHODS: 1005 consecutive vascular surgery patients were included in which COPD was determined using spirometry and LV function using echocardiography. Mild COPD was defined as FEV(1)>or=80% of predicted+FEV(1)/FVC-ratio<0.70. Moderate/severe COPD was defined as FEV(1)<80% of predicted+FEV(1)/FVC-ratio<0.70. Systolic LV dysfunction was defined as LV ejection fraction <50% and diastolic LV dysfunction was diagnosed based on E/A-ratio, pulmonary vein flow and deceleration time. Multivariate regression analyses were used to evaluate the impact of COPD and LV dysfunction on all-cause mortality. The mean follow-up time was 2.2+/-1.8 years.

RESULTS: Both, mild and moderate/severe COPD were associated with increased risk for subclinical LV dysfunction with odds ratio of 1.6 (95%-CI=1.1-2.3) and 1.7 (95%-CI=1.2-2.4), respectively. Mild- or moderate/severe COPD in combination with LV dysfunction was associated with increased risk for all-cause mortality (mild: hazard ratio 1.7; 95%-CI=1.1-3.6, moderate/severe: hazard ratio 2.5; 95%-CI=1.5-4.7).

CONCLUSIONS: COPD was associated with increased risk for subclinical LV dysfunction. COPD+subclinical LV dysfunction was associated with increased risk for all-cause mortality compared to patients with COPD+normal LV function. Echocardiography may be useful to detect subclinical cardiovascular disease and risk-stratify COPD patients undergoing vascular surgery.

Predictors of low bone mineral density in elderly males with chronic obstructive pulmonary disease: the role of body mass index.

Aging Male. 2010 Jun;13(2):142-7. Coin A, Sergi G, Marin S, Vianello A, Perissinotto E, Sarti S, Rinaldi G, Mosele M, Meral Inelmen E, Enzi G, Manzato E. Department of Medical and Surgical Sciences, University of Padova, Italy.

OBJECTIVE: The aim of this study was to investigate the relationships between nutritional indices (Body mass index (BMI), serum albumin), sarcopenia, bone mineral density (BMD) and the severity of their pulmonary obstruction in elderly patients with chronic obstructive pulmonary disease (COPD).

METHODS: The method involved was a prospective transversal study; 82 males >65 years old, 41 stable patients with COPD and 41 healthy elderly individuals (controls). All subjects underwent spirometry, biochemical analyses and dual energy X-ray absorptiometry. The significance of the differences between mean values and prevalence rates was tested. The relationships between BMD and independent predictors were analysed by multiple linear regressions. Logistic regression models were applied on dichotomised variables.

RESULTS: In patients with COPD, the prevalence of osteoporosis was higher in subjects with sarcopenia (46% vs. 0%; p < 0.05) and with BMI < 25.1 kg/m(2) (58% vs. 15%; p < 0.02). Multiple regression analysis indicated that BMI, appendicular skeletal muscle mass (ASMM), albumin, and forced expiration volume after 1 s (FEV1) explained the 70% of BMD variability at the hip and 56% at the spine. Logistic regression showed that a BMI < 25.1 kg/m(2) was independently associated with osteoporosis risk (OR = 10.0; 95%CI 1.3-76); no independent effect emerged for FEV1% (<and 50%).

CONCLUSION: In elderly males with COPD, the BMI values < or =25 kg/m (2) are more strongly related to low BMD levels than albumin values. Among those patients, BMI values within the normal range for younger adults might point out a higher risk of osteoporosis.

General practitioner's adherence to the COPD GOLD guidelines: baseline data of the Swiss COPD Cohort Study.

Swiss Med Wkly. 2010 Apr 21. Jochmann A, Neubauer F, Miedinger D, Schafroth S, Tamm M, Leuppi JD.

PRINCIPLES: Chronic obstructive pulmonary disease (COPD) is a major burden on patients and healthcare systems. Diagnosis and the management of COPD are often administered by general practitioners (GPs). This analysis investigated the adherence of GPs in Switzerland to the Global Initiative for Chronic Obstructive Lung Diseases (GOLD) guidelines.

METHODS: As part of an ongoing investigation into the effect of GPs prescriptions on the clinical course of COPD, 139 GPs submitted a standardised questionnaire for each COPD patient recruited. Information requested included spirometric parameters, management and demographic data. Participating GPs were provided with and received instruction on a spirometer with automatic feedback on quality. Patients were grouped by the investigators into the GOLD COPD severity classifications, based on spirometric data provided. Data from the questionnaires were compared between the groups and management was compared with the recommendations of GOLD.

RESULTS: Of the 615 patients recruited, 44% did not fulfil GOLD criteria for COPD. Pulmonary rehabilitation was prescribed to 5% of all patients and less than one-third of patients exercised regularly. Less than half the patients in all groups used short-acting bronchodilators. Prescribing long-acting bronchodilators or inhaled corticosteroids conformed to GOLD guidelines in two-thirds of patients with GOLD stage III or IV disease, and approximately half of the less severe patients. Systemic steroids were inappropriately prescribed during stable disease in 6% of patients.

CONCLUSIONS: Adherence to GOLD (COPD) guidelines is low among GPs in Switzerland and COPD is often misdiagnosed or treated inappropriately. This is probably due to poor knowledge of disease definitions

Recent improvement in long-term survival after a COPD hospitalisation.

Thorax. 2010 Apr;65(4):298-302. Almagro P, Salvadó M, Garcia-Vidal C, Rodriguez-Carballeira M, Delgado M, Barreiro B, Heredia JL, Soriano JB. Internal Medicine, Hospital Mútua de Terrassa, Pza. Dr. Robert no. 5, Terrassa 08221, Barcelona, Spain.

BACKGROUND: Evidence-based international guidelines on chronic obstructive pulmonary disease (COPD), and their corresponding recommendations, were established to improve individual COPD prognosis, and ultimately to improve survival. The aim of this study was to determine whether the long-term mortality after discharge from a COPD hospitalisation has improved recently, and the effect of co-morbidity treatment in improving COPD prognosis.

METHODS: In a prospective cohort study design of two cohorts 7 years apart, patients discharged from the same university hospital after a COPD exacerbation were followed-up, and their outcomes compared. Demographic and clinical variables, as well as lung function, were collected with the same protocol by the same investigators. Comprehensive assessments of co-morbidities and treatments were undertaken. Kaplan-Meier survival curves were estimated, and outcomes were compared by means of Cox regression methods.

RESULTS: Overall, 135 participants in the 1996-7 cohort and 181 participants in the 2003-4 cohort were studied. Both cohorts were comparable in their baseline demographic and clinical variables, and median follow-up was 439 days. The 3-year mortality was lower in the 2003-4 cohort (38.7%) than in the 1996-7 cohort (47.4%) (p=0.017), and the RR of death after adjustment for gender, age, body mass index, co-morbidities, lung function and mMRC (modified Medical Research Council scale) dyspnoea was 0.66 (95% CI 0.45 to 0.97). Long-term survival improved in the second cohort for patients with COPD with heart failure or cancer (p<0.001).

CONCLUSIONS: A recent trend towards better prognosis of patients with COPD after hospital discharge is described and is likely to be associated with better management and treatment of COPD and co-morbidities

The COPD Helplessness Index: a new tool to measure factors affecting patient self-management.

Chest. 2010 Apr;137(4):823-30. Omachi TA, Katz PP, Yelin EH, Iribarren C, Knight SJ, Blanc PD, Eisner MD. University of California, San Francisco, Box 0111, 505 Parnassus Ave, San Francisco, CA 94143-0111, USA.

BACKGROUND: Psychologic factors affect how patients with COPD respond to attempts to improve their self-management skills. Learned helplessness may be one such factor, but there is no validated measure of helplessness in COPD.

METHODS: We administered a new COPD Helplessness Index (CHI) to 1,202 patients with COPD. Concurrent validity was assessed through association of the CHI with established psychosocial measures and COPD severity. The association of helplessness with incident COPD exacerbations was then examined by following subjects over a median 2.1 years, defining COPD exacerbations as COPD-related hospitalizations or ED visits.

RESULTS: The CHI demonstrated internal consistency (Cronbach alpha = 0.75); factor analysis was consistent with the CHI representing a single construct. Greater CHI-measured helplessness correlated with greater COPD severity assessed by the BODE (Body-mass, Obstruction, Dyspnea, Exercise) Index (r = 0.34; P < .001). Higher CHI scores were associated with worse generic (Short Form-12, Physical Component Summary Score) and respiratory-specific (Airways Questionnaire 20) health-related quality of life, greater depressive symptoms, and higher anxiety (all P < .001). Controlling for sociodemographics and smoking status, helplessness was prospectively associated with incident COPD exacerbations (hazard ratio = 1.31; P < .001). After also controlling for the BODE Index, helplessness remained predictive of COPD exacerbations among subjects with BODE Index </= median (hazard ratio = 1.35; P = .01), but not among subjects with higher BODE Index values (hazard ratio = 0.93; P = .34).

CONCLUSIONS: The CHI is an internally consistent and valid measure, concurrently associated with health status and predictively associated with COPD exacerbations. The CHI may prove a useful tool in analyzing differential clinical responses mediated by patient-centered attributes.

Chronic renal failure: a neglected comorbidity of COPD.Chronic

Chest. 2010 Apr;137(4):831-7. Incalzi RA, Corsonello A, Pedone C, Battaglia S, Paglino G, Bellia V; Extrapulmonary Consequences of COPD in the Elderly Study Investigators. Istituto Nazionale di Ricovero e Cura per Anziani, C.da Muoio Piccolo, I-87100 Cosenza, Italy.

BACKGROUND: To the best of our knowledge, the association between COPD and chronic renal failure (CRF) has never been assessed. Lean mass is frequently reduced in COPD, and the glomerular filtration rate (GFR) might be depressed in spite of normal serum creatinine (concealed CRF). We investigated the prevalence and correlates of both concealed and overt CRF in elderly patients with COPD.

METHODS: We evaluated 356 consecutive elderly outpatients with COPD enrolled in the Extrapulmonary Consequences of COPD in the Elderly Study and 290 age-matched outpatients free from COPD. The GFR was estimated using the Modification of Diet in Renal Disease Study Group equation. Patients were categorized as having normal renal function (GFR > or = 60 mL/min/1.73 m(2)), concealed CRF (normal serum creatinine and reduced GFR), or overt CRF (increased serum creatinine and reduced GFR). Independent correlates of CRF were investigated by logistic regression analysis.

RESULTS: The prevalence of concealed and overt CRF in patients with COPD was 20.8% and 22.2%, respectively. Corresponding figures in controls were 10.0% and 13.4%, respectively. COPD and age were significantly associated with both concealed CRF (COPD: odds ratio [OR] = 2.19, 95% CI = 1.17-4.12; age: OR = 1.06, 95% CI = 1.04-1.09) and overt CRF (COPD: OR = 1.94, 95% CI = 1.01-4.66; age: OR = 1.06, 95% CI = 1.04-1.10). Diabetes (OR = 1.96, 95% CI = 1.02-3.76), hypoalbuminemia (OR = 2.83, 95% CI = 1.70-4.73), and muscle-skeletal diseases (OR = 1.78, 95% CI = 1.01-3.16) were significant correlates of concealed CRF. BMI (OR = 1.05, 95% CI = 1.01-1.10) and diabetes (OR = 2.25, 95% CI = 1.26-4.03) were significantly associated with overt CRF.

CONCLUSIONS: CRF is highly prevalent in patients with COPD, even with normal serum creatinine, and might contribute to explaining selected conditions such as anemia that are frequent complications of COPD.

The impact of disability on depression among individuals with COPD

Chest. 2010 Apr;137(4):838-45. Katz PP, Julian LJ, Omachi TA, Gregorich SE, Eisner MD, Yelin EH, Blanc PD. University of California, San Francisco, 3333 California St, Ste 270, San Francisco, CA 94143-0920, USA.

BACKGROUND: Both disability and depression are common in COPD, but limited information is available on the time-ordered relationship between increases in disability and depression onset.

METHODS: Subjects were members of a longitudinal cohort with self-reported physician-diagnosed COPD, emphysema, or chronic bronchitis. Data were collected through three annual structured telephone interviews (T1, T2, and T3). Depression was defined as a score >/= 4 on the Geriatric Depression Scale Short Form (S-GDS). Disability was measured with the Valued Life Activities (VLA) scale; three disability scores were calculated: percent of VLAs unable to perform, percent of VLAs affected (unable to perform or with some degree of difficulty), and mean VLA difficulty rating. Disability increases were defined as a 0.5 SD increase in disability score between T1 and T2. Multiple logistic regression analyses estimated the risk of T3 depression following a T1 to T2 disability increase for the total cohort and then excluding individuals who met the depression criterion at T1 or T2.

RESULTS: Approximately 30% of subjects met the depression criterion each year. Eight percent to 19% experienced a T1 to T2 disability increase, depending on the disability measure. Including all cohort members and controlling for baseline S-GDS scores, T1 to T2 increases in disability yielded a significantly elevated risk of T3 depression (% affected odds ratio [OR] =3.6; 95% CI, [1.7, 7.7]; % unable OR = 6.1 [17, 21.8]; mean difficulty OR= 3.6 [1.7, 8.0]). Omitting individuals depressed at T1 or T2 yielded even stronger risk estimates for % unable (OR = 13.4 [2.0, 91.4]) and mean difficulty (OR = 3.9 [1.3, 11.8]).

CONCLUSIONS: Increases in VLA disability are strongly predictive of the onset of depression.

Measurement of COPD severity using a survey-based score: validation in a clinically and physiologically characterized cohort.

Chest. 2010 Apr;137(4):846-51. Eisner MD, Omachi TA, Katz PP, Yelin EH, Iribarren C, Blanc PD. University of California San Francisco, 505 Parnassus Ave, M-1097, San Francisco, CA 94143-0111, USA.

BACKGROUND: A comprehensive survey-based COPD severity score has usefulness for epidemiologic and health outcomes research. We previously developed and validated the survey-based COPD Severity Score without using lung function or other physiologic measurements. In this study, we aimed to further validate the severity score in a different COPD cohort and using a combination of patient-reported and objective physiologic measurements.

METHODS: Using data from the Function, Living, Outcomes, and Work cohort study of COPD, we evaluated the concurrent and predictive validity of the COPD Severity Score among 1,202 subjects. The survey instrument is a 35-point score based on symptoms, medication and oxygen use, and prior hospitalization or intubation for COPD. Subjects were systemically assessed using structured telephone survey, spirometry, and 6-min walk testing.

RESULTS: We found evidence to support concurrent validity of the score. Higher COPD Severity Score values were associated with poorer FEV(1) (r = -0.38), FEV(1)% predicted (r = -0.40), Body mass, Obstruction, Dyspnea, Exercise Index (r = 0.57), and distance walked in 6 min (r = -0.43) (P < .0001 in all cases). Greater COPD severity was also related to poorer generic physical health status (r = -0.49) and disease-specific health-related quality of life (r = 0.57) (P < .0001). The score also demonstrated predictive validity. It was also associated with a greater prospective risk of acute exacerbation of COPD defined as ED visits (hazard ratio [HR], 1.31; 95% CI, 1.24-1.39), hospitalizations (HR, 1.59; 95% CI, 1.44-1.75), and either measure of hospital-based care for COPD (HR, 1.34; 95% CI, 1.26-1.41) (P < .0001 in all cases).

CONCLUSION: The COPD Severity Score is a valid survey-based measure of disease-specific severity, both in terms of concurrent and predictive validity. The score is a psychometrically sound instrument for use in epidemiologic and outcomes research in COPD.

Pulmonary rehabilitation for chronic obstructive pulmonary disease: a pilot study evaluating a once-weekly versus twice-weekly supervised programme.

Physiotherapy. 2010 Mar;96(1):68-74. Liddell F, Webber J. Department of Respiratory Medicine, East and North Herts NHS and Primary Care Trusts, Lister Hospital, Stevenage SG1 4AB, UK.

OBJECTIVES: To compare the effectiveness of a once-weekly supervised pulmonary rehabilitation programme with a standard twice-weekly format.

DESIGN: Randomised trial of equivalency.

SETTING: Pulmonary rehabilitation service of a primary care trust delivered at two physiotherapy outpatient departments.

PARTICIPANTS: Thirty patients with chronic obstructive pulmonary disease.

OUTCOME MEASURES: Primary outcomes were the Incremental Shuttle Walking Test (ISWT), Endurance Shuttle Walking Test (ESWT) and St George's Respiratory Questionnaire (SGRQ), assessed at baseline and at completion of the supervised programme. Secondary outcomes were home-exercise activity, attendance levels and patient satisfaction with the programme.

INTERVENTIONS: The once-weekly group (n=15) received one supervised rehabilitation session per week, and the twice-weekly group (n=15) received two sessions per week, both for 8 weeks, together with a home-exercise plan. RESULTS: After pulmonary rehabilitation, the groups showed similar improvements in exercise tolerance (median values: ISWT once-weekly 60metres, twice-weekly 50metres; ESWT once-weekly 226seconds, twice-weekly 109seconds). However, for health-related quality-of-life, the once-weekly group's score did not change (SGRQ 0), whereas an improvement was seen for the twice-weekly group (SGRQ 3.7). The number of home-exercise sessions and attendance levels were similar between the groups. Patient satisfaction with both formats was high and almost identical between the groups.

CONCLUSIONS: This pilot provides data to inform a larger study and shows that the methodology is feasible. The findings suggest that once-weekly supervision may be capable of producing equivalent improvements in exercise tolerance as a twice-weekly programme, but the health-related quality-of-life outcome appeared to be poorer for once-weekly supervision.

Primary care management of chronic obstructive pulmonary disease: an integrated goal-directed approach.

Curr Opin Pulm Med. 2010 Mar;16(2):83-8. Braman SS, Lee DW. Division of Pulmonary and Critical Care Medicine, The Alpert Medical School of Brown University, Providence, Rhode Island 02903, USA.

PURPOSE OF REVIEW: This review discusses the role of the primary care physician in the care of the patient with chronic obstructive pulmonary disease and considers how an integrated chronic care model can be applied.

RECENT FINDINGS: Evidence suggests that a multidisciplinary approach can be successfully applied to a chronic obstructive pulmonary disease patient. These interventions can lead to improvement in quality of life and reduced healthcare utilization.

SUMMARY: An integrated care program for chronic obstructive pulmonary disease to assist the primary care provider should include the elements of the chronic care model. The support of a community-based outreach nurse, allied health staff, rehabilitation services and a case manager can assure best practices and identify gaps in quality care

COPD health care in Sweden - A study in primary and secondary care.

Respir Med. 2010 Mar;104(3):404-411. Löfdahl CG, Tilling B, Ekström T, Jörgensen L, Johansson G, Larsson K. Department of Respiratory Medicine and Allergology, Lund University Hospital, SE-222 41 Lund, Sweden.

OBJECTIVES: To map out-patients with Chronic Obstructive Pulmonary Disease (COPD) with special reference to patients suffering from acute exacerbations, and to describe COPD health care structure and process in Swedish clinical practice in a real life setting.

DESIGN: Retrospective, non-interventional, epidemiological survey.

SETTING: 141 hospital based out patient clinics (OPC, n=30) and primary health care clinics (PC, n=111) were included in the structure evaluation.

SUBJECTS: 1004 COPD diagnosed patients from 100 of the centres (OPC, n=26) participated in the process evaluation.

METHODS: All Swedish OPC (n=40) and a random sample of 180 PC were asked to answer a questionnaire regarding COPD care. In addition, data from 10 randomly selected patients with a documented COPD disease were analysed from the centres.

RESULTS: Spirometers were available at all OPCs and at 99% of the PCs. Spirometry had been performed in 52% of PC-patients and in 89% of OPC-patients during the last 2 years prior to the study. More severe patients, as judged by investigator and lung function data, were treated at OPCs than at PCs. Physiotherapists, occupational therapists and dieticians were available at >80% of centres. Exacerbation rate was higher at PCs without a specialized nurse, 2.2/year versus 0.9/year at centres with a specialized nurse.

CONCLUSIONS: Special attention to COPD, marked by a specialised nurse in primary care improves the quality, as assessed by a lower number of exacerbations. The structure of COPD care in Sweden for diagnosed individuals seems satisfactory, but could be improved mainly through higher availability and educational activities.

Primary care management of chronic obstructive pulmonary disease: an integrated goal-directed approach.

Curr Opin Pulm Med.. Braman SS, Lee DW. Division of Pulmonary and Critical Care Medicine, The Alpert Medical School of Brown University, Providence, Rhode Island, USA.

Chronic obstructive pulmonary disease and cardiovascular mortality in elderly subjects from general population.

Blood Press. Mazza A, Zamboni S, Rubello D, Schiavon L, Zorzan S, Casiglia E. Department of Internal Medicine - General Hospital of Rovigo, Italy.

Aims. To ascertain whether chronic obstructive pulmonary disease (COPD) is an independent risk factor for cardiovascular (CV) mortality in the elderly subjects from general population.

Methods. 3282 subjects of the Northern Italy aged >/=65 years were followed up for 12 years in the frame of the CArdiovascular STtudy in the ELderly. Multivariate stepwise proportional hazard Cox regression was therefore used to identify the prognostic role of COPD on CV mortality in hypertensive (HT) and normotensive (NT) subjects. The hazard ratio (HR) of COPD with 95% confidence interval (CI) for mortality was adjusted for confounders in both genders.

Results. COPD resulted to be an independent predictor of CV mortality (HR 1.34, CI 1.13-1.61) in HT but not in NT subjects. This was evident both in men (HR 1.44, 1.25-1.95) and women (HR 1.32, CI 1.14-1.53); pulse pressure (PP) was directly related and anti-hypertensive therapy inversely related to risk of CV mortality, an association that was greater in subjects with than without COPD.

Conclusion. COPD should be included in the computation of global risk in HT subjects. PP is the main BP component in increasing CV risk in subjects with COPD. Controlled trials should be performed to evaluate the pressor targets to be reached in HT subjects with COPD, with the aim of decreasing their CV risk.

Increased risk of Myocardial Infarction and Stroke following Exacerbation of Chronic Obstructive Pulmonary Disease.

Chest. 2009 Dec 18. Donaldson GC, Hurst JR, Smith CJ, Hubbard RB, Wedzicha JA. 1Academic Unit of Respiratory Medicine, University College London, London, UK.

OBJECTIVE: Patients with chronic obstructive pulmonary disease (COPD) are at risk of cardiovascular events. This has been attributed to increased systemic inflammation. The course of COPD is punctuated by exacerbations, which further increase systemic inflammation, but the risk of vascular events in the post-exacerbation period has never been defined.

DESIGN: We analysed data from 25,857 COPD patients entered in The Health Improvement Network (THIN) database over a two year period. Exacerbations were defined using a health care utilization definition of prescription of oral corticosteroids >20mg/day and/or selected oral antibiotics. The risk of myocardial infarction (MI) and stroke in the post-exacerbation period was calculated relative to the patient's baseline risk using the self-controlled case series approach.

RESULTS: We identified 524 MI in 426 patients and 633 ischaemic strokes in 482 patients. The incidence rates of MI and stroke were 1.1 and 1.4 per 100 patient years respectively. There was a 2.27 fold (95% CI 1.1-4.7; P=0.03) increased risk of MI 1-5 days after exacerbation (defined by prescription of both steroids and antibiotics). This relative risk diminished progressively over time and was not significantly different from the baseline MI risk at any other post-exacerbation time interval. One in 2,513 exacerbations was associated with MI within 1-5 days. There was a 1.26 fold (95% CI 1.0-1.6; P=0.05) increased risk of stroke 1-49 days after exacerbation.

CONCLUSION: The results suggest that exacerbations of COPD increase the risk of myocardial infarction and stroke. This may have implications for therapy in both stable and exacerbated COPD.

Secondhand smoke at work.

Curr Opin Allergy Clin Immunol. 2009 Dec 23. Eisner MD. University of California, San Francisco, San Francisco, California, USA.

PURPOSE OF REVIEW: Secondhand smoke (SHS) exposure in the workplace remains common and has important acute and chronic health effects. The present study reviews the recent evidence linking workplace SHS exposure with poor health and the benefits of smoke-free workplace legislation.

RECENT FINDINGS: Workplace SHS exposure continues to occur in many parts of the United States and around the world. Occupational SHS exposure has been linked to serious chronic health effects including lung cancer, cardiovascular disease, chronic obstructive pulmonary disease, and poor general health. Smoke-free workplace laws rapidly reduce workplace SHS exposure and improve respiratory health including symptoms and lung function. Smoke-free workplace legislation is also expected to reduce the chronic health effects of passive smoking, including cardiopulmonary disease and lung cancer.

SUMMARY: Occupational exposure to SHS has serious negative health consequences and will shorten lifespan. Smoke-free workplace legislation should be universally adopted around the world.

Primary care burden and treatment of patients with heart failure and chronic obstructive pulmonary disease in Scotland.

Eur J Heart Fail. 2010 Jan;12(1):17-24. Epub 2009 Nov 30. Hawkins NM, Jhund PS, Simpson CR, Petrie MC, Macdonald MR, Dunn FG, Macintyre K, McMurray JJ. Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK.

AIMS: Heart failure (HF) and chronic obstructive pulmonary disease (COPD) frequently coexist and present major challenges to healthcare providers. The epidemiology, consultation rate, and treatment of patients with HF and COPD in primary care are ill-defined.

METHODS AND RESULTS: This was an analysis of cross-sectional data from 61 primary care practices (377 439 patients) participating in the Scottish Continuous Morbidity Recording scheme. The prevalence of COPD in patients with HF increased from 19.8% in 1999 to 23.8% in 2004. In 2004, the prevalence was similar in men and women (24.8% vs. 22.9%, P = 0.09), increased with age up to 75 years, and increased with greater socioeconomic deprivation (most deprived 31.3% vs. least deprived 18.6%, P = 0.01). Contact rates for HF or COPD in those with both conditions were greater than disease-specific contact rates in patients with either condition alone. Although overall beta-blocker prescribing increased over time; the adjusted odds of beta-blocker prescription in patients with COPD was low and failed to improve [odds ratio 0.30 (0.28-0.32), P < 0.001]. In 2004, only 18% of individuals with HF and COPD were prescribed beta-blockers vs. 41% in those without COPD.

CONCLUSION: Chronic obstructive pulmonary disease is a frequent comorbidity in patients with HF and represents a significant healthcare burden to primary care. Although beta-blocker prescribing in the community has increased, less than a fifth of patients with HF and COPD received beta-blockers.

Anesthesia for patients with severe chronic obstructive pulmonary disease.

Curr Opin Anaesthesiol. 2010 Feb;23(1):18-24. Edrich T, Sadovnikoff N. Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.

PURPOSE OF REVIEW: Patients with chronic obstructive lung disease experience an increased risk of perioperative pulmonary complications. This review presents an evidence-based approach to perioperative care designed to optimize management.

RECENT FINDINGS: Recent research has provided guidance regarding intraoperative and postoperative administration of oxygen and the selective use of volatile agents. The significance of preoperative malnutrition and postoperative epidural analgesia on outcomes has also been explored further. The opportunity for anesthesiologists to engage in tobacco interventions and the benefits of addressing smoking cessation have been studied.

SUMMARY: Optimization for surgery includes preoperative treatment of reversible airway obstruction and respiratory infections, smoking cessation, and possibly nutritional interventions. Meticulous intraoperative monitoring combined with a sound understanding of pathophysiological mechanisms underlying air trapping will help clinicians strike a balance between permissive hypercapnia and adequate ventilation.

Cost analysis of an integrated care model in the management of acute exacerbations of chronic obstructive pulmonary disease.

Chron Respir Dis. 2009;6(4):201-8. Bakerly ND, Davies C, Dyer M, Dhillon P. Respiratory Medicine, Walsgrave Hospital, Coventry, UK.

Home treatment models for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) proved to be a safe alternative to hospitalization. These models have the potential to free up resources; however, in the United Kingdom, it remains unclear to whether they provide cost savings compared with hospital treatment. Over a 12-month period from August 2003, 130 patients were selected for the integrated care group (total admissions with AECOPD = 546). These patients were compared with 95 retrospective controls in the hospital treatment group. Controls were selected from admissions during the previous 12 months (total of 662 admissions) to match the integrated care group in age, sex, and postal code. Resource use data were collected for both groups and compared using National Health Service (NHS) perspective for cost minimization analysis. In the integrated care group (130 patients), 107 (82%) patients received home support with average length of stay 3.3 (SD 3.9) days compared with 10.4 (SD 7.7) in the hospital group (95 patients). Average number of visits per patients in the integrated care group was 3.08 (SD = 0.95; 95% CI = 2.9-3.2). Cost per patient in the integrated care group was pound1653 (95% CI, pound1521-1802) compared with pound2256 (95% CI, pound2126- 2407) in the hospital group. The integrated care group resulted in cost saving of approximately pound600 (P < 0.001) per patient.

This integrated care model for the management of patients with AECOPD offered cost savings of pound600 per patient over the conventional hospital treatment model using the new NHS tariff from an acute trust provider perspective.

Pulse oximetry in family practice: indications and clinical observations in patients with COPD.

Fam Pract. 2009 Oct 8. Schermer T, Leenders J, In 't Veen H, van den Bosch W, Wissink A, Smeele I, Chavannes N. Department of Primary and Community Care, Radboud University Nijmegen Medical Centre.

PURPOSE. To establish situations in which family physicians (FPs) consider pulse oximetry a valuable addition to their clinical patient assessment; to explore pulse oximetry results (SpO(2)) when used by FPs in patients with chronic obstructive pulmonary disease (COPD); to explore associations between SpO(2) and other markers of COPD severity.

METHODS: We performed three separate studies: (i) interviews plus a Delphi consensus procedure with FPs experienced in using pulse oximetry to elucidate indications for pulse oximetry; (ii) analysis of SpO(2) and clinical data in COPD patients who presented to FPs with deteriorating symptoms and (iii) analysis of SpO(2), spirometry and clinical data in patients with stable COPD.

RESULTS: Interviewed FPs (n = 11) used their pulse oximeter for a range of acute (14) and non-acute (11) indications but valued it highest in acute (worsening of) dyspnoea, in suspected respiratory insufficiency/failure and in patients with COPD. In 88 patients with deteriorating COPD, 22% showed SpO(2) </=92%. Correlation between baseline forced expiratory volume in 1 second % predicted and SpO(2) in patients presenting with acute COPD exacerbations was r = 0.55 (P = 0.001). In 207 patients with stable COPD, 6.3% showed SpO(2) values </=92%. SpO(2) values were associated with Medical Research Council dyspnoea scores (P = 0.019).

CONCLUSIONS: FPs report a wide range of indications for pulse oximetry in acute as well as non-acute situations. In COPD, pulse oximetry appears to be especially useful in patients with severe disease and worsening of symptoms. Pulse oximetry may have a role in the monitoring of patients with COPD with exercise-related dyspnoea.

Prevalence of chronic obstructive pulmonary disease--secondary publication

Ugeskr Laeger. 2009 Oct 5;171(41):2986-8. Hansen JG, Pedersen L, Overvad K, Omland Ø, Jensen HK, Sørensen HT. Arhus Universitetshospital, Aalborg Sygehus

We investigated the prevalence of chronic obsctuctive pulmonary disease (COPD) and the proportion of affected patients receiving medical treatment.

A total of 155 general practitioners examined 4,757 persons aged 45-84 years. All had a spirometry performed. Obstruction was defined as a forced expired volume in the first second (FEV 1 )/forced vital capacity (FVC) ratio < 0.70 after bronchodilation, and severity was defined according to Global Initiative for Obstructive Lung Disease (GOLD) guidelines.

The determined prevalence was 12%. Standardized to the Danish population the true prevalence of COPD was 9% (95% confidence interval, 8-10%). The majority had mild or moderate COPD. Among persons with severe COPD, 42% did not receive medical treatment.

ABPM in COPD patients with sleep desaturation.

Arq Bras Cardiol. 2009 Sep;93(3):275-82. Aidar NA, Silva MA, Melo e Silva CA, Ferreira Júnior PN, Tavares P. Hospital Universitário de Brasília, Universidade de Brasília, Brasília, DF, Brazil.

BACKGROUND: Sleep hypoxemia may change blood pressure by sympathetic activation. Few studies have analyzed blood pressure parameters in COPD patients who do not present sleep apnea, but do present sleep desaturation.

OBJECTIVES: To analyze blood pressure parameters in COPD patients with sleep desaturation not caused by apnea.

METHODS: Thirteen patients with COPD underwent spirometry, blood gas, polysomnography and ABPM for blood pressure evaluation. Fourteen patients without COPD underwent spirometry, oximetry and ABPM. Blood pressure analyses were carried out both during wakefulness and sleep. Both groups were comprised of patients with no history of hypertension.

RESULTS: The two groups were similar as regards age, height, weight, and body mass index. A significant difference (p<0.05) was found between blood pressure levels during the wakefulness, sleep, 24-hour and sleep dip periods. Higher blood pressure levels were observed in patients with COPD, except for diastolic levels during wakefulness and maximum values during sleep and in the 24 hours. Sleep dip in the COPD group was attenuated, whereas physiological dip was observed in the control group, with lower blood pressure levels.

CONCLUSIONS: Systolic and diastolic blood pressure levels in the COPD group were higher than those of the control group, with a significant difference found for all periods studied, except for diastolic levels during wakefulness and in the 24 hours. We can conclude that the group of COPD patients with sleep desaturation has significantly higher blood pressure levels than the control group.

Feasibility and efficacy of COPD case finding by practice nurses.

Aust Fam Physician. 2009 Oct;38(10):826-30. Bunker J, Hermiz O, Zwar N, Dennis SM, Vagholkar S, Crockett A, Marks G. South West Area Health Service, and Conjoint Lecturer, School of Public Health and Community Medicine, University of New South Wales.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a leading cause of disability, hospital admission and premature mortality, but is often undiagnosed. This study assessed the effectiveness, feasibility and acceptability of COPD case finding by practice nurses performing spirometry on patients identified as being at risk of developing COPD.

METHODS: Practice nurses were trained in spirometry. From four general practices, 1010 patients were identified who were aged 40-80 years and current or ex-smokers. Four hundred were randomised to receive a written invitation to attend a case finding appointment with the practice nurse, including spirometry.

RESULTS: Seventy-nine patients attended, 16 (20.3% of attendees) had COPD diagnosed on spirometry; practice nurses correctly identified 10 of the 16, but also incorrectly identified a further six patients as having COPD. One patient in the usual care group was diagnosed with COPD, but this was not confirmed on spirometry.

DISCUSSION: This study confirmed that COPD is underdiagnosed, with 20% of those at risk and attending for screening having COPD. The search strategy successfully identified patients at risk. Further training in spirometry would be required for practice nurses to increase the accuracy of the diagnoses. The opportunity cost would require consideration. The acceptability to patients is also an issue, this may be related to the recruitment method or the intervention. This study also does not answer whether earlier diagnosis in these patients leads to any change in outcomes.

Osteoporose prominent bij COPD

Roularta Medica - De Huisarts

Geschat wordt dat chronische obstructieve longziekte (COPD) tegen 2020 de derde belangrijkste doodsoorzaak zal zijn. De componenten van morbiditeit en sterfte bij deze aandoening worden steeds beter in kaart gebracht. In gevorderde stadia blijkt osteoporose een belangrijk gegeven te zijn.

Verschillende studies hebben vastgesteld dat de prevalentie van osteoporose toeneemt naarmate COPD vordert. Een onderzoek werd uitgevoerd bij patiënten met COPD in een stadium GOLD III of IV, bij wie nog geen diagnose van osteoporose was gesteld: 68% van de populatie had of een lage botdensiteit of een onbekende wervelfractuur.

Verschillende factoren worden naar voren geschoven om de verhoogde prevalentie van osteoporose bij patiënten met COPD te verklaren. Voor de hand liggend is dat velen een lange geschiedenis van roken achter de rug hebben, wat een welbekende risicofactor voor osteoporose is. Een gebrek aan lichaamsbeweging is eveneens een verspreide factor in de populatie met ernstige COPD. Naarmate de longfunctie afneemt, wordt de patiënt immers minder mobiel. Ook een laag lichaamsgewicht en gewichtsafname zijn goed gedocumenteerde onafhankelijke voorspellers van osteoporose. Ongeveer 35-60% van de patiënten met matige tot ernstige COPD heeft een lage BMI of ziet zijn gewicht afnemen.

De huidige versie van de GOLD-richtlijnen (2008), de breedst gebruikte richtlijnen voor de behandeling van COPD, omvat geen specifieke aanbevelingen voor het opsporen en behandelen van osteoporose. Mogelijk komt daar in de toekomst verandering in.

Statins in COPD: a systematic review

Chest. 2009 Sep;136(3):734-43. Janda S, Park K, FitzGerald JM, Etminan M, Swiston J. Department of Medicine, University of British Columbia, Vancouver, BC, Canada.

BACKGROUND: The 3-hydroxy 3-methylglutaryl coenzyme A reductase inhibitors (ie, statins) are widely used for the treatment of patients with hypercholesterolemia and cardiovascular disease. Emerging evidence suggests a beneficial effect of statins on the morbidity and mortality of patients with COPD. The objective of this study was to perform a systematic review of the literature evaluating the effect of statin therapy on outcomes in patients with COPD.

METHODS: Medline, Excerpta Medica Database, PapersFirst, and the Cochrane collaboration and Cochrane Register of controlled trials were searched. Randomized controlled trials (RCTs), observational cohort studies, case-control studies, and population-based analyses were considered for inclusion.

RESULTS: Nine studies were identified for review (four retrospective cohorts, one nested case-control study of a retrospective cohort, one retrospective cohort and case series, two population-based analyses, and one RCT). All studies showed a benefit from statin therapy for various outcomes in COPD patients, including the number of COPD exacerbations (n = 3), the number of and time to COPD-related intubations (n = 1), pulmonary function (eg, FEV(1) and FVC) [n = 1], exercise capacity (n = 1), mortality from COPD (n = 2), and all-cause mortality (n = 3). No studies describing a negative or neutral effect from statin therapy on outcomes in COPD patients were identified.

CONCLUSIONS: The current literature collectively suggests that statins may have a beneficial role in the treatment of COPD. However, the majority of published studies have inherent methodological limitations of retrospective studies and population-based analyses. There is a need for prospective interventional trials designed specifically to assess the impact of statins on clinically relevant outcomes in COPD.

Expansion of the prognostic assessment of patients with chronic obstructive pulmonary disease: the updated BODE index and the ADO index.

Lancet. 2009 Aug 29;374(9691):704-11. Puhan MA, Garcia-Aymerich J, Frey M, ter Riet G, Antó JM, Agustí AG, Gómez FP, Rodríguez-Roisín R, Moons KG, Kessels AG, Held U. Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.

BACKGROUND: The BODE index (including body-mass index, airflow obstruction, dyspnoea, and exercise capacity) was an important contribution to the prognostic assessment of patients with chronic obstructive pulmonary disease (COPD). However, no study has assessed whether the risk of mortality predicted by the BODE index matches the observed mortality in different populations. We assessed the calibration of the BODE index, updated it to improve its calibration, and developed and validated a simplified index for use in primary-care settings.

METHODS: We included 232 patients from the Swiss Barmelweid cohort with longstanding and severe COPD and 342 patients from the Spanish Phenotype and Course of COPD cohort study who had had their first hospital admission due to moderate-to-severe COPD. In both cohorts we compared the observed 3-year risk of all-cause mortality with the risk predicted by the BODE index. We then updated the BODE index and developed a simplified ADO index (including age, dyspnoea, and airflow obstruction) from the Swiss cohort, and validated both in the Spanish cohort.

FINDINGS: Calibration of the BODE index was poor, with relative underprediction of 3-year risk of mortality by 36% in the Swiss cohort (median predicted risk 21.7% [IQR 12.7-31.7] vs 34.1% observed risk; p=0.013) and relative overprediction by 39% in the Spanish cohort (16.7% [12.7-31.7] vs 12.0%; p=0.035). The 3-year risk of mortality predicted by both the updated BODE (median 10.7% [8.1-13.8]) and ADO indices (11.8% [9.1-14.3]) matched the observed mortality in the Spanish cohort well (p=0.99 and p=0.98, respectively).

INTERPRETATION: Both the updated BODE and ADO indices could lend support to the prognostic assessment of patients with COPD in specialised and primary-care settings. Such assessment enhances the targeting of treatments to individual patients.

Effects of unsupported upper extremity exercise training in patients with COPD: a randomized clinical trial.

Chest. 2009 Aug;136(2):387-95. Costi S, Crisafulli E, Antoni FD, Beneventi C, Fabbri LM, Clini EM. Department of Oncology, University of Modena, Modena, Italy.

BACKGROUND: Current guidelines on pulmonary rehabilitation (PR) recommend upper extremity exercise training (UEET) in patients with COPD. However, the literature still questions the effectiveness of systematic UEET in this population. We studied the effects of 15 sessions of unsupported UEET on functional exercise capacity, the ability to perform activities of daily living (ADL), and symptoms perceived during activities involving arms in patients with COPD.

METHODS: We conducted a randomized trial that consisted of 3 weeks of inpatient PR, comparing the short-term effects of unsupported UEET plus PR (intervention group) to those of PR alone (control group). A change in the 6-min ring test (6MRT) was the primary outcome; the ADL field test (four shuttle stations), the dyspnea score as assessed by the Medical Research Council scale, the London Chest Activity of Daily Living scale (LCADL), and the distance walked in 6 min served as secondary outcomes of the study. At the 6-month follow-up, we repeated the 6MRT and the LCADL.

RESULTS: Fifty patients with COPD were randomly assigned to the two groups and completed the study. At the end of the study period, patients in the intervention group improved in the 6MRT and ADL field test compared with those patients in the control group (p = 0.018 and p = 0.010, respectively) with reduced perception of fatigue (p <or= 0.006). At the 6-month follow-up, 6MRT (p = 0.001) and LCADL (p = 0.039) scores were still significantly better in the intervention group compared with the control group.

CONCLUSIONS: Our trial corroborates the effectiveness of unsupported UEET in specifically improving functional exercise capacity of patients with COPD. Moreover, it also provides evidence that this training modality may ameliorate and maintain the patients' autonomy over and above standard PR.

A postmortem analysis of major causes of early death in patients hospitalized with COPD exacerbation.

Chest. 2009 Aug;136(2):376-80. Zvezdin B, Milutinov S, Kojicic M, Hadnadjev M, Hromis S, Markovic M, Gajic O. Biljana Institute for Pulmonary Diseases of Vojvodina, 21 208 Sremska,Kamenica, Serbia.

BACKGROUND: Mortality from COPD is increasing worldwide, but detailed causes of death are rarely assessed, particularly in low-income countries.

METHODS: In a retrospective study, we reviewed the autopsy reports and medical records of deceased patients admitted to the hospital for severe exacerbation of COPD, from January 2005 to December 2007, at the Institute for Pulmonary Diseases of Vojvodina, Serbia.

RESULTS: Forty-three patients with a hospital admission diagnosis of COPD exacerbation underwent autopsy; all had died within 24 h of admission to the hospital. Twenty-three patients (54%) had a long COPD history (> 10 years), and 19 patients (44%) had more than one hospitalization in the last year of life. The median age at death was 70 years (interquartile range, 65 to 75 years), and male sex was predominant (n = 31; 72%). The main (primary) causes of death were reported as cardiac failure (n = 16; 37.2%), pneumonia (n = 12; 27.9%), and pulmonary thromboembolism (PTE) (n = 9; 20.9%). Respiratory failure due to a progression of COPD was the primary cause of death in six patients (14%). Most patients had more then one comorbid disease (n = 33; 77%), and the most frequent comorbid disease was chronic heart failure (n = 25; 58%).

CONCLUSIONS: Autopsy results suggest that common contributing causes of early death in patients hospitalized with severe COPD exacerbation are concomitant complications, as follows: cardiac failure, pneumonia, and PTE. Quality improvement interventions should focus on recognizing and treating these conditions at the time of hospital admission

Pulse oximetry in family practice: indications and clinical observations in patients with COPD

Family Practice published online on October 8, 2009 Tjard Schermera, Jeroen Leendersa, Hans in 't Veenb, Wil van den Boscha, Aad Wissinkc, Ivo Smeeled and Niels Chavannese a Department of Primary and Community Care, Radboud University Nijmegen Medical Centre b Department of Chest Diseases, Sint Franciscus Gasthuis, Rotterdam c Department of Healthcare Solutions, GlaxoSmithKline, PO Box 780, 3700 AT, Zeist d Asthma and COPD Service, Stichting Huisartsenlaboratorium Etten-Leur/Breda, Bredaseweg 165, 4782 LA Etten-Luer e Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands

Purpose. To establish situations in which family physicians (FPs) consider pulse oximetry a valuable addition to their clinical patient assessment; to explore pulse oximetry results (SpO2) when used by FPs in patients with chronic obstructive pulmonary disease (COPD); to explore associations between SpO2 and other markers of COPD severity.

Methods. We performed three separate studies: (i) interviews plus a Delphi consensus procedure with FPs experienced in using pulse oximetry to elucidate indications for pulse oximetry; (ii) analysis of SpO2 and clinical data in COPD patients who presented to FPs with deteriorating symptoms and (iii) analysis of SpO2, spirometry and clinical data in patients with stable COPD.

Results. Interviewed FPs (n = 11) used their pulse oximeter for a range of acute (14) and non-acute (11) indications but valued it highest in acute (worsening of) dyspnoea, in suspected respiratory insufficiency/failure and in patients with COPD. In 88 patients with deteriorating COPD, 22% showed SpO2 ≤92%. Correlation between baseline forced expiratory volume in 1 second % predicted and SpO2 in patients presenting with acute COPD exacerbations was r = 0.55 (P = 0.001). In 207 patients with stable COPD, 6.3% showed SpO2 values ≤92%. SpO2 values were associated with Medical Research Council dyspnoea scores (P = 0.019).

Conclusions. FPs report a wide range of indications for pulse oximetry in acute as well as non-acute situations. In COPD, pulse oximetry appears to be especially useful in patients with severe disease and worsening of symptoms. Pulse oximetry may have a role in the monitoring of patients with COPD with exercise-related dyspnoea.

Comparison of the prevalence of chronic obstructive pulmonary disease diagnosed by lower limit of normal and fixed ratio criteria.

J Korean Med Sci. 2009 Aug;24(4):621-6 Hwang YI, Kim CH, Kang HR, Shin T, Park SM, Jang SH, Park YB, Kim CH, Kim DG, Lee MG, Hyun IG, Jung KS. Department of Internal Medicine, College of Medicine, Hallym University, Chuncheon, Korea.

The Global Initiative of Chronic Obstructive Lung Disease (GOLD) guidelines define chronic obstructive pulmonary disease (COPD) in subjects with FEV(1)/FVC <0.7. However, the use of this fixed ratio may result in over-diagnosis of COPD in the elderly, especially with mild degree of COPD. The lower limit of normal (LLN) can be used to minimize the potential misclassification. The aim of this study was to evaluate the impact of different definitions of airflow obstruction (LLN or fixed ratio of FEV(1)/FVC) on the estimated prevalence of COPD in a population-based sample. We compared the prevalence of COPD and its difference diagnosed by different methods using either fixed ratio (FEV(1)/FVC <0.7) or LLN criterion (FEV(1)/FVC below LLN). Among the 4,816 subjects who had performed spirometry, 2,728 subjects met new ATS/ERS spirometry criteria for acceptability and repeatability. The prevalence of COPD was 10.9% (14.7% in men, 7.2% in women) by LLN criterion and 15.5% (21.8% in men, 9.1% in women) by fixed ratio of FEV(1)/FVC among subjects older than 45 yr. The difference of prevalence between LLN and fixed ratio of FEV(1)/FVC was even higher among subjects with age >/=65, 14.9% and 31.1%, respectively.

In conclusion, the prevalence of COPD by LLN criterion was significantly lower in elderly compared to fixed ratio of FEV(1)/FVC. Implementing LLN criterion instead of fixed ratio of FEV(1)/FVC may reduce the risk of over-diagnosis of COPD in elderly people.

Use of spirometry in the diagnosis of chronic obstructive pulmonary disease and efforts to improve quality of care.

Transl Res. 2009 Sep;154(3):103-10. Joo MJ, Au DH, Lee TA. Center for Management of Complex Chronic Care (CMC3), Hines VA Hospital, Hines, Ill; CMC3, Jesse Brown VA Hospital, Chicago, Ill; Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Illinois at Chicago, Chicago, Ill.

Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation that is not fully reversible. In a patient presenting with respiratory symptoms and risk factors, the recommendation is to perform spirometry to determine the presence of airflow obstruction. However, only about a third of patients with a diagnosis of COPD have spirometry along with their diagnosis, although studies have shown that history and physical examination alone are neither sensitive nor specific for diagnosing COPD. Thus, in current practice, many health care providers continue to diagnose and manage COPD without an accurate diagnosis and assessment of severity based on spirometry. This can contribute to inconsistent care and outcomes, as evidenced by findings of variation in spirometry use and acute exacerbation rates of COPD across geographic regions. As there is increasing evidence that pharmacotherapy for COPD has associated risks, including poor cardiovascular outcomes and pneumonia, it is pertinent to obtain an accurate diagnosis to determine appropriate risk-benefit ratios. Previous studies have shown that spirometry has an impact on COPD management; however, there seem to be barriers to the use of spirometry at the patient, provider, and health system level. Innovative quality improvement approaches, such as the application of the various components of the Chronic Care Model, could improve spirometry use in COPD. Only with accurate diagnosis can appropriate management and evidence-based treatment strategies be applied in practice.

Therefore, it is important that we continue efforts to increase the use of spirometry in the diagnosis of COPD.

Chronic Bronchitis, COPD, and Lung Function in Farmers

The Role of Biological Agents Chest September 2009 vol. 136 no. 3 716-725 Wijnand Eduard, PhD, Neil Pearce, DSc and Jeroen Douwes, PhD

Background: Farmers have an increased risk of respiratory morbidity and mortality. The causal agents have not been fully established.

Methods: In a cross-sectional study of 4,735 Norwegian farmers, we assessed respiratory symptoms and lung function. Atopy was assessed in a subsample (n = 1,213). Personal exposures to dust, fungal spores, actinomycete spores, endotoxins, bacteria, storage mites, (1→3)-ß-D-glucans, fungal antigens, organic dust, inorganic dust, silica, ammonia, and hydrogen sulfide were measured for 127 randomly selected farms.

Results: Compared to crop farmers, livestock farmers were more likely to have chronic bronchitis (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.4 to 2.6) and COPD (OR, 1.4; 95% CI, 1.1 to 1.7). FEV1 (−41 mL; 95% CI, −75 to −7) was significantly reduced, but FVC (−15 mL; 95% CI, −54 to 24) was not. Exposure to most agents were predictors of respiratory morbidity, except FVC. Ammonia, hydrogen sulfide, and inorganic dust were most strongly associated in multiple regression models adjusted for coexposures, but the effects of specific biological agents could not be assessed in multiple regression models because they were too highly correlated. Farmers with atopy had a significantly lower FEV1 (OR, −87 mL; 95% CI, −170 to −7), but atopy was not directly associated with chronic bronchitis, COPD, and FVC. However, the effects of farming and specific exposures on COPD were substantially greater in farmers with atopy.

Conclusions: Livestock farmers have an increased risk of chronic bronchitis, COPD, and reduced FEV1. Ammonia, hydrogen sulfide, inorganic dust, and organic dust may be causally involved, but a role for specific biological agents cannot be excluded. Farmers with atopy appear more susceptible to develop farming-related COPD.

Sex differences in mortality in patients with COPD.

Eur Respir J. 2009 Mar;33(3):528-35. de Torres JP, Cote CG, López MV, Casanova C, Díaz O, Marin JM, Pinto-Plata V, de Oca MM, Nekach H, Dordelly LJ, Aguirre-Jaime A, Celli BR. Pulmonary Department, Clínica Universitaria de Navarra, Av. Pío XII 36, Pamplona, 31008, Spain.

Little is known about survival and clinical prognostic factors in females with chronic obstructive pulmonary disease (COPD). The aim of the present study was to determine the survival difference between males and females with COPD and to compare the value of the different prognostic factors for the disease. In total, 265 females and 272 males with COPD matched at baseline by BODE (body mass index, airflow obstruction, dyspnoea, exercise capacity) and American Thoracic Society/European Respiratory Society/Global Initiative of Chronic Obstructive Lung Disease criteria were prospectively followed. Demographics, lung function, St George's Respiratory Questionnaire, BODE index, the components of the BODE index and comorbidity were determined. Survival was documented and sex differences were determined using Kaplan-Meier analysis. The strength of the association of the studied variables with mortality was determined using multivariate and receiver operating curves analysis. All-cause (40 versus 18%) and respiratory mortality (24 versus 10%) were higher in males than females. Multivariate analysis identified the BODE index in females and the BODE index and Charlson comorbidity score in males as the best predictors of mortality. The area under the curve of the BODE index was a better predictor of mortality than the forced expiratory volume in one second for both sexes. At similar chronic obstructive pulmonary disease severity by BODE index and forced expiratory volume in one second, females have significantly better survival than males. For both sexes the BODE index is a better predictor of survival than the forced expiratory volume in one second.

Daily physical activity in patients with chronic obstructive pulmonary disease is mainly associated with dynamic hyperinflation.

Am J Respir Crit Care Med. 2009 Sep 15;180(6):506-12. Garcia-Rio F, Lores V, Mediano O, Rojo B, Hernanz A, López-Collazo E, Alvarez-Sala R. Servicio de Neumología, Hospital Universitario La Paz, Madrid, Spain.

RATIONALE: Although the major limitation to exercise performance in patients with COPD is dynamic hyperinflation, little is known about its relation to daily physical activity. Objectives: To analyze the contribution of dynamic hyperinflation, exercise tolerance, and airway oxidative stress to physical activity in patients with COPD.

METHODS: In a cross-sectional study, we included 110 patients with moderate to very severe COPD. Daily physical activity was measured using a triaxial accelerometer providing a mean of 1-minute movement epochs as vector magnitude units (VMU). Patients performed the 6-minute walk test, incremental exercise test with measurement of breathing pattern and operating lung volumes, and constant-work rate test at 75% of maximal work rate.

MEASUREMENTS AND MAIN RESULTS: Using the GOLD stage and BODE index, we determined arterial blood gases, lung volumes, diffusing capacity, and biomarkers in exhaled breath condensate. Daily physical activity was lower in the 89 patients who developed dynamic hyperinflation than in the 21 who did not (n =161 [SD 70] vs. n = 288 [SD 85] VMU; P = 0.001). Physical activity was mainly related to distance walked in 6 minutes (r = 0.72; P = 0.001), Vo(2) (r = 0.63; P = 0.001), change in end-expiratory lung volume during exercise (r = -0.73; P = 0.001), endurance time (r = 0.61; P = 0.001), and 8-isoprostane in exhaled breath condensate (r = -0.67; P = 0.001). In a multivariate linear regression analysis using VMU as a dependent variable, dynamic hyperinflation, change in end-expiratory lung volume, and distance walked in 6 minutes were retained in the prediction model (r(2) = 0.84; P = 0.001).

CONCLUSIONS: Daily physical activity of patients with COPD is mainly associated with dynamic hyperinflation, regardless of severity classification.

Vascular dysfunction in chronic obstructive pulmonary disease

Am J Respir Crit Care Med. 2009 Sep 15;180(6):513-20. Maclay JD, McAllister DA, Mills NL, Paterson FP, Ludlam CA, Drost EM, Newby DE, Macnee W. Centre for Inflammation Research, Edinburgh University, Edinburgh, United Kingdom.

RATIONALE: Cardiovascular disease is a major cause of morbidity and mortality in patients with chronic obstructive pulmonary disease (COPD), which may in part be attributable to abnormalities of systemic vascular function. It is unclear whether such associations relate to the presence of COPD or prior smoking habit.

OBJECTIVES: To undertake a comprehensive assessment of vascular function in patients with COPD and healthy control subjects matched for smoking history. METHODS: Eighteen men with COPD were compared with 17 healthy male control subjects matched for age and lifetime cigarette smoke exposure. Participants were free from clinically evident cardiovascular disease.

MEASUREMENTS AND MAIN RESULTS: Pulse wave velocity and pulse wave analysis were measured via applanation tonometry at carotid, radial, and femoral arteries. Blood flow was measured in both forearms using venous occlusion plethysmography during intrabrachial infusion of endothelium-dependent vasodilators (bradykinin, 100-1,000 pmol/min; acetylcholine, 5-20 microg/min) and endothelium-independent vasodilators (sodium nitroprusside, 2-8 microg/min; verapamil, 10-100 microg/min). Tissue plasminogen activator (t-PA) was measured in venous plasma before and during bradykinin infusions. Patients with COPD have greater arterial stiffness (pulse wave velocity, 11 +/- 2 vs. 9 +/- 2 m/s; P = 0.003; augmentation index, 27 +/- 10 vs. 21 +/- 6%; P = 0.028), but there were no differences in endothelium-dependent and -independent vasomotor function or bradykinin-induced endothelial t-PA release (P > 0.05 for all).

CONCLUSIONS: COPD is associated with increased arterial stiffness independent of cigarette smoke exposure. However, this abnormality is not explained by systemic endothelial dysfunction. Increased arterial stiffness may represent the mechanistic link between COPD and the increased risk for cardiovascular disease associated with this condition.

A predictive model of hospitalisation and death from chronic obstructive pulmonary disease.

Respir Med. 2009 Jun 8. Schembri S, Anderson W, Morant S, Winter J, Thompson P, Pettitt D, M Macdonald T, H Winter J. Department of Medicine and Therapeutics, University of Dundee, Dundee DD1 9SY, United Kingdom.

RATIONALE: A recent study showed that doctors are excessively pessimistic about the prognosis in patients with COPD and suggested that a simple tool to predict outcome is needed.

METHODS: In a prospective observational study, 3343 patients with an FEV(1)<80% of the predicted value and FEV(1)/FVC<70% were selected from a clinical network of patients screened for COPD in Tayside, Scotland. Data were collected during annual visits on demography, spirometry, smoking history, medical research council (MRC) dyspnoea scale, body mass index (BMI) and other variables. The main outcome measures were hospitalisations and death secondary to COPD. A proportional hazard model was used to identify significant risk factors.

RESULTS: Increasing age, low BMI, worsening MRC dyspnoea score, decreased FEV(1), and prior respiratory or cardiovascular admission hospitalisation were predictors of poor outcome. Influenza vaccination was protective.

CONCLUSION: We have developed a model that estimates the risk of respiratory hospitalisation and death in patients with COPD.

Prevalence of copd in spain: impact of undiagnosed copd on quality of life and daily life activities.

Thorax. 2009 Jun 23. Miravitlles M, Soriano JB, Garcia-Rio F, Muñoz L, Duran-Tauleria E, Sanchez G, Sobradillo V, Ancochea J. Fundació Clínic, Spain.

This study aimed to determine COPD prevalence in Spain and identify the level of undiagnosis and the impact of undiagnosed COPD on health-related quality of life (HRQL) and activities of daily living (ADL). We surveyed a population-based sample of 4,274 adults aged 40 to 80 years. They were invited to answer a questionnaire and undergo pre- and post-bronchodilator spirometry. COPD was defined as a postbronchodilator FEV1/FVC ratio of <0.70. For 3,802 participants with good-quality postbronchodilator spirometry, the overall prevalence of COPD was 10.2% (95% confidence interval 9.2% - 11.1%) and was higher in men (15.1%) than in women (5.6%). The prevalence of COPD stage II or higher was 4.4% (95%CI; 3.8%-5.1%). The prevalence of COPD increased with age and with cigarette smoking and was higher in low educational levels. A previous diagnosis of COPD was reported by 27% of COPD cases only. Diagnosed patients had more severe disease, higher cumulative smoking consumption and more severely impaired HRQL compared with undiagnosed subjects. However, even patients with undiagnosed COPD stage I+ already showed impairment in HRQL and in some aspects of ADL compared with participants without COPD. The prevalence of COPD in individuals between 40 and 80 years of age in Spain is 10.2% and increases with age, smoking consumption and lower educational levels. The rate of undiagnosis is very high and undiagnosed individuals with COPD already have a significant impairment in HRQL and ADL.

What mediates the effect of confrontational counselling on smoking cessation in smokers with COPD?

Patient Educ Couns. 2009 Jul;76(1):16-24. Kotz D, Huibers MJ, West RJ, Wesseling G, van Schayck OC. Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, Maastricht, The Netherlands.

OBJECTIVE: Within the framework of a randomized, active treatment controlled trial, we used a mediation analysis to understand the mechanisms by which an intervention that uses confrontation with spirometry for smoking cessation achieves its effects.

METHODS: Participants were 228 smokers from the general population with previously undetected chronic obstructive pulmonary disease (COPD), who were detected with airflow limitation by means of spirometry. They received two equally intensive behavioural treatments by a respiratory nurse combined with nortriptyline for smoking cessation: confrontational counselling with spirometry versus conventional health education and promotion (excluding confrontation with spirometry and COPD).

RESULTS: Cotinine validated abstinence rates from smoking at 5 weeks after the target quit date were 43.1% in the confrontational counselling group versus 31.3% in the control group (OR=1.67, 95%CI=0.97-2.87). The effect of confrontational counselling on abstinence was independently mediated by the expectation of getting a serious smoking related disease in the future (OR=1.76, 95%CI=1.03-3.00), self-exempting beliefs (OR=0.42, 95%CI=0.21-0.84), and self-efficacy (OR=1.38, 95%CI=1.11-1.73).

CONCLUSION: We conclude that confrontational counselling increases risk perceptions and self-efficacy, and decreases self-exempting beliefs (risk denial) in smokers with previously undetected COPD. These changes in mediators are associated with a higher likelihood of smoking cessation.

PRACTICE IMPLICATIONS: Apart from the intensity, the content of smoking cessation counselling may be an important factor of success. A confrontational counselling approach as we applied may have the potential to alter smoking-related cognitions in such a way that smokers are more successful in quitting. Nurses can be trained to deliver this treatment.

A feasible lifestyle program for early intervention in patients with chronic obstructive pulmonary disease (COPD): a pilot study in primary care.

Prim Care Respir J. 2009 Jul 13. Norrhall MF, Nilsfelt A, Varas E, Larsson R, Curiac D, Axelsson G, Månsson J, Brisman J, Söderström AL, Björkelund C, Thorn J. Sahlgrenska School of Public Health and Community Medicine, Section of Primary Health Care, University of Gothenburg, Sweden * Primary Health Care, Västra Götaland Region, Sweden.

AIM: To evaluate the feasibility of a lifestyle program for early intervention in patients with COPD in a primary care population.

METHODS: The study was performed in a Primary Health Care Centre in Western Sweden. During a four-week period, all smokers between 40-70 years of age were invited to answer a questionnaire and to perform spirometry. The intervention program included a specially designed smoking cessation program and programs for physical activity and diet.

RESULTS: 84 smokers were included. 42% fulfilled the criteria for COPD. All of the COPD patients were in GOLD stage I and II. Among the COPD subjects, 38% were underweight and 56% had a low fat-free mass - both together indicating malnutrition and the need for nutritional treatment. By the end of the intervention program, 47% of the COPD patients had stopped smoking.

CONCLUSIONS: The intervention program was feasible and effective with a very high smoking cessation rate.

Measurement of Dynamic Hyperinflation After a 6-Min Walk Test in COPD Patients.

Chest. 2009 Jul 6. Service de Physiologie (Drs. Callens, Graba, Gillet-Juvin, Essalhi, Peiffer, Mahut, and Delclaux), the Service de Pneumologie (Dr. Gillet-Juvin), and the Unité de Recherche Clinique et d'Epidémiologie (Dr. Bidaud-Chevalier), Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; and Unité de Formation et de Recherche Biomédicale des Saints-Pères (Drs. Mahut and Delclaux), Université Paris Descartes, Paris, France.

BACKGROUND: Patients with COPD develop dynamic hyperinflation (DH) during incremental exercise with cycle ergometer. The aims of this study were to determine whether DH can be evidenced after walking using a handheld spirometer, and to determine its functional consequences.

METHODS: Fifty COPD patients (39 men; age, median [interquartile]: 60 [54-69]; FEV(1) % predicted, 45 [31-67]) underwent pulmonary function tests and 6MWT. IC was measured in standing position at rest and immediately after 6MWT using a portable spirometer. Dyspnea was evaluated directly (Delta Borg during 6MWT) and indirectly (MRC scale). The first 20 patients had an incremental exercise test with cycle ergometer allowing the measurement of IC at peak exercise and repeatedly during the first 3 min of recovery.

RESULTS: The median change in IC during 6MWT was -210 mL [+55; -440] (n = 50), whereas the median change in IC during exercise test was -295 mL [-145; -515] (n = 20). Both IC and IC changes after 6MWT correlated to values after exercise test. DH decreased rapidly after the end of exercise test: non significantly different from baseline value at 75+/- s of recovery. The percentage of decrease in IC during 6MWT correlated to dyspnea (Delta Borg during 6MWT: r(2)=0.21, p = 0.0006).

CONCLUSIONS: Dynamic hyperinflation can be measured during a 6MWT using a handheld spirometer allowing its evaluation in daily practice and contributes to dyspnea at walk.

Prediction of risk of COPD exacerbations by the BODE index.

Respir Med. 2009 Mar;103(3):373-8. Marin JM, Carrizo SJ, Casanova C, Martinez-Camblor P, Soriano JB, Agusti AG, Celli BR. Hospital Miguel Servet, Instituto Aragonés de Ciencias de la Salud, Zaragoza, Spain.

OBJECTIVES: This study assesses the power of the BODE index, a multidimensional grading system that predicts mortality, to predict subsequent exacerbations in patients with COPD.

DESIGN: Prospective cohort study.

PATIENTS AND INTERVENTIONS: A total of 275 COPD patients were followed every 6 months up to 8 years (median of 5.1 years). Baseline clinical variables were recorded and the BODE index was calculated. We investigated the prognostic value of BODE quartiles (scores 0-2, 3-4, 5-6 and 7-10) for both the number and severity of exacerbations requiring ambulatory treatment, emergency room visit, or hospitalization.

RESULTS: The annual rate of COPD exacerbations was 1.95 (95% CI, 0.90-2.1). The mean time to a first exacerbation was inversely proportional to the worsening of the BODE quartiles (7.9 yrs, 5.7 yrs, 3.4 yrs and 1.3 yrs for BODE scores of 0-2, 3-4, 5-6 and 7-10, respectively). Similarly, the mean time to a first COPD emergency room visit was 6.7 yrs, 3.6 yrs, 2.0 yrs and 0.8 yrs for BODE quartiles (all p<0.05). Using ROC curves, the BODE index was a better predictor of exacerbation than the FEV(1) alone (p<0.01).

CONCLUSIONS: The BODE index is a better predictor of the number and severity of exacerbations in COPD than FEV(1) alone

Prevalence of bronchial obstruction in a tobacco smoke exposed population - the PNEUMOBIL project.

Rev Port Pneumol. 2009 Sep-Oct;15(5):803-46. Reis Ferreira JM, Matos MJ, Rodrigues F, Belo A, Brites H, Cardoso J, Simão P, Dos Santos JM, Almeida J, Gouveia A, Bárbara C. Pulmonology Specialist, Hospital Força Aérea.

The use of spirometry is not yet widespread enough in chronic respiratory or at -risk patients whose diagnosis is incomplete. There is scarce knowledge and inadequate management of the burden of these diseases, particularly chronic obstructive pulmonary disease (COPD).

Pneumobil, an initiative aimed at raising awareness among smokers and ex -smokers, was reactivated 10 years after its launch in Portugal. It found a large prevalence of bronchial obstruction as measured by spirometry (30% and 25% in men and women respectively) in a sample of 5324 smoke -exposed individuals, 50% current smokers, screened at state or business (private company group) health institutions. This risk is neither mainly attributable to occupational exposure nor mainly related to respiratory symptoms, which were very common in our population. Only dyspnoea (OR=1.28; p=0.02) and frequent episodes of sputum production (OR=1.21; p=0.008) or acute bronchitis (OR=1.31; p=0.05) were somewhat related to bronchial obstruction. Prior knowledge of COPD is rare and bronchial obstruction is not correlated (p=0.204) to a possible diagnosis of COPD.

Impaired sleep reduces quality of life in chronic obstructive pulmonary disease.

Lung. 2009 May-Jun;187(3):159-63. Nunes DM, Mota RM, de Pontes Neto OL, Pereira ED, de Bruin VM, de Bruin PF. Department of Clinical Medicine, Federal University of Ceara, Rua Prof. Costa Mendes, 1608-4 degrees andar, Fortaleza, CE, Brazil.

Disturbed sleep is reportedly common in chronic obstructive pulmonary disease (COPD), but the impact of quality of sleep on health-related quality of life (HRQL) has not been previously investigated in these individuals. The purpose of this study was to assess the impact of quality of sleep on HRQL in patients with COPD.

In 30 clinically stable patients with moderate to very severe COPD, we evaluated subjective sleep quality using the Pittsburgh Sleep Quality Index (PSQI) and HRQL using the Saint George's Respiratory Questionnaire. Additionally, lung function was assessed by spirometry, severity of dyspnea by the Modified Medical Research Council scale, and functional exercise capacity by the Six-Minute Walk Test. Twenty-one (70%) patients showed poor quality of sleep (PSQI > 5). HRQL was significantly correlated with quality of sleep (P = 0.02), post-bronchodilator FEV1 (P = 0.04), and severity of dyspnea (P < 0.01). Multiple regression analysis showed that quality of sleep was the best predictor of quality of life in our subjects.

Our data suggest that quality of sleep is major determinant of HRQL in COPD. Increased efforts to diagnose and treat sleep problems, including measures to improve factors that adversely affect sleep should receive great attention in the daily management of these patients.

Characteristics of patients admitted for the first time for COPD exacerbation.

Respir Med. 2009 May 7. Balcells E, Antó JM, Gea J, Gómez FP, Rodríguez E, Marin A, Ferrer A, de Batlle J, Farrero E, Benet M, Orozco-Levi M, Ferrer J, Agustí AG, Gáldiz JB, Belda J, Garcia-Aymerich J; PAC-COPD Study Group. Servei de Pneumologia, Hospital del Mar-IMIM, Passeig Marítim 25-29, 08003 Barcelona, Spain; Municipal Institute of Medical Research (IMIM-Hospital del Mar), Doctor Aiguader 88, 08003 Barcelona, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Recinte Hospital Joan March, Carretera Soller km 12, 07110 Bunyola, Spain.

BACKGROUND: This study describes the characteristics of a large sample of patients hospitalised for the first time for a chronic obstructive pulmonary disease (COPD) exacerbation.

METHODS: All subjects first admitted for a COPD exacerbation to nine teaching Spanish hospitals during January 2004-March 2006, were eligible. COPD diagnosis was confirmed by spirometry under stability. At admission, sociodemographic data, lifestyle, previous treatment and diagnosis of respiratory disease, lung function and Charlson index of co-morbidity were collected. A comprehensive assessment, including dyspnea, lung function, six-minute walking test, and St. George's Respiratory Questionnaire (SGRQ), was completed 3months after admission, during a clinically stable disease period.

RESULTS: Three-hundred and forty-two patients (57% of the eligible) participated in the study: 93% males, mean (SD) age 68 (9) years, 42% current smokers, 50% two or more co-morbidities, 54% mild-to-moderate dyspnea, post-bronchodilator FEV(1) 52 (16)% of predicted (54% mild-to-moderate COPD in ATS/ERS stages), 6-min walking distance 440m, total SGRQ score 37 (18), and 36% not report respiratory disease. The absence of a previous COPD diagnosis, positive bronchodilator test, female gender, older age, higher DLco and higher BMI were independently associated with less severe COPD.

CONCLUSIONS: We show that the patients admitted after presenting with their first COPD exacerbation have a wide range of severity, with a large proportion of patients in the less advanced COPD stages.

Comparison of spirometry criteria for the diagnosis of COPD: results from the BOLD Study.

Eur Respir J. 2009 May 21. Vollmer WM, Gíslason T, Burney P, Enright PL, Gulsvik A, Kocabas A, Buist AS, The Bold Collaborative Research Group F. Center for Health Research, Portland, OR, USA.

Published guidelines recommend spirometry to accurately diagnose COPD. However, even spirometry-based COPD prevalence estimates can vary widely. We compared properties of several spirometry-based COPD definitions using data from the international Burden of Obstructive Lung Disease (BOLD) study.

14 sites recruited population-based samples of adults aged 40 and older. Procedures included standardized questionnaires and post-bronchodilator spirometry. 10,001 individuals provided usable data.Use of the lower limit of normal (LLN) FEV1/FVC reduced the age-related increases in COPD prevalence that are seen among healthy never smokers when using the fixed ratio criterion (FEV1/FVC<0.7) as recommended by the Global Initiative for Obstructive Lung Disease (GOLD). The added requirement of an FEV1 either <80% predicted, or below the LLN, further reduced age-related increases and also led to the least site-to-site variability in prevalence estimates after adjusting for potential confounders. Use of the FEV1/FEV6 ratio in place of the FEV1/FVC yielded similar prevalence estimates.

Use of the FEV1/FVC<LLN criterion instead of the FEV1/FVC<0.7 should minimize known age biases and better reflect clinically significant irreversible airflow limitation. Our study also supports the use of the FEV1/FEV6 as a practical substitute for the FEV1/FVC.

Dietary counselling and food fortification in stable COPD: a randomised trial.

Thorax. 2009 Apr;64(4):326-31 Weekes CE, Emery PW, Elia M. Department of Nutrition and Dietetics, Guy's & St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK.

BACKGROUND: Malnutrition in chronic obstructive pulmonary disease (COPD) is associated with a poor prognosis, yet evidence to support the role of dietary counselling and food fortification is lacking. A study was undertaken to assess the impact of dietary counselling and food fortification on outcome in outpatients with COPD who are at risk of malnutrition.

METHODS: A randomised controlled unblinded trial was performed in 59 outpatients with COPD (6 months intervention and 6 months follow-up). The intervention group received dietary counselling and advice on food fortification and the controls received a dietary advice leaflet. Outcome measures were nutritional status, respiratory and skeletal muscle strength, respiratory function, perceived dyspnoea, activities of daily living (ADL) and quality of life.

RESULTS: The intervention group consumed more energy (difference 194 kcal/day; p = 0.02) and protein (difference 11.8 g/day; p<0.001) than controls. The intervention group gained weight during the intervention period and maintained weight during follow-up; the controls lost weight throughout the study. Significant differences were observed between the groups in St George's Respiratory Questionnaire total score (difference 10.1; p = 0.02), Short Form-36 health change score (difference 19.2; p = 0.029) and Medical Research Council dyspnoea score (difference 1.0; p = 0.03); the difference in ADL score approached statistical significance (difference 1.5; p = 0.06). No differences were observed between groups in respiratory function or skeletal and respiratory muscle strength. Improvements in some variables persisted for 6 months beyond the intervention period.

CONCLUSION: Dietary counselling and food fortification resulted in weight gain and improvements in outcome in nutritionally at-risk outpatients with COPD, both during and beyond the intervention period.

Cough and sputum production are associated with frequent exacerbations and hospitalizations in COPD subjects

Chest. 2009 Apr;135(4):975-82. Burgel PR, Nesme-Meyer P, Chanez P, Caillaud D, Carré P, Perez T, Roche N; Initiatives Bronchopneumopathie Chronique Obstructive Scientific Committee. Brinchault-Rabin G, Burgel PR, Caillaud D, Carré P, Chanez P, Pinet C, Chaouat A, Court-Fortune I, Cuvelier A, Escamilla R, Raherison C, Gut-Robert C, Leroyer C, Gebrak G, Kessler R, Lemoigne F, Peirera C, Nesme-Meyer P, Perez T, Tillie-Leblond I, Perrin C, Roche N. Service de Pneumologie, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, 27 rue du Faubourg St Jacques, Paris Cedex 14, France.

BACKGROUND: Epidemiologic studies indicate that chronic cough and sputum production are associated with increased mortality and disease progression in COPD subjects. Our objective was to identify features associated with chronic cough and sputum production in COPD subjects.

METHODS: Cross-sectional analysis of data were obtained in a multicenter (17 university hospitals in France) cohort of COPD patients. The cohort comprised 433 COPD subjects (65 +/- 11 years; FEV(1), 50 +/- 20% predicted). Subjects with (n = 321) and without (n = 112) chronic cough and sputum production were compared.

RESULTS: No significant difference was observed between groups for age, FEV(1), body mass index, and comorbidities. Subjects with chronic cough and sputum production had increased total mean numbers of exacerbations per patient per year (2.20 +/- 2.20 vs 0.97 +/- 1.19, respectively; p < 0.0001), moderate exacerbations (1.80 +/- 2.07 vs 0.66 +/- 0.85, respectively; p < 0.0001), and severe exacerbations requiring hospitalizations (0.43 +/- 0.95 vs 0.22 +/- 0.56, respectively; p < 0.02). The total number of exacerbations per patient per year was the only variable independently associated with chronic cough and sputum production. Frequent exacerbations (two or more per patient per year) occurred in 55% vs 22% of subjects, respectively, with and without chronic cough and sputum production (p < 0.0001). Chronic cough and sputum production and decreased FEV(1) were independently associated with an increased risk of frequent exacerbations and frequent hospitalizations.

CONCLUSIONS: Chronic cough and sputum production are associated with frequent COPD exacerbations, including severe exacerbations requiring hospitalizations.

Effect of depression care on outcomes in COPD patients with depression

Chest. 2009 Mar;135(3):626-32. Jordan N, Lee TA, Valenstein M, Pirraglia PA, Weiss KB. Northwestern University, 710 N Lake Shore Drive, Chicago, IL 60611, USA.

BACKGROUND: Although depression among COPD patients is a common problem with important consequences for the management of COPD and overall outcomes, the proportion of those who receive guideline-concordant depression care is low. Guideline-concordant depression care is associated with fewer depressive symptoms and lower risk for psychiatric hospitalization; however, it is unknown whether guideline-concordant depression care favorably impacts COPD-related outcomes for patients with both conditions.

METHODS: This retrospective cohort study investigated 5,517 veterans with COPD who experienced a new treatment episode for depression. Guideline-concordant depression care was defined as having an adequate supply of antidepressant medication and sufficient follow-up care. Multivariate methods were used to examine the relationship between the receipt of guideline-concordant depression care and (1) COPD-related hospitalization and (2) all-cause mortality 2 years after the depression episode, while controlling for care setting and other covariates.

RESULTS: There was no association between the receipt of guideline-concordant depression care and COPD-related hospitalization (odds ratio [OR], 0.98) or all-cause mortality (OR, 0.95). However, patients seen in mental health settings during their depressive episode had 30% lower odds of 2-year mortality than patients seen in primary care.

CONCLUSIONS: For patients with COPD and depression, interacting with a mental health professional may be an important intervention. However, receiving guideline-concordant depression care, as outlined in common quality monitors, was not significantly associated with decreased hospitalization or mortality. These findings suggest that more referrals to specialty care or better care coordination with mental health specialty care may lead to a significant reduction in mortality risk for these patients.

Depressive symptoms as predictors of mortality in patients with COPD.

Chest. 2009 Mar;135(3):619-25. de Voogd JN, Wempe JB, Koëter GH, Postema K, van Sonderen E, Ranchor AV, Coyne JC, Sanderman R. Center for Rehabilitation, University Medical Center Groningen, University of Groningen, Haren, the Netherlands.

OBJECTIVE: Prognostic studies of mortality in patients with COPD have mostly focused on physiologic variables, with little attention to depressive symptoms. This stands in sharp contrast to the attention that depressive symptoms have been given in the outcomes of patients with other chronic health conditions. The present study investigated the independent association of depressive symptoms in stable patients with COPD with all-cause mortality.

METHODS: The baseline characteristics of 121 COPD patients (78 men and 43 women; mean [+/- SD] age, 61.5 +/- 9.1 years; and mean FEV(1), 36.9 +/- 15.5% predicted) were collected on hospital admission to a pulmonary rehabilitation center. The data included demographic variables, body mass index (BMI), post-bronchodilator therapy FEV(1), and Wpeak (peak workload [Wpeak]). Depressive symptoms were assessed using the Beck depression inventory. The vital status was ascertained using municipal registrations. In 8.5 years of follow-up, 76 deaths occurred (mortality rate, 63%). Survival time ranged from 88 days to 8.5 years (median survival time, 5.3 years). The Cox proportional hazard model was used to quantify the association of the baseline characteristics (ie, age, sex, marital status, smoking behavior, FEV(1), BMI, Wpeak, and depressive symptoms) with mortality.

RESULTS: Depressive symptoms (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.12 to 3.33) were associated with mortality in patients with COPD, independent of other factors including male sex (OR, 1.73; 95% CI, 1.03 to 2.92), older age (OR, 1.05; 95% CI, 1.02 to 1.08), and lower Wpeak (OR, 0.98; 95% CI, 0.97 to 0.99).

CONCLUSIONS: This study provides evidence that depressive symptoms assessed in stable patients with COPD are associated with their subsequent all-cause mortality.

Prevalence, incidence, and lifetime risk for the development of COPD in the elderly: the Rotterdam study.

Chest. 2009 Feb;135(2):368-77 van Durme YM, Verhamme KM, Stijnen T, van Rooij FJ, Van Pottelberge GR, Hofman A, Joos GF, Stricker BH, Brusselle GG. Department of Epidemiology and Biostatistics,Ghent University Hospital, Ghent, Belgium.

BACKGROUND: COPD is a major cause of chronic morbidity and mortality throughout the world. Although the prevalence of COPD is already well documented, there are only few studies regarding the incidence of COPD.

METHODS: In a prospective population-based cohort study among subjects aged >or= 55 years, COPD was diagnosed with an algorithm based on the validation of hospital discharge letters, files from the general practitioner, and spirometry reports.

RESULTS: In this study cohort of 7,983 participants, 648 cases were identified with incident COPD after a median follow-up time of 11 years (interquartile range, 7.8 years). This resulted in an overall incidence rate (IR) of 9.2/1,000 person-years (PY) [95% confidence interval (CI), 8.5 to 10.0]. The IR of COPD was higher among men (14.4/1,000 PY; 95% CI, 13.0 to 16.0) than among women (6.2/1,000 PY; 95% CI, 5.5 to 7.0), and higher in smokers than in never-smokers (12.8/1,000 PY; 95% CI, 11.7 to 13.9 and 3.9/1,000 PY; 95% CI, 3.2 to 4.7, respectively). Remarkable was the high incidence in the youngest female age category of 55 to 59 years (7.4/1,000 PY; 95% CI, 4.1 to 12.6). For a 55-year-old man and woman still free of COPD at cohort entry, the risk for the development of COPD over the coming 40 years was 24% and 16%, respectively.

CONCLUSION: The overall incidence of COPD in an elderly population is 9.2/1,000 PY, with a remarkably high incidence in the youngest women, suggesting a further shift toward the female sex in the gender distribution of COPD. During their further lives, one of four men and one of six women free of COPD at the age of 55 years will have COPD develop.

Nicotine May Have More Profound Impact Than Previously Thought

ScienceDaily (Apr. 4, 2009)

Nicotine isn't just addictive. It may also interfere with dozens of cellular interactions in the body, new Brown University research suggests.

Conversely, the data could also help scientists develop better treatments for various diseases. Pharmaceutical companies rely on basic research to identify new cellular interactions that can, in turn, serve as targets for potential new drugs.
"It opens several new lines of investigation," said lead author Edward Hawrot, professor of molecular science, molecular pharmacology, physiology and biotechnology at Brown University.
Hawrot's research is highlighted in a paper published April 3 in the Journal of Proteome Research. He and a team that included graduate students William Brucker and Joao Paulo set out to provide a more basic understanding of how nicotine affects the process of cell communication through the mammalian nervous system.
The Brown University researchers looked specifically at the alpha-7 nicotinic acetylcholine receptor in mouse brain tissue. A very similar receptor exists in humans. The alpha-7 receptor is the most enigmatic of the so-called "nicotinic" receptors, so named because nicotine binds to them when it is introduced into the body. Most receptors are on the surface of cells and are sensitive to small signaling molecules such as the neurotransmitter acetylcholine, which is the naturally occurring signal the body uses to activate alpha-7 receptors.
Their discovery: 55 proteins were found to interact with the alpha-7 nicotinic receptor. Scientists had not previously known of those connections.
"This is called a "nicotinic" receptor and we think of it as interacting with nicotine, but it likely has multiple functions in the brain," Hawrot said. "And in various, specific regions of the brain this same alpha-7 receptor may interact with different proteins inside neurons to do different things."
One in particular — the G alpha protein — was among the most unexpected proteins to be identified in the study, as it is usually associated with a completely different class of receptors (the eponymous G-protein coupled receptors (GPCRs).
This finding is significant because G alpha proteins are involved in many different biochemical and signaling processes throughout the brain and the rest of the body. body.
An example of the importance of G alpha proteins: 40 percent of all currently used therapeutic drugs target a member of the large GPCR family of receptors.
The new finding suggests that the alpha-7 receptors have a much broader role in the body than previously suspected and that the newly identified associated proteins could also be affected when nicotine binds to the alpha-7 receptor.
Nicotine may affect bodily processes — and perhaps the actions of other commonly used drugs — more broadly than was previously thought.
This advance could lead to the development of new treatments to combat smoking addiction. At the same time, the finding could also have future implications for diseases such as schizophrenia, Hawrot said.
Recent genetic studies have suggested that some cases of schizophrenia are associated with deletions where a block of genes, including the gene for the alpha-7 receptor, is missing. Hawrot said the connection, while not conclusive, offers hope for new strategies in the development of treatments for those suffering from the disorder.
To conduct their study, Hawrot's lab looked at mice genetically engineered by other researchers to lack the alpha-7 nicotinic acetylcholine receptor. Those mice were compared with normal mice, so the difference in receptor-associated proteins could be highlighted.

Stratification of COPD patients by previous admission for targeting of preventative care

Respir Med. 2009 Apr;103(4):558-65. Bryden C, Bird W, Titley HA, Halpin DM, Levy ML. Met Office, Exeter, UK.

BACKGROUND: Hospital admissions for exacerbations of chronic obstructive pulmonary disease (COPD) impact considerably on disease evolution and healthcare provision. Building on previous studies, this study postulated that COPD patients could be stratified by risk of admission to determine which groups provide the greatest burden on resources, and how interventions should be targeted to prevent admissions.

METHODS: COPD admissions during 1997-2003 in three Strategic Health Authorities in England were analysed (n=80,291). Patients admitted during winter (1 November-31 March) were stratified into three groups according to the number of admissions during the previous year: 0 (NIL), 1-2 (MOD) or >or=3 (FRQ). Winter weeks were classified as "average", "above average", "high", or "very high" risk, compared with the long-term mean.

RESULTS: The risk of admission during winter for FRQ and MOD patients was 40% and 12% respectively. NIL patients contributed to 70% of winter admissions, and 90% of the variation between "average" and "very high" weeks, versus 9% and 1% for MOD and FRQ.

CONCLUSIONS: Patients with no previous admissions have lower individual risk, but contribute to a high overall utilisation of health care resources and should be targeted to prevent admissions. Focusing upon high-risk patients (frequent attenders or more severe) may only reduce a small proportion of admissions, and therefore clinicians should ensure that all COPD patients receive appropriate therapy to reduce risk of exacerbations.

The effects of smoking cessation on the risk of chronic obstructive pulmonary disease exacerbations.

J Gen Intern Med. 2009 Apr;24(4):457-63. Au DH, Bryson CL, Chien JW, Sun H, Udris EM, Evans LE, Bradley KA. Health Services Research and Development, VA Puget Sound Health Care System, 1660 S. Columbian Way (152), Seattle, WA 98108, USA.

BACKGROUND: Smoking cessation has been demonstrated to reduce the rate of loss of lung function and mortality among patients with mild to moderate chronic obstructive pulmonary disease (COPD). There is a paucity of evidence about the effects of smoking cessation on the risk of COPD exacerbations.

OBJECTIVE: We sought to examine whether smoking status and the duration of abstinence from tobacco smoke is associated with a decreased risk of COPD exacerbations.

DESIGN: We assessed current smoking status and duration of smoking abstinence by self-report. Our primary outcome was either an inpatient or outpatient COPD exacerbation. We used Cox regression to estimate the risk of COPD exacerbation associated with smoking status and duration of smoking cessation.

PARTICIPANTS: We performed a cohort study of 23,971 veterans who were current and past smokers and had been seen in one of seven Department of Veterans Affairs (VA) primary care clinics throughout the US.

MEASUREMENTS AND MAIN RESULTS: In comparison to current smokers, ex-smokers had a significantly reduced risk of COPD exacerbation after adjusting for age, comorbidity, markers of COPD severity and socio-economic status (adjusted HR 0.78, 95% CI 0.75-0.87). The magnitude of the reduced risk was dependent on the duration of smoking abstinence (adjusted HR: quit < 1 year, 1.04; 95% CI 0.87-1.26; 1-5 years 0.93, 95% CI 0.79-1.08; 5-10 years 0.84, 95% CI 0.70-1.00; > or = 10 years 0.65, 95% CI 0.58-0.74; linear trend <0.001).

CONCLUSIONS: Smoking cessation is associated with a reduced risk of COPD exacerbations, and the described reduction is dependent upon the duration of abstinence.

Do family physicians' records fit guideline diagnosed COPD?

Fam Pract. 2009 Apr;26(2):81-7. Albers M, Schermer T, Molema J, Kloek C, Akkermans R, Heijdra Y, van Weel C. Department of Primary Care Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.

BACKGROUND: In family practice, chronic obstructive pulmonary disease (COPD) is usually not diagnosed until clinically apparent and of moderately advanced severity.

OBJECTIVE: To analyse the diagnostic process from early development onwards and to assess the current state of underpresentation and underdiagnosis of COPD and asthma in primary care in the Netherlands.

METHODS: The population-based study sample consisted of formerly undiagnosed subjects (n = 532) from family practice. Family physicians' (FPs) chronic respiratory disease diagnoses (as recorded over 10 years in their patient records) were compared to a cross-sectional but extensive diagnostic assessment by a chest physician. Logistic regression modelling was used for a retrospective analysis on the relation between respiratory symptoms, practice visit rate and FPs' diagnosis of COPD.

RESULTS: After 10 years, the chest physician diagnosed 26% of subjects as COPD and 16% as (late-onset) asthma. Underpresentation of these patients in family practice was 46%, whereas underdiagnosis occurred in 37% of patients. A chest physician diagnosis of COPD was associated with the presence of chronic cough [odds ratio (OR) = 2.3, 95% confidence interval (CI) 1.1-4.6], a FP diagnosis of COPD with chronic phlegm (OR = 10.6, 95% CI 1.3-83.6). Repeated practice visits (OR = 1.8) and presence of wheeze and breathlessness (OR = 5.5) appeared to trigger the diagnostic process in family practice.

CONCLUSIONS: There is still considerable underpresentation and underdiagnosis of COPD in family practice. As FPs focus on presented symptoms and as detection increases with the frequency of practice visits, diagnostic guidelines should stress the importance of persistent cough and phlegm to support timely diagnosis of COPD in family practice.

Factors affecting chronic obstructive pulmonary disease (COPD)-related costs: a multivariate analysis of a Swedish COPD cohort.

Gerdtham UG, Andersson LF, Ericsson A, Borg S, Jansson SA, Rönmark E, Lundbäck B. Department of Community Medicine, Malmö University Hospital, Lund University, Malmö, Sweden

Chronic obstructive pulmonary disease (COPD) is an increasing public health problem, generating considerable costs. The objective of this study was to identify factors affecting COPD-related costs.

A cohort of 179 subjects with COPD was interviewed over the telephone on four occasions about their annual use of COPD-related resources. The data set and explanatory variables were analysed by means of multivariate regression techniques for six different types of cost: societal (or total), direct (health care) and indirect (productivity), and three subcomponents of direct costs-hospitalisation, outpatient and medication.

Poor lung function, dyspnoea and asthma were independently associated with higher costs. Poor lung function (severity of COPD) significantly increased all six examined cost types. Dyspnoea (breathing problems) also increased costs, though to a varying extent. The presence of reported asthma increased total, direct, outpatient and medication costs. Poor lung function and, to a lesser extent, extent of dyspnoea and concomitant asthma, were all strongly associated with higher COPD-related costs.

Strong efforts should be made to prevent the progression of COPD and its symptoms.

Smoking cessation in chronic obstructive pulmonary disease

Respir Med. 2009 Mar 13. Tashkin DP, Murray RP. Department of Medicine, David Geffen School of Medicine at UCLA, 37-131 Center for Health Sciences, 10833 Le Conte Avenue, Los Angeles, CA 90095-1690, USA.

Chronic obstructive pulmonary disease (COPD) is increasing in prevalence, and is predicted to become the third leading cause of deaths worldwide by 2020. The precise prevalence of COPD is not known, as many individuals with the disease are left undiagnosed, despite the requirement of only simple spirometry testing for disease detection. The major risk factor for the development of COPD is cigarette smoking, with 90% of deaths from COPD directly attributable to smoking. Therefore smoking cessation is the most effective means of halting or slowing the progress of this disease.

This review summarizes and compares the differential characteristics of smokers with COPD vs. those without COPD in relation to their smoking behavior and quitting attempts, and discusses the various strategies that can be used to help patients quit and improve their likelihood of long-term smoking cessation. Of the various behavioral interventions available that can increase the likelihood of smoking cessation, one of the simplest and most effective strategies that physicians can use is simply to advise their patients to quit, particularly if this advice is combined with informing the patients of their "lung age".

We also discuss the pharmacologic therapies used to enhance the likelihood of quitting, including nicotine replacement, bupropion SR and varenicline, along with novel nicotine vaccines, which are currently undergoing clinical trials.

Adherence to diagnostic guidelines and quality indicators in asthma and COPD in Swedish primary care.

Pharmacoepidemiol Drug Saf. 2009 Mar 13 Weidinger P, Nilsson JL, Lindblad U. Department of Clinical Sciences, Lund University, Malmö, Sweden.

PURPOSE: To study the clinical evaluation and treatment of patients with asthma and COPD in primary care in Sweden, with a focus on adherence to recommended guidelines and quality indicators.

METHODS: All visits at health care centres in Skaraborg, Sweden, are documented in computerized medical records constituting the Skaraborg Primary Care Database (SPCD). In a register-based retrospective observational study, all patients diagnosed with asthma or COPD during 2000-2005 (n = 12 328) were identified. In a 5% random sample (n = 623), information on performed investigations at initial visits and at follow-up during 2004-2005 was collected. Compliance with procedures as recommended by national guidelines was used for quality assessment.

RESULTS: Among 499 patients with asthma, 167 (33%) were investigated with spirometry or Peak Expiratory Flow (PEF) during initial visits in agreement with guidelines. Correspondingly, 40 out of 124 patients with COPD (32%) were investigated with spirometry. During follow-up, evaluation in agreement with guidelines was performed in 130 (60%) of patients with asthma and in 35 patients out of 77 (45%) with COPD. Prescribing of ICS reached quality target, still every second patient made an acute visit during follow-up.

CONCLUSION: Adherence to recommended guidelines in asthma/COPD was low. Acute visits were common and despite the prescribing of ICS according to recommendations, patients still seem uncontrolled in their disease. There is a need for quality improvement in the clinical evaluation and treatment of patients with asthma and COPD

Primary care of the patient with chronic obstructive pulmonary disease in Italy

Respir Med. 2009 Apr;103(4):582-8 Cazzola M, Bettoncelli G, Sessa E, Cricelli C. Department of Internal Medicine, Unit of Respiratory Diseases, University of Rome Tor Vergata, Rome, Italy.

Using a general practice research database with general practitioner (GP) clinical records, it has been observed that among the 617,280 subjects registered with 400 Italian GPs, 15,229 (2.47%) patients were suffering from chronic obstructive pulmonary disease (COPD). Of these, 67.7% had a chest radiograph at least once in a period of 10 years (1997-2006), while in the same period only 31.9% had a spirometry, 29.9% had a visit to a specialist, and 0.94% had a visit to an allergologist. From 1997 to 2006, 7.5% of patients with COPD, especially the oldest ones, were hospitalized at least once for the disease, although 44.0% of all patients with COPD were hospitalized for other pathologies. With regard to treatment, in 2006, 10,936 (71.1%) of COPD patients received at least one drug for their disease (drugs classified within the R03 therapeutic pharmacological subgroup of the Anatomical Therapeutic Chemical Classification). In particular, salmeterol/fluticasone was prescribed 6441 times, tiotropium 4962, theophylline 3142, beclomethasone 2853, salbutamol 2256, formoterol 2191, salbutamol/beclomethasone 2129, oxitropium 1802 and formoterol/budesonide 1741 times.

Based on these findings, the level of COPD management in Italy seems to fall short of recommended international COPD guidelines. In particular, it appears that GPs usually prescribe treatment without the use of spirometry, and/or without taking into account the severity of airway obstruction. It must also be noted that, in general, patients with COPD are undertreated.

Obstructive lung diseases in a French prison: Results of systematic screening

Rev Pneumol Clin. 2009 Feb;65(1):1-8. Sannier O, Gignon M, Defouilloy C, Hermant A, Manaouil C, Jardé O. Unité de consultations et soins ambulatoires, centre pénitentiaire de Liancourt, avenue Badinter, 60140 Liancourt, France.

BACKGROUND: French prisoners have health problems that have been inadequately treated before imprisonment. This population has insufficient access to the healthcare system. Addictive behaviours, particularly smoking, are widespread. The aim of the study is to evaluate the prevalence of airflow limitation by using a primary care screening method adapted for the correctional facility and its inmates.

METHOD: The screening of airflow limitation using a mobile spirometer is carried out in inmates consulting the primary care unit (UCSA) of Amiens prison. Patients consulting the UCSA between 16August and 17October 2006 and providing their consent are included in the study. The criteria for exclusion are: a counter-indication for spirometry, poor compliance with the effort of forced expiry after eight efforts, as well as refusal to take part in the study. The descriptive statistical analysis includes all of the quantitative and qualitative variables.

RESULTS: Among the 210patients included in the sample, only five patients refused to take part in the study. Their mean age was 37 (range: 16-65) and 90% were men. Ninety percent of this population were active smokers. Sixty percent of these smokers would like to quit. The spirometry detected 11% undiagnosed airflow limitation: 11prisoners suffered from chronic obstructive lung disease and 13prisoners suffered from asthma.

DISCUSSION: Given the relative youth and high risk nature of these diagnosed patients, the potential for the long or short term aggravation, and a growing recognition of the seriousness of exposure to tobacco, the authors suggest that the systematic screening of inmates for airflow limitation may be used to assist in detecting serious health issues. Along with new French antismoking legislation, this screening may enable primary care workers to better reduce smoking habits in prisons.

Chronic obstructive pulmonary disease and hospitalizations for pneumonia in a US cohort.

Respir Med. 2009 Feb;103(2):224-9. Mannino DM, Davis KJ, Kiri VA. Department of Preventive Medicine and Environmental Health, University of Kentucky College of Public Health, 121 Washington Avenue, Lexington, KY 40536, USA.

OBJECTIVE: To better understand risk factors for pneumonia hospitalizations in people with impaired lung function.

METHODS: We analyzed longitudinal data from participants in the Atherosclerosis Risk in Communities Study (ARIC) and the Cardiovascular Health Study (CHS). We limited our analysis to 20,375 participants aged 45 and older at baseline. We stratified the sample based on prebronchodilator baseline lung function data, according to modified GOLD criteria, including a "restrictive" category (FEV(1)/FVC>70% and FVC<80%). We defined "pneumonia" as a hospitalization with a pneumonia discharge diagnosis (ICD-9 codes 480-486) within 36 months. We used Cox proportional hazard models to determine pneumonia risk associated with COPD stage, adjusting for age, sex, race, smoking status and comorbid disease (diabetes mellitus or cardiovascular disease at the baseline examination).

RESULTS: Pneumonia hospitalization risk was associated with older age, male gender, comorbid conditions, smoking status, and level of lung function impairment. Overall, people with normal lung function had the lowest pneumonia hospitalization rate (1.5 per 1000 person-years) and those with GOLD stage 3 or 4 COPD had the highest rate (22.7 per 1000 person-years). After adjusting for other potential confounding factors, GOLD stages 3 or 4 and 2 COPD were associated with an increased risk of pneumonia (hazard ratio [HR] 5.65, 95% confidence interval [CI] 3.29, 9.67 and 2.25 (1.35, 3.75), respectively) relative to normal lung function.

CONCLUSION: COPD severity (GOLD stage) is an important and independent predictor of pneumonia hospitalizations in this cohort.

Determinants and impact of fatigue in patients with chronic obstructive pulmonary disease.

Respir Med. 2009 Feb;103(2):216-23. Baghai-Ravary R, Quint JK, Goldring JJ, Hurst JR, Donaldson GC, Wedzicha JA. Academic Unit of Respiratory Medicine, University College London, Hampstead Campus, Rowland Hill Street, London NW3 2PF, United Kingdom.

RATIONALE: The perception of fatigue in COPD has been associated with reduced health status. We have shown that exacerbations are associated with reduced activity and health status. However, the relationship between fatigue and exacerbation is unknown.

OBJECTIVES: To investigate the hypothesis that increased fatigue is related to physical inactivity and COPD exacerbations.

METHODS: Fatigue was studied in COPD and age-matched control subjects. The relationship between fatigue and stable patient characteristics in COPD, and the effect of exacerbation on fatigue were evaluated.

MEASUREMENTS: 107 COPD patients mean age 69 years (range 43-86), FEV(1) 53% (SD 21), and 30 aged-matched control subjects; Functional Assessment of Chronic Illness Therapy-Fatigue Scale, Centre for Epidemiological Studies Depression Scale. MAIN

RESULTS: Fatigue in COPD patients was significantly increased compared to control subjects (mean 35.3 units (SD 11.0) versus 43.2 (10.5), p=0.001). Increase in fatigue in COPD was related to reduced time spent outdoors (r=-0.43, p<0.001), increase in depression (r=-0.59, p<0.001) and annual exacerbation frequency (r=-0.27, p=0.005). Fatigue increased at exacerbation in 31/32 patients. Overall, fatigue increased by 8.3 units (5.9), p<0.001. Change in fatigue at exacerbation was related to increase in depression (r=-0.46, p=0.008). Fatigue recovered at 6 weeks following exacerbation.

CONCLUSIONS: The perception of fatigue increased in patients with COPD compared to age-matched control subjects, and associated with morbidity when patients were stable and at exacerbation

Prevalence of chronic obstructive pulmonary diseases in general clinics in terms of FEV1/FVC.

Int J Clin Pract. 2009 Feb;63(2):269-74. Fukahori S, Matsuse H, Takamura N, Hirose H, Tsuchida T, Kawano T, Fukushima C, Mizuta Y, Kohno S. Second Department of Internal Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.

BACKGROUND: The prevalence of chronic obstructive pulmonary disease (COPD) continues to increase all over the world. Nonetheless, COPD is often misdiagnosed in general clinics because of insufficient use of spirometry.

OBJECTIVES: To estimate the prevalence of COPD in general clinics in Japan, we performed spirometry to screen patients who consulted general clinics.

METHODS: Patients 40 years of age and older who consulted clinics in Nagasaki Prefecture, Japan, for non-respiratory diseases and who met certain inclusion criteria had their airflow limitation measured by spirometry. We defined COPD as forced expiratory volume in the first second (FEV(1)) over forced vital capacity (FVC) (FEV(1)/FVC) of < 70% in patients without active pulmonary disease, including physician-diagnosed asthma.

RESULTS: Of the 1424 patients included in the study, 193 (13.6%) showed airflow limitation. Airflow limitation was significantly related to older age, male gender and cumulative pack-years. FEV(1)/FVC in patients with hypertension and chronic hepatitis were significantly lower than in patients without these diseases when adjusted for age, gender and pack-years.

CONCLUSIONS: We showed that there are potentially a number of cases with COPD that are undiagnosed by general physicians in Japan. Measuring airflow limitation by spirometry in smokers with coexisting diseases, such as hypertension and chronic hepatitis, may be very beneficial because COPD is thought to be a systemic disease. The distribution of spirometers to general clinics is definitely needed to detect undiagnosed COPD.

COPD prevalence is increased in lung cancer independent of age, gender and smoking history.

Eur Respir J. 2009 Feb 5. Young RP, Hopkins RJ, Christmas T, Black PN, Metcalf P, Gamble GD. University of Auckland, New Zealand.

Chronic obstructive pulmonary disease (COPD) is a common co-morbid disease in lung cancer, estimated to affect between 40-70% depending on diagnostic criteria. As smoking exposure is found in 85-90% of those diagnosed with either COPD or lung cancer, co-existing disease could merely reflect a shared smoking exposure.

Potential confounding by age, gender and pack year history and/or the possible effects of lung cancer on spirometry, may result in "over-diagnosis" of COPD prevalence. In this study the prevalence of COPD (pre-bronchodilator GOLD 2+ criteria) in patients diagnosed with lung cancer was 50% compared to 8% in a randomly recruited community control group, matched for age, gender, and pack year exposure (n=602, OR=11.6, P<0.0001). In a subgroup analysis of those with lung cancer and lung function measured prior to the diagnosis of lung cancer (n=127), we found a non-significant increase in COPD prevalence following diagnosis (56% to 61%, p=0.45).

After controlling for important variables, the prevalence of COPD in newly diagnosed lung cancer cases was six fold greater than in matched smokers and this is much greater than previously reported. We conclude that COPD is both a common and important independent risk factor for lung cancer.

Pulmonary function tests in chronic obstructive pulmonary disease

Presse Med. 2009 Mar;38(3):421-31. Weitzenblum E, Canuet M, Kessler R, Chaouat A. Service de Pneumologie, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg Cedex, France

The diagnosis of chronic obstructive pulmonary disease (COPD) relies on the presence of chronic airflow limitation poorly reversible or not reversible at all, defined by an FEV1/FVC ratio less than 70%. Stages of severity of COPD are defined according to the level of post-bronchodilator FEV1: > 80% of the predicted value (stage I); 50-80% (stage II); 30-50% (stage III); < 30% (stage IV). Accordingly, the measurement of pulmonary volumes (spirometry) is required for the diagnosis but also for the follow-up of COPD patients. The investigations which are required depend on the severity of COPD: spirometry and flow-volume curves during forced expiration are sufficient in stage I; measurement of static lung volumes and bronchodilator reversibility testing are required in stage II. Arterial blood gases should be measured in stages III and IV. Pulse oxymetry and 6minute walk test (6MWT) are recommended from stage II. For appreciating the severity of COPD and for the follow-up of patients it is recommended to evaluate other variables than FEV1: results of the 6MWT, level of dyspnea, body mass index. The results of FEV1 and of these variables are included in the recently developed BODE index. Measurement of CO transfer capacity is recommended in the presence of emphysema; cardiopulmonary exercise testing (bicycle) is recommended before initiating exercise training.

Validation of the COPD severity score for use in primary care: the NEREA study.

Eur Respir J. 2009 Mar;33(3):519-27 Miravitlles M, Llor C, de Castellar R, Izquierdo I, Baró E, Donado E. Pneumology Department, Clinic Institute of Thorax, Ciber de Enfermedades Respiratorias, Hospital Clinic, Barcelona, Spain.

Spirometry is underused for the assessment of severity of chronic obstructive pulmonary disease (COPD) in primary care (PC). Therefore, simple assessment tools are required in this setting. The aim of the present study was to validate the COPD severity score (COPDSS) for use in PC.

A multicentric study was carried out in stable COPD patients in PC. The concurrent validity of the COPDSS was evaluated by examining the association between COPDSS, COPD clinical indicators and the London Chest Activity of Daily Living (LCADL) scale, European quality of life (EuroQOL) questionnaires and Charlson comorbidity index. A total of 837 patients with COPD were analysed (males 84.3%; mean+/-sd age 68+/-11 yrs; forced expiratory volume in one second 54.6+/-17.7% of the predicted value). A strong correlation was found between COPDSS and dyspnoea level and a moderate correlation between COPDSS and exacerbation number. The COPDSS discriminated between patients with varying degrees of dyspnoea (area under receiver operating characteristic (ROC) curve 0.837), and according to number of exacerbations in the last year (area under ROC curve 0.773). Higher COPDSS scores were significantly associated with lower EuroQOL scores, lower EuroQOL visual analogue scale scores and higher LCADL scores.

The present results indicate that the chronic obstructive pulmonary disease severity score is a useful and reliable tool for assessing the severity of chronic obstructive pulmonary disease in primary care.

Primary care of the patient with chronic obstructive pulmonary disease in Italy.

Respir Med. 2009 Apr;103(4):582-8. Cazzola M, Bettoncelli G, Sessa E, Cricelli C. Department of Internal Medicine, Unit of Respiratory Diseases, University of Rome Tor Vergata, Rome, Italy.

The coordination of breathing and swallowing in chronic obstructive pulmonary disease

Am J Respir Crit Care Med. 2009 Apr 1;179(7):559-65. Gross RD, Atwood CW Jr, Ross SB, Olszewski JW, Eichhorn KA. Department of Otolaryngology, University of Pittsburgh, Pennsylvania, USA.

RATIONALE: During deglutition, a strongly preferred exhale-swallow-exhale pattern has been shown in healthy adults. Disruption of this pattern can provoke prandial aspiration. Impaired coordination of breathing and swallowing has been measured in patients with chronic obstructive pulmonary disease (COPD) during the exacerbated state, but no reports describe the coordination of breathing and swallowing in stable patients with COPD during oral intake.

OBJECTIVES: To test the hypothesis that persons with moderate to severe COPD would show disordered coordination of breathing and swallowing during oral intake when compared with a matched, healthy control group.

METHODS: This study used a prospective, repeated measures design using 25 subjects with COPD and 25 control subjects. Respiratory inductance plethysmography and nasal thermistry were used simultaneously to track respiratory signals. Submental surface EMG was used to mark the presence of each swallow within the respiratory cycle. Data were recorded while participants randomly and spontaneously swallowed solids and semi-solids.

MEASUREMENTS AND MAIN RESULTS: Logistic regression showed that participants with COPD swallowed solid food during inhalation more frequently than normal subjects (P = 0.002) and had a significantly higher rate of inhaling after swallowing semi-solid material (P < 0.001). Subjects with COPD also swallowed pudding at low Vt significantly more often than they did the cookie (P = 0.006). Conversely, the control subjects swallowed cookie at low Vt significantly more often than pudding (P = 0.034). Significant differences in deglutitive apnea durations were also found.

CONCLUSIONS: Patients with COPD exhibit disrupted coordination of the respiratory cycle with deglutition. Disrupted breathing-swallowing coordination could increase the risk of aspiration in patients with advanced COPD and may contribute to exacerbations.

Management of acute bronchiolitis: can evidence based guidelines alter clinical practice?

Thorax. 2008 Dec;63(12):1103-9. Barben J, Kuehni CE, Trachsel D, Hammer J; Swiss Paediatric Respiratory Research Group. Paediatric Pulmonology, Children's Hospital, CH-9006 St Gallen, Switzerland.

BACKGROUND: Acute bronchiolitis is the most common lower respiratory tract infection in infants and there is no evidence that drug treatment alters its natural course. Despite this, most Swiss paediatricians reported in 2001 prescribing bronchodilators and inhaled corticosteroids (ICS). This situation led to the creation of national guidelines followed by a tailored implementation programme. The aim of this study was to examine if treatment practices changed after the implementation of the new guidelines.

METHODS: A questionnaire on treatment of bronchiolitis was sent to all Swiss paediatricians before (2001) and after (2006) creation and implementation of national guidelines (2003-2005). Guidelines were created in collaboration with all paediatric pulmonologists and implemented carefully using a multifaceted approach.

RESULTS: Questionnaires were returned by 541 paediatricians (58%) in 2001 and by 639 (54%) in 2006. While both surveys showed a wide variation in the treatment of bronchiolitis between physicians, reported drug prescription decreased significantly between the two surveys. For outpatients, general use (for all patients) of bronchodilators dropped from 60% to 23%, and general use of ICS from 34% to 6%. For inpatients, general use of bronchodilators and ICS dropped from 55% to 18% and from 26% to 6%, respectively (all p<0.001). The decrease was evident in all regions, among hospital and primary care physicians, and among general paediatricians and paediatric pulmonologists.

CONCLUSIONS: National guidelines together with a tailored implementation programme can have a major impact on medical management practices in a country.

Pulmonary function tests in chronic obstructive pulmonary disease

Presse Med. 2009 Jan 24 Weitzenblum E, Canuet M, Kessler R, Chaouat A. Service de pneumologie, Nouvel hôpital civil, Hôpitaux universitaires de Strasbourg, F-67091 Strasbourg Cedex, France.

The diagnosis of chronic obstructive pulmonary disease (COPD) relies on the presence of chronic airflow limitation poorly reversible or not reversible at all, defined by an FEV1/FVC ratio less than 70%. Stages of severity of COPD are defined according to the level of post-bronchodilator FEV1: > 80% of the predicted value (stage I); 50-80% (stage II); 30-50% (stage III); < 30% (stage IV). Accordingly, the measurement of pulmonary volumes (spirometry) is required for the diagnosis but also for the follow-up of COPD patients. The investigations which are required depend on the severity of COPD: spirometry and flow-volume curves during forced expiration are sufficient in stage I; measurement of static lung volumes and bronchodilator reversibility testing are required in stage II. Arterial blood gases should be measured in stages III and IV. Pulse oxymetry and 6minute walk test (6MWT) are recommended from stage II.

For appreciating the severity of COPD and for the follow-up of patients it is recommended to evaluate other variables than FEV1: results of the 6MWT, level of dyspnea, body mass index. The results of FEV1 and of these variables are included in the recently developed BODE index. Measurement of CO transfer capacity is recommended in the presence of emphysema; cardiopulmonary exercise testing (bicycle) is recommended before initiating exercise training.

Resting and exercise response to altitude in patients with chronic obstructive pulmonary disease.

Aviat Space Environ Med. 2009 Feb;80(2):102-7. Kelly PT, Swanney MP, Stanton JD, Frampton C, Peters MJ, Beckert LE. Respiratory Physiology Laboratory, 4th floor Riverside Block, Christchurch Hospital, private bag 4710, Christchurch 8001, New Zealand.

INTRODUCTION: Exposure to altitude invariably involves some form of physical activity. There are limited data available to help predict the response to activity at altitude in patients with chronic obstructive pulmonary disease (COPD). The aim of the present study was to investigate the response to acute altitude exposure at rest and during exercise in patients with COPD.

METHODS: Sea level measures of cardio-pulmonary function were compared to the resting and exercise hypoxemic response at the summit of the Mt. Hutt ski field (2086 m), New Zealand, in 18 patients with COPD.

RESULTS: Ascent from sea level to altitude caused significant hypoxemia at rest (PaO2: 75 +/- 9 vs. 51 +/- 6 mmHg), and during a walk test (41 +/- 7 mmHg). At altitude, the walk test distance was reduced by 52%. Sea level PaO2 and SaO2 correlated with resting PaO2 (r = 0.69) and SaO2 (r = 0.79) at altitude. Diffusion capacity corrected for alveolar volume (K(CO)) correlated with resting SaO2 (r = 0.74) and exercise PaO2 (r = 0.75) at altitude. Aerobic capacity correlated with the walk test distance at altitude (r = 0.70). Spirometry, lung volumes, and ventilatory reserve did not correlate with the hypoxemic response to altitude.

DISCUSSION: Baseline arterial oxygen levels and K(CO) are key measures in predicting the hypoxemic response to acute altitude exposure in patients with COPD. The impairment in gas exchange associated with COPD is a significant mechanism causing altitude-related hypoxemia in this group.

Prevalence, Incidence, and Lifetime Risk for the Development of COPD in the Elderly: The Rotterdam Study.

Chest. 2009 Feb;135(2):368-77. van Durme YM, Verhamme KM, Stijnen T, van Rooij FJ, Van Pottelberge GR, Hofman A, Joos GF, Stricker BH, Brusselle GG. MB, Department of Epidemiology and Biostatistics, Erasmus University Medical Center, PO Box 2040, 3000 DR Rotterdam, the Netherlands.

BACKGROUND: COPD is a major cause of chronic morbidity and mortality throughout the world. Although the prevalence of COPD is already well documented, there are only few studies regarding the incidence of COPD.

METHODS: In a prospective population-based cohort study among subjects aged >/= 55 years, COPD was diagnosed with an algorithm based on the validation of hospital discharge letters, files from the general practitioner, and spirometry reports.

RESULTS: In this study cohort of 7,983 participants, 648 cases were identified with incident COPD after a median follow-up time of 11 years (interquartile range, 7.8 years). This resulted in an overall incidence rate (IR) of 9.2/1,000 person-years (PY) [95% confidence interval (CI), 8.5 to 10.0]. The IR of COPD was higher among men (14.4/1,000 PY; 95% CI, 13.0 to 16.0) than among women (6.2/1,000 PY; 95% CI, 5.5 to 7.0), and higher in smokers than in never-smokers (12.8/1,000 PY; 95% CI, 11.7 to 13.9 and 3.9/1,000 PY; 95% CI, 3.2 to 4.7, respectively). Remarkable was the high incidence in the youngest female age category of 55 to 59 years (7.4/1,000 PY; 95% CI, 4.1 to 12.6). For a 55-year-old man and woman still free of COPD at cohort entry, the risk for the development of COPD over the coming 40 years was 24% and 16%, respectively.

CONCLUSION: The overall incidence of COPD in an elderly population is 9.2/1,000 PY, with a remarkably high incidence in the youngest women, suggesting a further shift toward the female sex in the gender distribution of COPD. During their further lives, one of four men and one of six women free of COPD at the age of 55 years will have COPD develop

Healthcare for Obstructive Lung Disease in an Industrial Spirometry Surveillance Program.

J Occup Environ Med. 2009 Feb 14. Gulati M, Slade MD, Fiellin MG, Cullen MR. From the Yale Occupational and Environmental Medicine Program, Yale University School of Medicine, New Haven, Conn.

OBJECTIVE: The efficacy of workplace spirometry surveillance programs is unclear. We examine whether aluminum industry workers with airflow obstruction (AO) received health care for obstructive lung disease.

METHODS: We performed a cross sectional analysis over 7 years of 6821 aluminum production workers. The primary outcome was the association between obstructive lung disease insurance claims and the presence of AO. We also examined whether the presence of claims was associated with increasing AO severity.

RESULTS: Although workers with AO more frequently had claims, 60% of workers with AO, most frequently those with mild and borderline obstruction, had no claim.

CONCLUSIONS: Workers with AO, particularly borderline and mild obstruction, frequently do not receive health care despite respiratory surveillance. Further investigation is needed to determine if workers with undiagnosed AO are symptomatic or have accelerated losses in lung function over time.

Prevalence of Pulmonary Embolism in Acute Exacerbations of COPD
A Systematic Review and Metaanalysis

Chest March 1, 2009; 135 (3) Jacques Rizkallah, MD, S. F. Paul Man, MD, FCCP and Don D. Sin, MD, FCCP* From the Department of Medicine, Respiratory Division, University of British Columbia, Heart and Lung Center, James Hogg iCAPTURE Center for Cardiovascular and Pulmonary Research at St. Paul's Hospital, Vancouver, BC, Canada.

Background: Nearly 30% of all exacerbations of COPD do not have a clear etiology. Although pulmonary embolism (PE) can exacerbate respiratory symptoms such as dyspnea and chest pain, and COPD patients are at a high risk for PE due to a variety of factors including limited mobility, inflammation, and comorbidities, the prevalence of PE during exacerbations is uncertain.

Methods: A systematic review of the literature was performed to determine the reported prevalence of PE in acute exacerbations of COPD in patients who did and did not require hospitalization. The literature search was performed using MEDLINE, CINAHL, and EMBASE, and complemented by hand searches of bibliographies. Only cross-sectional or prospective studies that used CT scanning or pulmonary angiography for PE diagnosis were included.

Results: Of the 2,407 articles identified, 5 met the inclusion criteria (sample size, 550 patients). Overall, the prevalence of PE was 19.9% (95% confidence interval [CI], 6.7 to 33.0%; p = 0.014). In hospitalized patients, the prevalence was higher at 24.7% (95% CI, 17.9 to 31.4%; p = 0.001) than those who were evaluated in the emergency department (3.3%). Presenting symptoms and signs were similar between patients who did and did not have PE.

Conclusions: One of four COPD patients who require hospitalization for an acute exacerbation may have PE. A diagnosis of PE should be considered in patients with exacerbation severe enough to warrant hospitalization, especially in those with an intermediate-to-high pretest probability of PE.

Airflow limitation in smokers is associated with subclinical atherosclerosis

Am J Respir Crit Care Med. 2009 Jan 1;179(1):35-40. Iwamoto H, Yokoyama A, Kitahara Y, Ishikawa N, Haruta Y, Yamane K, Hattori N, Hara H, Kohno N. Department of Molecular and Internal Medicine, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan.

RATIONALE: Chronic obstructive pulmonary disease (COPD) is associated with increased morbidity and mortality from cardiovascular disease. Although a close association between COPD and atherosclerosis has been speculated, such scientific information is limited.

OBJECTIVES: To evaluate subclinical atherosclerosis in smokers with airflow limitation.

METHODS: The subjects of this study were healthy middle-aged men. Smokers with airflow limitation (n = 61) and age-matched control smokers (n = 122) and control never-smokers (n = 122) without airflow limitation were included in the present study. Subjects with diabetes, acute infection, and respiratory disease other than COPD were excluded beforehand. All subjects underwent chest radiogram, spirometry, blood sampling, and carotid ultrasonography. We determined carotid intima-media thickness and focal atheromatous plaque as indicators of subclinical atherosclerosis.

MEASUREMENTS AND MAIN RESULTS: Mean carotid intima-media thickness was greater in smokers with airflow limitation than in control smokers (P < 0.01) and control never-smokers (P < 0.005). Focal carotid plaque was significantly more prevalent in smokers with airflow limitation than in control never-smokers (P < 0.005). Multivariate analyses showed significant associations between thickened intima-media thickness and decreased percent predicted FEV(1) (P = 0.001) and between plaque and log(10) C-reactive protein (P = 0.013) independent of age, pack-years of smoking, body mass index, peripheral mean arterial pressure, heart rate, glucose, and low-density lipoprotein cholesterol.

CONCLUSIONS: Smokers with airflow limitation had exaggerated subclinical atherosclerosis. This study suggests that middle-aged men who are susceptible to COPD may also be susceptible to vascular atherosclerosis by smoking, and atherosclerotic change starts early in the disease process of COPD.

"Derdehands rook" een ander gevaar

Jennifer A. Kern, M.S., C.T.T.S.

De meeste mensen weten dat “tweedehands roken of meeroken” schadelijk is, vooral voor kinderen en mensen met chronische gezondheidsproblemen zoals hart- of longziekten. Dit heeft geleid tot regels als rookverbod en zuivere binnenlucht. Recent onderzoek levert nu een nieuwe bezorgdheid op.
"Derdehands rook" is de term die men geeft aan het residu van rookvervuiling dat zich in de omgeving nestelt en er ook blijft zelfs als de sigaret gedoofd werd. De chemische deeltjes die voortkomen uit het verbranden van tabak, met inbegrip van teer en nicotine, nestelen zich op de kleren, het haar, de meubelbekleding, de gordijnen enz, en blijven daar lang nadat de rook uit de lucht verdween.
Deze deeltjes zijn samengeteld uit meer dan 200 giftige gassen, waarvan verschillende kanker kunnen veroorzaken, zoals cyanide, ammonium, arsenic en polonium-210 (dit laatste is bovendien radio aktief). Deze chemische produkten worden afgezet op oppervlakkige zones en komen na verloop van tijd terug in de lucht.
Nieuw onderzoek wees uit dat restanten van tabak in de longen blijven nadat de roker zijn laatste trek deed aan zijn sigaret. Het kan 2 tot 3 minuten duren alvorens de roker geen toxische stoffen van de verbranding meer inademt. Deze uitgeblazen lucht kan eveneens bijdragen tot “tweedehands roken” en tot het achterblijven van tabaksdeeltjes die zich kunnen nestelen in de als rookvrij geziene plaatsen.
De meeste mensen zijn zich bewust van de negatieve effecten van zichtbare rook en doen inspanningen om de hoeveelheid waaraan niet rokers worden blootgesteld te controleren. We leren nu dat tabaktoxines kunnen achterblijven in het milieu als “derdehands rook” lang nadat de rookperiode voorbij is. Kinderen schijnen het grootste risico te lopen om aangetast te worden gezien zij deze deeltjes inademen vanuit kleren, tapijten, gordijnen, enz.
Het huis en de auto totaal rookvrij maken is de beste manier om diegenen de beschermen die u lief zijn. Ook 2 tot 3 minuten wachten nadat u een sigaret rookte, alvorens u terug contact legt met kinderen of alvorens u terugkeert naar rookvrije ruimten is allicht gunstig.
In mijn praktijk van professionele hulpverlening heb ik mensen gehad die me vroegen of zij hun huis of auto moesten reinigen na het stoppen met roken. Het antwoord is zeer duidelijk: “Ja!” Eens u de beslssing nam om te stoppen met roken geeft u uw auto en uw huis een goede, grondige schoonmaakbeurt om van die derdehands rook af te geraken. Door dit te doen beschermt u niet alleen uzelf maar ook diegenen die u lief zijn voor de schadelijke restanten van uw vorige, door tabak gecontroleerd leven, maar u verstevigt eveneens uw beslissing om voor eens en altijd een niet roker te blijven.

Smoking and Colorectal Cancer

A Meta-analysis JAMA. 2008;300(23):2765-2778. Edoardo Botteri, MSc; Simona Iodice, MSc; Vincenzo Bagnardi, PhD; Sara Raimondi, MSc; Albert B. Lowenfels, MD; Patrick Maisonneuve, Eng

Context: Colorectal cancer is the third most common form of cancer and the fourth most frequent cause of cancer deaths worldwide. The association between cigarette smoking and colorectal cancer has been inconsistent among studies.

Objective: To clarify the association of cigarette smoking and colorectal cancer, we performed a comprehensive literature search and a meta-analysis of observational studies considering both incidence and mortality.

Data Sources: We performed a literature search using PubMed, ISI Web of Science (Science Citation Index Expanded), and EMBASE to May 2008, with no restrictions. We also reviewed references from all retrieved articles.

Study Selection: All articles that were independent and contained the minimum information necessary to estimate the colorectal cancer risk associated with cigarette smoking and a corresponding measure of uncertainty.

Data Extraction: Articles were reviewed and data were extracted and cross-checked independently by 3 investigators, and any disagreement was resolved by consensus among all 3.

Results: One hundred six observational studies were included in the analysis of incidence. Twenty-six studies provided adjusted risk estimates for ever smokers vs never smokers, leading to a pooled relative risk of 1.18 (95% confidence interval [CI], 1.11-1.25). Smoking was associated with an absolute risk increase of 10.8 cases per 100 000 person-years (95% CI, 7.9-13.6). We found a statistically significant dose-relationship with an increasing number of pack-years and cigarettes per day. However, the association was statistically significant only after 30 years of smoking. Seventeen cohort studies were included in the analysis of mortality. The pooled risk estimate for ever vs never smokers was 1.25 (95% CI, 1.14-1.37). Smoking was associated with an absolute risk increase of 6.0 deaths per 100 000 person-years (95% CI, 4.2-7.6). For both incidence and mortality, the association was stronger for cancer of the rectum than of the colon.

Conclusion: Cigarette smoking is significantly associated with colorectal cancer incidence and mortality.

Identifying COPD patients at increased risk of mortality: predictive value of clinical study baseline data.

Respir Med. 2008 Nov;102(11):1615-24. Halpin DM, Peterson S, Larsson TP, Calverley PM. Royal Devon & Exeter Hospital, Barrack Road, Exeter, EX2 5DW, UK.

BACKGROUND: Identifying chronic obstructive pulmonary disease (COPD) patients at increased risk of mortality is an important component of effective disease management.

METHODS: A pooled analysis of patients with severe COPD, from two well-controlled 1-year studies, was conducted using Cox regression and spline analysis to evaluate predictability of baseline demographic data and in-study variables for mortality risk, and to evaluate the effect of treatment allocation to budesonide and formoterol, versus their respective control groups, on these outcomes.

RESULTS: In the pooled analysis, a Cox regression model reported a higher baseline St George's Respiratory Questionnaire (SGRQ) total score as a significant predictor of mortality (hazard ratio 1.037 [95% confidence interval 1.021-1.054]; p<0.0001). The 36-item short-form health survey (SF-36) mental and physical component scores were also predictive of an increased mortality risk (p<0.05). Age, forced expiratory volume in 1 s (FEV(1)), body mass index and smoking status were not significant predictors. Spline analysis of baseline variables revealed a linear association between SGRQ total score and mortality risk over 1 year (logarithmic scale). Other baseline variables, including FEV(1), showed different bimodal patterns in the spline analysis. There was no difference in mortality in the formoterol versus the non-formoterol treatment group while budesonide-containing treatment was associated with reduced 1-year, all-cause, in-study mortality compared with non-budesonide therapy.

CONCLUSION: Health status measured by SGRQ and SF-36 may be important for predicting COPD patients at increased mortality risk, with SGRQ total score emerging as the strongest predictor compared with other baseline covariates.

Respiratory viral infection in exacerbations of COPD.

Respir Med. 2008 Nov;102(11):1575-80. McManus TE, Marley AM, Baxter N, Christie SN, O'Neill HJ, Elborn JS, Coyle PV, Kidney JC. Department of Respiratory Medicine, Belfast Health and Social Care Trust, Belfast, N. Ireland, BT14 6AB, UK.

BACKGROUND: Patients with COPD have frequent exacerbations. The role of respiratory viral infection is just emerging. We wished to determine prospectively the incidence of viral infection in exacerbated and stable COPD patients as well as smokers who do not have airways obstruction.

METHODS: Stable and exacerbated COPD patients were recruited along with a group of patients who had smoked but who did not have any airways obstruction. Spirometry was performed and sputum specimens were tested for a range of 12 different respiratory viruses using PCR.

RESULTS: One hundred and thirty-six patients with exacerbations of COPD, 68 stable COPD patients and 16 non-obstructed smokers were recruited. A respiratory virus was detected in 37% of exacerbations, 12% of stable COPD patients and 12% of non-obstructed smokers, p<0.0005. Rhinovirus was most frequently detected. The symptom of fever was associated with virus detection, p<0.05. Infection with more than one virus was only found in the exacerbated COPD patients.

CONCLUSION: Respiratory viral infection is associated with exacerbations of COPD. Rhinovirus was the most common infecting agent identified and in two cases human metapneumovirus was also detected. Dual infections were only seen amongst those patients admitted to hospital with acute exacerbations of COPD. Viruses were more commonly detected in those with more severe airways disease.

Secondhand Smoke Linked to Dementia
Exposure may increase risk by 44%, researchers say

By Steven Reinberg HealthDay Reporter

THURSDAY, Feb. 12 (HealthDay News) -- People exposed to secondhand smoke may face as much as a 44 percent increased risk of developing dementia, a new study suggests.

While previous research has established a connection between smoking and increased risk for dementia and Alzheimer's disease, this new study is the largest review to date showing a link between secondhand smoke and the threat of dementia, the authors said.

"There is an association between cognitive function, which is often but not necessarily a precursor of dementia, and exposure to passive smoking," said lead researcher Iain Lang, a research fellow in the Public Health and Epidemiology Group at Peninsula Medical School in Exeter, England.

What's more, Lang said, the risk of impaired cognitive function increases with the amount of exposure to secondhand smoke, the findings suggest. "For people at the highest levels of exposure, the risk is probably higher," he said.

The study was published online Feb. 13 in the journal BMJ.com.

For the study, Lang's team collected data on more than 4,800 nonsmokers who were over 50 years old. The researchers tested saliva samples from these people for levels of cotinine, a product of nicotine that can be found in saliva for about 25 hours after exposure to smoke.

The study participants also took neuropsychological tests to assess brain function and cognitive impairment. These tests evaluated memory, math and verbal skills. People whose scores were in the lowest 10 percent were classified as having some level of cognitive impairment.

The researchers found that people with the highest cotinine levels had a 44 percent increased risk of cognitive impairment, compared with people with the lowest cotinine levels. And, while the risk of impairment was lower in people with lower cotinine levels, the risk was still significant.

"We know that active smoking is bad -- being a smoker is bad for your health and increases your risk of Alzheimer's. This study suggests that this is the same for passive smoking," Lang said. "We know that passive smoking is associated with an increased risk of stroke and heart disease. This is just another reason to avoid exposing other people to your smoke, and if you are not a smoker to stay away from smoking places."

Maria Carrillo, director of medical and scientific relations for the Alzheimer's Association, said this study offers more evidence of the dangers of secondhand smoke and the risk for dementia. Smoking is already recognized as a risk factor for Alzheimer's, and the risk can be extended to exposure to secondhand smoke, she said.

"There are findings that secondhand smoke can be just as detrimental as smoking itself," Carrillo said. "We recommend that people do not smoke and try to reduce their exposure to secondhand smoke as well."

Dr. Mark Eisner, an associate professor of medicine at the University of California, San Francisco, and author of an accompanying editorial in the journal, said, "This study should provide further motivation for public policy aimed at making all public spaces smoke-free."

The obesity paradox in patients with peripheral arterial disease

Chest. 2008 Nov;134(5):925-30 Galal W, van Gestel YR, Hoeks SE, Sin DD, Winkel TA, Bax JJ, Verhagen H, Awara AM, Klein J, van Domburg RT, Poldermans D. Department of Anesthesiology, Erasmus Medical Center, Rotterdam, the Netherlands.

BACKGROUND: Cardiac events are the predominant cause of late mortality in patients with peripheral arterial disease (PAD). In these patients, mortality decreases with increasing body mass index (BMI). COPD is identified as a cardiac risk factor, which preferentially affects underweight individuals. Whether or not COPD explains the obesity paradox in PAD patients is unknown.

METHODS: We studied 2,392 patients who underwent major vascular surgery at one teaching institution. Patients were classified according to COPD status and BMIs (ie, underweight, normal, overweight, and obese), and the relationship between these variables and all-cause mortality was determined using a Cox regression analysis. The median follow-up period was 4.37 years (interquartile range, 1.98 to 8.47 years).

RESULTS: The overall mortality rates among underweight, normal, overweight, and obese patients were 54%, 50%, 40%, and 31%, respectively (p < 0.001). The distribution of COPD severity classes showed an increased prevalence of moderate-to-severe COPD in underweight patients. In the entire population, BMI (continuous) was associated with increased mortality (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.94 to 0.98). In addition, patients who were classified as being underweight were at increased risk for mortality (HR, 1.42; 95% CI, 1.00 to 2.01). However, after adjusting for COPD severity the relationship was no longer significant (HR, 1.29; 95% CI, 0.91 to 1.93).

CONCLUSIONS: The excess mortality among underweight patients was largely explained by the overrepresentation of individuals with moderate-to-severe COPD. COPD may in part explain the "obesity paradox" in the PAD population.

Smoking and Cognitive Decline Among Middle-Aged Men and Women: The Doetinchem Cohort Study

American Journal of Public Health December 2008 Vol 98 No 12 Pp 2244- 2250 Astrid C. J. Nooyens, MSc, Boukje M. van Gelder, PhD and W. M. Monique Verschuren, PhD The authors are with the Centre for Prevention and Health Services Research, National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands.

Objectives. We studied the effect of smoking on cognitive decline over a 5-year period at middle age (43 to 70 years).

Methods. In the Doetinchem Cohort Study, 1964 men and women in the Netherlands were examined for cognitive function at baseline and 5 years later. The association between smoking status and memory function, speed of cognitive processes, cognitive flexibility, and global cognitive function were assessed.

Results. At baseline, smokers scored lower than never smokers in global cognitive function, speed, and flexibility. At 5-year follow-up, decline among smokers was 1.9 times greater for memory function, 2.4 times greater for cognitive flexibility, and 1.7 times greater for global cognitive function than among never smokers. Among ever smokers, the declines in all cognitive domains were larger with increasing number of pack-years smoked.

Occupational exposures and the risk of COPD: dusty trades revisited.

Thorax. 2009 Jan;64(1):6-12. Blanc PD, Iribarren C, Trupin L, Earnest G, Katz PP, Balmes J, Sidney S, Eisner MD. Division of Occupational and Environmental Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA 94117, USA.

BACKGROUND: The contribution of occupational exposures to chronic obstructive pulmonary disease (COPD) and, in particular, their potential interaction with cigarette smoking remains underappreciated.

METHODS: Data from the FLOW study of 1202 subjects with COPD (of which 742 had disease classified as stage II or above by Global Obstructive Lung Disease (GOLD) criteria) and 302 referent subjects matched by age, sex and race recruited from a large managed care organisation were analysed. Occupational exposures were assessed using two methods: self-reported exposure to vapours, gas, dust or fumes on the longest held job (VGDF) and a job exposure matrix (JEM) for probability of exposure based on occupation. Multivariate analysis was used to control for age, sex, race and smoking history. The odds ratio (OR) and adjusted population attributable fraction (PAF) associated with occupational exposure were calculated.

RESULTS: VGDF exposure was associated with an increased risk of COPD (OR 2.11; 95% CI 1.59 to 2.82) and a PAF of 31% (95% CI 22% to 39%). The risk associated with high probability of workplace exposure by JEM was similar (OR 2.27; 95% CI 1.46 to 3.52), although the PAF was lower (13%; 95% CI 8% to 18%). These estimates were not substantively different when the analysis was limited to COPD GOLD stage II or above. Joint exposure to both smoking and occupational factors markedly increased the risk of COPD (OR 14.1; 95% CI 9.33 to 21.2).

CONCLUSIONS: Workplace exposures are strongly associated with an increased risk of COPD. On a population level, prevention of both smoking and occupational exposure, and especially both together, is needed to prevent the global burden of disease.

Impact of gastro-oesophageal reflux disease symptoms on COPD exacerbation

Thorax. 2008 Nov;63(11):951-5. Terada K, Muro S, Sato S, Ohara T, Haruna A, Marumo S, Kinose D, Ogawa E, Hoshino Y, Niimi A, Terada T, Mishima M. Department of Respiratory Medicine, Kyoto University, 54, Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.

BACKGROUND: The association between gastro-oesophageal reflux disease (GORD) and chronic obstructive pulmonary disease (COPD) exacerbation has so far remained unclear.

OBJECTIVE: To prospectively establish the clinical significance of GORD symptoms on exacerbation.

METHODS: 82 patients with COPD and 40 age matched controls were enrolled in this study. Symptoms were evaluated by a questionnaire using the Frequency Scale for the Symptoms of GORD (FSSG). Patients with COPD were prospectively surveyed for 6 months, and episodes of exacerbation were identified using a diary based on modified Anthonisen's criteria. Exhaled breath condensate (EBC) pH was measured in both groups, and induced sputum was evaluated in patients with COPD.

RESULTS: Positive GORD symptoms were reported in 22 (26.8%) patients with COPD and in five (12.5%) controls (p = 0.10). The frequency of exacerbations was significantly associated with the FSSG score (p = 0.03, r = 0.24, 95% CI 0.02 to 0.43). Multiple regression analysis revealed that GORD symptoms were significantly associated with the occurrence of exacerbations (p<0.01; relative risk 6.55, 95% CI 1.86 to 23.11). EBC pH was inversely correlated with FSSG score in both groups (p = 0.01, r = -0.37, 95% CI -0.55 to -0.14 in patients with COPD, and p<0.01, r = -0.45, 95% CI -0.67 to -0.16 in control subjects).

CONCLUSIONS: GORD symptoms were identified as an important factor associated with COPD exacerbation.

Inspiratory muscle training in adults with chronic obstructive pulmonary disease: an update of a systematic review

Respir Med. 2008 Dec;102(12):1715-29. Geddes EL, O'Brien K, Reid WD, Brooks D, Crowe J. School of Rehabilitation Science, Institute of Applied Health Science, Room 403, McMaster University, 1400 Main Street West, Hamilton, ON, Canada L8S 1C7.

The purpose was to update an original systematic review to determine the effect of inspiratory muscle training (IMT) on inspiratory muscle strength and endurance, exercise capacity, dyspnea and quality of life for adults with chronic obstructive pulmonary disease (COPD).

The original MEDLINE and CINAHL search to August 2003 was updated to January 2007 and EMBASE was searched from inception to January 2007. Randomized controlled trials, published in English, with adults with stable COPD, comparing IMT to sham IMT or no intervention, low versus high intensity IMT, and different modes of IMT were included. Nineteen of 274 articles in the original search met the inclusion criteria. The updated search revealed 17 additional articles; 6 met the inclusion criteria, all of which compared targeted, threshold or normocapneic hyperventilation IMT to sham IMT. An update of the sub-group analysis comparing IMT versus sham IMT was performed with 10 studies from original review and 6 from the update. Sixteen meta-analyses are reported.

Results demonstrated significant improvements in inspiratory muscle strength (PI(max), PI(max) % predicted, peak inspiratory flow rate), inspiratory muscle endurance (RMET, inspiratory threshold loading, MVV), exercise capacity (Ve(max), Borg Score for Respiratory Effort, 6MWT), Transitional Dyspnea Index (focal score, functional impairment, magnitude of task, magnitude of effort), and the Chronic Respiratory Disease Questionnaire (quality of life).

Results suggest that targeted, threshold or normocapneic hyperventilation IMT significantly increases inspiratory muscle strength and endurance, improves outcomes of exercise capacity and one measure of quality of life, and decreases dyspnea for adults with stable COPD.

Non-reversible airway obstruction in never smokers: results from the Austrian BOLD study

Respir Med. 2008 Dec;102(12):1833-8. Lamprecht B, Schirnhofer L, Kaiser B, Buist S, Studnicka M. Department of Pulmonary Medicine, Paracelsus Medical University Hospital, Salzburg, Austria.

BACKGROUND: The presence of non-reversible airway obstruction (AO) in never smokers has only received limited attention until now.

METHODS: We analyzed data from the Austrian Burden of Obstructive Lung Disease (BOLD) study. We defined non-reversible AO as post-bronchodilator FEV(1)/FVC <0.7 which corresponds to COPD I and higher (COPD I+) according to current GOLD guidelines. Significant AO was defined as FEV(1)/FVC <0.7 and FEV(1) <80% predicted (GOLD II and higher, GOLD II+). The prevalence and characteristics of non-reversible AO in never smokers were analyzed in relation to the severity of the disease.

RESULTS: Never smokers comprised 47.3% of the study population. Non-reversible AO was seen in 18.2% of never smokers, and 5.5% of never smokers fulfilled criteria for significant non-reversible AO (GOLD stage II+). Therefore, the resulting population prevalence of significant non-reversible AO (GOLD stage II+) was 2.6%. Never smokers with non-reversible AO were predominantly female and slightly older. The airway obstruction was found to be less severe as compared with ever smokers. Despite this, 20% of never smokers with significant non-reversible AO (GOLD stage II+) reported respiratory symptoms and 50% reported impairment of quality of life. This burden of illness in never smokers was similar to that in smokers when severity of AO was taken into account.

CONCLUSION: Approximately every third subject with non-reversible AO has never smoked, yet still demonstrates a substantial burden of symptoms and impairment of quality of life. Never smokers should receive far greater attention when efforts are undertaken to prevent and treat chronic airway obstruction.

Impact of occupational exposure on severity of COPD.

Chest. 2008 Dec;134(6):1237-43. Rodríguez E, Ferrer J, Martí S, Zock JP, Plana E, Morell F. Respiratory Medicine Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CIBER Enfermedades Respiratorias, Barcelona, Spain.

BACKGROUND: The relationship between occupational exposures and COPD has been analyzed in population-based and occupational cohort studies. However, the influence of these exposures on the clinical characteristics of COPD is not well known. The aim of this study was to analyze the impact of occupational exposures on respiratory symptoms, lung function, and employment status in a series of COPD patients.

METHODS: We conducted a cross-sectional study of 185 male COPD patients. Patients underwent baseline spirometry and answered a questionnaire that included information on respiratory symptoms, hospitalizations for COPD, smoking habits, current employment status, and lifetime occupational history. Exposure to biological dust, mineral dust, and gases and fumes was assessed using an ad hoc job exposure matrix.

RESULTS: Having worked in a job with high exposure to mineral dust or to any dusts, gas, or fumes was associated with an FEV(1) of < 30% predicted (mineral dust: relative risk ratio, 11; 95% confidence interval [CI], 1.4 to 95; dusts, gas, or fumes: relative risk ratio, 6.9; 95% CI, 1.1 to 45). High exposure to biological dust was associated with chronic sputum production (odds ratio [OR], 4.3; 95% CI, 1.6 to 12), dyspnea (OR, 2.7; 95% CI, 1.1 to 6.7), and work inactivity (OR, 2.4; 95% CI, 1.4 to 4.2). High exposure to dusts, gas, or fumes was associated with sputum production (OR, 2.8; 95% CI, 1.2 to 6.7) and dyspnea (OR, 1.2; 95% CI, 1.1 to 1.4).

CONCLUSIONS: Occupational exposures are independently associated with the severity of airflow limitation, respiratory symptoms, and work inactivity in patients with COPD.

Tele-assistance in Chronic Respiratory Failure Patients: a Randomised Clinical Trial.

Eur Respir J. 2008 Sep 17. Vitacca M, Bianchi L, Guerra A, Fracchia C, Spanevello A, Balbi B, Scalvini S. Fondazione S. Maugeri, IRCCS, Lumezzane (Bs) - Italy.

Chronic respiratory patients requiring oxygen or home mechanical ventilation experience frequent exacerbations and hospitalisations with related costs. Strict monitoring and care have been recommended.

The primary aim was to evaluate reduction in hospitalisations and secondarely exacerbations, general practictioner (GP) calls and related cost-effectiveness of tele-assistance (TA) for these patients.

240 patients (101 COPD) were randomized to two groups: intervention group received one year TA program while controls received traditional careNo anthropometric and clinical differences were found between groups both in baseline and in mortality (18% for TA, 23% for controls). As compared with controls, TA group experianced less hospitalizations (-36% p<0.02), less GP urgent calls (-65% p<0.002), less acute exacerbations (-71% p<0.0001). Only COPD patients, as a separate group had more subject free from hospitalizations (p=0.012), emergency room admissions (p=0.0008), urgent GP calls (p=0.013) or exacerbations (p<0.0001). Each patient referred to staff 36+/-25 times. After deduction of TA costs, the average overall cost per each patient was 33% less than that for usual care.

In chronic respiratory failure patients on oxygen or home mechanical ventilation, a nurse-centred Tele-assistance prevents hospitalizations while it is cost/effective. The COPD group seems to have the bigger advantage from tele-assistance.

Predictors of Survival in COPD: more than just the FEV1.

Respir Med. 2008 Jun;102 Suppl 1:S27-35 Celli BR, Cote CG, Lareau SC, Meek PM. Caritas St. Elizabeth's Medical Center, Boston, MA, USA.

Chronic obstructive pulmonary disease (COPD) ranks fourth as a cause of death in the United States, behind heart disease, cancer, and stroke. Additionally, since serious co-morbidities are often present in patients with COPD, many die from other diseases such as cardiac disease or cancer. Not surprisingly, multiple factors, reflective of both respiratory disease process and the substantial co-morbidity, predict survival in the disease. As might be expected, physiologic derangements such as airflow obstruction, hypoxemia, lung hyperinflation, and exercise capacity predict survival in COPD. Anemia, cachexia and reductions in lean body mass also relate to prognosis. Perhaps less recognized is the more recent documentation that more subjective assessments, such as dyspnea and health related quality of life, are also important predictors of survival.

The integration of some of the most important of these variables may provide a more comprehensive evaluation of disease severity. For example, a validated multi-dimensional disease rating that includes the body mass index (B), degree of airflow obstruction (O), dyspnea (D), and exercise capacity (E) (BODE Index) is capable of predicting COPD-related hospitalization and mortality more than its individual components.

Effects of smoking and solid-fuel use on COPD, lung cancer, and tuberculosis in China: a time-based, multiple risk factor, modelling study.

Lancet. 2008 Oct 25;372(9648):1473-83. Lin HH, Murray M, Cohen T, Colijn C, Ezzati M. Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA.

BACKGROUND: Chronic obstructive pulmonary disease (COPD), lung cancer, and tuberculosis are three leading causes of death in China, where prevalences of smoking and solid-fuel use are also high. We aimed to predict the effects of risk-factor trends on COPD, lung cancer, and tuberculosis.

METHODS: We used representative data sources to estimate past trends in smoking and household solid-fuel use and to construct a range of future scenarios. We obtained the aetiological effects of risk factors on diseases from meta-analyses of epidemiological studies and from large studies in China. We modelled future COPD and lung cancer mortality and tuberculosis incidence, taking into account the accumulation of hazardous effects of risk factors on COPD and lung cancer over time, and dependency of the risk of tuberculosis infection on the prevalence of disease. We quantified the sensitivity of our results to methods and data choices.

FINDINGS: If smoking and solid-fuel use remain at current levels between 2003 and 2033, 65 million deaths from COPD and 18 million deaths from lung cancer are predicted in China; 82% of COPD deaths and 75% of lung cancer deaths will be attributable to the combined effects of smoking and solid-fuel use. Complete gradual cessation of smoking and solid-fuel use by 2033 could avoid 26 million deaths from COPD and 6.3 million deaths from lung cancer; interventions of intermediate magnitude would reduce deaths by 6-31% (COPD) and 8-26% (lung cancer). Complete cessation of smoking and solid-fuel use by 2033 would reduce the projected annual tuberculosis incidence in 2033 by 14-52% if 80% DOTS coverage is sustained, 27-62% if 50% coverage is sustained, or 33-71% if 20% coverage is sustained.

INTERPRETATION: Reducing smoking and solid-fuel use can substantially lower predictions of COPD and lung cancer burden and would contribute to effective tuberculosis control in China.

Illness perceptions and COPD: an emerging field for COPD patient management.

J Asthma. 2008 Oct;45(8):625-9 Kaptein AA, Scharloo M, Fischer MJ, Snoei L, Cameron LD, Sont JK, Rabe KF, Weinman J. Unit of Psychology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands.

OBJECTIVE: Patients with chronic obstructive pulmonary disease have perceptions of their illness and its management that determine their coping behaviors (e.g., adherence, self-management) and, consequently, their outcomes. This article reviews the empirical literature on illness perceptions in patients with COPD to provide clinicians with information regarding the potential utility of incorporating illness perceptions into clinical COPD care.

METHOD: A literature search in PubMed identified 16 studies examining associations between illness perceptions and outcomes in patients with COPD.

RESULTS: Seven of the 16 papers were from US authors, followed by 3 each from the UK and The Netherlands, and one study each from Australia, Canada, and New Zealand. The first study was published in 1983, and the numbers of patients per study ranged fom 10 to 266. The illness perceptions were those delineated by two theoretical models (cognitive behavioral theory and the Common Sense Model), and they were assessed with open interviews and validated questionnaires. Outcomes were disability, quality of life, and psychological characteristics. The studies revealed clinically meaningful associations between illness perceptions and outcomes.

CONCLUSION: Our review supports the incorporation of illness perceptions into clinical care for patients with COPD. The assessment of illness perceptions should be routine, similar to routine assessments of pulmonary function. Discussing and changing illness perceptions will improve COPD patients' quality of life and reduce their levels of disability. COPD-specific assessments ("diagnosis") of illness perceptions and COPD-specific intervention methods ("therapy") that help change inadequate and maladaptive illness perceptions are research priorities.

Predictors of Smoking Cessation After a Myocardial Infarction
The Role of Institutional Smoking Cessation Programs in Improving Success

Arch Intern Med. 2008;168(18):1961-1967. Nazeera Dawood, MD, MPH; Viola Vaccarino, MD, PhD; Kimberly J. Reid, MS; John A. Spertus, MD, MPH; Nesruddin Hamid, MD; Susmita Parashar, MD, MPH, MS; for the PREMIER Registry Investigators

Background: Smoking cessation after myocardial infarction (MI) is an important goal for secondary prevention of mortality. Whether new initiatives to promote cessation improve patients' quit rates after MI is unknown.

Methods: The Prospective Registry Evaluating Outcomes After Myocardial Infarction Events and Recovery (PREMIER) enrolled 2498 patients with MI from 19 US centers between January 2003 and June 2004. Smoking behavior was assessed by self-report during hospitalization and 6 months after an MI. Extensive sociodemographic, comorbidity, psychosocial, disease severity, and treatment data were collected by interview and medical record abstraction. Hierarchical multivariable logistic regression models with random site effects were constructed to predict smoking cessation 6 months after admission, with a focus on the presence of an inpatient smoking cessation program as a hospital-level covariate.

Results: Among 834 patients who smoked at the time of MI hospitalization, 639 were interviewed and reported their smoking habits 6 months post-MI (77%). Of these, 297 were not smoking at 6 months (46%). The odds of smoking cessation were greater among those receiving discharge recommendations for cardiac rehabilitation (odds ratio [OR], 1.80; 95% confidence interval [CI], 1.17-2.75) and being treated at a facility that offered an inpatient smoking cessation program (OR, 1.71; 95% CI, 1.03-2.83). However, medical chart–based individual smoking cessation counseling did not predict smoking cessation rates (OR, 0.80; 95% CI, 0.51-1.25). Patients with depressive symptoms during the MI hospitalization were less likely to quit smoking (OR, 0.57; 95% CI, 0.36-0.90).

Conclusions: While individual smoking cessation counseling was not associated with smoking cessation post-MI, hospital-based smoking cessation programs, as well as referral to cardiac rehabilitation, were strongly associated with increased smoking cessation rates. Such programs appear to be underutilized in current clinical practice and may be a valuable structural measure of health care quality. Moreover, smoking cessation programs should likely incorporate screening for and treating depressive disorders.

Smoking Cessation Interventions for Hospitalized Smokers

A Systematic Review Arch Intern Med. 2008;168(18):1950-1960. Nancy A. Rigotti, MD; Marcus R. Munafo, PhD; Lindsay F. Stead, MSc

Background: A hospital admission provides an opportunity to help people stop smoking. Providing smoking cessation advice, counseling, or medication is now a quality-of-care measure for US hospitals. We assessed the effectiveness of smoking cessation interventions initiated during a hospital stay.

Methods: We searched the Cochrane Tobacco Addiction Review Group's register for randomized and quasirandomized controlled trials of smoking cessation interventions (behavioral counseling and/or pharmacotherapy) that began during hospitalization and had a minimum of 6 months of follow-up. Two authors independently extracted data from each article, with disagreements resolved by consensus.

Results: Thirty-three trials met inclusion criteria. Smoking counseling that began during hospitalization and included supportive contacts for more than 1 month after discharge increased smoking cessation rates at 6 to 12 months (pooled odds ratio [OR], 1.65; 95% confidence interval [CI], 1.44-1.90). No benefit was found for interventions with less postdischarge contact. Counseling was effective when offered to all hospitalized smokers and to the subset admitted for cardiovascular disease. Adding nicotine replacement therapy to counseling produced a trend toward efficacy over counseling alone (OR, 1.47; 95% CI, 0.92-2.35). One study added bupropion hydrochloride to counseling, which had a nonsignificant result (OR, 1.56; 95% CI, 0.79-3.06).

Conclusions: Offering smoking cessation counseling to all hospitalized smokers is effective as long as supportive contacts continue for more than 1 month after discharge. Adding nicotine replacement therapy to counseling may further increase smoking cessation rates and should be offered when clinically indicated, especially to hospitalized smokers with nicotine withdrawal symptoms

The Association Between Alcohol Consumption and Risk of COPD Exacerbation in a Veteran Population

Chest October 2008; 134:761-767 Courtney C. Greene, MD*; Katharine A. Bradley, MD, MPH; Chris L. Bryson, MD, MS; David K. Blough, PhD; Laura E. Evans, MD, MS, FCCP; Edmonds M. Udris, MPH and David H. Au, MD, MS *From the Health Services Research and Development (Drs. Au, Bradley, and Bryson, and Mr. Udris), Seattle, WA; the Department of Medicine (Dr. Greene), University of Washington, Seattle, WA; the Department of Pharmacy (Dr. Blough), University of Washington, Seattle, WA; and the Department of Medicine (Dr. Evans), New York University, New York, NY.

Background: Alcohol has been associated with COPD-related mortality but has not yet been demonstrated to be an independent risk factor for COPD exacerbation. Our objective was to evaluate the association between alcohol consumption and the subsequent risk of COPD exacerbation.

Methods: A prospective cohort study of general medicine outpatients seen at one of seven Veterans Affairs (VA) medical centers who returned health screening questionnaires. Three screening questionnaires, AUDIT-C (0 to 12 points), CAGE (0 to 4 points), and a single item about the frequency of drinking six or more drinks on an occasion (binge drinking), were used to classify alcohol consumption. The main outcome, COPD exacerbation, was based on primary VA discharge diagnosis (International Classification of Diseases, Ninth Revision) or outpatient diagnosis of COPD accompanied by prescriptions for either antibiotics or prednisone within 2 days.

Results: Among the 30,503 patients followed up for a median of 3.35 years, those patients with AUDIT-C scores ≥6, CAGE scores ≥2, or who reported binge drinking at least weekly were at an increased risk of COPD exacerbation in age-adjusted analysis. Adjusted hazard ratios were 1.4 (95% confidence interval [CI], 1.1 to 1.7) for AUDIT-C score ≥6, 1.4 (95% CI, 1.3 to 1.5) for CAGE score ≥2, and 1.6 (95% CI, 1.2 to 2.2) for those who reported binge drinking daily or almost daily. However, with adjustment for measures of tobacco use, the association between alcohol consumption and increased risk of COPD exacerbation was no longer evident.

Conclusions: Alcohol consumption, whether quantified by AUDIT-C, CAGE score, or binge drinking, was not associated with an increased risk of COPD exacerbation independent of tobacco use.

Secondhand Smoke Worse for Children
Kids at higher risk, since they breathe in more air by weight than adults, study says

HealthDay News

Children exposed to secondhand smoke often have levels of carbon monoxide in their blood that are similar to those of adult smokers, and frequently higher levels than adults exposed to secondhand smoke, a new study found.

The study, to be presented at the American Society of Anesthesiologists annual meeting that concludes Oct. 22 in Orlando, Fla., said the younger the child, the greater the potential for exposure.

"The physiology of children -- especially the youngest -- is different from that of adults," Dr. Branden E. Yee, of the anesthesiology department at Tufts Medical Center in Boston, said in a news release issued by the society. "Children breathe in a greater amount of air per body weight compared to adults."

The study measured levels of carboxyhemoglobin, which is formed when carbon monoxide binds to the blood, in 200 children between the ages of 1 and 12. The exact ramifications of high levels of carboxyhemoglobin are not entirely known, but long-term, low-level exposure includes changes in heart and lung tissue as it hampers delivery of oxygen to body tissue.

While household and environmental factors such as stoves, heaters and automobiles are potential sources of carbon monoxide exposure, secondhand cigarette smoke is often the most likely source of elevated carboxyhemoglobin, the researchers said.

Yee said educating parents about the need to change their smoking habits, especially around children, is vital.

"Personalized education coupled with the act of physically showing a parent the carboxyhemoglobin measurement in his or her child's blood may provide a graphic and concrete message to that parent," he said.

Survival and quality of life for patients with COPD or asthma admitted to intensive care in the UK: multi-centre observational cohort study. The COPD and Asthma Outcome Study (CAOS).

Thorax. 2008 Oct 13 Wildman MJ, Sanderson C, Groves J, Reeves B, Ayres J, Harrison DA, Young D, Rowan K. Northern General Hospital, United Kingdom.

BACKGROUND: Non-invasive ventilation is first-line treatment for patients with acutely decompensated chronic obstructive pulmonary disease (COPD), but endotracheal intubation, involving admission to critical care, may sometimes be required. Decisions to admit to critical care are commonly based on predicted survival and quality of life, but the information base for these decisions is limited, and there is some evidence that clinicians tend to be pessimistic. We studied outcomes in COPD patients admitted to critical care for decompensated type II respiratory failure.

METHODS: A prospective cohort study was carried out in 92 intensive care and 3 respiratory high dependency units in the United Kingdom. Patients aged 45 years and older with breathlessness, respiratory failure or change in mental status due to an exacerbation of COPD, asthma or a combination of the two were recruited. Outcomes included survival and quality of life at 180 days.

RESULTS: Of the 832 patients recruited 517 (62%) survived to 180 days. Of the survivors, 421 (81%) responded to a questionnaire. Of the respondents, 73% considered their quality of life to be the same as or better than it had been in the stable period before they were admitted, and 96% would choose similar treatment again. Function during the stable pre-admission period was a reasonable indicator of function reported by 180-day survivors.

CONCLUSIONS: Most patients with COPD who survive to 180 days after ICU have a heavy burden of symptoms but almost all of them, including those who have been intubated, would want similar intensive care again under similar circumstances.

Are patients with COPD more active after pulmonary rehabilitation?

Chest. 2008 Aug;134(2):273-80. Pitta F, Troosters T, Probst VS, Langer D, Decramer M, Gosselink R. Respiratory Rehabilitation and Respiratory Division, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium.

BACKGROUND: Despite a variety of benefits brought by pulmonary rehabilitation to patients with COPD, it is unclear whether these patients are more active during daily life after the program.

METHODS: Physical activities in daily life (activity monitoring), pulmonary function (spirometry), exercise capacity (incremental cycle-ergometer testing and 6-min walk distance testing), muscle force (quadriceps and handgrip force, and inspiratory and expiratory maximal pressures), quality of life (chronic respiratory disease questionnaire), and functional status (pulmonary functional status and dyspnea questionnaire-modified version) were assessed at baseline, after 3 months of a multidisciplinary rehabilitation program, and at the end of a 6-month multidisciplinary rehabilitation program in 29 patients (mean [+/- SD] age, 67 +/- 8 years; FEV(1), 46 +/- 16% predicted).

RESULTS: Exercise capacity, muscle force, quality of life, and functional status improved significantly after 3 months of pulmonary rehabilitation (all p < 0.05), with further improvements in muscle force, functional status, and quality of life at 6 months. Movement intensity during walking improved significantly after 3 months (p = 0.046) with further improvements after 6 months (p = 0.0002). Walking time in daily life did not improve significantly at 3 months (mean improvement, 7 +/- 35%; p = 0.21), but only after 6 months (mean improvement, 20 +/- 36%; p = 0.008). No significant changes occurred in other activities or in the pattern of the time spent walking in daily life. Changes in dyspnea after the program were significantly related to changes in walking time in daily life (r = 0.43; p = 0.02).

CONCLUSION: If one aims at changing physical activity habits in the daily life of COPD patients, the contribution of long-lasting programs might be important.

Impact of cough across different chronic respiratory diseases: comparison of two cough-specific health-related quality of life questionnaires.

Chest. 2008 Aug;134(2):295-302 Polley L, Yaman N, Heaney L, Cardwell C, Murtagh E, Ramsey J, Macmahon J, Costello RW, McGarvey L. Department of Medicine, The Queen's University of Belfast, Northern Ireland.

BACKGROUND: Cough is a prominent symptom across a range of common chronic respiratory diseases and impacts considerably on patient health status.

METHODS: We undertook a cross-sectional comparison of scores from two cough-specific health-related quality of life (HRQoL) questionnaires, the Leicester Cough Questionnaire (LCQ), and the Cough Quality of Life Questionnaire (CQLQ), together with a generic HRQoL measure, the EuroQol. Questionnaires were administered to and spirometry performed on 147 outpatients with chronic cough (n = 83), COPD (n = 18), asthma (n = 20), and bronchiectasis (n = 26).

RESULTS: There was no significant difference in the LCQ and CQLQ total scores between groups (p = 0.24 and p = 0.26, respectively). Exploratory analyses of questionnaire subdomains revealed differences in psychosocial issues and functional impairment between the four groups (p = 0.01 and p = 0.05, respectively). CQLQ scores indicated that chronic coughers have more psychosocial issues than patients with bronchiectasis (p = 0.03) but less functional impairment than COPD patients (p = 0.04). There was a significant difference in generic health status across the four disease groups (p = 0.04), with poorest health status in COPD patients. A significant inverse correlation was observed between CQLQ and LCQ in each disease group (chronic cough r = - 0.56, p < 0.001; COPD r = - 0.49, p = 0.04; asthma r = - 0.94, p < 0.001; and bronchiectasis r = - 0.88, p < 0.001). There was no correlation between cough questionnaire scores and FEV(1) in any group, although a significant correlation between EuroQol visual analog scale component and FEV(1) (r = 0.639, p = 0.004) was observed in COPD patients.

CONCLUSION: Cough adversely affects health status across a range of common respiratory diseases. The LCQ and CQLQ can each provide important additional information concerning the impact of cough.

Longitudinal change in the BODE index predicts mortality in severe emphysema.

Am J Respir Crit Care Med. 2008 Sep 1;178(5):491-9. Martinez FJ, Han MK, Andrei AC, Wise R, Murray S, Curtis JL, Sternberg A, Criner G, Gay SE, Reilly J, Make B, Ries AL, Sciurba F, Weinmann G, Mosenifar Z, DeCamp M, Fishman AP, Celli BR; National Emphysema Treatment Trial Research Group. Collaborators (444) Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, Michigan 48109-0360, USA.

RATIONALE: The predictive value of longitudinal change in BODE (Body mass index, airflow Obstruction, Dyspnea, and Exercise capacity) index has received limited attention. We hypothesized that decrease in a modified BODE (mBODE) would predict survival in National Emphysema Treatment Trial (NETT) patients.

OBJECTIVES: To determine how the mBODE score changes in patients with lung volume reduction surgery versus medical therapy and correlations with survival.

METHODS: Clinical data were recorded using standardized instruments. The mBODE was calculated and patient-specific mBODE trajectories during 6, 12, and 24 months of follow-up were estimated using separate regressions for each patient. Patients were classified as having decreasing, stable, increasing, or missing mBODE based on their absolute change from baseline. The predictive ability of mBODE change on survival was assessed using multivariate Cox regression models. The index of concordance was used to directly compare the predictive ability of mBODE and its separate components.

MEASUREMENTS AND MAIN RESULTS: The entire cohort (610 treated medically and 608 treated surgically) was characterized by severe airflow obstruction, moderate breathlessness, and increased mBODE at baseline. A wide distribution of change in mBODE was seen at follow-up. An increase in mBODE of more than 1 point was associated with increased mortality in surgically and medically treated patients. Surgically treated patients were less likely to experience death or an increase greater than 1 in mBODE. Indices of concordance showed that mBODE change predicted survival better than its separate components.

CONCLUSIONS: The mBODE demonstrates short- and intermediate-term responsiveness to intervention in severe chronic obstructive pulmonary disease. Increase in mBODE of more than 1 point from baseline to 6, 12, and 24 months of follow-up was predictive of subsequent mortality. Change in mBODE may prove a good surrogate measure of survival in therapeutic trials in severe chronic obstructive pulmonary disease.

Minimum clinically important improvement for the incremental shuttle walking test.

Thorax. 2008 Sep;63(9):775-7. Singh SJ, Jones PW, Evans R, Morgan MD. Pulmonary Rehabilitation Research Group, Department of Respiratory Medicine and Thoracic Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Groby Road, Leicester LE3 9QP, UK.

BACKGROUND: The incremental shuttle walking test (ISWT) is used to assess exercise capacity in patients with chronic obstructive pulmonary disease (COPD) and is employed as an outcome measure for pulmonary rehabilitation. This study was designed to establish the minimum clinically important difference for the ISWT.

METHODS: 372 patients (205 men) performed an ISWT before and after a 7-week outpatient pulmonary rehabilitation programme. After completing the course, subjects were asked to identify, from a 5-point Likert scale, the perceived change in their exercise performance immediately upon completion of the ISWT. The scale ranged from "better" to "worse".

RESULTS: The mean (SD) age was 69.4 (8.4) years, forced expiratory volume in 1 s (FEV(1)) 1.06 (0.53) l and FEV(1)/forced vital capacity (FVC) ratio 50.8 (18.1)%. The baseline shuttle walking test distance was 168.5 (114.6) m which increased to 234.7 (125.3) m after rehabilitation (mean difference 65.9 m (95% CI 58.9 to 72.9)). In subjects who felt their exercise tolerance was "slightly better" the mean improvement was 47.5 m (95% CI 38.6 to 56.5) compared with 78.7 m (95% CI 70.5 to 86.9) in those who reported that their exercise tolerance was "better" and 18.0 m (95% CI 4.5 to 31.5) in those who felt their exercise tolerance was "about the same".

CONCLUSION: Two levels of improvement were identified. The minimum clinically important improvement for the ISWT is 47.5 m. In addition, patients were able to distinguish an additional benefit at 78.7 m

Incidence and predictive factors of lower respiratory tract infections among the very elderly in the general population. The Leiden 85-plus Study.

Thorax. 2008 Sep;63(9):817-22. Sliedrecht A, den Elzen WP, Verheij TJ, Westendorp RG, Gussekloo J. Department of Public Health and Primary Care, Leiden University Medical Center, Post zone V-0-P, PO Box 9600, 2300 RC Leiden, The Netherlands.

OBJECTIVES: To target preventive strategies in old age, which of the very elderly are predisposed to developing lower respiratory tract infections was investigated.

DESIGN: Prospective observational follow-up study. SETTING: General population.

PARTICIPANTS: Unselected cohort of 587 participants aged 85 years in Leiden, The Netherlands. Measurements: As reported in the literature, predictive factors were selected and assessed at baseline. During a 5 year follow-up period, information on the development of lower respiratory tract infections was obtained from general practitioners or nursing home physicians. Associations between predictive factors were analysed with Cox regression, and population attributable risks were calculated.

RESULTS: The incidence of lower respiratory tract infections among persons aged 85-90 years was 94 (95% CI 80-108) per 1000 person years. After multivariate analysis, history of chronic obstructive pulmonary disease (COPD), smoking, oral glucocorticosteroid use, severe cognitive impairment, history of stroke and declined functional status remained independently associated with the occurrence of lower respiratory tract infections. Smoking was the greatest contributor with a population attributable risk of 32%.

CONCLUSION: In the very old, smoking, COPD, stroke and declined functional status were associated with the occurrence of lower respiratory tract infections and provide a means of targeting patients at risk of severe health complications.

Swimming pool-based exercise as pulmonary rehabilitation for COPD patients in primary care: feasibility and acceptability.

Prim Care Respir J. 2008 Sep 9. Rae S, White P. Community Specialist Practitioner, Sydenham Green Group Practice, Sydenham, London, UK.

AIM: To assess the feasibility and acceptability of swimming pool-based exercise as pulmonary rehabilitation (PR) for COPD sufferers.

METHOD: 101 patients with mild or moderate COPD registered with a South London general practice were invited to a swimming poolbased PR programme. Participants completed spirometry, the Chronic Respiratory Questionnaire (CRQ-SR), and the Incremental Shuttle Walk Test (ISWT) before and after the programme. A qualitative interview was used to assess participants' views.

RESULTS: 24 patients (24%) expressed interest; 18 were recruited and 16 (16%) completed the PR programme. Their mean age was 69 yrs, seven were female, and mean % predicted FEV1 was 59%. The mean number of sessions attended was 10.6 out of 12. Significant improvements in dyspnoea score (difference 4.9; 95% CI -8.27 to -1.48) and walking distance (difference 32 metres; 95% CI -52.63 to -11.36) were observed, and all other findings were in the direction of improvement. Most patients enjoyed being in the water, were happy to expose themselves in swimsuits, overcame their fears, valued learning about COPD and socialising with fellow sufferers, and were positive about their physical improvement.

CONCLUSION: The swimming pool is a feasible and positive alternative venue for PR for COPD patients in primary care.

Long-term decline in lung function, utilisation of care and quality of life in modified GOLD stage 1 COPD.

Thorax. 2008 Sep;63(9):768-74. Bridevaux PO, Gerbase MW, Probst-Hensch NM, Schindler C, Gaspoz JM, Rochat T. University Hospitals of Geneva, Division of Pulmonary Medicine, 24 rue Micheli-du-Crest, 1211 Geneva, Switzerland.

BACKGROUND: Little is known about the long-term outcomes of individuals with mild chronic obstructive pulmonary disease (COPD) as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD).

METHODS: A population cohort of 6671 randomly selected adults without asthma was stratified into categories of modified GOLD-defined COPD (prebronchodilator spirometry). Further stratification was based on the presence or absence of respiratory symptoms. After 11 years, associations between baseline categories of COPD and decline in forced expiratory volume in 1 s (FEV(1)), respiratory care utilisation and quality of life as measured by the SF-36 questionnaire were examined after controlling for age, sex, smoking and educational status

RESULTS: At baseline, modified GOLD criteria were met by 610 (9.1%) participants, 519 (85.1%) of whom had stage 1 COPD. At follow-up, individuals with symptomatic stage 1 COPD (n = 224) had a faster decline in FEV(1) (-9 ml/year (95% CI -13 to -5)), increased respiratory care utilisation (OR 1.6 (95% CI 1.0 to 2.6)) and a lower quality of life than asymptomatic subjects with normal lung function (n = 3627, reference group). In contrast, individuals with asymptomatic stage 1 COPD (n = 295) had no significant differences in FEV(1) decline (-3 ml/year (95% CI -7 to +1)), respiratory care utilisation (OR 1.05 (95% CI 0.63 to 1.73)) or quality of life scores compared with the reference group.

CONCLUSIONS: In population-based studies, respiratory symptoms are of major importance for predicting long-term clinical outcomes in subjects with COPD with mild obstruction. Population studies based on spirometry only may misestimate the prevalence of clinically relevant COPD.

IPCRG Consensus statement: Tackling the smoking epidemic - practical guidance for primary care.

Prim Care Respir J. 2008 Sep;17(3):185-93. van Schayck CP, Pinnock H, Ostrem A, Litt J, Tomlins R, Williams S, Buffels J, Giannopoulos D, Henrichsen S, Kaper J, Korzh O, Rodriguez AM, Kawaldip S, Zwar N, Yaman H. Care and Public Health Research Institute (Caphri), Maastricht University, The Netherlands.

Tobacco use will become the world's foremost cause of premature death and disability within 20 years unless current trends are reversed. Many opportunities to reduce this epidemic are missed in primary care. This Discussion paper from the International Primary Care Respiratory Group (IPCRG) - which reflects the IPCRG's understanding of primary care practitioners' needs - summarises a new approach based on strong evidence for effective interventions. All primary care health professionals can increase smoking cessation rates among their patients, even when time and resources are limited. Medical and non-medical staff can support patients who choose to quit by providing information, referral to telephone counselling services, and behavioural counselling using motivational interviewing techniques, where resources permit. Drug therapy to manage nicotine dependence can significantly improve patients' chances of quitting successfully, and is recommended for people who smoke 10 or more cigarettes per day. All interventions should be tailored to the individual's circumstances and attitudes.

Effect of the California Tobacco Control Program on Personal Health Care Expenditures

PLos Medicine James M. Lightwood1,2, Alexis Dinno1, Stanton A. Glantz1,3* 1 Center for Tobacco Control Research and Education, University of California San Francisco, San Francisco, California, United States of America, 2 School of Pharmacy, University of California San Francisco, San Francisco, California, United States of America, 3 Philip R. Lee Institute for Health Policy Studies and Department of Medicine (Cardiology), University of California San Francisco, San Francisco, California, United States of America

Background

Large state tobacco control programs have been shown to reduce smoking and would be expected to affect health care costs. We investigate the effect of California's large-scale tobacco control program on aggregate personal health care expenditures in the state.

Methods and Findings

Cointegrating regressions were used to predict (1) the difference in per capita cigarette consumption between California and 38 control states as a function of the difference in cumulative expenditures of the California and control state tobacco control programs, and (2) the relationship between the difference in cigarette consumption and the difference in per capita personal health expenditures between the control states and California between 1980 and 2004. Between 1989 (when it started) and 2004, the California program was associated with $86 billion (2004 US dollars) (95% confidence interval [CI] $28 billion to $151 billion) lower health care expenditures than would have been expected without the program. This reduction grew over time, reaching 7.3% (95% CI 2.7%–12.1%) of total health care expenditures in 2004.

Conclusions

A strong tobacco control program is not only associated with reduced smoking, but also with reductions in health care expenditures.

Smoke-free Legislation and Hospitalizations for Acute Coronary Syndrome

New England Journal of Medicine Volume 359:482-491 July 31, 2008 Number 5 Jill P. Pell, M.D., Sally Haw, B.Sc., Stuart Cobbe, M.D., David E. Newby, Ph.D., Alastair C.H. Pell, M.D., Colin Fischbacher, M.B., Ch.B., Alex McConnachie, Ph.D., Stuart Pringle, M.D., David Murdoch, M.B., Ch.B., Frank Dunn, M.D., Keith Oldroyd, M.D., Paul MacIntyre, M.D., Brian O'Rourke, M.D., and William Borland, B.Sc.

Background: Previous studies have suggested a reduction in the total number of hospital admissions for acute coronary syndrome after the enactment of legislation banning smoking in public places. However, it is unknown whether the reduction in admissions involved nonsmokers, smokers, or both.

Methods: Since the end of March 2006, smoking has been prohibited by law in all enclosed public places throughout Scotland. We collected information prospectively on smoking status and exposure to secondhand smoke based on questionnaires and biochemical findings from all patients admitted with acute coronary syndrome to nine Scottish hospitals during the 10-month period preceding the passage of the legislation and during the same period the next year. These hospitals accounted for 64% of admissions for acute coronary syndrome in Scotland, which has a population of 5.1 million.

Results: Overall, the number of admissions for acute coronary syndrome decreased from 3235 to 2684 — a 17% reduction (95% confidence interval, 16 to 18) — as compared with a 4% reduction in England (which has no such legislation) during the same period and a mean annual decrease of 3% (maximum decrease, 9%) in Scotland during the decade preceding the study. The reduction in the number of admissions was not due to an increase in the number of deaths of patients with acute coronary syndrome who were not admitted to the hospital; this latter number decreased by 6%. There was a 14% reduction in the number of admissions for acute coronary syndrome among smokers, a 19% reduction among former smokers, and a 21% reduction among persons who had never smoked. Persons who had never smoked reported a decrease in the weekly duration of exposure to secondhand smoke (P<0.001 by the chi-square test for trend) that was confirmed by a decrease in their geometric mean concentration of serum cotinine from 0.68 to 0.56 ng per milliliter (P<0.001 by the t-test).

Conclusions: The number of admissions for acute coronary syndrome decreased after the implementation of smoke-free legislation. A total of 67% of the decrease involved nonsmokers. However, fewer admissions among smokers also contributed to the overall reduction.

Dose-Response Relationship Between Cigarette Smoking and Risk of Ischemic Stroke in Young Women

Stroke. 2008;39:2439. Viveca M. Bhat, MD; John W. Cole, MD, MS; John D. Sorkin, MD, PhD; Marcella A. Wozniak, MD, PhD; Ann M. Malarcher, PhD; Wayne H. Giles, MD, MS; Barney J. Stern, MD Steven J. Kittner, MD, MPH

Background and Purpose— Although cigarette smoking is known to be a risk factor for ischemic stroke, there are few data on the dose-response relationship between smoking and stroke risk in a young ethnically diverse population.

Methods— We used data from the Stroke Prevention in Young Women Study, a population-based case-control study of risk factors for ischemic stroke in women aged 15 to 49 years to examine the relationship between cigarette smoking and ischemic stroke. Historical data, including smoking history, was obtained through standardized interviews. Odds ratios (OR) were estimated using logistic regression. Cases (n=466) were women with stroke in the greater Baltimore-Washington area, and controls (n=604) were women free of a stroke history identified by random digit dialing.

Results— After multivariable adjustment, the OR comparing current smokers to never smokers was 2.6 (P<0.0001); no difference in stroke risk was observed between former smokers and never smokers. Adjusted OR increased with increasing number of cigarettes smoked per day (OR=2.2 for 1 to 10 cigs/d; 2.5 for 11 to 20 cigs/d; 4.3 for 21 to 39 cigs/d; 9.1 for 40 or more cigs/d).

Conclusion— These results suggest a strong dose-response relationship between cigarette smoking and ischemic stroke risk in young women and reinforce the need for aggressive smoking cessation efforts in young adults.

Lung fibroblast repair functions in patients with chronic obstructive pulmonary disease are altered by multiple mechanisms.

Am J Respir Crit Care Med. 2008 Aug 1;178(3):248-60. Togo S, Holz O, Liu X, Sugiura H, Kamio K, Wang X, Kawasaki S, Ahn Y, Fredriksson K, Skold CM, Mueller KC, Branscheid D, Welker L, Watz H, Magnussen H, Rennard SI. University of Nebraska Medical Center, 985885 Nebraska Medical Center, Omaha, NE 68198-5885, USA.

RATIONALE: Fibroblasts are believed to be the major cells responsible for the production and maintenance of extracellular matrix. Alterations in fibroblast functional capacity, therefore, could play a role in the pathogenesis of pulmonary emphysema, which is characterized by inadequate maintenance of tissue structure.

OBJECTIVES: To evaluate the hypothesis that deficient fibroblast repair characterizes cells obtained from individuals with chronic obstructive pulmonary disease (COPD) compared with control subjects.

METHODS: Fibroblasts were cultured from lung tissue obtained from individuals undergoing thoracotomy and were characterized in vitro.

MEASUREMENTS AND MAIN RESULTS: Fibroblasts from individuals with COPD, defined by reduced FEV(1), manifested reduced chemotaxis toward fibronectin and reduced contraction of three-dimensional collagen gels, two bioassays associated with fibroblast repair function. At least two mechanisms appear to account for these differences. Prostaglandin E (PGE), a known inhibitor of fibroblast repair functions, was produced in increased amount by fibroblasts from subjects with COPD, which also expressed increased amounts of the receptors EP2 and EP4, both of which signal through cyclic AMP. Incubation of fibroblasts with indomethacin or with the PKA inhibitor KT-5720 partially restored COPD subject fibroblast function. In addition, fibroblasts from subjects with COPD produced more transforming growth factor (TGF)-beta1, but manifested reduced response to TGF-beta1. The functional alterations in fibroblasts correlated with both lung function assessed by FEV(1) and, for the data available, with severity of emphysema assessed by Dl(CO).

CONCLUSIONS: Fibroblasts from individuals with COPD have reduced capability to sustain tissue repair, which suggests that this may be one mechanism that contributes to the development of emphysema.

Sexual intercourse and respiratory failure

Respir Med. 2008 Jun;102(6):927-31. Polverino F, Santoriello C, De Sio V, Andò F, de Blasio F, Polverino M. Respiratory Physiopathology, Cava de' Tirreni City Hospital, SA, Italy.

Sexual activity is an important component of quality of life in patients suffering from chronic illnesses. To our knowledge, the effects of sexual activity on gas exchange in patients with respiratory failure have not been yet studied. To such an extent, we evaluated the oxygen saturation (SaO2), by a pulse oxymeter, during three different sexual performances in a 63-yr-old patient affected by chronic obstructive pulmonary disease (COPD) on long-term oxygen therapy (LTOT). The sexual performances were divided in four periods: basal, sex, 10 min after sex and relax. In each performance during sex, we observed a significant increase of either heart rate (HR) or SaO2, with the highest value of the latter achieved within the 10 min of the post-sex period. SaO2 returned to basal value (pre-sex) by the end of the relax period.

We conclude that the observed improvement of SaO2 during sexual activity might be due to a better ventilation/perfusion ratio (V/Q) obtained for either an increase of ventilation (hyperventilation) and perfusion (tachycardia), without significant muscle expenditure.

Predictors of poor attendance at an outpatient pulmonary rehabilitation programme

Respir Med. 2008 Jun;102(6):819-24. Sabit R, Griffiths TL, Watkins AJ, Evans W, Bolton CE, Shale DJ, Lewis KE. Department of Respiratory Medicine, Cardiff University, Academic Centre, Llandough Hospital, Penarth, Vale of Glamorgan, CF64 2XX, UK.

BACKGROUND: Pulmonary rehabilitation (PR) is recommended for patients with respiratory disease who feel limited by breathlessness. Poor attendance wastes finite resources, increases waiting times and is probably associated with poorer clinical outcomes. We investigated what factors, identifiable from routine hospital data, predict poor attendance once enrolled in a pulmonary rehabilitation programme (PRP).

METHODS: Retrospective case note study of 239 patients (60% male) of mean (S.D.) age of 66.6 (8.7) years, mean FEV(1) 39.6 (14.6)% predicted, who attended a 6 (short) or 18 (long) week, 18 session, outpatient PRP. Attendance data was analysed using linear multiple regression analysis with the log transformed odds ratio of attendance as the dependant variable.

RESULTS: Overall median attendance was 16 out of 18 sessions. Being a current smoker (p<0.05), attending a long PRP (p<0.05), more previous hospital admissions (p<0.01), higher Medical Research Council (MRC) dyspnoea score (p<0.01) or enduring a long journey (p<0.001) were independent risk factors for low attendance. Lower body mass index (BMI) and distance from PR centre were of borderline importance (p<0.1) but age, gender, co-morbidity, respiratory diagnosis, FEV(1) and St. Georges Respiratory Questionnaire Score at baseline did not predict later attendance (p>0.2).

CONCLUSIONS: Attendance at PRPs is independently influenced by smoking status, the degree of breathlessness, frequency of hospital admissions, length of the programme and journey time.

Sleep, hypnotics and chronic obstructive pulmonary disease

Respir Med. 2008 Jun;102(6):801-14 Stege G, Vos PJ, van den Elshout FJ, Richard Dekhuijzen PN, van de Ven MJ, Heijdra YF. Department of Pulmonology, Rijnstate Hospital, PO Box 9555, 6800 TA, Arnhem, The Netherlands

The quality of sleep is significantly compromised in many patients with chronic obstructive pulmonary disease (COPD) and may be further diminished when certain comorbidities are present. A reduced sleep quality is associated with daytime consequences like fatigue, psychiatric problems and an impaired quality of life. Sleep induces physiologic alterations in respiratory function, which can become pathologic and may provoke or worsen hypoxemia and hypercapnia in COPD. Dyspnea, cough and excessive mucus production should be optimised to minimise causes for sleep disturbance. Pharmacological therapy may be helpful; sedatives like benzodiazepines and non-benzodiazepine benzodiazepine-receptor agonists (NBBRAs) are (equally) effective in improving sleep quality. Whether or not these hypnotics produce serious adverse respiratory effects during sleep, remains unclear due to opposing studies. Therefore, their use should be as short as possible.

Tobacco Control Program Saved Billions in Health Costs

usnews.com

Rapid benefits in California tied to fact program was directed at adults, not youth, study finds

California's state tobacco program resulted in a 50-to-1 return on investment over 15 years, say researchers from the University of California, San Francisco.

In a study published in the Aug. 25 issue of PLoS Medicine, researchers evaluated the health care savings that occurred as a result of the tobacco control program between 1989, when the program began, and 2004, when the study ended.

They found that the program saved $86 billion -- in 2004 dollars -- while only costing the state $1.8 billion to fund the program.

The savings were due to the fact that the program prevented 3.6 billion packs of cigarettes from being smoked over the 15-year period.

"The benefits of the program accrued very quickly and are very large," senior author Stanton Glantz, director of the UCSF Center for Tobacco Control Research and Education, said in a university press release.

Glantz said that the reason the California program had such sizable and rapid benefits in health-care cost savings was the fact it was directed at adults, not youth.

"When adults stop smoking, you see immediate benefits in heart disease, with impacts on cancer and lung diseases starting to appear a year or two later," he said.

These savings occurred despite the fact that there was a substantial diversion of funding during the mid-1990s. In fact, the researchers estimated, if the funding had been maintained at the same intensity as it had in the program's early years, the total health-care cost savings would have increased from $86 billion to $156 billion over the 15 years.

Previous research has shown that large state tobacco control programs can reduce smoking, heart attacks and cancer. But this study is the first to quantify the health-care savings that result from these types of programs.

Glantz teamed up with James Lightwood, assistant adjunct professor in the UCSF School of Pharmacy, who specializes in mathematical modeling, health economics, and statistics.

For this study, Lightwood used methods that were developed to analyze financial markets. The researchers used these methods to model the relationship between per capita tobacco control expenditures, per capita cigarette consumption, and health-care expenditures across the study time frame. They compared the California results to those from 38 states that did not have comprehensive tobacco control programs before 2000.

The researchers hope that this study will help support the development of new tobacco control programs.

"The methods in this study can be used to forecast future costs and will provide important additional means for validating program evaluations that previously did not exist," Lightwood in the university new release.

Impact of chronic airflow obstruction in a working population

Eur Respir J. 2008 Jun;31(6):1227-33. Roche N, Dalmay F, Perez T, Kuntz C, Vergnenègre A, Neukirch F, Giordanella JP, Huchon G. René Descartes University of Paris, Respiratory and Intensive Care Medicine, Hôtel-Dieu Hospital, France.

Data on the individual and collective impact of chronic airflow obstruction at a population level are scarce. In a nationwide survey, dyspnoea, quality of life and missed working days were compared between subjects with and without spirometrically diagnosed chronic airflow obstruction. Subjects aged > or =45 yrs were recruited in French health prevention centres (n = 5,008). Results of pre-bronchodilator spirometry and questionnaires (European Community Respiratory Health Survey-derived questionnaire and European quality of life five-dimension questionnaire) were collected. Adequate datasets were available for 4,764 subjects aged 60+/-10 yrs (only 2% were aged > or =80 yrs). The prevalence of airflow obstruction (forced expiratory volume in one second/forced vital capacity of <0.70) was 7.5%. The vast majority (93.9%) of cases had not been diagnosed previously. Health status was significantly influenced by dyspnoea. Both were associated with the number of missed working days. Despite mild-to-moderate severity, subjects with chronic airflow obstruction exhibited more dyspnoea, poorer quality of life and higher numbers of missed working days (mean 6.71 versus 1.45 days.patient(-1).yr(-1) in patients without airflow obstruction, for the population with no known heart or lung disease).

In conclusion, even mild-to-moderate airflow obstruction is associated with an impaired health status, which represents an additional argument in favour of early detection in chronic obstructive pulmonary disease.

Multifaceted mechanisms in COPD: inflammation, immunity, and tissue repair and destruction

Eur Respir J. 2008 Jun;31(6):1334-56 Chung KF, Adcock IM. Section of Airways Disease, National Heart and Lung Institute, Imperial College London, Dovehouse Street, London, SW3 6LY, UK.

Chronic obstructive pulmonary disease is a leading global cause of morbidity and mortality that is characterised by inexorable deterioration of small airways obstruction with emphysema associated with cellular inflammation and structural remodelling. Other features include apoptosis as well as proliferation of cells, and both tissue repair and lack of tissue repair. Metalloprotease release, together with that of apoptotic factors, may underlie the emphysema, and, conversely, fibrosis of the small airways may be accounted for by the effects of growth factor activation. In advanced disease, influential factors include the development of autoimmunity, with activation of dendritic cells and T-helper cells of both type 1 and 2, and the senescence response. An inability of macrophages to ingest apoptosed cells and bacteria may exacerbate inflammatory responses. Systemic inflammation with concomitant cardiovascular disease and metabolic syndrome may reflect the effect of cigarette smoke on nonpulmonary cells. Corticosteroid resistance may be secondary to oxidative stress mechanisms, such as inactivation of histone deacetylases. The mechanisms of chronic obstructive pulmonary disease may be heterogeneous, according to severity, and clinical phenotypes need to be correlated with cellular and pathological processes. Treatments may be targeted to patients with specific mechanisms.

What community measurements can be used to predict bone disease in patients with COPD?

Respir Med. 2008 May;102(5):651-7. Bolton CE, Cannings-John R, Edwards PH, Ionescu AA, Evans WD, Pettit RJ, Faulkner TA, Stone MD, Shale DJ. Department of Respiratory Medicine, School of Medicine, Cardiff University, Academic Centre, Llandough Hospital, Penarth, Penlan Road, Vale of Glamorgan, CF64 2XX, UK.

BACKGROUND: Osteoporosis is common in patients with COPD. Previously we have reported that loss of fat-free mass (FFM), measured by dual X-ray absorptiometry (DXA) is associated with loss of bone mineral density (BMD). In addition, in patients with a low body mass index (BMI) and a low FFM, all had evidence of bone thinning, 50% having osteopenia and 50% osteoporosis. We explored the utility of different anthropometric measures in detecting osteoporosis in a community-based COPD population.

METHODS: Patients with confirmed COPD and not on long-term oral corticosteroids (n=58) performed spirometry. They underwent nutritional assessment by skinfold anthropometry, midarm circumference, calculation of both % ideal body weight (IBW) and BMI. All had DXA assessment of BMD.

RESULTS: A total of 58 COPD patients had anthropometric measurements taken, with a mean age of 66.8 (SD 8.7) years, 31 (58%) were male, with a forced expiratory volume in 1s (FEV(1)) of 54.17 (20.18)% predicted. Osteoporosis was present at either the hip or lumbar region in 14 patients (24%). The useful anthropometric measurements identifying those with osteoporosis were both % IBW and BMI. The adjusted odds ratio for %IBW was 0.93 (95% confidence interval (CI) 0.87, 0.99), p=0.016 and for BMI: 0.79 (0.64-0.98), p=0.03. The receiver operating characteristics (ROC) score for both was 0.88, indicating a good fit.

CONCLUSION: Osteoporosis is common, even in patients with mild airways obstruction. Nutritional assessment, incorporating a calculation of their BMI or %IBW may confer an additional benefit in detecting those at risk of osteoporosis and guide referral for BMD measurement.

The metabolic response during resistance training and neuromuscular electrical stimulation (NMES) in patients with COPD, a pilot study.

Respir Med. 2008 May;102(5):786-9. Sillen MJ, Janssen PP, Akkermans MA, Wouters EF, Spruit MA. Department of Physiotherapy, Center for Integrated Rehabilitation of Organ Failure (CIRO), Horn, The Netherlands.

Resistance training and transcutaneous neuromuscular electrical stimulation (NMES) are new modalities in rehabilitation of severely disabled patients with chronic obstructive pulmonary disease (COPD). The purpose of this study was to compare the metabolic response during resistance training and during NMES of the quadriceps femoris muscles in patients with COPD entering pulmonary rehabilitation. Pulmonary function, body composition, peak aerobic capacity, the Medical Research Council dyspnoea grade, the one-repetition maximum strength assessment were evaluated in 13 COPD patients. Additionally, peak oxygen uptake, peak minute ventilation and Borg symptom scores were assessed during a resistance training session and a NMES session. The median peak oxygen uptake and median peak minute ventilation during the resistance training session were significantly higher compared to the NMES session. Additionally, these higher metabolic responses were accompanied by higher symptom Borg scores for dyspnoea and leg fatigue.

To conclude, the metabolic response was significantly lower during a NMES session compared to a resistance exercise training session in patients with COPD. Nevertheless, both modalities seem to result in an acceptable metabolic response accompanied by a clinically acceptable sensation of dyspnoea and leg fatigue.

COPD stage and risk of hospitalization for infectious disease.

Chest. 2008 Jul;134(1):46-53. Benfield T, Lange P, Vestbo J. Department of Infectious Diseases 144, Hvidovre University Hospital, DK-2650 Hvidovre, Denmark.

BACKGROUND: Respiratory tract infections are a frequent complication of COPD, but little is known about the incidence, association, and risk of infectious diseases related to impaired lung function.

METHODS: Participants in the Copenhagen City Heart Study had lung function measured at baseline, and were followed for up to 25 years. All hospitalizations due to any infection were identified through registry linkage. Impaired lung function was defined according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) staging system. MAIN

RESULTS: A total of 3,333 infectious disease hospitalizations (IDHs) occurred during 230,653 person-years of follow-up (PY), corresponding to an overall incidence of 145 IDHs (95% confidence interval [CI], 139 to 149) per 10,000 PY. The incidence increased with GOLD stage, from 131 (95% CI, 126 to 136) for normal COPD, to 170 (95% CI, 146 to 193) for mild COPD, to 230 (95% CI, 207 to 253) for moderate COPD, and 394 (95% CI, 330 to 459) for severe/very severe COPD. The trend in risk persisted after the control of background characteristics using Cox proportional hazards analysis (adjusted relative risks: 1.06 [95% CI, 0.92 to 1.23], 1.39 [95% CI, 1.24 to 1.56], and 2.21 [95% CI, 1.84 to 2.64], respectively; p=0.001). In subgroup analysis, the increased risk was associated with lower and upper respiratory tract infections, pyothorax, and tuberculosis, but not with influenza, sepsis, skin infections, urinary tract infections, diarrheal disease, or other infectious diseases.

CONCLUSIONS: The presence of obstructive lung disease is a significant predictor of IDH caused by respiratory tract infections, but not of hospitalizations due to infections outside the respiratory system.

COPD as a Lung Disease with Systemic Consequences - Clinical Impact, Mechanisms, and Potential for Early Intervention.

COPD. 2008 Aug;5(4):235-56. Decramer M, Rennard S, Troosters T, Mapel DW, Giardino N, Mannino D, Wouters E, Sethi S, Cooper CB. Respiratory Division and Department of Rehabilitation Science, University Hospital, Katholieke Universiteit, Leuven, Belgium.

The natural course of chronic obstructive pulmonary disease (COPD) is complicated by the development of systemic consequences and co-morbidities. These may be major features in the clinical presentation of COPD, prompting increasing interest. Systemic consequences may be defined as non-pulmonary manifestations of COPD with an immediate cause-and-effect relationship, whereas co-morbidities are diseases associated with COPD.

The major systemic consequences/co-morbidities now recognized are: deconditioning, exercise intolerance, skeletal muscle dysfunction, osteoporosis, metabolic impact, anxiety and depression, cardiovascular disease, and mortality. The mechanisms by which these develop are unclear. Probably many factors are involved. Two appear of paramount importance: systemic inflammation, which presents in some patients with stable disease and virtually all patients during exacerbations, and inactivity, which may be a key link to most COPD-related co-morbidities. Further studies are required to determine the role of inflammatory cells/mediators involved in systemic inflammatory processes in causing co-morbidities; the link between activity and co-morbidities; and how COPD therapy may affect activity. Both key mechanisms appear to be influenced significantly by COPD exacerbations.

Importantly, although the prevalence of systemic consequences increases with increasing severity of airflow obstruction, both systemic consequences and co-morbidities are already present in the Global Initiative for Chronic Obstructive Lung Disease Stage II. This supports the concept of early intervention in chronic obstructive pulmonary disease.

Although at present early intervention studies in COPD are lacking, circumstantial evidence suggests that current treatments may influence events leading to the systemic consequences and co-morbidities, and thus may affect the clinical manifestations of the disease.

Home warmth and health status of COPD patients.

Eur J Public Health. 2008 Aug;18(4):399-405 Osman LM, Ayres JG, Garden C, Reglitz K, Lyon J, Douglas JG. Department of Environmental & Occupational Medicine, University of Aberdeen, Liberty Safe Work Research Centre, Foresterhill Road, Aberdeen, AB252ZP, UK.

BACKGROUND: Home Energy Efficiency guidelines recommend domestic indoor temperatures of 21 degrees C for at least 9 h per day in living areas. Is health status of patients with Chronic Obstructive Pulmonary Disease (COPD) associated with maintaining this level of warmth in their homes?

METHODS: In a cross-sectional observational study of patients, living in their own homes, living room (LR) and bedroom (BR) temperatures were measured at 30 min intervals over 1 week using electronic dataloggers. Health status was measured with the St George's Respiratory Questionnaire (SGRQ) and EuroQol: EQ VAS. Outdoor temperatures were provided by Met Office.

RESULTS: One hundred and forty eight patients consented to temperature monitoring. Patients' mean age was 69 (SD 8.5) years, 67 (45%) male, mean percentage of predicted Forced Expiratory Volume in one second (FEV(1)) 41.7 (SD 17.4). Fifty-eight (39%) were current smokers. Independent of age, lung function, smoking and outdoor temperatures, poorer respiratory health status was significantly associated (P = 0.01) with fewer days with 9 h of warmth at 21 degrees C in the LR. A sub analysis showed that patients who smoked experienced more health effects than non-smokers (P < 0.01).

CONCLUSION: Maintaining the warmth guideline of 21 degrees C in living areas for at least 9 h per day was associated with better health status for COPD patients. Patients who were continuing smokers were more vulnerable to reduction in warmth.

Designing patient-related interventions in COPD care: Empirical test of a theoretical model.

Patient Educ Couns. 2008 Aug;72(2):223-31. Lemmens KM, Nieboer AP, Huijsman R. Erasmus University Medical Centre, Institute of Health Policy and Management, Rotterdam, The Netherlands.

OBJECTIVES: The aim of this exploratory study was to test the applicability of a theoretical model to develop patient-related interventions. In this model knowledge, psychosocial mediators, self-efficacy and behaviour are determinants of patient-related interventions.

METHODS: The model was tested on 278 patients with mild or moderate chronic obstructive pulmonary disease (COPD), recruited in a primary care setting. Hierarchical regression analyses were applied using data from self-reported questionnaires and clinical data from an electronic data registry.

RESULTS: Knowledge, psychosocial mediators, self-efficacy and behaviour proved to be, to a moderate degree, predictors of outcomes in COPD care. Moreover, physical activity appeared to be a significant predictor for all clinical and functional outcomes.

CONCLUSION: Theoretically expected associations of patient-related interventions are existent in patients with mild or moderate COPD. The application of theoretical models in designing patient-directed interventions in COPD care is therefore feasible.

PRACTICE IMPLICATIONS: More attention should be paid to the patterns of physical activity in patients with mild to moderate COPD. The results of this study are also useful in the development of patient-related interventions. Future interventions should be designed along the lines of theory on behaviour change, such as social cognitive theory.

Detecting oxygen desaturation in patients with COPD: Incremental versus endurance shuttle walking.

Respir Med. 2008 Aug;102(8):1148-52. Sandland CJ, Morgan MD, Singh SJ. Pulmonary Rehabilitation Research Group, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Groby Road, Leicester LE3 9QP, United Kingdom.

BACKGROUND: There has been no direct comparison between an incremental and endurance walking test to detect the relative oxygen desaturation in patients with chronic obstructive pulmonary disease (COPD). This is of some importance as current guidelines have suggested that ambulatory oxygen should only be prescribed after a standard assessment and desaturation documented. No clear advice about the nature of the required exercise task is given. This study therefore compared the relative desaturation between the incremental shuttle walking test (ISWT) and the constant speed walking test (ESWT) and response to ambulatory oxygen.

METHODS: Forty-one patients (29 male), mean (SD), age 71.18 (7.48) yrs, FEV(1) 0.85 (0.29) l with stable COPD were recruited after completion of a 7-week pulmonary rehabilitation programme. Patients completed a baseline (without carrying a cylinder) ISWT and ESWT and then, in random order in double blind fashion, completed the walk tests with a cylinder of air or a cylinder of oxygen. Measurements included distance walked, oxygen saturation, heart rate, perceived breathlessness and exertion (Borg scale).

RESULTS: All patients desaturated (<4% below 90%). There was no significant difference in desaturation between the ISWT and the ESWT. There was a significant improvement in performance with supplementary oxygen compared to cylinder air (p<0.05) for both tests. However, compared to the baseline walk, supplementary oxygen did not enhance the distance walked for either test. There was a significant decrease in walking performance on both the ISWT and the ESWT when carrying an air cylinder compared with the control walk. When comparing the percentage difference between oxygen and air for responders (i.e. those that achieve a 10% or more increase), the ESWT showed a greater percentage change 42.1% compared to 26.1% for the ISWT.

CONCLUSIONS: This study identifies that incremental and endurance walking provokes significant desaturation and that there is a short-term benefit of oxygen versus air in enhancing exercise performance. There was no significant difference in the level of desaturation between tests. Therefore the ISWT is a suitable exercise test that can be used to evaluate desaturation and is practically more realistic.

Home-Based Exercise Training as Maintenance after Outpatient Pulmonary Rehabilitation.

Respiration. 2008 Jul 31. du Moulin M, Taube K, Wegscheider K, Behnke M, van den Bussche H. Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Background: Pulmonary rehabilitation is successful in improving exercise capacity and quality of life in patients with chronic obstructive pulmonary disease (COPD). However, training effects diminish over time.

Objectives:We evaluated the effects of simple, daily, structured, self-monitored, home-based exercise training for patients with moderate COPD after a 3-week outpatient rehabilitation.

Methods: We conducted a randomized, controlled, observer-blind trial. Twenty patients were recruited. Ten patients performed home-based exercise training (mean age 67 years, 95% confidence interval [CI] 63-72; FEV(1) 58.6%, 95% CI 53.8-63.4), and 10 patients served as controls (mean age 72 years, 95% CI 69-77; FEV(1) 62.5%, 95% CI 57.7-67.3). At baseline, and after 3 and 6 months, we assessed exercise capacity (6-min walk test, 6MWT, primary endpoint), health-related quality of life (Chronic Respiratory Questionnaire, CRQ) and lung function. An intention-to-treat analysis was performed using two-way ANOVA models for comparison of time trends between random groups

Results: The training group had better results than the control group in 6MWT (p = 0.033), in CRQ total (p = 0.027), CRQ dyspnea (p = 0.014) and CRQ fatigue (p = 0.016). Improvement in FEV(1) was also better in the intervention group than in the control group (p = 0.007).

Conclusions: We demonstrated that training effects obtained from an outpatient rehabilitation program can be maintained by home-based exercise training in patients with moderate COPD

Panic attacks and perception of inspiratory resistive loads in chronic obstructive pulmonary disease.

Am J Respir Crit Care Med. 2008 Jul 1;178(1):7-12. Livermore N, Butler JE, Sharpe L, McBain RA, Gandevia SC, McKenzie DK. Department of Respiratory Medicine, Prince of Wales Hospital, Barker St., Randwick, NSW 2031, Australia.

RATIONALE: Panic attacks are common in chronic obstructive pulmonary disease (COPD), and the prevalence of panic disorder is at least 10 times higher than in the general population. In the current study, we examined resistive load perception in patients with COPD with and without panic attacks.

OBJECTIVES: We tested competing hypotheses, based on conflicting results of earlier studies, that those patients with COPD with panic attacks or panic disorder would show either heightened or blunted perception of dyspnea as the magnitude of inspiratory resistive loads increased.

METHODS: We compared 20 patients with COPD with panic attacks or panic disorder, 20 patients without panic, and 20 healthy, age-matched subjects using an inspiratory resistive load-testing protocol.

Measurements and Main Results: We administered a diagnostic interview for panic attacks and panic disorder. We measured perceived dyspnea in response to increasing inspiratory resistive loads (modified Borg scale) and several respiratory variables. Dyspnea ratings increased linearly for all groups as the size of resistive loads increased. No significant differences were found between groups on the respiratory variables. Patients with COPD with panic attacks or panic disorder rated their level of dyspnea significantly higher than did other subjects.

CONCLUSIONS: Patients with COPD with panic attacks showed heightened sensitivity to inspiratory loads. The result reinforces the influence of psychological factors on symptom perception in this disease.

Reduction in hospitalisation following pulmonary rehabilitation in patients with COPD.

Aust Health Rev. 2008 Aug;32(3):415-22. Cecins N, Geelhoed E, Jenkins SC. Physiotherapy Department, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, WA 6009, Australia.

OBJECTIVES: Pulmonary rehabilitation (PR) improves exercise capacity and health-related quality of life (HRQoL), and reduces health care utilisation. This study quantified outcomes of a PR program over a 6-year period and determined the effects of PR on hospitalisation.

METHODS: Patients with chronic obstructive pulmonary disesae (COPD) who entered an 8-week outpatient PR program from 1998 to 2003 were included. Functional exercise capacity (6-minute walk distance [6MWD]) and HRQoL (Chronic Respiratory Disease Questionnaire) were measured before and following PR. The number of hospital admissions and total bed-days due to a COPD exacerbation in the 12 months before and following PR were recorded.

SETTING: Physiotherapy Department, Sir Charles Gairdner Hospital, Western Australia.

RESULTS: 187 (73%) of the 256 patients who entered PR completed the program. Improvements in 6MWD (404.2 +/- 114.6 m to 439.6 +/- 115.0m, P < 0.001) and HRQoL (4.1 +/- 0.9 points per item to 4.9 +/- 0.9 points per item, P < 0.001) occurred following PR. There was a 46% reduction in the number of patients admitted to hospital (71 to 38) with a COPD exacerbation and a 62% reduction in total bed-days (1131 to 432) following PR.

CONCLUSION: Pulmonary rehabilitation provided in an Australian teaching hospital was associated with a reduction in COPD hospitalisation, and the resultant savings outweighed the costs of providing the program.

Impact of COPD on outcome among patients with complicated peptic ulcer

Chest. 2008 Jun;133(6):1360-6. Christensen S, Thomsen RW, Tørring ML, Riis A, Nørgaard M, Sørensen HT. Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus C, Denmark.

BACKGROUND: COPD is associated with an increased risk of peptic ulcer disease, but limited data exist on whether COPD influences short-term mortality among patients with bleeding and a perforated peptic ulcer. We examined the association between COPD and 30-day mortality following bleeding and perforation of a peptic ulcer.

METHODS: We identified all patients who had been hospitalized with a first-time diagnosis of peptic ulcer perforation (n = 2,033) or bleeding (n = 7,486) in northern Denmark between 1991 and 2004. Information on COPD, comorbidities, and filled prescriptions was obtained from medical databases. Mortality was ascertained using the Danish Civil Registration System. We computed the cumulative 30-day mortality rates for ulcer patients with COPD and for other ulcer patients, and used regression analysis to obtain the 30-day mortality rate ratios (MRRs), controlling for potential confounding factors.

RESULTS: Among patients who were hospitalized with perforated peptic ulcers, 218 (10.7%) had previously been hospitalized with COPD. The 30-day mortality rate was 44.0% among perforated ulcer patients with COPD vs 25.5% among other ulcer patients (adjusted MRR, 1.48; 95% confidence interval [CI], 1.18 to 1.85). Among patients hospitalized with a bleeding peptic ulcer, 759 (10.1%) had previously been hospitalized with COPD. The 30-day mortality rate was 16.5% among bleeding peptic ulcer patients with COPD vs 10.8% among other ulcer patients (adjusted MRR, 1.38; 95% CI, 1.14 to 1.68). The use of oral glucocorticoids among COPD patients was associated with higher MRRs for both perforated and bleeding peptic ulcers.

CONCLUSIONS: COPD substantially increased 30-day mortality among patients with bleeding and perforated peptic ulcers.

Update on the management of COPD.

Chest. 2008 Jun;133(6):1451-62. Celli BR. Pulmonary and Critical Care Medicine, Caritas St Elizabeth's Medical Center, Boston, MA 02135-2997, USA.

COPD is highly prevalent and will continue to be an increasing cause of morbidity and mortality worldwide. COPD is now viewed under a new paradigm as preventable and treatable. In addition, it has become accepted that COPD is not solely a pulmonary disease but also one with important measurable systemic consequences. Patients with COPD have to be comprehensively evaluated to determine the extent of disease so that therapy can be adequately individualized.

We now know that smoking cessation, oxygen for hypoxemic patients, lung reduction surgery for selected patients with emphysema, and noninvasive ventilation during severe exacerbations have an impact on mortality. The completion of well-planned pharmacologic trials have shown the importance of decreasing resting and dynamic hyperinflation on patient-centered outcomes and the possible impact on mortality and rate of decline of lung function. In addition, therapy with pulmonary rehabilitation and lung transplantation improve patient-centered outcomes such as health-related quality of life, dyspnea, and exercise capacity. Rational use of single or multiple therapeutic modalities in combination have an impact on exacerbations and hospitalizations.

This monograph presents an integrated approach to patients with COPD and updates their management incorporating the recent advances in the field. The future for patients with COPD is bright as primary and secondary prevention of smoking becomes more effective and air quality improves. In addition, current research will unravel the pathogenesis, clinical, and phenotypic manifestations of COPD, thus providing exciting therapeutic targets. Ultimately, the advent of newer and more effective therapies will lead to a decline in the contribution of this disease to poor world health.

Secondhand Smoke Raises Stroke Risk for Spouses

But researchers note risk dissipates quickly once smoking spouse quits Posted July 29, 2008 By Alan Mozes TUESDAY, July 29 (HealthDay News)

Nonsmokers who are married to smokers run a significantly higher risk for experiencing a stroke, a new study suggests.

Researchers also found that ex-smokers married to men and women who still smoke carry an even greater risk for stroke. However, nonsmoking spouses of former smokers do not appear to bear any higher risk for stroke than those married to someone who had never smoked.

"This adds to the growing evidence that secondhand smoke is bad for you, and I hope that it will help people who want to stop smoking to know that it will probably be good for their spouse's health, too," said Maria Glymour, an assistant professor of society, human development and health at the Harvard School of Public Health in Boston. Glymour is also a health and society scholar in the department of epidemiology at Columbia University in New York City.

She and her team were expected to publish the findings in the September issue of the American Journal of Preventive Medicine.

Glymour pointed out that hers is one of the few studies to specifically focus on the potential link between secondhand smoke and stroke risk. She further noted that indications that the association is real and strong stem from a larger National Institute on Aging research effort that tracked a wide range of social factors and their relationship to stroke risk.

In that study, all 16,000-plus participants were 50 and older and married. All were categorized according to smoking habits, and observed for stroke incidence over an average of about nine years between 1992 and 2006.

Nonsmokers married to a current smoker were found to have a 42 percent increased risk for stroke, compared with those married to spouses who had never smoked. Similarly compared, ex-smokers married to a current smoker had a 72 percent increased risk for stroke.

As for those married to ex-smokers, Glymour and her team only observed that the former smokers had kicked their habit at some point one to 50 years before the start of the study. They could not pinpoint exactly how much time would need to elapse after a smoking spouse quits before their husband or wife's stroke risk fully dissipated.

"But we think the risk to the spouse probably starts to decline right away," Glymour noted. "And that would be consistent with what we already know about stroke and active smoking, which is that if you stop smoking your own health risks decline quickly."

Thomas J. Glynn, director of cancer science and trends at the American Cancer Society, said that he found Glymour's analysis to be "very reasonable."

"I agree that one might expect a fairly steep drop-off in stroke risk for the spouse once the smoking partner quits," he said. "We know, for example, that although it takes about 15 years of not smoking to halve your risk for lung cancer, with heart disease it may take not much more than one to two years of cessation to cut back one's own risk to basically that of a nonsmoker, depending on how long you had been smoking. So, this conclusion makes sense."

"And, in general, I would say that this study provides further valuable evidence of the general dangers of secondhand smoke, and, in particular, the great and often over-looked danger of heart disease, he said. And, of course, it emphasizes the need for anyone who smokes to stop smoking, and at a minimum to establish smoke-free zones in the home, or not smoke in the home at all."

Role of comorbidities in a cohort of patients with COPD undergoing pulmonary rehabilitation

Thorax. 2008 Jun;63(6):487-92 Crisafulli E, Costi S, Luppi F, Cirelli G, Cilione C, Coletti O, Fabbri LM, Clini EM. University of Modena and Ospedale Villa Pineta, Department of Oncology, Haematology and Pneumology, Ospedale Villa Pineta, Via Gaiato 127, 41026 Pavullo (MO), Italy.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is often associated with other chronic diseases. These patients are often admitted to hospital based rehabilitation programmes.

OBJECTIVES: To determine the prevalence of chronic comorbidities in patients with COPD undergoing pulmonary rehabilitation and to assess their influence on outcome. DESIGN: Observational retrospective cohort study.

SETTING: A single rehabilitation centre. PATIENTS: 2962 inpatients and outpatients with COPD (73% male, aged 71 (SD 8) years, forced expiratory volume in 1 s (FEV(1)) 49.3 (SD 14.8)% of predicted), graded 0, 1 or >/=2 according to the comorbidity categories and included in a pulmonary rehabilitation programme. Measurements: The authors analysed the number of self-reported comorbidities and recorded the Charlson Index. They then calculated the percentage of patients with a predefined positive response to pulmonary rehabilitation (minimum clinically important difference (MCID)), as measured by improvement in exercise tolerance (6 min walking distance test (6MWD)), dyspnoea (Medical Research Council scale) and/or health related quality of life (St George's Respiratory Questionnaire (SGRQ)).

RESULTS: 51% of the patients reported at least one chronic comorbidity added to COPD. Metabolic (systemic hypertension, diabetes and/or dyslipidaemia) and heart diseases (chronic heart failure and/or coronary heart disease) were the most frequently reported comorbid combinations (61% and 24%, respectively) among the overall diseases associated with COPD. The prevalence of patients with MCID was different across the comorbidity categories and outcomes. In a multiple categorical logistic regression model, the Charlson Index (OR 0.72 (96% CI 0.54 to 0.98) and 0.51 (96% CI 0.38 to 0.68) vs 6MWD and SGRQ, respectively), metabolic diseases (OR 0.57 (96% CI 0.49 to 0.67) vs 6MWD) and heart diseases (OR 0.67 (96% CI 0.55 to 0.83) vs SGRQ) reduced the probability to improve outcomes of rehabilitation.

CONCLUSIONS: Most patients with COPD undergoing pulmonary rehabilitation have one or more comorbidities. Despite the fact that the presence of comorbidities does not preclude access to rehabilitation, the improvement in exercise tolerance and quality of life after rehabilitation may be reduced depending on the comorbidity.

What is Lung Disease - Data: 2008?

American Lung Association

This report includes important facts and figures about some of the most common lung diseases in the United States today.

The American Lung Association strongly believes that if cigarette smoking, preventable premature child birth, disregard for workers’ safety and violation of clean air laws were to end today, we could expect a future largely free of the most lethal forms of lung disease.

Below are a few important facts on lung diseases overall:

* Every year almost 400,000 Americans die from lung disease—an age-adjusted death rate of 135.5 per 100,000.
* Lung disease is the number three killer (behind heart disease and cancer) in the United States, responsible for one in six deaths.
* The lung disease death rate has been continuously increasing while death rates due to other leading causes of death such as heart disease, cancer and stroke have been declining.
* Overall, various forms of lung disease and breathing problems constitute one of the leading causes of death in babies under the age of one year, accounting for 20.2 percent of infant deaths in 2004.
* More than 35 million Americans have chronic lung diseases.
* An estimated 438,000 Americans die each year from diseases directly related to cigarette smoking, including heart and lung diseases.
* Millions of children and adults with lung disease in this country are exposed to levels of ozone and particle air pollution that could potentially make them sick.
* Asthma and chronic obstructive pulmonary disease (emphysema and chronic bronchitis), the most common obstructive lung diseases, are associated with substantial health impairment and work disability.
* Lung disease costs the U.S. economy $95 billion in direct health-care expenditures every year, plus indirect costs of $59 billion—a total of $154 billion.

Chronic obstructive pulmonary disease in patients admitted with heart failure.

J Intern Med. 2008 Jun 3. Iversen KK, Kjaergaard J, Akkan D, Kober L, Torp-Pedersen C, Hassager C, Vestbo J, Kjoller E; The ECHOS-Lung Function Study Group*. Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.

OBJECTIVE. Chronic obstructive pulmonary disease (COPD) is an important differential diagnosis in patients with heart failure (HF). The primary aims were to determine the prevalence of COPD and to test the accuracy of self-reported COPD in patients admitted with HF. Secondary aims were to study a possible relationship between right and left ventricular function and pulmonary function.

DESIGN. Prospective substudy. Setting. Systematic screening at 11 centres. Subjects. Consecutive patients (n = 532) admitted with HF requiring medical treatment with diuretics and an episode with symptoms corresponding to New York Heart Association class III-IV within a month prior to admission. Interventions. Forced expiratory volume in 1 s (FEV(1)) and forced vital capacity (FVC) were measured by spirometry and ventricular function by echocardiography. The diagnosis of COPD and HF were made according to established criteria.

RESULTS. The prevalence of COPD was 35%. Only 43% of the patients with COPD had self-reported COPD and one-third of patients with self-reported COPD did not have COPD based on spirometry. The prevalence of COPD in patients with preserved left ventricular ejection fraction (i.e. LVEF >/=45%) was significantly higher than in patients with impaired LVEF (41% vs. 31%, P = 0.03). FEV(1) and FVC were negatively correlated with right ventricular end-diastolic diameter and tricuspid annular plane systolic excursion and FVC positively correlated with systolic gradient across the tricuspid valve.

CONCLUSION. Chronic obstructive pulmonary disease is frequent in patients admitted with HF and self-reported COPD only identifies a minority. The prevalence of COPD was high in both patients with systolic and nonsystolic HF.

Primary care of the patient with chronic obstructive pulmonary disease-part 2: pharmacologic treatment across all stages of disease.

Am J Med. 2008 Jul;121(7 Suppl):S13-24 Gross N, Levin D. Hines VA Hospital, Hines, Illinois 60141-1485, USA.

National guidelines for the pharmacologic treatment of chronic obstructive pulmonary disease (COPD) can be clarified for busy primary care practitioners who must deal with dozens of such treatment algorithms. MEDLINE searches and reviews of national evidence-based guidelines identified clinical trials and meta-analyses with relevant information on the stage-by-stage pharmacologic treatment of COPD. After formal presentations to a panel of pulmonary specialists and primary care physicians, key messages to assist in the implementation of guideline-based care in the primary care setting were identified and integrated into this article, the second in a 4-part mini-symposium.

Main points of the roundtable consensus were as follows: (1) Spirometry is required for the diagnosis and staging of patients with COPD before treatment initiation; (2) all patients with COPD should be counseled to stop smoking, encouraged to start regular physical activity, and given a yearly influenza vaccination; (3) severity-based drug treatment of mild or moderate COPD, which accounts for 95% of all COPD cases, generally involves long-acting > or =1 bronchodilator because of their effectiveness and convenience; (4) patient response in terms of dyspnea, exercise ability, and side effects should be the primary guide for monitoring therapy; and (5) proper treatment of COPD can relieve patient symptoms, boost exercise capacity, reduce the number and severity of exacerbations, and improve the overall quality of life.

We conclude that implementation of a relatively simple evidence-based treatment algorithm can be applied to that vast majority of the COPD population seen only in primary care.

Primary care of the patient with chronic obstructive pulmonary disease-part 1: frontline prevention and early diagnosis.

Am J Med. 2008 Jul;121(7 Suppl):S3-12. Radin A, Cote C. Arbor Medical Group LLC, Wilton, Connecticut 06897, USA.

Chronic obstructive pulmonary disease (COPD) is the most important chronic respiratory illness affecting adults in the United States, yet it remains grossly underdiagnosed. This article translates key guideline recommendations for prevention and early diagnosis of COPD into the practical context of primary care. A literature review identified clinical trials with relevant information on COPD epidemiology, diagnosis, the role of primary care clinicians, the implementation of spirometry, and the impact of smoking cessation. After formal presentations to a panel of pulmonary specialists and primary care clinicians, key messages were identified and integrated to create this first report in a 4-part mini-symposium.

The main points of the roundtable consensus were as follows: (1) > or =50% of smokers will develop some degree of COPD; (2) patients with earlier stages of COPD are often undiagnosed; (3) too many clinicians are not aware that COPD is partially reversible; (4) treatment of COPD can improve patient symptoms, exercise capacity, quality of life, and health status, and prevent exacerbations; (5) diagnosis can be easily accomplished with a careful history and in-office spirometry in symptomatic patients and those at risk (e.g., present and past smokers); and (6) all smokers should be identified and targeted for smoking cessation programs.

We conclude that primary care clinicians see the vast majority of patients with early or mild COPD. These practitioners must become aware that COPD is an important problem in their patient population and that they need to integrate simple questions and in-office tools into their practice to increase their diagnosis of COPD.

COPD: Long Term Lung Function Decline, Utilization of Care and Quality of Life in Modified GOLD stage 1.

Thorax. 2008 May 27. Bridevaux PO, Gerbase MW, Probst-Hensch NM, Schindler C, Gaspoz JM, Rochat T. Division of Pulmonary Medicine, University Hospitals of Geneva, Switzerland.

BACKGROUND: Little is known on the long term outcomes of individuals with mild COPD, as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD).

METHODS: A population cohort of 6671 randomly selected adults without asthma was stratified into categories of modified GOLD-defined COPD (pre-bronchodilator spirometry). Further stratification was based on the presence or absence of respiratory symptoms. After 11 years, associations between baseline categories of COPD and FEV1 decline, respiratory care utilization, and quality of life as measured by the SF-36 questionnaire, were examined after controlling for age, sex, smoking and educational status.

RESULTS: At baseline, modified GOLD criteria were met by 610 (9.1%) participants from whom 519 (85.1%) had stage 1 COPD. At follow-up, individuals with symptomatic stage 1 COPD (n=224) had faster FEV1 decline (-9 ml/yr [CI95% -13; -5]), increased respiratory care utilization (OR 1.6 [CI95% 1.0 ; 2.6]) and lower quality of life compared to asymptomatic subjects with normal lung function (n=3627, reference group). By contrast, asymptomatic stage 1 COPD subjects (n=295) had no significant differences in FEV1 decline (-3 ml/yr [CI95% -7; +1]), respiratory care utilization (OR 1.05 [CI95% 0.63 ;1.73]) or quality of life scores when compared to the reference group.

CONCLUSIONS: In population-based studies, respiratory symptoms are of major importance for predicting long-term clinical outcomes in COPD subjects with mild obstruction. Population studies that are based on spirometry only may misestimate the prevalence of clinically relevant COPD.

Persistent smoking by Japanese patients within four years from diagnosis of chronic obstructive pulmonary disease.

Addict Behav. 2008 Sep;33(9):1235-8. Hirayama F, Lee AH, Binns CW, Tanikawa Y. National Drug Research Institute, Curtin University of Technology, Perth, Australia; School of Public Health, Curtin University of Technology, Perth, Australia.

This study ascertained the smoking prevalence and factors affecting continuous smoking by Japanese patients within four years from diagnosis of chronic obstructive pulmonary disease (COPD).

Of the 300 patients referred from six hospitals in central Japan, 276 eligible participants (mean age 66.5 years, SD 6.7) were interviewed for their habitual cigarette consumption. Overall, 22.5% of patients were current smokers but the prevalence appeared to decrease from <1 year (24.5%) to 2-4 years (19%) after diagnosis. They had smoked on average for 41 (SD 11) years and 89% of the current smokers smoked daily. Continuous smoking was inversely associated with age (odds ratio (OR)=0.94, 95% CI 0.90-0.98), body mass index (OR=0.88, 95% CI 0.80-0.97) and disease severity (OR=0.29, 95% CI 0.12-0.74 for severe COPD and OR=0.29, 95% CI 0.09-0.92 for very severe COPD).

It is alarming to find mild and moderate COPD patients continue to smoke. The implementation of a co-ordinated tobacco control program immediately post diagnosis is needed for the effective pulmonary rehabilitation of COPD patients.

Prevalence, severity and underdiagnosis of COPD in the primary care setting.

Thorax. 2008 May;63(5):402-7. Bednarek M, Maciejewski J, Wozniak M, Kuca P, Zielinski J. 2nd Department of Respiratory Medicine, National Research Institute of Tuberculosis and Lung Diseases, 26 Plocka St, Warsaw 01-138, Poland.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a common disease with a steadily increasing prevalence and mortality. However, recent epidemiological estimates differ depending on the population studied and methods used. AIM: To investigate the prevalence, severity and burden of COPD in a primary care setting.

METHODS: From 4730 patients registered in a single primary care practice, all 2250 patients aged 40 years or more were invited to participate. Participants completed a questionnaire on smoking, respiratory symptoms, education and social status. A physical examination was followed by pre- and post-bronchodilator (BD) spirometry.

RESULTS: Of the eligible patients, 1960 (87%) participated. 92% of spirometric tests met the ATS criteria. Airflow limitation was demonstrated in 299 (15%) of the participants pre-BD and in 211 (11%) post-BD. COPD was diagnosed in 183 patients (9.3%). Of these patients, the degree of post-BD airflow limitation was mild in 30.6%, moderate in 51.4%, severe in 15.3% and very severe in 2.7%. Only 18.6% of these patients had previously been diagnosed with COPD; almost all of these had severe or very severe airflow limitation. As a result of the study, a diagnosis of asthma was made in 122 patients.

CONCLUSIONS: The prevalence and underdiagnosis of COPD in adult patients in this primary care setting made case finding worthwhile. Large numbers of newly detected patients were symptomatic and needed treatment. Limiting investigations to smokers would have reduced the number of COPD diagnoses by 26%.

Cigarette Smoking and Erectile Dysfunction: Focus on NO Bioavailability and ROS Generation

The Journal of Sexual Medicine published online 4 March 2008 (doi:10.1111/j.1743-6109 Rita C. Tostes,et al.

Introduction. Thirty million men in the United States suffer from erectile dysfunction (ED) and this number is expected to double by 2025. Considered a major public health problem, which seriously affects the quality of life of patients and their partners, ED becomes increasingly prevalent with age and chronic smoking is a major risk factor in the development of ED.

Aim. To review available evidence concerning the effects of cigarette smoking on vascular changes associated with decreased nitric oxide (NO) bioavailability and increased reactive oxygen species (ROS) generation.

Methods. We examined epidemiological and clinical data linking cigarette smoking and ED, and the effects of smoking on vascular NO bioavailability and ROS generation.

Main Outcome Measures. There are strong parallels between smoking and ED and considerable evidence supporting the concept that smoking-related ED is associated with reduced bioavailability of NO because of increased ROS.

Results. Cigarette smoking-induced ED in human and animal models is associated with impaired arterial flow to the penis or acute vasospasm of the penile arteries. Long-term smoking produces detrimental effects on the vascular endothelium and peripheral nerves and also causes ultrastructural damage to the corporal tissue, all considered to play a role in chronic smoking-induced ED. Clinical and basic science studies provide strong indirect evidence that smoking may affect penile erection by the impairment of endothelium-dependent smooth muscle relaxation or more specifically by affecting NO production via increased ROS generation. Whether nicotine or other products of cigarette smoke mediate all effects related to vascular damage is still unknown.

Conclusions. Smoking prevention represents an important approach for reducing the risk of ED. The characterization of the components of cigarette smoke leading to ED and the mechanisms by which these components alter signaling pathways activated in erectile responses are necessary for a complete comprehension of cigarette smoking-associated ED.

Extrapulmonary effects of chronic obstructive pulmonary disease on physical activity: a cross-sectional study.

Am J Respir Crit Care Med. 2008 Apr 1;177(7):743-51 Watz H, Waschki B, Boehme C, Claussen M, Meyer T, Magnussen H. Pulmonary Research Institute at Hospital Grosshansdorf, Center for Pneumology and Thoracic Surgery, Woehrendamm 80, D-22927 Grosshansdorf, Germany.

RATIONALE: Physical activity is reduced in patients with chronic obstructive pulmonary disease (COPD). COPD has a systemic component that includes significant extrapulmonary effects that may contribute to its severity in individual patients.

OBJECTIVES: To investigate the association of extrapulmonary effects of the disease and its comorbidities with reduced physical activity in patients with COPD.

METHODS: In a cross-sectional study, 170 outpatients with COPD (GOLD [Global Initiative for Chronic Obstructive Lung Disease] stages I-IV; BODE [body mass index, airway obstruction, dyspnea, and exercise capacity] score 0-10) underwent a series of tests. Physical activity was assessed over 5 to 6 consecutive days by using a multisensor accelerometer armband that records steps per day and the physical activity level (total daily energy expenditure divided by whole-night sleeping energy expenditure). Cardiovascular status was assessed by echocardiography, vascular Doppler sonography, and levels of N-terminal pro-B-type natriuretic peptide. Mental status, metabolic/muscular status, systemic inflammation, and anemia were assessed by Beck Depression Inventory, bioelectrical impedance analysis, handgrip strength, high-sensitivity C-reactive protein/fibrinogen, and hemoglobin, respectively.

MEASUREMENTS AND MAIN RESULTS: In a multivariate linear regression analysis using either steps per day or physical activity level as a dependent variable, the extrapulmonary parameters that were associated with reduced physical activity in patients with COPD independently of GOLD stages or BODE score were N-terminal pro-B-type natriuretic peptide levels, echocardiographically measured left ventricular diastolic function, and systemic inflammation.

CONCLUSIONS: Higher values of systemic inflammation and left cardiac dysfunction are associated with reduced physical activity in patients with COPD.

Underreporting exacerbation of chronic obstructive pulmonary disease in a longitudinal cohort.

Am J Respir Crit Care Med. 2008 Feb 15;177(4):396-401. Langsetmo L, Platt RW, Ernst P, Bourbeau J. Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, 3650 St. Urbain, Montreal, PQ, Canada.

RATIONALE: Unreported exacerbations and failure to seek medical attention may have consequences on the health of patients with chronic obstructive pulmonary disease.

OBJECTIVES: This study aims to determine the incidence of reported and unreported exacerbations, to identify predictors of reporting, and to compare the impact of reported and unreported exacerbations on health status. METHODS: The study is based on a multicenter Canadian cohort of patients with chronic obstructive pulmonary disease.

MEASUREMENTS AND MAIN RESULTS: Patients completed a daily diary from which exacerbations were defined as a worsening of at least one key symptom (dyspnea, sputum amount, sputum color) recorded on at least 2 consecutive days. Patients were asked to contact the study center if there was a sustained worsening of symptom. Reported exacerbations were events that led to contacting study center or health care visit. The study enrolled 421 patients. The overall incidence of diary exacerbations was 2.7 per person per year, but only 0.8 per person per year was reported. Predictors of reporting included age (HR [hazard ratio], 0.90; 95% confidence interval [CI], 0.81-0.98 per 5-yr increase), FEV(1)% predicted (HR, 0.84; 95% CI, 0.70-0.99 per 10% increase), number of symptoms at onset (HR, 1.59; 95% CI, 1.37-1.84 per additional symptom), and time of the week (HR, 0.35; 95% CI, 0.22-0.56 weekend vs. weekday). There was a clinically important decline in health status for 52% of patients with reported exacerbation and 43% with unreported exacerbations.

CONCLUSIONS: This study has shown that less than one-third of the exacerbations were reported. The number of symptoms at onset was the most important predictor of reporting an exacerbation, and both reported and unreported exacerbations had an impact on health status.

Variability of the prevalence of undiagnosed airflow obstruction in smokers using different diagnostic criteria.

Chest. 2008 Jan;133(1):42-8. Lau AC, Ip MS, Lai CK, Choo KL, Tang KS, Yam LY, Chan-Yeung M. Department of Intensive Care, The University of Hong Kong, Queen Mary Hospital Pokfulam, Hong Kong SAR, China.

PURPOSES: To estimate the prevalence of undiagnosed airflow obstruction (AFO) in Hong Kong smokers with no previous diagnosis of respiratory disease, and to assess its variability when applying different prediction equations and diagnostic criteria.

METHODS: A multicenter, population-based, cross-sectional prevalence study was performed in smokers aged 20 to 80 years. Three different criteria (fixed 70% [Global Initiative for Chronic Obstructive Lung Disease and British Thoracic Society], fixed 75%, and European Respiratory Society [ERS]) were applied to define a lower limit of normal (LLN) of the FEV(1)/FVC ratio to compare with the Hong Kong Chinese reference equation (criterion 1), which had used a distribution-free method to obtain the lower fifth percentile of FEV(1)/FVC ratio as the LLN.

RESULTS: In 525 male patients, using criterion 1 (local internal prediction equation) and defining AFO as FEV(1)/FVC less than LLN, the overall prevalence of AFO was 13.7%: 8.3% in age > or = 20 to 40 years, 14.0% in age > or = 40 to 60 years, and 17.8% in age > or = 60 to 80 years. When the local internal prediction equation was used as the comparison reference, the fixed-ratio methods tended to miss AFO in younger age groups and overdiagnose AFO in old age, while the ERS criteria, which uses an almost lower fifth percentile-equivalent method, showed less of such a trend but still only showed moderate agreement with criterion 1.

CONCLUSIONS: Undiagnosed AFO was prevalent in Hong Kong smokers. Estimated prevalence rates were highly affected by the criteria used to define AFO. The predicted lower fifth percentile values calculated from a local reference equation as the LLN of FEV(1)/FVC ratio should be used for the diagnosis of AFO.

Clinical determinants of exacerbations in severe, early-onset COPD

Eur Respir J. 2007 Dec;30(6):1124-30 Foreman MG, DeMeo DL, Hersh CP, Reilly JJ, Silverman EK. Channing Laboratory, 181 Longwood Avenue, Boston, MA 02115, USA.

Chronic obstructive pulmonary disease (COPD) exacerbations impair health. The present authors analysed participants in the Boston Early-Onset COPD Study for familial aggregation and propensity for COPD exacerbations. In the present study, two exacerbation outcomes, episodes of cough and phlegm, and frequent exacerbations were analysed with multivariable modelling and generalised estimating equations.

In early-onset COPD probands, passive tobacco smoke exposure within the home was strongly associated with episodes of cough and phlegm. Chronic phlegm production was associated with both exacerbation phenotypes in probands. In first-degree relatives of early-onset COPD probands, chronic bronchitis, episodic wheezing, pneumonia and active smoking were associated with the episodes of cough and phlegm phenotype. In relatives, identical characteristics plus exertional dyspnoea were associated with frequent exacerbations. Exacerbation risk increased with declining lung function. Familial aggregation for episodes of cough and phlegm was observed in relatives with severe obstruction.

In conclusion, passive smoke exposure increases morbidity in severe early-onset chronic obstructive pulmonary disease probands, and chronic obstructive pulmonary disease exacerbations correlate with chronic sputum production in probands and relatives. The familial aggregation of exacerbations suggests a genetic basis for susceptibility to chronic obstructive pulmonary disease exacerbations.

Role of physiotherapy in the management of chronic lung diseases: an overview of systematic reviews.

Respir Med. 2007 Dec;101(12):2429-36. Garrod R, Lasserson T. School of Physiotherapy, St. George's, University of London, Faculty of Health and Social Care Sciences, Cranmer Terrace, London SW17 0RE, UK.

Four Cochrane respiratory reviews of relevance to physiotherapeutic practice are discussed in this overview. Physiotherapists aim to improve ventilation for people with respiratory disease, and approach this using a variety of techniques. As such, the reviews chosen for discussion consider a wide range of interventions commonly used by physiotherapists: breathing exercises, bronchopulmonary hygiene techniques and physical training for peripheral and respiratory muscles. The reviews show that breathing exercises may have beneficial effects on health-related quality of life in asthma, and that inspiratory muscle training (IMT) may improve inspiratory muscle strength. However, the clinical relevance of increased respiratory muscle strength per se is unknown, and the longer-term effects of breathing exercises on morbidity have not been considered. One review clearly shows that bronchopulmonary hygiene techniques in chronic obstructive pulmonary disease (COPD) and bronchiectasis increase sputum production. Frequent exacerbation is associated with increased sputum and high bacterial load, suggesting that there may be important therapeutic benefit of improved sputum clearance. Future studies evaluating the long-term effects of bronchopulmonary hygiene techniques on morbidity are recommended. In the third review, the importance of pulmonary rehabilitation in the management of COPD is once again reinforced. Physiotherapists are crucial to the delivery of exercise training programmes, and it is likely that the effects of pulmonary rehabilitation extend to other important outcomes, such as hospital admission and re-admission. On the basis of the evidence provided by these Cochrane reviews, this overview highlights important practice points of relevance to physiotherapy, and recommendations for future studies.

Bronchial airflow limitation, smoking, body mass index, and statin use are strongly associated with the C-reactive protein level in the elderly. The Tromsø Study 2001.

Respir Med. 2007 Dec;101(12):2541-9. Melbye H, Halvorsen DS, Hartz I, Medbø A, Brox J, Eggen AE, Njølstad I. Institute of Community Medicine, University of Tromso, 9037 Tromso, Norway.

BACKGROUND: Bronchial airflow limitation is a known predictor of raised C-reactive protein (CRP) level. The aim of this study was to explore this association in an elderly population, as well as the influence of other known and possible predictors of the CRP level, like smoking and the use of statins and inhaled corticosteroids.

POPULATION AND METHODS: The study population consists of 3877 Norwegians aged 60 years or more who took part in the fifth Tromsø study in 2001, a cross-sectional study. The examinations included questionnaires, spirometry and the measurement of CRP.

RESULTS: A geometric mean CRP value of 3.15 mg/L was found in subjects with severe airflow limitation (FEV(1)%<50 predicted and FEV(1)/FVC<70%), compared to 1.64 mg/L in subjects with normal spirometry, (p<0.001), and 19% of the subjects with severe airflow limitation had a CRP value above 10 mg/L compared to 4.9% in those with mild airflow limitation or normal spirometry. Elevated body mass index (BMI), smoking, hormone replacement therapy, and increasing age, were also strong independent predictors of increased CRP. Statin use was a strong predictor of decreased CRP level, while the use of inhaled corticosteroids was not associated with decreased CRP values.

CONCLUSION: We found a strong link between bronchial airflow limitation and the circulating CRP level in an elderly population, independent of self-reported diseases, medication, smoking, and elevated BMI. The CRP value increased with increasing age in men, but not in women, which may be partly explained by a greater impact of chronic obstructive pulmonary disease (COPD) morbidity on the CRP level in men than in women. Measuring CRP may show to be a useful part of the diagnostic work-up in COPD patients.

Efficacy of pulmonary rehabilitation in chronic respiratory failure (CRF) due to chronic obstructive pulmonary disease (COPD): The Maugeri Study.

Respir Med. 2007 Dec;101(12):2447-53. Carone M, Patessio A, Ambrosino N, Baiardi P, Balbi B, Balzano G, Cuomo V, Donner CF, Fracchia C, Nava S, Neri M, Pozzi E, Vitacca M, Spanevello A. Fondazione Salvatore Maugeri, IRCCS, Department of Pulmonary Disease, Scientific Institute of Veruno, Italy.

While the effectiveness of pulmonary rehabilitation (PR) in chronic obstructive pulmonary disease (COPD) is well established, its effectiveness in the most severe category of COPD, i.e. patients with chronic respiratory failure (CRF), is less well known.

OBJECTIVE: To verify the effects of PR in patients with CRF, and compare the level of improvement with PR in these patients to that of COPDs not affected by CRF. METHODS: A multi-centre study was carried out on COPD patients with versus without CRF. The PR program included educational support, exercise training, and nutritional and psychological counselling. Lung function, arterial gases, walk test (6MWT), dyspnoea (MRC; BDI/TDI), and quality of life (MRF(28); SGRQ) were evaluated.

RESULTS: Thousand forty seven consecutive COPD inpatients (327 with CRF) were evaluated. In patients with CRF all parameters improved after PR (0.001). Mean changes: FEV(1), 112 ml; PaO(2), 3.0 mmHg; PaCO(2), 3.3 mmHg; 6MWT, 48 m; MRC, 0.85 units; MRF(28) total score, 11.5 units. These changes were similar to those observed in patients without CRF.

CONCLUSIONS: This study, featuring the largest cohort so far reported in the literature, shows that PR is equally effective in the more severe COPD patients, i.e. those with CRF, and supports the prescription of PR also in these patients

The 6-min walk distance, peak oxygen uptake, and mortality in COPD

Chest. 2007 Dec;132(6):1778-85 Cote CG, Pinto-Plata V, Kasprzyk K, Dordelly LJ, Celli BR. Pulmonary and Critical Care Medicine, Bay Pines VA Health Care System, 10,000 Bay Pines Blvd, Bay Pines, FL 33744, USA.

In patients with COPD, the maximal oxygen uptake (Vo2) measured at peak exercise and the 6-min walk distance (6MWD) have been associated with survival; however, no study has compared the strength of the association in the same patients. In this study, we compared the association between the 6MWD and peak Vo2 and mortality in 365 patients with COPD. Patients' cardiopulmonary cycle ergometry test results and 6MWD were determined at entry, and patients were followed up for a mean period of 67 months. There were 171 deaths. Compared with survivors, nonsurvivors were older (mean [+/- SD] age, 67.9 +/- 8 vs 65.9 +/- 8 years, respectively; p = 0.008), had worse mean FEV1 (36.5 +/- 12 vs 42.6 +/- 14 L, respectively; p = 0.02), had lower mean peak Vo2 (9.8 +/- 3 vs 11.8 +/- 3.6 mL/Kg/min, respectively; p < 0.0001), lower mean 6MWD (312 +/- 104 vs 377 +/- 95 m, respectively; p < 0.0001), and lower mean exercise minute ventilation (37.4 +/- 12 vs 42.3 +/- 13 L/min, respectively; p = 0.004). Univariate analysis showed that peak Vo2 and 6MWD as well as comorbidity, FEV1, and body mass index were associated with death. Logistic regression analysis with mortality as the dependent variable revealed that 6MWD (hazard ratio [HR], 0.996; 95% confidence interval [CI], 0.993 to 0.999; p < 0.01) had a stronger association than the peak Vo2 (HR, 0.971; 95% CI, 0.959 to 1.000; p = 0.050) with mortality.

This study shows the 6MWD is as good predictor of mortality as the peak Vo2 in patients with COPD.

Predictors of rehospitalization and death after a severe exacerbation of COPD

Chest. 2007 Dec;132(6):1748-55 McGhan R, Radcliff T, Fish R, Sutherland ER, Welsh C, Make B. Denver Health and Hospital Authority, Denver, CO, USA.

BACKGROUND: Patients who survive a severe exacerbation of COPD are at high risk of rehospitalization for COPD and death. The objective of this study was to determine predictors of these events in a large cohort of Veterans Affairs (VA) patients.

METHODS: We identified 51,353 patients who were discharged after an exacerbation of COPD in the VA health-care system from 1999 to 2003, and determined the rates of rehospitalization for COPD and death from all causes. Potential risk factors were assessed with univariate and multivariate survival analysis.

RESULTS: On average, the cohort was elderly (mean age, 69 years), predominately white (78% white, 13% black, 3% other, and 6% unknown), and male (97%), consistent with the underlying VA population. The risk of death was 21% at 1 year, and 55% at 5 years. Independent risk factors for death were age, male gender, prior hospitalizations, and comorbidities including weight loss and pulmonary hypertension; nonwhite race and other comorbidities (asthma, hypertension, and obesity) were associated with decreased mortality. The risk of rehospitalization for COPD was 25% at 1 year, and 44% at 5 years, and was increased by age, male gender, prior hospitalizations, and comorbidities including asthma and pulmonary hypertension. Hispanic ethnicity and other comorbidities (diabetes and hypertension) were associated with a decreased risk of rehospitalization.

CONCLUSIONS: Age, male gender, prior hospitalizations, and certain comorbid conditions were risk factors for death and rehospitalization in patients discharged after a severe COPD exacerbation. Nonwhite race and other comorbidities were associated with decreased risk.

Bronchodilator responsiveness in patients with COPD.

Eur Respir J. 2008 Feb 6 [Epub ahead of print]Click here to read Links Tashkin DP, Celli B, Decramer M, Liu D, Burkhart D, Cassino C, Kesten S. UCLA, Los Angeles, CA, United States.

The degree of acute improvement in spirometric indices after bronchodilator inhalation varies among COPD patients and depends on the type, dose and timing of bronchodilator administered.

We examined acute bronchodilator responsiveness at baseline in a large cohort of patients with moderate to very severe COPD participating in UPLIFT, a 4-year, randomized, double-blind trial evaluating the efficacy of tiotropium 18 mcg daily in reducing the rate of decline in lung function. After washout of respiratory medications, patients received 80 mcg ipratropium followed by 400 mcg albuterol. Spirometry was performed before and 90 minutes following ipratropium. Criteria used for FEV1 responsiveness: >/=12% and 200 ml, >/=15% increase over baseline, and >/=10% absolute increase in percent predicted.

5,756 patients had data meeting criteria for analysis. Age=64.5 years; males=75%. Baseline FEV1=1.10 L (39.3% predicted) and FVC=2.63 L. Compared with baseline, mean improvements in FEV1=229 ml, FVC=407 ml. 53.9% of patients had 12% and 200 ml improvements in FEV1; 65.6% had >/=15% improvement in FEV1; and 38.6% had >/=10% absolute increase in FEV1 percent predicted.

The majority of patients with moderate to very severe COPD demonstrate meaningful increases in lung function following administration of an inhaled anticholinergic plus sympathomimetic bronchodilators.

A Nationally Representative Case–Control Study of Smoking and Death in India

nejm.org February 13, 2008 (10.1056/NEJMsa0707719) Prabhat Jha, M.D., Binu Jacob, M.Sc., Vendhan Gajalakshmi, Ph.D., Prakash C. Gupta, D.Sc., Neeraj Dhingra, M.D., Rajesh Kumar, M.D., Dhirendra N. Sinha, M.D., Rajesh P. Dikshit, Ph.D., Dillip K. Parida, M.D., Rajeev Kamadod, M.Sc., Jillian Boreham, Ph.D., Richard Peto, F.R.S., for the RGI–CGHR Investigators

Background: The nationwide effects of smoking on mortality in India have not been assessed reliably.

Methods: In a nationally representative sample of 1.1 million homes, we compared the prevalence of smoking among 33,000 deceased women and 41,000 deceased men (case subjects) with the prevalence of smoking among 35,000 living women and 43,000 living men (unmatched control subjects). Mortality risk ratios comparing smokers with nonsmokers were adjusted for age, educational level, and use of alcohol.

Results: About 5% of female control subjects and 37% of male control subjects between the ages of 30 and 69 years were smokers. In this age group, smoking was associated with an increased risk of death from any medical cause among both women (risk ratio, 2.0; 99% confidence interval [CI], 1.8 to 2.3) and men (risk ratio, 1.7; 99% CI, 1.6 to 1.8). Daily smoking of even a small amount of tobacco was associated with increased mortality. Excess deaths among smokers, as compared with nonsmokers, were chiefly from tuberculosis among both women (risk ratio, 3.0; 99% CI, 2.4 to 3.9) and men (risk ratio, 2.3; 99% CI, 2.1 to 2.6) and from respiratory, vascular, or neoplastic disease. Smoking was associated with a reduction in median survival of 8 years for women (99% CI, 5 to 11) and 6 years for men (99% CI, 5 to 7). If these associations are mainly causal, smoking in persons between the ages of 30 and 69 years is responsible for about 1 in 20 deaths of women and 1 in 5 deaths of men. In 2010, smoking will cause about 930,000 adult deaths in India; of the dead, about 70% (90,000 women and 580,000 men) will be between the ages of 30 and 69 years. Because of population growth, the absolute number of deaths in this age group is rising by about 3% per year.

Conclusions: Smoking causes a large and growing number of premature deaths in India.

Vervuiling doodt jaarlijks 10.000 Belgen

hln.be

De vervuilingspieken doden jaarlijks 1.000 mensen, bovenop de 9.000 overlijdens die het gevolg zijn van de dagdagelijkse vervuiling. Dat zegt de Leuvense longspecialist Benoît Nemery de Bellevaux.

Volgens de specialist is het niet makkelijk overlijdens aan één oorzaak toe te wijzen. Maar infarcten doden, en vervuiling is een risicofactor voor een infarct, aldus de professor.

Patiënten met chronische bronchitis lijden onder het huidige weer: veel fijn stof en stikstofdioxide. Het hart krijgt te weinig zuurstof.

Op basis van internationale vergelijkingen schat men dat de Belg gemiddeld 13,2 maanden levensverwachting inboet door luchtvervuiling.

Underreporting exacerbation of chronic obstructive pulmonary disease in a longitudinal cohort

Am J Respir Crit Care Med. 2008 Feb 15;177(4):396-401 Langsetmo L, Platt RW, Ernst P, Bourbeau J. Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, 3650 St. Urbain, Montreal, PQ, Canada.

RATIONALE: Unreported exacerbations and failure to seek medical attention may have consequences on the health of patients with chronic obstructive pulmonary disease.

OBJECTIVES: This study aims to determine the incidence of reported and unreported exacerbations, to identify predictors of reporting, and to compare the impact of reported and unreported exacerbations on health status.

METHODS: The study is based on a multicenter Canadian cohort of patients with chronic obstructive pulmonary disease.

MEASUREMENTS AND MAIN RESULTS: Patients completed a daily diary from which exacerbations were defined as a worsening of at least one key symptom (dyspnea, sputum amount, sputum color) recorded on at least 2 consecutive days. Patients were asked to contact the study center if there was a sustained worsening of symptom. Reported exacerbations were events that led to contacting study center or health care visit. The study enrolled 421 patients. The overall incidence of diary exacerbations was 2.7 per person per year, but only 0.8 per person per year was reported. Predictors of reporting included age (HR [hazard ratio], 0.90; 95% confidence interval [CI], 0.81-0.98 per 5-yr increase), FEV(1)% predicted (HR, 0.84; 95% CI, 0.70-0.99 per 10% increase), number of symptoms at onset (HR, 1.59; 95% CI, 1.37-1.84 per additional symptom), and time of the week (HR, 0.35; 95% CI, 0.22-0.56 weekend vs. weekday). There was a clinically important decline in health status for 52% of patients with reported exacerbation and 43% with unreported exacerbations.

CONCLUSIONS: This study has shown that less than one-third of the exacerbations were reported. The number of symptoms at onset was the most important predictor of reporting an exacerbation, and both reported and unreported exacerbations had an impact on health status.

COPD: A Pediatric Disease

COPD. 2008 Feb;5(1):53-67 Bush A. Professor of Paediatric Respirology, Imperial School of Medicine at National Heart and Lung Institute.

Chronic obstructive pulmonary disease (COPD) is conventionally thought of as a disease of adult smokers, related to airway inflammation and structural airway changes (remodeling). However, there is important epidemiological evidence, from a series of studies with overlapping age groups from birth to late middle age that early life events, including antenatal influences on lung growth, program the child to be at increased risk for future COPD. This paper reviews the evidence for potential gene: environment interactions in this process, in particular with respect to the maternal genotype of the COPD patient. It explores the hypothesis that genes important in early lung development are also important in determining adult risk for COPD.

Although the major preventable factor adversely impacting on child lung health is maternal smoking, the effects of viral infection, nutrition, and indoor and outdoor pollution are reviewed. The survivors of preterm birth are another important cohort who may develop premature COPD in adult life. Early life events provide the substrate for COPD, with later cigarette smoking, and occasionally other exposures, pulling the trigger to produce COPD.

Although a rigorous anti-smoking program is necessary to halt this spiral of lung destruction leading to COPD, a focus on early (including prenatal) lung health is also important. Any model of COPD which does not take into account early life influences is likely to be fatally flawed.

Rookverbod in de EU verder uitgebreid

Gepubliceerd in ZrgKrant

Frankrijk is het nieuwe jaar begonnen met een rookverbod in de horeca. Ook in grote delen van Duitsland en in Portugal is op 1 januari een rookverbod in de horeca ingegaan.

Elf maanden geleden werd in Frankrijk het rookverbod in openbare plaatsen van kracht. Dat is sinds 1 januari uitgebreid naar onder meer cafés, discotheken, restaurant en hotels. Op niet overdekte terrassen mogen de Fransen nog wel een sigaretje opsteken. Overtreders kunnen een boete van 68 euro verwachten. Eigenaren van horecagelegenheden worden bij overtreding bestraft met 135 euro.

In Duitsland zijn er acht deelstaten met een rookverbod. In een aantal deelstaten gold al een tijd het rookverbod. Er zijn nu nog vijf deelstaten zonder rookverbod, maar die volgen in de loop van 2008.

Nederland

In ons land wordt officieel per 1 juli 2008 een rookverbod van kracht in de horeca. Veel horecabedrijven verbieden het roken al met ingang van 1 januari. Dat geldt ook voor Schiphol. Daar is sinds 1 januari een algemeen rookverbod van kracht. Schiphol is daarmee de eerste grote Europese luchthaven die het rookverbod zo drastisch doorvoert.

Verschillende onderzoeken van TNS NIPO laten zien dat tweederde van de bevolking een rookvrije horeca wil.

Geschiedenis

Het eerste Europese land dat een rookverbod invoerde - in fabrieken, kantoren, pubs en restaurants - was Ierland, in 2004. Schotland en Noorwegen volgden al snel en in juli 2007 werden ook de Britse pubs rookvrij.

Italië voerde een jaar na Ierland een rookverbod in. Sinds begin 2005 is daar een rookverbod voor openbare gelegenheden, inclusief restaurants en bars. Het gevolg was dat een half miljoen Italianen stopte met roken. Volgens het Italiaanse ministerie van Volksgezondheid leeft men het rookverbod goed na in bars en restaurants, maar wordt op de werkplek nog vaak gerookt.

Ook in Zweden, Finland en Denemarken mag niet langer in horecagelegenheden worden gerookt. Wel zijn speciale afgescheiden rookruimtes voor gasten toegestaan. In Denemarken is roken in kleine barretjes (net als Portugal) nog wél geoorloofd.

Standpunt KWF Kankerbestrijding

KWF Kankerbestrijding vindt een rookverbod in de horeca noodzakelijk in de strijd tegen kanker. Een rookvrije horeca is onontbeerlijk als een van de maatregelen om tot een daling van het aantal rokers naar 20 procent in 2010 te komen. Dit doel hebben KWF Kankerbestrijding, Astma Fonds, Nederlandse Hartstichting en het Ministerie van VWS geformuleerd in het Nationaal Programma Tabaksontmoediging. In Nederland overlijden jaarlijks ongeveer 200 mensen als gevolg van het jarenlang inademen van andermans tabaksrook. Alleen al daarom is een rookverbod in de horeca van evident belang.

Principles of confrontational counselling in smokers with chronic obstructive pulmonary disease (COPD).

Med Hypotheses. 2008;70(2):384-6 Kotz D, Huibers MJ, Vos R, van Schayck CP, Wesseling G. Department of General Practice, Care and Public Health Research Institute (CAPHRI), Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands.

Chronic obstructive pulmonary disease (COPD) is a major public health problem. The use of spirometry for early detection of COPD is a current issue of debate because of lack of convincing evidence of the additional positive effect of spirometry on smoking cessation.

In this article, we present conditions under which early detection of COPD and confrontation may be effective, highlighting the principles of "confrontational counselling". Confronting patients with COPD is not an isolated approach but should be integrated into state-of-the-art smoking cessation treatment.

Confrontational counselling should consist of several counselling sessions on an individual, face-to-face level, under supervision of a trained smoking cessation specialist, and in combination with evidence-based pharmacological treatment for smoking cessation.

Hospital admission rates among men and women with symptoms of chronic bronchitis and airflow limitation corresponding to the GOLD stages of chronic obstructive pulmonary disease

Respir Med. 2008 Jan;102(1):109-20 Ekberg-Aronsson M, Löfdahl K, Nilsson JA, Löfdahl CG, Nilsson PM. Department of Respiratory Medicine and Allergology, University of Lund, S-221 85 Lund, Sweden.

Chronic obstructive pulmonary disease is a major cause of increased morbidity and mortality. The aim of this study was to investigate hospital admission rates among individuals with symptoms of chronic bronchitis and among those with airflow limitation corresponding to GOLD stages 1-4.

METHOD: Between 1974 and 1992, 22044 middle-aged individuals participated in a health screening, which included spirometry (without broncho-dilation), as well as recording of respiratory symptoms and smoking habits. Information on hospital admissions until 31 December 2002 was obtained from local and national registers. The hospital admission rates due to all causes, obstructive lung disease and cardiovascular disease were analysed among individuals with symptoms of chronic bronchitis and among those with airflow limitation corresponding to GOLD stages 1-4 using ordinal regression with adjustment for age and with individuals with normal lung function and without symptoms of chronic bronchitis as reference group.

RESULTS: Symptoms of chronic bronchitis and GOLD stages 1-4 showed increased hospital admission rates (hospital admission rates due to obstructive lung disease excluded) among smokers of both genders. Furthermore, symptoms of chronic bronchitis showed increased hospital admission rates due to obstructive lung disease among smoking women. There were also increased hospital admission rates due to obstructive lung disease among smokers of GOLD stages 1-4 and increased hospital admission rates due to cardiovascular disease among female smokers of GOLD stage 2.

CONCLUSION: Among smokers, symptoms of chronic bronchitis as well airflow limitation corresponding to GOLD stages 1-4 conveyed a substantial morbidity with increased hospital admission rates due to all causes. The burden of disease is most likely underestimated among individuals with symptoms of chronic bronchitis and chronic obstructive pulmonary disease.

Complex chronic comorbidities of COPD.

Eur Respir J. 2008 Jan;31(1):204-12 Fabbri LM, Luppi F, Beghé B, Rabe KF. Dept of Oncology, Haematology and Respiratory Diseases, University of Modena and Reggio Emilia, Via del Pozzo 71, 41100 Modena, Italy.

Chronic obstructive pulmonary disease (COPD) is defined by fixed airflow limitation associated with an abnormal pulmonary and systemic inflammatory response of the lungs to cigarette smoke. The systemic inflammation induced by smoking may also cause chronic heart failure, metabolic syndrome and other chronic diseases, which may contribute to the clinical manifestations and natural history of COPD. Thus COPD can no longer be considered a disease only of the lungs, as it is often associated with a wide variety of systemic consequences.

A better understanding of the origin and consequences of systemic inflammation, and of potential therapies, will most likely lead to better care of patients with COPD. Medical textbooks and clinical guidelines still largely ignore the fact that COPD seldom occurs in isolation.

As the diagnosis and assessment of severity of COPD may be greatly affected by the presence of comorbid conditions, the current authors believe that lung function measurement, noninvasive assessment of cardiovascular and metabolic functions, and circulating inflammatory markers (e.g. C-reactive protein) might help to better characterise these patients. Similarly, preventive and therapeutic interventions should address the patient in their complexity.

Arterial stiffness is independently associated with emphysema severity in patients with chronic obstructive pulmonary disease.

Am J Respir Crit Care Med. 2007 Dec 15;176(12):1208-14 McAllister DA, Maclay JD, Mills NL, Mair G, Miller J, Anderson D, Newby DE, Murchison JT, Macnee W. ELEGI/Colt Laboratories, MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, EH164SB UK.

RATIONALE: More patients with chronic obstructive pulmonary disease (COPD) die of cardiovascular causes than of respiratory causes, and patients with COPD have increased morbidity and mortality from stroke and coronary heart disease. Arterial stiffness independently predicts cardiovascular risk, is associated with atheromatous plaque burden, and is increased in patients with COPD compared with control subjects matched for cardiovascular risk factors. Elastin fragmentation and changes in collagen are found in the connective tissue of both emphysematous lungs and stiff arteries, but it is not known whether the severity of arterial stiffness in patients with COPD is associated with the severity of emphysema.

OBJECTIVES: To identify whether the extent of arterial stiffness is associated with emphysema severity.

METHODS: We performed a cross-sectional study in 157 patients with COPD.

MEASUREMENTS AND MAIN RESULTS: We measured pulse wave velocity (a validated measure of arterial stiffness), blood pressure, smoking pack-years, glucose, cholesterol, and C-reactive protein in 157 patients with COPD. We assessed emphysema using quantitative computed tomography scanning in a subgroup of 73 patients. We found that emphysema severity was associated with arterial stiffness (r = 0.471, P < 0.001). The association was independent of smoking, age, sex, FEV(1)% predicted, highly sensitive C-reactive protein and glucose concentrations, cholesterol-high-density lipoprotein ratio, and pulse oximetry oxygen saturations.

CONCLUSIONS: Emphysema severity is associated with arterial stiffness in patients with COPD. Similar pathophysiological processes may be involved in both lung and arterial tissue and further studies are now required to identify the mechanism underlying this newly described association.

Impaired flow-mediated dilation is associated with low pulmonary function and emphysema in ex-smokers

Am J Respir Crit Care Med. 2007 Dec 15;176(12):1200-7 Barr RG, Mesia-Vela S, Austin JH, Basner RC, Keller BM, Reeves AP, Shimbo D, Stevenson L. Dr.P.H., Presbyterian Hospital 9 East, Room 105, Columbia University Medical Center, 630 West 168th Street, New York, NY 10032, USA.

RATIONALE: Basic science research suggests a causal role for endothelial dysfunction in chronic obstructive pulmonary disease (COPD). Clinical studies examining endothelial function are lacking, particularly early in the disease. Flow-mediated dilation (FMD) is a physiologic measure of endothelial reactivity to endogenous nitric oxide.

OBJECTIVES: We hypothesized that lower FMD among former smokers would be associated with lower post-bronchodilator FEV(1), higher percentage of emphysema using computed tomography (CT) and lower diffusing capacity.

METHODS: We measured FMD, pulmonary function, and CT percentage of emphysema in a random sample of 107 cotinine-confirmed former smokers in the ongoing EMCAP study. FMD was defined as percentage change in the brachial artery diameter with reactive hyperemia. Generalized additive models were used to adjust for potential confounders and assess linearity.

MEASUREMENTS AND MAIN RESULTS: Mean age of participants was 71 +/- 5 years, 46% were female, and pack-years averaged 48 +/- 26. Mean FMD was 3.8 +/- 3.1%; mean post-bronchodilator FEV(1), 2.3 +/- 0.8 L; and mean CT percentage of emphysema, 26 +/- 10%. A 1 SD decrease in FMD was associated with a 132-ml (95% confidence interval, 16-248 ml; P = 0.03) decrement in post-bronchodilator FEV(1) and a 2.6% (95% confidence interval, 0.5-4.7%; P = 0.02) increase in CT percentage of emphysema in fully adjusted models. These associations were linear across the spectrum from normality to disease, independent of smoking history, and also significant among participants without COPD. Associations with diffusing capacity were consistent but nonsignificant (P = 0.09). The FMD-FEV(1) association was entirely attributable to percentage of emphysema.

CONCLUSIONS: Impaired endothelial function, as measured by FMD, was associated with lower FEV(1) and higher CT percentage of emphysema in former smokers early in COPD.

Costs of chronic obstructive pulmonary disease (COPD) in Italy: The SIRIO study (Social Impact of Respiratory Integrated Outcomes).

Respir Med. 2008 Jan;102(1):92-101. Dal Negro RW, Tognella S, Tosatto R, Dionisi M, Turco P, Donner CF. Divisione di Pneumologia, Ospedale Orlandi, Bussolengo, Verona, Italy; CESFAR-Centro Studi Nazionale FISAR di Farmacoeconomia e Farmacoepidemiologia Respiratoria, Verona, Italy.

Chronic respiratory diseases affect a large number of subjects in Italy and are characterized by high socio-health costs. The aim of the Social Impact of Respiratory Integrated Outcomes (SIRIO) study was to measure the health resources consumption and costs generated in 1 year by a population of patients with chronic obstructive pulmonary disease (COPD) in a real-life setting. This bottom-up, observational, prospective, multicentric study was based on the collection of demographic, clinical, diagnostic, therapeutic and outcome data from COPD patients who reported spontaneously to pneumological centers participating in the study, the corresponding economic outcomes being assessed at baseline and after a 1-year survey.

A total of 748 COPD patients were enrolled, of whom 561 [408m, mean age 70.3 years (SD 9.2)] were defined as eligible by the Steering Committee. At the baseline visit, the severity of COPD (graded according to GOLD 2001 guidelines) was 24.2% mild COPD, 53.7% moderate and 16.8% severe. In the 12 months prior to enrollment, 63.8% visited a general practitioner (GP); 76.8% also consulted a national health service (NHS) specialist; 22.3% utilized Emergency Care and 33% were admitted to hospital, with a total of 5703 work days lost.

At the end of the 1-year survey, the severity of COPD changed as follows: 27.5% mild COPD, 47.4% moderate and 19.4% severe. Requirement of health services dropped significantly: 57.4% visited the GP; 58.3% consulted an NHS specialist; 12.5% used Emergency Care and 18.4% were hospitalized. Compared to baseline, the mean total cost per patient decreased by 21.7% (p<0.002).

In conclusion, a significant reduction in the use of health resources and thus of COPD-related costs (both direct and indirect costs) was observed during the study, likely due to a more appropriate care and management of COPD patients.

The clinical utility of the GOLD classification of COPD disease severity in pulmonary rehabilitation.

Respir Med. 2008 Jan;102(1):162-71. Huijsmans RJ, de Haan A, Ten Hacken NN, Straver RV, Van't Hul AJ. Institute for Fundamental and Clinical Human Movement Sciences, Free University, Van der Boechorststraat 9, 1081 BT Amsterdam, The Netherlands; Department of Rehabilitation, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has introduced a four-stage classification of chronic obstructive pulmonary disease (COPD) severity. The present study investigated the discriminatory capacity of the GOLD classification for health status outcomes in patients with COPD. An additional analysis was performed to investigate the discriminatory capacity of a multidimensional staging system, i.e. the Body-Mass Index, Degree of Airflow Obstruction and Dyspnea, and Exercise Capacity Index (BODE index) for the outcome of quality of life.

Retrospective analysis was performed on 253 COPD patients (30% stage II, 48% stage III, 22% stage IV), referred for outpatient pulmonary rehabilitation. Pulmonary function, exercise capacity, dyspnoea and quality of life were evaluated. Analyses of variance were used to detect differences between GOLD stages and BODE index quartiles, and scatterplots of individual responses were produced as well.

The GOLD classification discriminated between stages for pulmonary function (p<0.001), exercise capacity (p<0.001), dyspnoea (p<0.001) and the activities section (p=0.001) of the St. George Respiratory Questionnaire (SGRQ). The BODE index discriminated between quartiles for the activities section (p<0.001), impacts section (p=0.04) and the total score (p=0.01) of the SGRQ. Scatterplots revealed marked inter-individual variation within each GOLD stage or BODE index quartile, and considerable overlap between stages for all health status outcomes.

These findings show that the GOLD classification indeed can be used to discern groups of COPD patients, but due to large inter-individual variability it does not seem adequate as a basis for individual management plans in rehabilitation. The BODE index appeared to discriminate slightly better for quality of life, however, it still leaves a significant part of the variance unexplained.

Intervention by phone calls raises domiciliary activity and exercise capacity in patients with severe COPD.

Respir Med. 2008 Jan;102(1):20-26. Wewel AR, Gellermann I, Schwertfeger I, Morfeld M, Magnussen H, Jörres RA. Hospital Großhansdorf, Center for Pneumology and Thoracic Surgery, Großhansdorf, Germany.

BACKGROUND: Patients with severe COPD suffer from impairments of exercise capacity which affects daily activity. Conversely, activity might exert effects on the functional state. We studied whether a short-term intervention by regular phone calls caused an increase in activity at home and whether this resulted in a gain in exercise capacity.

METHODS: Over a 2-week period (P1) normal daily activity was assessed in 21 patients with stable severe COPD (GOLD III/IV). After this, the individual setting was explored in a short home visit. The subsequent 2-week period (P2) involved phone calls every other day to raise home-based activity (target: 3x15min daily at 75% of maximum dyspnea). During the study, patients wore an actograph plus pedometer and kept a diary. Before P1 and after P2, 6-min walking distance (6MWD), lung function, the Borg score and quality of life (SF-36, SGRQ) were determined.

RESULTS: Compared to P1, actograph counts (p<0.05) were higher in P2. There was also an increase in 6MWD (p<0.05) and quality of life scores (SF-36, p<0.05) between initial and final visit, whereby improvements in 6MWD correlated with changes in activity (p<0.01). Conversely, four patients who experienced an exacerbation in P2 showed no increase in activity or 6MWD.

CONCLUSIONS: In patients with stable severe COPD, it was possible to increase activity by regular phone calls without performing previous rehabilitation. Increased activity resulted in increased exercise capacity and quality of life within 2 weeks, underlining the effectiveness of continued motivational support in patients with severe COPD.

Effect of occupational exposures on decline of lung function in early chronic obstructive pulmonary disease.

Am J Respir Crit Care Med. 2007 Nov 15;176(10):994-1000. Harber P, Tashkin DP, Simmons M, Crawford L, Hnizdo E, Connett J; Lung Health Study Group. Division of Occupational and Environmental Medicine, David Geffen School of Medicine at University of California, Los Angeles, California 90024, USA.

RATIONALE: Several occupational exposures adversely affect lung function.

OBJECTIVES: This study reports the influence of continued occupational dust and fume exposures on the rate of decline of lung function in participants with early chronic obstructive pulmonary disease (COPD) studied in a population-based study.

METHODS: Subjects consisted of 5,724 participants in the Lung Health Study, a multicenter study of smoking cessation and anticholinergic bronchodilator administration in smokers with early COPD (3,592 men; 2,132 women). Average post-bronchodilator FEV1 at entry was 78.4% predicted for men and 78.2% predicted for women; all participants had an FEV1/FVC ratio less than 0.70.

MEASUREMENTS AND MAIN RESULTS: Participants underwent a baseline evaluation and five annual follow-up assessments, including questionnaires and spirometry. The effect of ongoing dust or fume exposure on FEV1 in each follow-up year was statistically evaluated with a mixed-effects regression model, which was adjusted for FEV1 at entry, age, airway responsiveness to methacholine, baseline smoking intensity, and time-varying (yearly) smoking status during each follow-up year. In men with early COPD, each year of continued fume exposure was associated with a 0.25% predicted reduction in post-bronchodilator FEV1% predicted. Continued smoking and airway hyperresponsiveness were also associated with reduction in FEV1 during each year of follow-up in both men and women. Statistically significant effects of dust exposure on the rate of decline were not found, nor were effects of fume exposure noted in women.

CONCLUSIONS: These results suggest a need for secondary prevention by controlling occupational fume exposures.

Early Detection and Impaired Quality of Life in COPD GOLD Stage 0: A Pilot Study.

COPD. 2007 Dec;4(4):313-20
Maleki-Yazdi MR, Lewczuk CK, Haddon JM, Choudry N, Ryan N.
Division of Respiratory Medicine, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada.

This pilot study aimed to identify early stages of chronic obstructive pulmonary disease (COPD) in an urban population of smokers and ex-smokers using the Global Initiative for Chronic Obstructive Lung Disease (GOLD 2001, 2003) classification guidelines and to assess the impact of early disease on quality of life.

Smokers and ex-smokers of >/= 10 pack years and age >/= 50 years were recruited. After an initial telephone interview, eligible subjects completed a clinical assessment, spirometry tests, and the St. George's Respiratory Questionnaire (SGRQ). A total of 244 subjects completed the study; 91 subjects (37%) were normal, 153 subjects (63%) met the criteria for GOLD stages 0 to III: 65 stage 0 (27%), 43 stage I (18%), 38 stage II (16%), 7 stage III (3%) and 0 in stage IV. The stage 0 patients were younger than any other COPD groups (p < 0.0005), including normal subjects (55.5 +/- 5.4 years vs. 59.6 +/- 7.2 years; p = 0.0005). The frequency of current smoking in stage 0 patients was greater than those in the normal category (80% vs. 33%; p < 0.0001).

There were significant impairments in quality of life measures between normal subjects and all GOLD stages (SGRQ total scores; p < 0.0001) except for stage I (SGRQ total scores; p = 0.1409). Subjects with COPD at GOLD stage 0 were markedly under-diagnosed. These subjects had a significant impairment in their health-related quality of life measures, were younger than other categories, and were mostly current smokers.

Thus, detection of COPD at GOLD stage 0 may provide a unique opportunity for early intervention and smoking cessation and the removal of GOLD stage 0 from the 2006 update should be re-assessed.

The impact of home hospitalization on healthcare costs of exacerbations in COPD patients.

Eur J Health Econ. 2007 Dec;8(4):325-32.
Puig-Junoy J, Casas A, Font-Planells J, Escarrabill J, Hernández C, Alonso J, Farrero E, Vilagut G, Roca J.
Research Center for Health and Economics (CRES), Universitat Pompeu Fabra, Trias Fargas 25-27, 34-08005, Barcelona, Spain

Home-hospitalization (HH) improves clinical outcomes in selected patients with chronic obstructive pulmonary disease (COPD) admitted at the emergency room due to an exacerbation, but its effects on healthcare costs are poorly known.

The current analysis examines the impact of HH on direct healthcare costs, compared to conventional hospitalizations (CH). A randomized controlled trial was performed in two tertiary hospitals in Barcelona (Spain). A total of 180 exacerbated COPD patients (HH 103 and CH 77) admitted at the emergency room were studied. In the HH group, a specialized respiratory nurse delivered integrated care at home.

The average direct cost per patient was significantly lower for HH than for CH, with a difference of 810 (95% CI, 418-1,169) in the mean cost per patient. The magnitude of monetary savings attributed to HH increased with the severity of the patients considered eligible for the intervention.

Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline from the American College of Physicians.

Ann Intern Med. 2007 Nov 6;147(9):633-638.
Qaseem A, Snow V, Shekelle P, Sherif K, Wilt TJ, Weinberger S, Owens DK; for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians*.
the American College of Physicians and Drexel University College of Medicine, Philadelphia, Pennsylvania; Veterans Affairs Greater Los Angeles Healthcare System and RAND, Santa Monica, California; Veterans Affairs Palo Alto Health Care System and Stanford University, Stanford, California; and Minnesota Veterans Affairs Medical Center, Minneapolis, Minnesota.

Recommendation 1: In patients with respiratory symptoms, particularly dyspnea, spirometry should be performed to diagnose airflow obstruction. Spirometry should not be used to screen for airflow obstruction in asymptomatic individuals. (Grade: strong recommendation, moderate-quality evidence.)

Recommendation 2: Treatment for stable chronic obstructive pulmonary disease (COPD) should be reserved for patients who have respiratory symptoms and FEV(1) less than 60% predicted, as documented by spirometry. (Grade: strong recommendation, moderate-quality evidence.)

Recommendation 3: Clinicians should prescribe 1 of the following maintenance monotherapies for symptomatic patients with COPD and FEV(1) less than 60% predicted: long-acting inhaled beta-agonists, long-acting inhaled anticholinergics, or inhaled corticosteroids. (Grade: strong recommendation, high-quality evidence.)

Recommendation 4: Clinicians may consider combination inhaled therapies for symptomatic patients with COPD and FEV(1) less than 60% predicted. (Grade: weak recommendation, moderate-quality evidence.)

Recommendation 5: Clinicians should prescribe oxygen therapy in patients with COPD and resting hypoxemia (Pao(2)

Recommendation 6: Clinicians should consider prescribing pulmonary rehabilitation in symptomatic individuals with COPD who have an FEV(1) less than 50% predicted. (Grade: weak recommendation, moderate-quality evidence.)

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary.

Am J Respir Crit Care Med. 2007 Sep 15;176(6):532-55
Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P, Fukuchi Y, Jenkins C, Rodriguez-Roisin R, van Weel C, Zielinski J; Global Initiative for Chronic Obstructive Lung Disease.
Leiden University Medical Center, Pulmonology, P.O. Box 9600, NL-2300 RC, Leiden, The Netherlands.

Chronic obstructive pulmonary disease (COPD) remains a major public health problem. It is the fourth leading cause of chronic morbidity and mortality in the United States, and is projected to rank fifth in 2020 in burden of disease worldwide, according to a study published by the World Bank/World Health Organization. Yet, COPD remains relatively unknown or ignored by the public as well as public health and government officials.

In 1998, in an effort to bring more attention to COPD, its management, and its prevention, a committed group of scientists encouraged the U.S. National Heart, Lung, and Blood Institute and the World Health Organization to form the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Among the important objectives of GOLD are to increase awareness of COPD and to help the millions of people who suffer from this disease and die prematurely of it or its complications. The first step in the GOLD program was to prepare a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD, published in 2001. The present, newly revised document follows the same format as the original consensus report, but has been updated to reflect the many publications on COPD that have appeared. GOLD national leaders, a network of international experts, have initiated investigations of the causes and prevalence of COPD in their countries, and developed innovative approaches for the dissemination and implementation of COPD management guidelines. We appreciate the enormous amount of work the GOLD national leaders have done on behalf of their patients with COPD.

Despite the achievements in the 5 years since the GOLD report was originally published, considerable additional work is ahead of us if we are to control this major public health problem. The GOLD initiative will continue to bring COPD to the attention of governments, public health officials, health care workers, and the general public, but a concerted effort by all involved in health care will be necessary.

Confidence and understanding among general practitioners and practice nurses in the UK about diagnosis and management of COPD.

Respir Med. 2007 Nov;101(11):2378-85
Halpin DM, O'reilly JF, Connellan S, Rudolf M; on behalf of the BTS COPD Consortium.
Department of Respiratory Medicine, Royal Devon & Exeter Hospital, Exeter, EX2 5DW, UK.

In order to assess the confidence of healthcare professionals in diagnosing and managing COPD telephone interviews were conducted with 60 practice nurses and 46 general practitioners (GPs) in 2001 and 61 nurses and 39 GPs in 2005. The nurses all ran respiratory clinics.

80% of GPs were confident about diagnosing COPD and this had increased from 52% in 2001. Fifty five percent of nurses were confident and there was no change from 2001. In 2005, 79% of GPs and 70% of nurses were confident about differentiating asthma and COPD. Smoking history, breathlessness, age of onset, lack of response to asthma therapy and cough were reported as features differentiating COPD from asthma. Most respondents stated that spirometry is essential to diagnose COPD and in 2005 nearly all practices had access to a spirometry service. GPs were more confident about interpreting spirometry results in 2005 than nurses and their confidence had increased significantly from 2001. In 2005, nearly all respondents had heard of pulmonary rehabilitation, and significantly more had a programme in their area in 2005 than 2001 (69% vs. 49% p=0.05). Fifty four percent of GPs were confident about which patients to refer for long term oxygen therapy in 2005 but nurses were less confident.

There had not been any significant change between 2001 and 2005. In 2005 only 35% of respondents had access to a pulse oximeter. When presented with case scenarios, GPs self-reported confidence was not reflected in their diagnoses or investigation and management strategies and they seem to favour cardiac over respiratory diagnoses.

Prevalence of Chronic Obstructive Pulmonary Disease in China: A Large, Population-based Survey.

Am J Respir Crit Care Med. 2007 Oct 15;176(8):753-60.
Zhong N, Wang C, Yao W, Chen P, Kang J, Huang S, Chen B, Wang C, Ni D, Zhou Y, Liu S, Wang X, Wang D, Lu J, Zheng J, Ran P.
Guangzhou Institute of Respiratory Diseases, The First Affiliated Hospital, Guangzhou Medical College, 151 Yanjiang Road, Guangzhou, Guangdong, 510120, China.

Rationale: The prevalence of chronic obstructive pulmonary disease (COPD) in China is largely unknown.

Objectives: To obtain the COPD prevalence in China through a large-population, spirometry-based, cross-sectional survey of COPD.

Methods: Urban and rural population-based cluster samples were randomly selected from seven provinces/cities. All residents 40 years of age or older in the selected clusters were interviewed with a standardized questionnaire revised from the international BOLD (Burden of Obstructive Lung Diseases) study. Spirometry was performed on all eligible participants. Patients with airflow limitation (FEV(1)/FVC < 0.70) were further examined by post-bronchodilator spirometry, chest radiograph, and electrocardiogram. Post-bronchodilator FEV(1)/FVC of less than 70% was defined as the diagnostic criterion of COPD.

Measurements and Main Results: Among 25,627 sampling subjects, 20,245 participants completed the questionnaire and spirometry (response rate, 79.0%). The overall prevalence of COPD was 8.2% (men, 12.4%; women, 5.1%). The prevalence of COPD was significantly higher in rural residents, elderly patients, smokers, in those with lower body mass index, less education, and poor ventilation in the kitchen, in those who were exposed to occupational dusts or biomass fuels, and in those with pulmonary problems in childhood and family history of pulmonary diseases. Among the patients who had COPD, 35.3% were asymptomatic; only 35.1% reported lifetime diagnosis of bronchitis, emphysema, or other COPD; and only 6.5% have been tested with spirometry.

Conclusions: COPD is prevalent in individuals 40 years of age or older in China

Prospective study of dietary patterns and chronic obstructive pulmonary disease among US men.

Thorax. 2007 Sep;62(9):786-91
Varraso R, Fung TT, Hu FB, Willett W, Camargo CA.
Department of Nutrition, Harvard School of Public Health, 655 Huntington Avenue, Boston, Massachusetts 02115, USA.

BACKGROUND: Many foods are associated with chronic obstructive pulmonary disease (COPD) symptoms or lung function. Because foods are consumed together and nutrients may interact, dietary patterns are an alternative way of characterising diet. A study was undertaken to assess the relation between dietary patterns and newly diagnosed COPD in men.

METHODS: Data were collected from a large prospective cohort of US men (Health Professionals Follow-up Study). Using principal component analysis, two dietary patterns were identified: a prudent pattern (high intake of fruits, vegetables, fish and whole grain products) and a Western pattern (high intake of refined grains, cured and red meats, desserts and French fries). Dietary patterns were categorised into quintiles and Cox proportional hazards models were adjusted for age, smoking, pack-years, (pack-years)(2), race/ethnicity, physician visits, US region, body mass index, physical activity, multivitamin use and energy intake.

RESULTS: Between 1986 and 1998, 111 self-reported cases of newly diagnosed COPD were identified among 42,917 men. The prudent pattern was inversely associated with the risk of newly diagnosed COPD (RR for highest vs lowest quintile 0.50 (95% CI 0.25 to 0.98), p for trend = 0.02), and the Western pattern was positively associated with the risk of newly diagnosed COPD (RR for highest vs lowest quintile 4.56 (95% CI 1.95 to 10.69), p for trend <0.001).

CONCLUSIONS: In men, a diet rich in fruits, vegetables and fish may reduce the risk of COPD whereas a diet rich in refined grains, cured and red meats, desserts and French fries may increase the risk of COPD.

American Lung Association Commends Nationwide Initiative to Protect Children from Secondhand Smoke

Children Are Especially Vulnerable to Its Dangerous Health Consequences*
*Statement by Bernadette A. Toomey
President and Chief Executive Officer
American Lung Association

Washington, DC (September 18, 2007) – Today’s announcement of a new partnership designed to protect children enrolled in Head Start from the dangers of secondhand smoke is significant. The American Lung Association commends Acting Surgeon General Kenneth Moritsugu and the American Academy of Pediatrics and their partners for taking this step to protect one of our most vulnerable populations.

No child should ever be exposed to secondhand smoke. Parents, grandparents and caregivers all must take steps to protect children from exposure. The American Lung Association also encourages all health care providers and educators to talk with parents and caregivers about protecting their children from this deadly smoke.

Last year’s Surgeon General's Report on /The Health Consequences of Involuntary Exposure to Tobacco Smoke/ made it clear that there is no safe level of exposure to secondhand smoke, particularly when it comes to children. Today’s announcement, “Children and Secondhand Smoke Exposure,” emphasizes the harmful consequences to children. Almost 60 percent of U.S. children aged three years to eleven years—or almost 22 million children—are exposed to secondhand smoke. Infants exposed are at an increased risk for sudden infant death syndrome (SIDS) and children are especially vulnerable to other people’s smoke, suffering acute respiratory infections such as bronchitis and pneumonia, more severe asthma and ear infections as a result. Secondhand smoke causes an estimated 150,000 to 300,000 lower respiratory tract infections in infants and children less than 18 months of age, and each year, hundreds of thousands of children with asthma have their symptoms worsened by being exposed to other people’s smoke.

Currently, 21 states, the District of Columbia and Puerto Rico have already passed strong smokefree air laws that protect everyone from the dangers of secondhand smoke in workplaces including bars and restaurants. In January of 2006, the American Lung Association launched our Smokefree Air 2010 Challenge, urging all states to go smokefree by 2010.

Relation between smoking and risk of dementia and Alzheimer disease
The Rotterdam Study

NEUROLOGY 2007;69:998-1005
C. Reitz, MD, PhD, T. den Heijer, MD, PhD, C. van Duijn, PhD, A. Hofman, MD, PhD and M.M.B. Breteler, MD, PhD
From the Departments of Epidemiology & Biostatistics (C.R., T.d.H., C.v.D., A.H., M.M.B.B.) and Neurology (T.d.H.), Erasmus Medical Center, Rotterdam, The Netherlands.
Address correspondence and reprint requests to DrB. Breteler, Department of Epidemiology & Biostatistics, Erasmus Medical Center, PO Box 1738, 3000DR Rotterdam, The Netherlands

Background and Objective: Previous studies relating smoking with the risk of dementia have been inconsistent and limited in their validity by short follow-up times, large intervals between baseline and follow-up assessments, and unspecific determination of dementia diagnosis. We re-assessed after longer follow-up time in the large population-based cohort of the Rotterdam Study whether smoking habits and pack-years of smoking are associated with the risk of dementia, Alzheimer disease (AD), and vascular dementia (VaD).

Methods: Prospective population-based cohort study in 6,868 participants, 55 years or older and free of dementia at baseline. First, Cox proportional hazard models were used to relate smoking status at baseline with the risks of incident dementia, VaD, and AD, using never smokers as the reference category in all analyses. Then Cox proportional hazard models were used to relate pack-years of smoking with the risks of incident dementia, VaD, and AD. To explore the impact of the APOE{varepsilon}4 allele, sex, and age on the association between smoking status and dementia, we repeated all analyses stratifying, in separate models, by APOE{varepsilon}4 genotype, sex, and median of age.

Results: After a mean follow-up time of 7.1 years, current smoking at baseline was associated with an increased risk of dementia (HR 1.47, 95% CI 1.18 to 1.86) and AD (HR 1.56, 95% CI 1.21 to 2.02). This increase in disease risk was restricted to persons without the APOE{varepsilon}4 allele. There was no association between current smoking and risk of VaD, and there was no association between past smoking and risk of dementia, AD, or VaD.

Conclusion: Current smoking increases the risk of dementia. This effect is more pronounced in persons without the APOE{varepsilon}4 allele than APOE{varepsilon}4 carriers

Changes in child exposure to environmental tobacco smoke (CHETS) study after implementation of smoke-free legislation in Scotland: national cross sectional survey

BMJ 2007;335:545 (15 September),
Patricia C Akhtar, research fellow1, Dorothy B Currie, senior statistician1, Candace E Currie, director1, Sally J Haw, principal public health adviser2
1 Child and Adolescent Health Research Unit (CAHRU), University of Edinburgh, Edinburgh EH8 8AQ, 2 NHS Health Scotland, Edinburgh EH12 5EZ

Objective
To detect any change in exposure to secondhand smoke among primary schoolchildren after implementation of smoke-free legislation in Scotland in March 2006.

Design
Comparison of nationally representative, cross sectional, class based surveys carried out in the same schools before and after legislation.

Setting Scotland.

Participants
2559 primary schoolchildren (primary 7; mean age 11.4 years) surveyed in January 2006 (before smoke-free legislation) and 2424 in January 2007 (after legislation).

Outcome
measures Salivary cotinine concentrations, reports of parental smoking, and exposure to tobacco smoke in public and private places before and after legislation.

Results
The geometric mean salivary cotinine concentration in non-smoking children fell from 0.36 (95% confidence interval 0.32 to 0.40) ng/ml to 0.22 (0.19 to 0.25) ng/ml after the introduction of smoke-free legislation in Scotland—a 39% reduction. The extent of the fall in cotinine concentration varied according to the number of parent figures in the home who smoked but was statistically significant only among pupils living in households in which neither parent figure smoked (51% fall, from 0.14 (0.13 to 0.16) ng/ml to 0.07 (0.06 to 0.08) ng/ml) and among pupils living in households in which only the father figure smoked (44% fall, from 0.57 (0.47 to 0.70) ng/ml to 0.32 (0.25 to 0.42) ng/ml). Little change occurred in reported exposure to secondhand smoke in pupils' own homes or in cars, but a small decrease in exposure in other people's homes was reported. Pupils reported lower exposure in cafes and restaurants and in public transport after legislation.

Conclusions
The Scottish smoke-free legislation has reduced exposure to secondhand smoke among young people in Scotland, particularly among groups with lower exposure in the home. We found no evidence of increased secondhand smoke exposure in young people associated with displacement of parental smoking into the home. The Scottish smoke-free legislation has thus had a positive short term impact on young people's health, but further efforts are needed to promote both smoke-free homes and smoking cessation.

Chronic bronchitis and chronic obstructive pulmonary disease. The Finnish Action Programme, interim report.

Respir Med. 2007 Jul;101(7):1419-25.
Pietinalho A, Kinnula VL, Sovijärvi AR, Vilkman S, Säynäjäkangas O, Liippo K, Kontula E, Laitinen LA.
Filha (Finnish Lung Health Association), Sibeliuksenkatu 11 A 1, FI-00250 Helsinki, Finland.

The Finnish National Prevention and Treatment Programme for Chronic Bronchitis and COPD, launched in 1998, has, to date, been running for 6 years (2003). The goals of this action programme were to reduce the incidence of COPD and the number of moderate and severe cases of the disease, and to reduce both the number of days of hospitalisation and treatment costs.

A prevalent implementation of over 250 information and training events started. Health centres and pharmacies appointed a person in charge of COPD patients. In order to improve the cooperation between primary and specialised care, two thirds of hospital districts created local COPD treatment chains. The early diagnosis of COPD by spirometric examination was activated during the programme. Number of health centres with available spirometric services increased to 95%.

Before the start of the programme, approximately 5-9% of the adult population had COPD. During the whole programme, the proportion of male and female smokers decreased from 30% to 26% and from 20% to 19%, respectively. The total number of hospitalisation periods and days due to COPD decreased by 15% and 18%, respectively. Both the number of pensioners and daily sickness days due to COPD also decreased by 18%. Registered COPD induced deaths remained at their previous levels during the monitoring period, i.e. around 1000 deaths out of 5.2 millions annually.

The measures recommended by the programme have been widely introduced but they need to be still more effective.

Passive smoking exposure and risk of COPD among adults in China: the Guangzhou Biobank Cohort Study

P Yin MSc a, Prof CQ Jiang MD b c, Prof KK Cheng PhD email address a Corresponding Author Information, Prof TH Lam MD d, KH Lam MPhil a, MR Miller MD e, WS Zhang PhD b, GN Thomas PhD d and P Adab MD a
a. Department of Public Health and Epidemiology, University of Birmingham, UK b. Guangzhou Number 12 People's Hospital, Guangzhou, China c. Guangzhou Medical College, Guangzhou, China d. School of Public Health, Department of Community Medicine, University of Hong Kong, Hong Kong, SAR China e. University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
The Lancet 2007; 370:751-757

Background

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality in China, where the population is also exposed to high levels of passive smoking, yet little information exists on the effects of such exposure on COPD. We examined the relation between passive smoking and COPD and respiratory symptoms in an adult Chinese population.

Methods

We used baseline data from the Guangzhou Biobank Cohort Study. Of 20.430 men and women over the age of 50 recruited in 2003–06, 15.379 never smokers (6497 with valid spirometry) were included in this cross-sectional analysis. We measured passive smoking exposure at home and work by two self-reported measures (density and duration of exposure). Diagnosis of COPD was based on spirometry and defined according to the GOLD guidelines.

Findings

There was an association between risk of COPD and self-reported exposure to passive smoking at home and work (adjusted odds ratio 1.48, 95% CI 1.18–1.85 for high level exposure; equivalent to 40 h a week for more than 5 years). There were significant associations between reported respiratory symptoms and increasing passive smoking exposure (1.16, 1.07–1.25 for any symptom). Interpretation

Exposure to passive smoking is associated with an increased prevalence of COPD and respiratory symptoms. If this association is causal, we estimate that 1.9 million excess deaths from COPD among never smokers could be attributable to passive smoking in the current population in China. Our findings provide strong evidence for urgent measures against passive smoking in China.

Spirometry Utilization for COPD. How Do We Measure Up?

How Do We Measure Up?
Chest. 2007; 132:403-409
MeiLan K. Han, MD, MS; Min Gayles Kim, MPH; Russell Mardon, PhD; Phil Renner, MBA; Sean Sullivan, PharmD; Gregory B. Diette, MD, MHS and Fernando J. Martinez, MD, MS, FCCP
* >From the Division of Pulmonary and Critical Care Medicine (Drs. Han and Martinez), University of Michigan Health System, Ann Arbor, MI; University of Washington (Dr. Sullivan), Seattle, WA; Johns Hopkins University (Dr. Diette), Baltimore, MD; National Committee for Quality Assurance (Mrs. Kim and Mr. Rener), Washington, DC; and Westat (Dr. Mardon), Rockville, MD.

Background: COPD is a significant cause of morbidity and mortality. Guidelines recommend the confirmation of a COPD diagnosis with spirometry. Limited evidence exists, however, documenting the frequency of spirometry use in clinical practice.

Methods: The National Committee for Quality Assurance recruited five health plans to determine the proportion of patients ≥40 years old with a new diagnosis of COPD who had received spirometry during the interval starting 720 days prior to diagnosis and ending 180 days after diagnosis. Patients were identified via International Classification of Diseases, Ninth Revision diagnostic codes for encounters during the period July 1, 2002, through June 30, 2003. For each patient, the participating plans provided patient demographic and claims data from administrative data systems.

Results: Participating health plans covered 1,597,749 members with a total of 5,039 eligible COPD patients identified. Patients in the 40 to 64 age range had the highest percentage of new COPD diagnoses. Women were also slightly more likely to undergo spirometry (33.5% vs 29.4%, p = 0.001). Approximately 32% of patients with a new diagnosis of COPD had undergone spirometry in the specified interval. Spirometry frequency was lowest in older patients, with the lowest frequency in those ≥75 years old.

Conclusions: Our study suggests that approximately 32% of a broad range of patients with a new COPD diagnosis had undergone spirometry within the previous 2 years to 6 months following diagnosis. In addition, spirometric testing appeared to decrease with increasing age. As opposed to a prior report, women were not less likely to have undergone spirometry. This study shows that spirometry is infrequently used in clinical practice for diagnosis of COPD and suggests opportunities for practice improvement.

Sex Differences in Severe Pulmonary Emphysema

American Journal of Respiratory and Critical Care Medicine Vol 176. pp. 243-252, (2007)
Fernando J. Martinez et al.
University of Michigan, Division of Pulmonary and Critical Care Medicine

Rationale: Limited data on sex differences in advanced COPD are available.

Objectives: To compare male and female emphysema patients with severe disease.

Methods: One thousand fifty-three patients (38.8% female) evaluated for lung volume reduction surgery as part of the National Emphysema Treatment Trial were analyzed.

Measurements and Main Results: Detailed clinical, physiological, and radiological assessment, including quantitation of emphysema severity and distribution from helical chest computed tomography, was completed. In a subgroup (n = 101), airway size and thickness was determined by histological analyses of resected tissue. Women were younger and exhibited a lower body mass index (BMI), shorter smoking history, less severe airflow obstruction, lower DLco and arterial PO2, higher arterial PCO2, shorter six-minute walk distance, and lower maximal wattage during oxygen-supplemented cycle ergometry. For a given FEV1% predicted, age, number of pack-years, and proportion of emphysema, women experienced greater dyspnea, higher modified BODE, more depression, lower SF-36 mental component score, and lower quality of well-being. Overall emphysema was less severe in women, with the difference from men most evident in the outer peel of the lung. Females had thicker small airway walls relative to luminal perimeters.

Conclusions: In patients with severe COPD, women, relative to men, exhibit anatomically smaller airway lumens with disproportionately thicker airway walls, and emphysema that is less extensive and characterized by smaller hole size and less peripheral involvement.

Effects of smoking on respiratory capacity and control.

Clin Linguist Phon. 2007 Aug;21(8):623-36
Awan SN, Alphonso VA.
Bloomsburg University of Pennsylvania, Bloomsburg, PA, USA.

The purpose of this study was to provide information concerning the possible early effects of smoking on measures of respiratory capacity and control in young adult female smokers vs. nonsmokers. In particular, maximum performance test results (vital capacity and maximum phonation time) and measures of air pressures and airflows during voiceless, stop-plosive productions were analysed.

Subjects were 45 female nonsmokers and 30 female smokers (total n = 75) between the ages of 18-30 years. For the purposes of this study, a smoker was defined as any subject who, at the time of this study, had smoked at least two cigarettes per day for at least 1 year. All of the subjects in the nonsmoker category were those who, at the time of this study, did not smoke and who had not smoked for at least 5 years prior to the study. Vital capacity measures were conducted using a hand-held digital spirometer, while maximum phonation productions and voiceless, stop-plosive pressures and flows were recorded and measured.

Results showed significantly lower vital capacities and maximum phonation times in smokers vs. nonsmokers. The maximum phonation time task was also produced with significantly higher mean airflow rates in smokers than nonsmokers. In addition, the smokers were observed to produce significantly greater peak and mean pressures during the voiceless stop-plosive task than the nonsmokers. A weak, but significant correlation was observed between the number of days the subject had smoked and the mean pressure produced during the voiceless, stop-plosive task.

The findings of reduced respiratory capacity and control in smokers may be associated with factors such as increased bronchial reactivity secondary to exposure to cigarette smoke and/or mild airway obstruction, increased airflow secondary to increased glottal gap size during phonation, and increased vocal fold mass and/or inefficiency in vocal fold closure. The findings of this study indicate that decrements in respiratory capacity and control may occur even in relatively young smokers who have only been smoking for a comparatively short time.

Smoking as a Risk Factor for Dementia and Cognitive Decline: A Meta-Analysis of Prospective Studies

American Journal of Epidemiology 2007 166(4):367-378
Kaarin J. Anstey, Chwee von Sanden, Agus Salim and Richard O'Kearney
Centre for Mental Health Research, The Australian National University, Canberra, Australia
School of Psychology, The Australian National University, Canberra, Australia

The authors assessed the association of smoking with dementia and cognitive decline in a meta-analysis of 19 prospective studies with at least 12 months of follow-up.

Studies included a total of 26,374 participants followed for dementia for 2–30 years and 17,023 participants followed up for 2–7 years to assess cognitive decline. Mean study age was 74 years. Current smokers at baseline, relative to never smokers, had risks of 1.79 (95% confidence interval (CI): 1.43, 2.23) for incident Alzheimer's disease, 1.78 (95% CI: 1.28, 2.47) for incident vascular dementia, and 1.27 (95% CI: 1.02, 1.60) for any dementia. Compared with those who never smoked, current smokers at baseline also showed greater yearly declines in Mini-Mental State Examination scores over the follow-up period (effect size (ß) = –0.13, 95% CI: –0.18, –0.08). Compared with former smokers, current smokers at baseline showed an increased risk of Alzheimer's disease (relative risk = 1.70, 95% CI: 1.25, 2.31) and an increased decline in cognitive abilities (effect size (ß) = –0.07, 95% CI: –0.11, –0.03), but the groups were not different regarding risk of vascular dementia or any dementia.

The authors concluded that elderly smokers have increased risks of dementia and cognitive decline.

Number of People with COPD Expected to Increase Significantly by 2013

New research from Frost & Sullivan indicates that the number of people diagnosed with chronic obstructive pulmonary disease (COPD) will increase by 34.5 percent by 2013, bringing the number of people diagnosed in the United States from 13.6 million to 18.4 million.

Although smoking is the largest contributing factor to the development of COPD, the number of adult smokers has actually decreased in the last decade. The increase in COPD is expected to happen as a result of the high number of current and former smokers -- 45 million and 45.9 million respectively -- an increase in the aging population, and an increase in the number of people seeking diagnosis for COPD.

The number of people requiring treatment for the disease is expected to result in revenue growth for the oxygen market.

Frost & Sullivan's Research, entitled, Therapeutic Overview and Patient Outlook, cites patient noncompliance as one of the major obstacles in the expansion of the market. According to research, it is estimated that the prescription compliance rate for these patients is under 50 percent, and many experts believe that actual compliance rates are much lower. In the Lung Health Study, it was determined that for bronchodilators, compliance as measured by canister weight was actually 10 percent lower than reported compliance rates. Another study found that compliance rates for patient use of inhaled corticosteroids were as low as 18 percent.

Medications used to treat COPD often come with side effects, which discourage patients from continued use. Drugs that need less frequent dosing have been useful in improving compliance

Arterial stiffness and osteoporosis in chronic obstructive pulmonary disease

Am J Respir Crit Care Med. 2007 Jun 15;175(12):1259-65
Sabit R, Bolton CE, Edwards PH, Pettit RJ, Evans WD, McEniery CM, Wilkinson IB, Cockcroft JR, Shale DJ.
Department of Respiratory Medicine, Cardiff University, Academic Centre, Llandough Hospital, Penlan Road, Penarth, Vale of Glamorgan CF64 2XX, UK.

RATIONALE: Chronic obstructive pulmonary disease (COPD) is associated with an increased risk of cardiovascular events and osteoporosis. Increased arterial stiffness is an independent predictor of cardiovascular disease.

OBJECTIVES: We tested the hypothesis that patients with COPD would have increased arterial stiffness, which would be associated with osteoporosis and systemic inflammation.

METHODS: We studied 75 clinically stable patients with a range of severity of airway obstruction and 42 healthy smoker or ex-smoker control subjects, free of cardiovascular disease. All subjects underwent spirometry, measurement of aortic pulse wave velocity (PWV) and augmentation index, dual-energy X-ray absorptiometry, and blood sampling for inflammatory mediators.

MEASUREMENTS AND MAIN RESULTS: Mean (SD) aortic PWV was greater in patients, 11.4 (2.7) m/s, than in control subjects, 8.95 (1.7) m/s, p < 0.0001. Inflammatory mediators and augmentation index were also greater in patients. Patients with osteoporosis at the hip had a greater aortic PWV, 13.1 (1.8) m/s, than those without, 11.2 (2.7) m/s, p < 0.05. In patients, aortic PWV was related to age (r = 0.63, p < 0.0001) and log(10) IL-6 (r = 0.31, p < 0.01), and inversely to FEV(1) (r = -0.34, p < 0.01). The strongest predictors of aortic PWV in all subjects were age (p < 0.0001), percent predicted FEV(1) (p < 0.05), mean arterial pressure (p < 0.05), and log(10) IL-6 (p < 0.05).

CONCLUSIONS: Increased arterial stiffness was related to the severity of airflow obstruction and may be a factor in the excess risk for cardiovascular disease in COPD. The increased aortic PWV in patients with osteoporosis and the association with systemic inflammation suggest that age-related bone and vascular changes occur prematurely in COPD.

COPD patients perspectives at the time of diagnosis: a qualitative study.

Prim Care Respir J. 2007 Jul 12;
Arne M, Emtner M, Janson S, Wilde-Larsson B.
Primary Care Research Unit, County Council of Värmland, Universitetsgatan 3, SE 656 37 Karlstad, Sweden • Department of Medical Sciences, Respiratory Medicine and Allergology, Uppsala University, SE 751 85 Uppsala, Sweden.

AIMS: To gain an understanding of patients perspectives and perceptions of chronic obstructive pulmonary disease (COPD) at the time of diagnosis.

METHODS: A qualitative study using grounded theory. Ten patients in primary care in Sweden, newly diagnosed with COPD or with suspected COPD, were interviewed.

RESULTS: The analysis created a process model with a core category "Consequences of smoking" and main categories "Shame", "Appearance of symptoms", "Adaptation", "Reflection", and "Action". "Restrictions in physical capacity" was a key indicator of evolving disease and "Getting a diagnosis" was crucial for the patient.

CONCLUSIONS: The COPD patient needs a clear diagnosis at an early stage. It is important to seize the opportunity when the presumptive COPD patient is receptive towards support and further action. To detect and support the patient, health professionals must be aware of minor symptoms and underlying mechanisms of possible shame.

Geen behandeling voor verstokte rokers

De Britse gezondheidsdienst wil dat verstokte rokers hun slechte gewoonte opgeven voordat ze op een wachtlijst kunnen worden geplaatst voor ingrepen zoals hartoperaties of het zetten van een nieuwe heup. Dat schrijft de Sunday Times.

Rokers aan de overkant van het Kanaal gaan toch al moeilijke tijden tegemoet wanneer op 1 juli in pubs en restaurants een algemeen rookverbod van kracht wordt. Maar nu zijn er plannen om hen ook medisch te bestraffen voor hun verslaving.

Deskundigen van de Nationale Gezondheidszorg (NHS) in Leicester, waar dit plan al vaste vorm heeft gekregen, stellen namelijk dat rokers een langere herstelperiode nodig hebben na een ingreep dan nicotinevrije patiënten en daardoor ziekenhuisbedden langer bezet houden dan nodig en de kosten van een hospitalisatie opdrijven.

"Als mensen, voor een operatie, stoppen met roken dan zal dat hun herstel bevorderen. Het vermindert de kans op hart- en longcomplicaties en wonden genezen dan sneller. Het is niet de bedoeling om mensen het recht op een operatie te ontzeggen, maar wel om na te gaan of het resultaat niet kan worden verbeterd door hen te doen stoppen met roken", aldus een woordvoerder van de NHS.

In de praktijk zou dat erop neerkomen dat een patiënt een maand voor de ingreep de sigaretten opgeeft. Maar aangezien het langer dan een maand kan duren voor dat goede voornemen wordt uitgevoerd, zouden operaties in veel gevallen met twee tot drie maanden kunnen worden uitgesteld. Het gaat hier niet om een onwrikbare regel, zo wordt beklemtoond, want bij patiënten die echt niet kunnen stoppen, bepaalt de behandeldende arts of er toch wordt geopereerd.

Walking distance is a predictor of exacerbations in patients with chronic obstructive pulmonary disease.

Respir Med. 2007 May;101(5):1037-40.
Emtner MI, Arnardottir HR, Hallin R, Lindberg E, Janson C. Pulmonary Medicine and Allergology, Medical Sciences, Uppsala
University, Akademiska sjukhuset, Entrance 50, 751 85 Uppsala, Sweden.

METHODS: Twenty-one patients (14 female) with COPD (65 years, 40-79 years) admitted to the Department of Respiratory Medicine in Uppsala, performed a pulmonary function test (FEV(1)% predicted=37) and health status measurement (St. Georges Respiratory Questionnaire, SGRQ) at discharge. Four to six weeks after discharge, when they were in a stable clinical condition, they performed an exercise test (Incremental Shuttle Walk Test, ISWT) to measure their exercise capacity.

RESULTS: Nine of 21 patients (43%) were rehospitalised within 12 month. The mean distance walked in the ISWT was 174m in patients who were hospitalised and 358m in non-hospitalised patients (P<0.001). Oxygen saturation 88% after the ISWT was found in 73% of hospitalised patients in contrast to only 22% in non-hospitalised patients (P<0.05). Activity related health status (SGRQ-activity) was higher (worse) in hospitalised patients than in non-hospitalised patients (75 vs. 50) (P<0.05). The association between walking distance and the risk of rehospitalisation was significant after adjusting for oxygen saturation and health status (hazard risk ratio 0.8 (0.67-0.97) per 10m).

This study has shown that walking distance is a good and reliable predictor of rehospitalisations in moderately and severely disabled patients with COPD.

Prevalence of COPD in Iceland - The ISOLD study

Laeknabladid. 2007 Juni;93(6):471-477.
Benediktsdottir B, Gudmundsson G, Jorundsdottir KB, Vollmer W, Gislason T.

Objective: To investigate the prevalence of chronic obstructive pulmonary disease (COPD) in Iceland and possible risk factors.

Materials and Methods: This Icelandic survey is a part of an international study (www.BOLDCOPD.org). The target population consisted of a simple random sample taken among all non-institutionalized Icelanders 40 years and older living in Reykjavik and adjacent suburbs (n=938). Participants were subjected to a structured interview based on questionnaires on respiratory diseases, symptoms, life style and possible risk factors. They also underwent a spirometry that was repeated after inhalation of a bronchodilating agent. COPD stage I, or higher, was defined according to the GOLD staging (www.goldcopd.org) based on chronic airflow limitation (FEV1/FVC 70%) persisting after inhaled bronchodilator.

Results: Full participation was by 755 (80.5%). Altogether 18.0 % of the participants fullfilled criteria for COPD, GOLD stage I or higher and 9.0 % for GOLD stage II or higher. There were proportionally more young females (40-49 years) than males diagnosed with COPD GOLD stage I or higher (8.1% compared to 4.8%), even though there was no difference in total prevalence between males and females. The prevalence of COPD increased with increasing age and the amount of tobacco smoked. Only a part of those fulfilling criteria for COPD had been diagnosed by doctors.

Conclusion: Our results show a high prevalence of COPD among Icelanders 40 years and older when internationally accepted criteria and methods are used. These results are useful for heath authorites when planning and giving priority in our future health care system.

Farming and the prevalence of non-reversible airways obstruction-results from a population-based study

Am J Ind Med. 2007 Jun;50(6):421-6.
Lamprecht B, Schirnhofer L, Kaiser B, Studnicka M, Buist AS.
Department of Pneumology, Paracelsus Medical University, Salzburg, Austria.

INTRODUCTION: Occupational exposure to noxious dusts, gases, and fumes most likely contributes to obstructive lung disease. We studied whether self-reported farming work is associated with non-reversible airways obstruction.

METHODS: Following the burden of obstructive lung disease (BOLD) study protocol, we surveyed a gender-stratified population-based sample of 2,200 adults aged 40 years and over. Pre- and post-bronchodilator spirometry, as well as information on smoking, occupation, and reported respiratory disease was recorded. According to GOLD criteria, non-reversible airways obstruction was defined as a post-bronchodilator forced expiratory volume (FEV(1))/forced vital capacity (FVC) < 0.70. Occupational and smoking history was based on questionnaire. Farming was defined as ever working in this occupation for 3 months or longer.

RESULTS: For 1,258 participants with complete data (post-bronchodilator spirometry and questionnaire data), 288 (=22.9%) reported farming. Among the 288 participants reporting farming, the prevalence of non-reversible airways obstruction was 30.2%. Farming was significantly associated with airways obstruction: chronic obstructive pulmonary disease (COPD) GOLD stage I or higher (OR 1.5; 95% CI 1.1-2.0) and COPD GOLD stage II or higher (OR 1.8; 95% CI 1.2-2.7). The latter estimate was unchanged when adjustment for competing risks gender, age, and smoking was done. In this population the risk for non-reversible airways obstruction attributable to farming was 7.7%.

CONCLUSION: Farming should be considered a risk factor for non-reversible airways obstruction

American Lung Association Applauds Institute of Medicine Report

Statement of John L. Kirkwood
President and CEO
American Lung Association

New York, NY (May 24, 2007) – A new report from the Institute of Medicine further reinforces the urgent need for Congress to pass legislation giving the U.S. Food and Drug Administration (FDA) authority over tobacco products. This groundbreaking report, Ending the Tobacco Problem: A Blueprint for the Nation, recognizes the responsibility the federal government must assume if our nation is to reduce the deadly toll of tobacco. The report recommends that Congress give FDA the regulatory authority over the manufacture, distribution, marketing and use of tobacco products.

The report recognizes and recommends strengthening the actions taken by states to increase tobacco taxes, pass comprehensive smokefree workplace laws and fund tobacco control programs at levels recommended by the Centers for Disease Control and Prevention (CDC). However, despite these important efforts by states, the IOM committee states, “maintaining our present course will not end the tobacco problem.” Each year, more than 438,000 Americans die from tobacco-caused diseases, including lung cancer and COPD (which includes chronic bronchitis and emphysema).

Currently, identical bipartisan bills are pending in the U.S. Senate (S. 625) and House of Representatives (H.R. 1108) that would give the FDA the authority this report calls for. Congress must act quickly and pass this legislation before leaving for its summer recess.

Exacerbations and lung function decline in COPD: New insights in current and ex-smokers.

Respir Med. 2007 Jun;101(6):1305-12.
Makris D, Moschandreas J, Damianaki A, Ntaoukakis E, Siafakas NM, Milic Emili J, Tzanakis N.
Department of Thoracic Medicine, University of Crete, Medical School, P.O. Box 1352, 71110 Heraklion, Greece.

AIM: To investigate whether there is a significant relationship between an increased frequency of exacerbations and the rate of forced expiratory volume in 1s (FEV(1)) decline in COPD patients.

METHODS-MEASUREMENTS: About 102 COPD patients (44 smokers, 58 ex-smokers) participated in a 3-year prospective study. Exacerbations were identified as worsening of patient's respiratory symptoms as recorded on diary cards. Spirometry was performed every 6 months. The effect of frequent exacerbations on lung function was investigated using random effects models.

RESULTS: The median (mean(95% CI)) annual exacerbation rate was 2.85 (3.1 (2.7-3.6)). Patients with an annual exacerbation rate over the median rate had significantly lower baseline post-bronchodilation FEV(1)(%pred), higher MRC dyspnoea score and chronic cough compared to patients who had an annual exacerbation rate less than the median. The average annual rate of FEV(1)(%pred), adjusted for smoking decline (DeltaFEV(1)), was found significantly increased in frequent compared to infrequent exacerbators (P=0.017). The highest DeltaFEV(1) was observed in smokers frequent exacerbators and a significant interaction between exacerbation frequency and DeltaFEV(1) was also observed in ex-smokers.

CONCLUSIONS: Our findings suggest that an increased frequency of exacerbations is significantly associated with FEV(1) decline even in ex-smokers. Thus, smoking and frequent exacerbations may have both negative impact on lung function. Smoking cessation and prevention of exacerbations should be a major target in COPD.

Tobacco smoking and acute myocardial infarction in young adults: A population-based case-control study

Preventive Medicine
Volume 44, Issue 4, April 2007, Pages 311-316
Andreia Oliveira, Henrique Barros, Maria Júlia Maciel and Carla Lopes Department of Hygiene and Epidemiology, University of Porto Medical School, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal Department of Cardiology, Hospital S. João and University of Porto Medical School, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal

Objective
To evaluate the effect of tobacco smoking on the risk of non-fatal acute myocardial infarction in young adults (≤ 45 years), and whether there is modification of this effect by sex.

Methods
We conducted a population-based case-control study with 329 incident acute myocardial infarction cases (42 women; 287 men), consecutively admitted to the Cardiology department of hospitals in Porto, Portugal, and 778 controls (486 women; 292 men), selected within the non-institutionalized Porto population, during 2001–2003. Odds ratios and 95% confidence intervals (OR, 95%CI) were calculated using unconditional logistic regression.

Results
The prevalence of current smoking was 80.8% in male cases and 53.8% in male controls (OR = 3.63, 95%CI: 2.50, 5.27) and 59.5% of female cases were smokers compared to 35.8% of controls (OR = 2.64, 95%CI: 1.39, 5.02).
No interaction was found between current smoking and sex on myocardial infarction risk (p = 0.401). A dose–effect response was present, the odds favoring myocardial infarction reaching an eight-fold increase for those that smoked > 25 cigarettes/day compared to never smokers. The risk estimate for former smokers was similar to never smokers.

Conclusions
Tobacco smoking is an important independent risk factor for acute myocardial infarction in young adults, with similar strength of association for both sexes.

Impact of COPD exacerbations on patient-centered outcomes.

Chest. 2007 Mar;131(3):696-704
Cote CG, Dordelly LJ, Celli BR.
Bay Pines Veterans Affairs Health Care System, Respiratory Disease Section 111A, 10,000 Bay Pines Blvd, Bay Pines, FL 33744, USA.

BACKGROUND: Frequent exacerbations are associated with a faster decline in FEV(1), impaired health status, and worse survival. Their impact and temporal relationship with other outcomes such as functional status, dyspnea, and the multidimensional body mass index, obstruction, dyspnea, exercise capacity (BODE) index remain unknown.

HYPOTHESIS: We reasoned that exacerbations affect the BODE index and its components, and that changes in the BODE index could be used to monitor the effect of exacerbations on the host.

STUDY DESIGN: Prospective observational study in a Veterans Affairs medical center.

METHODS: We studied 205 patients with COPD (mean [+/- SD] FEV(1), 43 +/- 15% predicted), and recorded the body mass index, FEV(1) percent predicted, modified Medical Research Council dyspnea scale, 6-min walk distance, and the BODE index at baseline, during the exacerbation, and at 6, 12, and 24 months following the first episode, and documented all exacerbations for 2 years after the first acute exacerbation.

RESULTS: From the cohort, 130 patients (63%) experienced 352 exacerbations or (0.85 exacerbations per patient per year); 48 patients (23%), experienced one episode, 82 patients (40%) experienced 2 or more exacerbations, and 50 patients required hospitalization. At study entry, exacerbators had a worse mean baseline BODE index score (4.2 +/- 2.1 vs 3.57 +/- 2.3, respectively; p < 0.03). The BODE index score worsened by 1.38 points during the exacerbation, and remained 0.8 and 1.1 points above baseline at 1 and 2 years, respectively. There was little change in BODE index score at 2 years in nonexacerbators.

CONCLUSION: COPD exacerbations negatively impact on the BODE index and its components. The BODE index is a sensitive tool used to assess the impact of exacerbations and to monitor COPD disease progression.

The cost of treating patients with COPD in Denmark--a population study of COPD patients compared with non-COPD controls.

Respir Med. 2007 Mar;101(3):539-46. Bilde L, Rud Svenning A, Dollerup J, Baekke Borgeskov H, Lange P. DSI Danish Institute for Health Services Research, Dampfaergevej 27-29, DK 2100 Copenhagen, Denmark.

This paper describes a population-based study of health care resource use of patients with chronic obstructive pulmonary disease (COPD) compared to non-COPD controls. Through a screening of the Danish Patient Registry for patients admitted with COPD diagnoses for a 5-year period, 1998-2002, 66,000 individuals with COPD still alive at the beginning of 2002 were identified. Their use of health care resources in 2002 were compared with equivalent data, stratified for age, sex and mortality rates, for a control population without COPD based on data for the 300,000 remaining patients on the Danish Patient Registry in 2002.

Results indicated that the gross cost of treating patients with COPD in the Danish somatic hospital and primary health care sector corresponded to 10% of the total cost of treating patients of 40 years or more. The net cost for COPD patients was 1.9 billion DKK (256 million euro), 6% of the total annual costs of treating the population of 40 years or more. The gross cost related to any disease and the net cost reflected the resource use which could be attributed to COPD and its related diagnoses.
The incidence of inpatient hospital admissions was almost four times higher in the COPD population than in the control group. COPD patients contacted their general practitioner 12 times more per year than non-COPD controls, but for specialist and paramedic treatment in the primary care sector there was no significant difference between COPD patients and non-COPD controls.
Only one third of the COPD costs were due to treatment of COPD as the primary diagnosis. The remaining two-thirds of the COPD-related costs were mainly due to admissions for other diseases such as cardio-vascular diseases, other respiratory diseases, and cancer.

Respiratory symptoms/diseases and environmental tobacco smoke (ETS) in never smoker Italian women.

Respir Med. 2007 Mar;101(3):531-8.
Simoni M, Baldacci S, Puntoni R, Pistelli F, Farchi S, Lo Presti E, Pistelli R, Corbo G, Agabiti N, Basso S, Matteelli G, Di Pede F, Carrozzi L, Forastiere F, Viegi G.
Unita di Epidemiologia Ambientale Polmonare, Istituto di Fisiologia Clinica, CNR Institute of Clinical Physiology, Via Trieste, 41 56126 Pisa, Italy.

AIM: To study the relationship between respiratory/allergic disorders and chronic environmental tobacco smoke (ETS) exposure to husband or at workplace among non-smoking women of a general population in Italy.

METHODS: Analyses regard 2195 married or employed women. Information was collected through a self-administered questionnaire. ETS exposure was validated by salivary cotinine.

RESULTS: Exposure both to husband and at work resulted a significant risk factor for current dyspnoea (odds ratio (OR) 1.61, 95% confidence interval (CI) 1.20-2.16), any shortness of breath at rest (OR 2.81, 95% CI 1.83-4.30), recent wheeze (OR 1.71, 95% CI 1.04-2.82), recent attacks of shortness of breath with wheeze (OR 1.85, 95% CI 1.05-3.26), asthma diagnosis/symptoms (OR 1.50, 95% CI 1.09-2.08), diagnosis of asthma or bronchitis/emphysema (obstructive lung diseases (OLD)) (OR 2.24, 95% CI 1.40-3.58), current cough/phlegm (OR 1.52, 95% CI 1.07-2.15), and rhino-conjunctivitis (OR 1.48, 95% CI 1.13-1.94).

Exposure only at work yielded higher adjusted odds ratios for all health conditions, except for rhino-conjunctivitis. Overall, about 24% of shortness of breath at rest, 16% of dyspnoea, 17% of rhino-conjunctivitis, 12% of OLD, and 10% of asthma diagnosis/symptoms are attributable to the effect of exposures to both husband and at work. Twelve percent of shortness of breath at rest and 10% of rhino-conjunctivitis cases might be avoided by eliminating exposure only at work and only to husband, respectively.

CONCLUSIONS: Lifetime ETS exposure, especially at work, is associated with respiratory symptoms/diseases, and it accounts for a sizeable proportion of such disorders. The combined effect of both exposures is higher than the separate effects.

Exacerbations of chronic obstructive pulmonary disease: when are antibiotics indicated? A systematic review

Respiratory Research 2007, 8:30 doi:10.1186/1465-9921-8-30
Milo A Puhan, Daniela Vollenweider Tsogyal Latshang, Johann Steurer and Claudia Steurer-Stey Horten Centre, University Hospital of Zurich, Postfach Nord, CH-8091 Zurich, Switzerland

Background: For decades, there is an unresolved debate about adequate prescription of antibiotics for patients suffering from exacerbations of chronic obstructive pulmonary disease (COPD). The aim of this systematic review was to analyse randomised controlled trials investigating the clinical benefit of antibiotics for COPD exacerbations.

Methods: We conducted a systematic review of randomised, placebo-controlled trials assessing the effects of antibiotics on clinically relevant outcomes in patients with an exacerbation. We searched bibliographic databases, scrutinized reference lists and conference proceedings and asked the pharmaceutical industry for unpublished data. We used fixed-effects models to pool results. The primary outcome was treatment failure of COPD exacerbation treatment.

Results: We included 13 trials (1557 patients) of moderate to good quality. For the effects of antibiotics on treatment failure there was much heterogeneity across all trials (I2 = 82%). Meta-regression revealed severity of exacerbation as significant explanation for this heterogeneity (p = 0.016): Antibiotics did not reduce treatment failures in outpatients with mild to moderate exacerbations (pooled odds ratio 1.09, 95% CI 0.75–1.59, I2 = 18%). Inpatients with severe exacerbations had a substantial benefit on treatment failure rates (pooled odds ratio of 0.25, 95% CI 0.16–0.39, I2 = 0%; number-needed to treat of 4, 95% CI 3–5) and on mortality (pooled odds ratio of 0.20, 95% CI 0.06–0.62, I2 = 0%; number-needed to treat of 14, 95% CI 12–30).

Conclusion: Antibiotics effectively reduce treatment failure and mortality rates in COPD patients with severe exacerbations. For patients with mild to moderate exacerbations, antibiotics may not be generally indicated and further research is needed to guide antibiotic prescription in these patients.

The validity of the diagnosis of chronic obstructive pulmonary disease in general practice.

Prim Care Respir J. 2007 Mar 21;
Sichletidis L, Chloros D, Spyratos D, Chatzidimitriou N, Chatziiliadis P, Protopappas N, Charalambidou O, Pelagidou D, Zarvalis E, Patakas D.
Associate Professor of Medicine, Aristotle University of Thessalonica, and Head of the Laboratory for the Investigation of Environmental Diseases, G. Papanicolaou General Hospital, Thessalonica, Greece.

AIM: To determine the validity of the diagnosis of chronic obstructive pulmonary disease (COPD) in general practice in patients given a diagnosis of COPD and treated with bronchodilators.

METHODS: From the medical records of eight Health Centres in Northern Greece, 319 subjects aged over 40 years and diagnosed as "COPD" were entered into the study. All filled in a special questionnaire and were subjected to spirometry, rhinomanometry and chest X-ray.

RESULTS: One hundred and sixty patients (50.2%) met the GOLD criteria for COPD. Twenty-six of them were non-smokers and underwent further evaluation: blood eosinophil count, serum IgE assay, high resolution computed tomography (HRCT) scan of the chest, and echocardiography; 16 were given a different diagnosis. One hundred and fifty-nine subjects (49.8%) with an FEV1/ FVC ratio >0.7 did not meet the GOLD criteria for COPD; 71 suffered from nasal obstruction, 13 from asthma, six had restrictive pulmonary disease and 69 had no respiratory disease.

CONCLUSION: Diagnostic errors in patients with respiratory symptoms in the primary healthcare setting are frequent. Patients suspected to have COPD should undergo spirometry testing after bronchodilation. An alternative diagnosis must be sought for non-smoking patients with irreversible airway obstruction.

Walking distance is a predictor of exacerbations in patients with chronic obstructive pulmonary disease.

Respir Med. 2007 May;101(5):1037-40.
Emtner MI, Arnardottir HR, Hallin R, Lindberg E, Janson C.
Pulmonary Medicine and Allergology, Medical Sciences, Uppsala University, Akademiska sjukhuset, Entrance 50, 751 85 Uppsala, Sweden.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) are responsible for a high utilisation of the health care resources, and the cost is expected to increase. Physiological measures of lung function often fail to describe the impact the symptoms have on exacerbations, days of hospitalisation, and on a patient's health.

METHODS: Twenty-one patients (14 female) with COPD (65 years, 40-79 years) admitted to the Department of Respiratory Medicine in Uppsala, performed a pulmonary function test (FEV(1)% predicted=37) and health status measurement (St. Georges Respiratory Questionnaire, SGRQ) at discharge. Four to six weeks after discharge, when they were in a stable clinical condition, they performed an exercise test (Incremental Shuttle Walk Test, ISWT) to measure their exercise capacity.

RESULTS: Nine of 21 patients (43%) were rehospitalised within 12 month. The mean distance walked in the ISWT was 174m in patients who were hospitalised and 358m in non-hospitalised patients (P<0.001). Oxygen saturation 88% after the ISWT was found in 73% of hospitalised patients in contrast to only 22% in non-hospitalised patients (P<0.05). Activity related health status (SGRQ-activity) was higher (worse) in hospitalised patients than in non-hospitalised patients (75 vs. 50) (P<0.05). The association between walking distance and the risk of rehospitalisation was significant after adjusting for oxygen saturation and health status (hazard risk ratio 0.8 (0.67-0.97) per 10m).

This study has shown that walking distance is a good and reliable predictor of rehospitalisations in moderately and severely disabled patients with COPD.

Retrospective incremental cost analysis of a hospital-based COPD Disease Management Programme in Sweden.

Health Policy. 2007 May;81(2-3):309-19. Tunsater A, Moutakis M, Borg S, Persson U, Stromberg L, Nielsen AL. Simrishamn Hospital, Narsjukvarden Osterlen AB, Sjukhuset S-272 81, Simrishamn, Sweden.

This paper reports on a retrospective analysis of hospital-based healthcare costs associated with the management of chronic obstructive pulmonary disease (COPD). During the second half of 2001, Simrishamn Hospital, Sweden, implemented a structured Disease Management Programme (DMP) for COPD and a total of 784 patients with COPD, enrolled in the DMP, were included in the analysis. The goal was to reduce the number of clinical events, such as severe exacerbations by early intervention, aggressive drug treatment, specialists easy available for advice, improved support for smoking cessation, increased number of scheduled follow-ups and closer tracking of high-risk COPD patients. The hospital administrative system provided data on resource consumption, such as outpatient care, inpatient care and drugs and unit cost, used in the economic analysis. The total cost of COPD drugs doubled (from euro14,133 to euro30,855 per year) as did the total number of outpatient visits (from 580 to 996 visits per year). The number of hospitalizations for acute COPD exacerbations and COPD with acute lower respiratory infection decreased from 67 to 25 per year. Total COPD-related healthcare costs decreased. The results presented here support the hypothesis that a COPD DMP can offer substantial overall direct cost savings.

Quadriceps strength predicts mortality in patients with moderate to severe chronic obstructive pulmonary disease.

Thorax. 2007 Feb;62(2):115-20. Swallow EB, Reyes D, Hopkinson NS, Man WD, Porcher R, Cetti EJ, Moore AJ, Moxham J, Polkey MI. Respiratory Muscle Laboratory, Royal Brompton Hospital, Fulham Road, London SW3 6NP, UK.

BACKGROUND: Prognosis in chronic obstructive pulmonary disease (COPD) is poorly predicted by indices of air flow obstruction, because other factors that reflect the systemic nature of the disease also influence prognosis.

OBJECTIVE: To test the hypothesis that a reduction in quadriceps maximal voluntary contraction force (QMVC) is a useful predictor of mortality in patients with COPD.

METHODS: A mortality questionnaire was sent to the primary care physician of 184 patients with COPD who had undergone quadriceps strength measurement over the past 5 years. QMVC was expressed as a percentage of the patient's body mass index. The end point measured was death or lung transplantation, and median (range) follow-up was 38 (1-54) months.

RESULTS: Data were obtained for 162 patients (108 men and 54 women) with a mean (SD) percentage of forced expiratory volume in 1 s (FEV1) predicted of 35.6 (16.2), giving a response rate of 88%. Transplant-free survival of the cohort was 93.5% at 1 year and 87.1% at 2 years. Cox regression models showed that the mortality risk increased with increasing age and with reducing QMVC. Only age (HR 1.72 (95% CI 1.14 to 2.6); p = 0.01) and QMVC (HR 0.91 (95% CI 0.83 to 0.99); p = 0.036) continued to be significant predictors of mortality when controlled for other variables in the multivariate analysis.

CONCLUSION: QMVC is simple and provides more powerful prognostic information on COPD than that provided by age, body mass index and forced expiratory volume in 1 s.

Incidence of chronic obstructive pulmonary disease in a cohort of young adults according to the presence of chronic cough and phlegm.

Am J Respir Crit Care Med. 2007 Jan 1;175(1):32-9. de Marco R, Accordini S, Cerveri I, Corsico A, Anto JM, Kunzli N, Janson C, Sunyer J, Jarvis D, Chinn S, Vermeire P, Svanes C, Ackermann-Liebrich U, Gislason T, Heinrich J, Leynaert B, Neukirch F, Schouten JP, Wjst M, Burney P. Sezione di Epidemiologia & Statistica Medica, Dipartimento di Medicina e Sanita Pubblica, Universita degli Studi di Verona, c/o Istituti Biologici II, Strada Le Grazie 8 37134, Verona, Italy.

RATIONALE: The few prospective studies aimed at assessing the incidence of chronic obstructive pulmonary disease (COPD) in relation to the presence of chronic cough/phlegm have produced contrasting results.

OBJECTIVES: To assess the incidence of COPD in a cohort of young adults and to test whether chronic cough/phlegm and dyspnea are independent predictors of COPD.

METHODS: An international cohort of 5,002 subjects without asthma (ages 20-44 yr) with normal lung function (FEV(1)/FVC ratio >/= 70%) from 12 countries was followed from 1991-2002 in the frame of the European Community Respiratory Health Survey II. Incident cases of COPD were those who had an FEV(1)/FVC ratio less than 70% at the end of the follow-up, but did not report having had a doctor diagnose asthma during the follow-up.

MAIN RESULTS: The incidence rate of COPD was 2.8 cases/1,000/yr (95% confidence interval [CI], 2.3-3.3). Chronic cough/phlegm was an independent and statistically significant predictor of COPD (incidence rate ratio [IRR], 1.85; 95% CI, 1.17-2.93) after adjusting for smoking habits and other potential confounders, whereas dyspnea was not associated with the disease (IRR = 0.98; 95% CI, 0.64-1.50). Subjects who reported chronic cough/phlegm both at baseline and at the follow-up had a nearly threefold-increased risk of developing COPD with respect to asymptomatic subjects (IRR = 2.88; 95% CI, 1.44-5.79).

CONCLUSIONS: The incidence of COPD is substantial even in young adults. The presence of chronic cough/phlegm identifies a subgroup of subjects with a high risk of developing COPD, independently of smoking habits.

COPD prevalence in Salzburg, Austria: results from the Burden of Obstructive Lung Disease (BOLD) Study.

Chest. 2007 Jan;131(1):29-36.
Schirnhofer L, Lamprecht B, Vollmer WM, Allison MJ, Studnicka M, Jensen RL, Buist AS.
Department of Pneumology, Paracelsus Private Medical School, Salzburg, Austria.

BACKGROUND: COPD is projected to be the third leading cause of death worldwide by 2020. The Burden of Obstructive Lung Disease initiative was started to measure the prevalence of COPD in a standardized way and to provide estimates of the social and economic burden of disease.

METHODS: We surveyed a gender-stratified, population-based sample of 2,200 adults >or= 40 years of age. The findings of prebronchodilator and postbronchodilator spirometry, as well as information on smoking and reported respiratory disease was recorded. Irreversible airflow obstruction was defined as a postbronchodilator FEV(1)/FVC ratio of < 0.70.

RESULTS: For 1,258 participants with good-quality postbronchodilator spirometry findings, the overall prevalence of COPD at stage I or higher was 26.1%, and was equal in men and women. The prevalence of COPD stage II or higher (FEV(1)/FVC ratio, < 0.7; FEV(1), < 80% predicted) was 10.7%. The prevalence of COPD stage I+, and COPD stage II+, increased with age and cigarette smoking. A doctor diagnosis of COPD was reported by only 5.6% of participants.

CONCLUSION: One quarter of residents of Salzburg County (Austria) who were >or= 40 years of age had at least mild irreversible airflow obstruction. The high prevalence of COPD highlights the impending health-care crisis that will affect many countries as a result of this greatly underappreciated condition.

Diagnostic labeling of COPD in five Latin American cities.

Chest. 2007 Jan;131(1):60-7.
Talamo C, de Oca MM, Halbert R, Perez-Padilla R, Jardim JR, Muino A, Lopez MV, Valdivia G, Pertuze J, Moreno D, Menezes AM; PLATINO team.

Universidad Central de Venezuela, Facultad de Medicina, Hospital Universitario de Caracas, Catedra de Neumonologia Piso 8, Caracas 1040, Venezuela.

BACKGROUND: COPD is a major worldwide problem with a rising prevalence. Despite its importance, there is a lack of information regarding underdiagnosis and misdiagnosis of COPD in different countries. As part of the Proyecto Latinoamericano de Investigacion en Obstruccion Pulmonar study, we examined the relationship between prior diagnostic label and airway obstruction in the metropolitan areas of five Latin American cities (Sao Paulo, Santiago, Mexico City, Montevideo, and Caracas).

METHODS: A two-stage sampling strategy was used in each of the five areas to obtain probability samples of adults aged >or= 40 years. Participants completed a questionnaire that included questions on prior diagnoses, and prebronchodilator and postbronchodilator spirometry. A study diagnosis of COPD was based on airway obstruction, defined as a postbronchodilator FEV(1)/FVC < 0.70.

RESULTS: Valid spirometry and prior diagnosis information was obtained for 5,303 participants; 758 subjects had a study diagnosis of COPD, of which 672 cases (88.7%) had not been previously diagnosed. The prevalence of undiagnosed COPD was 12.7%, ranging from 6.9% in Mexico City to 18.2% in Montevideo. Among 237 subjects with a prior COPD diagnosis, only 86 subjects (36.3%) had postbronchodilator FEV(1)/FVC < 0.7, while 151 subjects (63.7%) had normal spirometric values. In the same group of 237 subjects, only 34% reported ever undergoing spirometry prior to our study.

CONCLUSIONS: Inaccurate diagnostic labeling of COPD represents an important health problem in Latin America. One possible explanation is the low rate of spirometry for COPD diagnosis.

Cured Meat Consumption, Lung Function and Chronic Obstructive Pulmonary Disease Among US Adults.

Am J Respir Crit Care Med. 2007 Jan 25;
Jiang R, Paik DC, Hankinson JL, Barr RG.
Division of General Medicine, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY, USA.

RATIONALE: Cured meats are high in nitrites. Nitrites generate reactive nitrogen species that may cause nitrative and nitrosative damage to the lung resulting in emphysema.

OBJECTIVE: To test the hypothesis that frequent consumption of cured meats is associated with lower lung function and increased odds of chronic obstructive pulmonary disease (COPD).

METHODS: Cross-sectional study of 7,352 participants in the National Health and Nutrition Examination Survey III, 45 years of age or more who had adequate measures of cured meat, fish, fruit, and vegetable intake and spirometry.

RESULTS: After adjustment for age, smoking, and multiple other potential confounders, frequency of cured meat consumption was inversely associated with FEV1 and FEV1/FVC but not FVC. The adjusted differences in FEV1 between individuals who did not consume cured meats and those who consumed cured meats 1-2, 3-4, 5-13, and >/=14 times/month were -37.6, -11.5, -42.0, and -110 mL, respectively (P for trend<0.001). Corresponding differences for FEV1/FVC were -0.91, -0.54, -1.13, and -2.13 % (P for trend=0.001). These associations were not modified by smoking status. The multivariate odds ratio for COPD (FEV1/FVC
CONCLUSIONS: Frequent cured meat consumption was associated independently with an obstructive pattern of lung function and increased odds of COPD. Additional studies are required to determine if cured meat consumption is a causal risk factor for COPD.

Respiratory symptoms and 30 year mortality from obstructive lung disease and pneumonia.

Thorax. 2006 Nov;61(11):951-6.
Frostad A, Soyseth V, Haldorsen T, Andersen A, Gulsvik A. Cancer Registry of Norway, Montebello, N-0310 Oslo, Norway.

BACKGROUND: As little is known about the long term relationship between respiratory symptoms and mortality from non-malignant respiratory diseases, a study was undertaken to investigate the predictive value of respiratory symptoms and symptom load for mortality from obstructive lung disease (OLD) and pneumonia in the long term in a Norwegian population.

METHODS: In 1972, 19 998 persons aged 15-70 years living in Oslo were randomly selected for a respiratory survey. The response rate was 89%. All were followed for 30 years. The association between cough, asthma-like symptoms, two levels of dyspnoea on exercise, a symptom score, and mortality from OLD and pneumonia were investigated separately for men and women by multivariable analyses, with adjustment for age, occupational exposure to air pollution, and smoking habits.

RESULTS: OLD accounted for 43% and pneumonia for 50% of all deaths from respiratory causes. In men the hazard ratio for mortality from OLD varied from 4.0 (95% confidence interval (CI) 2.4 to 6.5) for cough to 9.6 (95% CI 5.1 to 18.3) for severe dyspnoea, and in women from 5.1 (95% CI 2.3 to 11.3) for moderate dyspnoea to 13.0 (95% CI 6.0 to 28.3) for severe dyspnoea. The symptom score was strongly predictive of death from OLD in a dose-response manner.

CONCLUSIONS: There is a significant, positive, strong association between respiratory symptoms and 30 year mortality from OLD. The association between respiratory symptoms and mortality from pneumonia is weaker and not significant.

The prevalence of osteoporosis in patients with chronic obstructive pulmonary disease-A cross sectional study.

Respir Med. 2007 Jan;101(1):177-85. Jorgensen NR, Schwarz P, Holme I, Henriksen BM, Petersen LJ, Backer V. Department of Clinical Biochemistry, Copenhagen University Hospital Hvidovre, DK-2650 Hvidovre, Denmark.

Chronic obstructive pulmonary disease (COPD) is a complex disease, where the initial symptoms are often cough as a result of excessive mucus production and dyspnea. With disease progression several other symptoms may develop, and patients with moderate to severe COPD have often multiorganic disease with severely impaired respiratory dysfunction, decreased physical activity, right ventricular failure of the heart, and a decreased quality of life. In addition osteoporosis might develop possibly due to a number of factors related to the disease. We wanted to investigate the prevalence of osteoporosis in a population of patients with severe COPD as well as to correlate the use of glucocorticoid treatment to the occurrence of osteoporosis in this population.

Outpatients from the respiratory unit with COPD, a history of forced expiratory volume in 1s (FEV1) less than 1.3L, with FEV1% pred. ranging from 17.3% to 45.3% (mean 31.4%, standard deviation (sd) 7.3%). Patients between 50 and 70 years were included. Other causes of osteoporosis were excluded before inclusion.

At study entry spirometry, X-ray of the spine (to evaluate presence of vertebral fractures), and bone mineral density of lumbar spine and hip were performed. Of 181 patients invited by mail, 62 patients were included (46 females and 16 males). All had symptoms of COPD such as exertional dyspnea, productive cough, limitations in physical activity etc. The mean FEV1 was 0.90L (sd: 0.43L) and the mean FEV1% pred. of 32.6% (sd: 14.1%). All had sufficient daily intake of calcium and vitamin D. In 15 patients, X-ray revealed compression fractures previously not diagnosed. Bone density measurements showed osteoporosis in 22 patients and osteopenia in 16. In total, 26 of the COPD patients were osteoporotic as evaluated from both X-ray and bone density determinations.

Thus 68% of the participants had osteoporosis or osteopenia, but glucocorticoid use alone could not explain the increased prevalence of osteoporosis. A large fraction of these needed treatment for severe osteoporosis in order to prevent further bone loss and to reduce future risk of osteoporotic fractures. Thus, there is a significant need to screen patients with COPD to select the individuals in risk of fracture and to initiate prophylaxis or treatment for the disease.

Respiratory effects of environmental tobacco exposure are enhanced by bronchial hyperreactivity.

Am J Respir Crit Care Med. Gerbase MW, Schindler C, Zellweger JP, Kunzli N, Downs SH, Brandli O, Schwartz J, Frey M, Burdet L, Rochat T, Ackermann-Liebrich U, Leuenberger P. Division of Pulmonary Medicine, University Hospitals of Geneva, 24 rue Micheli-du-Crest, 1211 Geneva 14, Switzerland.

RATIONALE: Exposure to environmental tobacco smoke (ETS) is associated with increased reports of respiratory symptoms and reduced lung function, but the long-term effects of ETS are unclear, notably in healthy individuals with bronchial hyperresponsiveness (BHR).

OBJECTIVE: To assess the longitudinal effects of ETS exposure on the development of respiratory symptoms and spirometry in subjects with BHR.

METHODS: The study population included 1,661 never-smokers from the SAPALDIA (Swiss Study on Air Pollution and Lung Diseases in Adults) cohort, assessed in 1991 (baseline) and 11 yr later, who were symptom-free at baseline. Incident reports of respiratory symptoms and results of spirometry were assessed at the follow-up survey.

MAIN RESULTS: Exposure to ETS reported in the two surveys was strongly associated with the development of cough (odds ratio, 2.1; 95% confidence interval, 1.2-3.7; p = 0.01). In subjects with BHR exposed to ETS at both surveys, a trend for strong associations were observed for wheeze, cough, dyspnea, and chronic bronchitis; however, the association reached statistical significance only for the symptom of dyspnea (p < 0.01). Lower FEV(1)/FVC (mean ± SD, 72.9 ± 7.7 vs. 76.8 ± 6.1%; p < 0.01) and FEF(25-75) (forced expiratory flow, midexpiratory phase)/FVC (mean ± SD, 56.1 ± 22.5 vs. 68.1 ± 21.6%; p < 0.01) were observed in subjects with BHR exposed to ETS compared with nonexposed subjects without BHR. Lower values were found in subjects continuing exposure by the follow-up survey.

CONCLUSION: Exposure to ETS was strongly associated with the development of respiratory symptoms in previously asymptomatic subjects with BHR within 11 yr. Furthermore, subjects with underlying BHR had reduced lung function at follow-up, thus suggesting a higher risk for the development of chronic respiratory disease in this subset of the population.

Exacerbations and lung function decline in COPD: New insights in current and ex-smokers.

Respir Med. 2006 Nov 15; Makris D, Moschandreas J, Damianaki A, Ntaoukakis E, Siafakas NM, Emili JM, Tzanakis N. Department of Thoracic Medicine, University of Crete, Medical School

AIM: To investigate whether there is a significant relationship between an increased frequency of exacerbations and the rate of forced expiratory volume in 1s (FEV(1)) decline in COPD patients.

METHODS-MEASUREMENTS: About 102 COPD patients (44 smokers, 58 ex-smokers) participated in a 3-year prospective study. Exacerbations were identified as worsening of patient's respiratory symptoms as recorded on diary cards. Spirometry was performed every 6 months. The effect of frequent exacerbations on lung function was investigated using random effects models.

RESULTS: The median (mean(95% CI)) annual exacerbation rate was 2.85 (3.1 (2.7-3.6)). Patients with an annual exacerbation rate over the median rate had significantly lower baseline post-bronchodilation FEV(1)(%pred), higher MRC dyspnoea score and chronic cough compared to patients who had an annual exacerbation rate less than the median. The average annual rate of FEV(1)(%pred), adjusted for smoking decline (DeltaFEV(1)), was found significantly increased in frequent compared to infrequent exacerbators (P=0.017). The highest DeltaFEV(1) was observed in smokers frequent exacerbators and a significant interaction between exacerbation frequency and DeltaFEV(1) was also observed in ex-smokers.

CONCLUSIONS: Our findings suggest that an increased frequency of exacerbations is significantly associated with FEV(1) decline even in ex-smokers. Thus, smoking and frequent exacerbations may have both negative impact on lung function. Smoking cessation and prevention of exacerbations should be a major target in COPD.

Prevalence, diagnosis and relation to tobacco dependence of chronic obstructive pulmonary disease in a nationally representative population sample.

Thorax. 2006 Dec;61(12):1043-7. Shahab L, Jarvis MJ, Britton J, West R. MSc, Cancer Research Health Behaviour Unit, Department of Epidemiology and Public Health, University College London, London WC1E 6BT, UK.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is the fourth most common cause of death worldwide. It is caused primarily by cigarette smoking. Given its importance, it is remarkable that reliable national prevalence data are lacking for most countries. This study provides estimates of the national prevalence of COPD in England, the extent of under-detection of the disorder, and patterns of cigarette smoking, dependence, and motivation to stop smoking in those with the disease.

METHODS: Data from 8215 adults over the age of 35 who participated in the Health Survey for England were analysed. Information was obtained on self-reported and cotinine validated smoking status, cigarette dependence, motivation to stop smoking, COPD defined by spirometry using joint American Thoracic Society and European Respiratory Society criteria, and self-reports of diagnosis with respiratory disorders.

RESULTS: Spirometry-defined COPD was present in 13.3% (95% CI 12.6 to 14.0) of participants, over 80% of whom reported no respiratory diagnosis. Even among people with severe or very severe COPD by spirometric assessment, only 46.8% (95% CI 39.1 to 54.6) reported any diagnosed respiratory disease. A total of 34.9% (95% CI 32.1 to 37.8) of people with spirometry-defined COPD were smokers compared with 22.4% (95% CI 21.4 to 23.4) of those without, and smoking prevalence increased with disease severity. Smokers with spirometry-defined COPD were more cigarette dependent but had no greater desire to quit than other smokers.

CONCLUSION: COPD is common among adults in England and is predominantly undiagnosed. In smokers it is associated with higher degrees of cigarette dependence but not with a greater motivation to stop smoking.

Are patient characteristics helpful in recognizing mild COPD (GOLD I) in daily practice?

Scand J Prim Health Care. 2006 Dec;24(4):237-42. Geijer RM, Sachs AP, Verheij TJ, Lammers JW, Salome PL, Hoes AW. Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands.

OBJECTIVE. To determine whether in a high-risk group of middle-aged male current smokers, patient characteristics are useful to recognize mild COPD (GOLD stage I).

DESIGN. In a cross-sectional study spirometry was performed according to the American Thoracic Society criteria. COPD was defined according to the GOLD criteria for COPD.

SETTING. Primary care.

SUBJECTS. Male smokers, aged 40-65 years, without documented lung disease in the population at large.

MAIN OUTCOME MEASURES. Medical records were scrutinized to collect patient characteristics. Multiple logistic regression analysis was used to identify independent determinants of mild COPD.

RESULTS. A total of 567 subjects participated. COPD, defined by a FEV1/FVC ratio < 0.7, was detected in 170 subjects (30.0%, 95% CI 26.2-33.9%). In 149 subjects (26.3%; 22.7-30.1%) COPD was mild (GOLD stage I) and in 21 subjects (3.7%; 2.3-5.6%) moderate (GOLD stage II). Only age and cough were independently associated with the presence of mild COPD. The ability of these determinants to discriminate between subjects with or without mild COPD was relatively poor (ROC area 0.65). Therefore no prediction rule was developed.

CONCLUSION. Our results indicate that patient characteristics are not helpful to recognize mild COPD (GOLD stage I) in middle-aged male smokers.

Role of Gastroesophageal Reflux Symptoms in Exacerbations of COPD

Chest. 2006;130:1096-1101. Ivan E. Rascon-Aguilar, MD; Mark Pamer, DO; Peter Wludyka, PhD; James Cury, MD; David Coultas, MD; Louis R. Lambiase, MD; N. Stanley Nahman, MD and Kenneth J. Vega, MD Department of Internal Medicine, Division of Gastroenterology (Drs. Lambiase and Vega), and Department of Internal Medicine, Office of Research Affairs (Drs. Rascon-Aguilar, Pamer, Wludyka, Cury, Coultas, and Nahman), University of Florida Health Science Center/Jacksonville, Jacksonville FL.

BACKGROUND AND AIMS: The impact of gastroesophageal reflux disease (GERD) on exacerbations of COPD has never been evaluated. The aims of this investigation were to determine the prevalence of gastroesophageal reflux (GER) symptoms in COPD patients and the effect of GER on the rate of exacerbations of COPD per year.

METHODS: A questionnaire-based, cross sectional survey was performed. Subjects were recruited from the outpatient pulmonary clinics at the University of Florida Health Science Center/Jacksonville. Included patients had an established diagnosis of COPD. Exclusion criteria were respiratory disorders other than COPD, known esophageal disease, active peptic ulcer disease, Zollinger-Ellison syndrome, mastocytosis, scleroderma, and current alcohol abuse. Those meeting criteria and agreeing to participate were asked to complete the Mayo Clinic GERD questionnaire by either personal/telephone interview. Clinically significant reflux was defined as heartburn and/or acid regurgitation weekly. Other outcome measures noted were frequency and type of COPD exacerbations. Statistical analysis was performed using the Fisher exact test for categorical data and the independent t test for interval data.

RESULTS: Eighty-six patients were enrolled and interviewed (mean age, 67.5 years). Male patients ac