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Indacaterol vs tiotropium in COPD patients classified as GOLD A and B

According to current GOLD strategy, patients with COPD classified as groups A and B may be treated with inhaled bronchodilators, either long-acting β2-agonist (LABA) or long-acting muscarinic antagonist (LAMA). However, there is little guidance on which class of agent is preferred and a lack of prospective data to differentiate the two.

Methods : In this study, we performed post-hoc analyses of pooled data from two prospective, controlled clinical trials comparing the LABA indacaterol and LAMA tiotropium in 1422 patients with moderate airflow limitation and no history of exacerbations in the previous year. This population fits the definitions of GOLD A and B groups and could be further stratified by symptom severity using Baseline Dyspnea Index (i.e. modeling GOLD A or B) and inhaled corticosteroid (ICS) use at baseline. Outcomes measured after 12 weeks of treatment were lung function (forced expiratory volume in 1 second; FEV1), health status (St George’s Respiratory Questionnaire; SGRQ), symptoms (Transition Dyspnea Index; TDI) and rescue medication use.

Results : In ‘GOLD A’ patients not receiving ICS, differences favored indacaterol versus tiotropium (trough FEV1 0.05 L; rescue medication use −0.41 puffs/day; TDI total score 0.94 points; SGRQ total score −3.13 units, all p<0.01). In ‘GOLD B, no ICS’ patients, compared with tiotropium, indacaterol treatment increased trough FEV1 (0.055L, p<0.05) and permitted a larger reduction in rescue medication use (−0.81 puffs/day, p=0.004). In all patients, and in patients not using ICS, differences favored indacaterol for all variables.

Conclusions : Our findings suggest that patients in GOLD groups A and B may experience greater benefits with indacaterol than with tiotropium.

The impact of rare EGFR mutations on the treatment response of patients with non-small cell lung cancer

Mutational activation of the epidermal growth factor receptor (EGFR) gene is implicated in lung cancer; clinical and cancer genome sequencing studies have identified hundreds of mutations in the protein kinase domain.

EGFR mutation testing usually focuses on common mutations like the exon 19 deletion and exon 21 point mutation (L858R). However, molecular screening methods have started to extend beyond identification of classic EGFR mutations to prevent exclusion of patients with rare or complex mutations who may benefit from anti-EGFR therapy. Rare EGFR-mutated non-small-cell lung cancers are heterogeneous: exon 20 insertions lack sensitivity to tyrosine kinase inhibitors while exon 18 or complex mutations are more sensitive and require individual assessment.

Until testing for uncommon EGFR mutations evolves and studies with large number of patients are performed, knowledge of this field will remain limited.

Prevalence, risk factors and underdiagnosis of asthma and wheezing in adults 40 years and older: A population-based study

Objective: There are differences in the prevalence and risk factors of asthma around the world. The epidemiological situation of adults 40 years and older is not well established. Our aim was to determine the prevalence, underdiagnosis and risk factors of asthma and wheezing in adults in Colombia.

Methods: A cross-sectional, population-based study including 5539 subjects from 40 to 93 years selected by a probabilistic sampling technique in five cities was conducted. Measurements: respiratory symptoms and risk factors questionnaire and spirometry. Definitions: (a) Wheezing: Affirmative answer to the question “have you ever had two or more attacks of “wheezes” causing you to feel short of breath?” (b) Asthma: Wheezing definition and FEV1/FVC post-bronchodilator ≥ 70%. (c) Underdiagnosis: Asthma definition without a physician-diagnosis. Logistic regression was used for exploring risk factors.

Results: Prevalence of asthma was 9.0% (95% CI: 8.3-9.8) and wheezing 11.9% (95% CI: 11.0-12.8). Asthma underdiagnosis was 69.9% and increased to 79.0% in subjects 64 years or older. The risk factors related to asthma and/or wheezing were: living in Bogota or Medellin, female gender, first degree relative with asthma, respiratory disease before 16 years of age, obesity, no education, indoor wood smoke exposure and occupational exposure to dust particles, gases or fumes.

Conclusion: We described the epidemiologic situation of asthma in adults 40 years and older in Colombia. In addition to some recognized risk factors, our data supports the association of indoor wood smoke and occupational exposures with asthma and wheezing. Underdiagnosis of asthma in adults was high, particularly in older subjects.

Promoting the Use of Capnography in Acute Care Settings: An Evidence-Based Practice Project

Opioid-induced respiratory depression (OIRD) is a life-threatening complication of opioid analgesia. End-tidal carbon dioxide monitoring (capnography) has been shown to detect early signs of OIRD earlier than other commonly used monitoring methods.

The goal of this evidence-based practice project was to promote the standardized use of capnography to reduce the incidence of OIRD.

The project included an updated nursing protocol, an electronic order trigger, improved access to capnography monitors, and staff education about OIRD risk assessment and the use of capnography. A survey of registered nurses was also conducted to gather their perceptions on the ease of use and effectiveness of capnography. Twelve months after introducing the intervention there was an increase in monitoring frequency, with 2.56 times more patients at high risk for OIRD being monitored with capnography than at baseline. Of the 171 registered nurses surveyed during this project, 99% perceived the portable capnography monitors as easy to use and interpret. However, 71% reported systems issues in obtaining the monitoring equipment, and 65% reported problems with patient adherence.

The intervention succeeded in increasing the number of high-risk patients being monitored with capnography and reducing the number of cases of OIRD.

Bacterial vaccines in chronic obstructive pulmonary disease: effects on clinical outcomes and cytokine levels

BacteriaChronic obstructive pulmonary disease (COPD) is a major cause of mortality and morbidity worldwide. Exacerbation episodes impair lung function leading to disease progression. Levels of inflammation markers correlate with disease severity. Bacterial immunomodulators have shown a beneficial effect in COPD, improving symptoms and reducing the rate of exacerbations.

This is an observational prospective study on 30 patients diagnosed with bronchiectasis and COPD, who received bacterial autogenous vaccine for 12 months. The rate of exacerbation, severity of symptoms and lung function were studied at baseline and after treatment. In addition, plasma levels CRP, IL6, IL8, and TNFα were measured. After treatment we found a reduction in mean acute respiratory infections and signs of lung disease. ...

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