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COPD Exacerbation Seasonality

Background:

Patients with COPD experience more frequent exacerbations in the winter. However, little is known about the impact of the seasons on exacerbation characteristics.

 Methods:

Between November 1, 1995, and November 1, 2009, 307 patients in the London COPD cohort (196 men; age, mean, 68.1 years [SD, 8.4]; FEV1, mean, 1.12 L [SD, 0.46]; FEV1, mean, % predicted, 44.4% [SD, 16.1]) recorded their increase in daily symptoms and time outdoors for a median of 1,021 days (interquartile range [IQR], 631-1,576). Exacerbation was identified as ≥ 2 consecutive days with an increase in two different symptoms.

 Results:

There were 1,052 exacerbations in the cold seasons (November to February), of which 42.5% and 50.6% were patients who had coryzal and cough symptoms, respectively, compared with 676 exacerbations in the warm seasons (May to August), of which 31.4% and 45.4% were in patients who had coryzal and cough symptoms, respectively (P < .05). The exacerbation recovery period was longer in the cold seasons (10 days; IQR, 6-19) compared with the warm seasons (9 days; IQR, 5-16; P < .005). The decrease in outdoor activity during exacerbation, relative to a pre-exacerbation period (–14 to –8 days), was greater in the cold seasons (–0.50 h/d; IQR, –1.1 to 0) than in the warm seasons (–0.26 h/d; IQR, –0.88 to 0.18; P = .048). In the cold seasons, 8.4% of exacerbations resulted in patients who were hospitalized, compared with 4.6% of exacerbations in the warm seasons (P = .005).

 Conclusions:

Exacerbations are more severe between November and February. This contributes to the increased morbidity during the winter seasons.

Changes in Mortality in US Adults With COPD

Background:

COPD is a major contributor to the global burden of disease. Our objective was to examine changes in the mortality rate among persons with COPD in the United States.

 Methods:

We conducted prospective studies using data from 5,185 participants in the National Health and Nutrition Examination Survey (NHANES) I Epidemiologic Follow-up Study (baseline examination from 1971-1975; follow-up from 1992-1993) and 10,954 participants of the NHANES III Linked Mortality Study (baseline examination from 1988-1994; follow-up through 2006).

 Results:

The age-adjusted rate (per 1,000 person-years) among participants with moderate or severe COPD (23.9 and 20.2) was about 2.5 to 3 times higher than the rate among participants with normal lung function (10.4 and 6.2) in NHANES I and NHANES III, respectively. Compared with NHANES I, the mortality rate among participants in NHANES III decreased by 15.8% for those with moderate or severe COPD, 25.2% for those with mild COPD, 35.9% for those with respiratory symptoms with normal lung function, 16.6% for those with restrictive impairment, and 40.1% for those with normal lung function. However, the decrease did not reach statistical significance among participants with moderate or severe COPD. The decreases in the mortality rate among men with moderate or severe COPD (–17.8%) or with restrictive impairment (–35.1%) exceeded the changes among women (+3% and –6.1%, respectively).

 Conclusions:

The secular decline in the mortality rate in the United States benefited people with COPD less than those with normal lung function.

Combined Pulmonary Fibrosis and Emphysema Review

There is increasing clinical, radiologic, and pathologic recognition of the coexistence of emphysema and pulmonary fibrosis in the same patient, resulting in a clinical syndrome known as combined pulmonary fibrosis and emphysema (CPFE) that is characterized by dyspnea, upper-lobe emphysema, lower-lobe fibrosis, and abnormalities of gas exchange. This syndrome frequently is complicated by pulmonary hypertension, acute lung injury, and lung cancer. The CPFE syndrome typically occurs in male smokers, and the mortality associated with this condition, especially if pulmonary hypertension is present, is significant. In this review, we explore the current state of the literature and discuss etiologic factors and clinical characteristics of the CPFE syndrome.

Arm Exercise Tests in Patients with COPD

Background:

There are no recommendations on how to measure arm exercise capacity in individuals with COPD. The objectives of this study were (1) to synthesize the literature on measures of arm exercise capacity in individuals with COPD, (2) to describe the psychometric properties and the target construct of each measure, and (3) to make recommendations for clinical practice and research.

 Methods:

Studies conducted in patients with COPD that included a measure of arm exercise capacity were identified after searches of five electronic databases (PubMed, CINAHL, EMBASE, PEDro, and Cochrane Library) and reference lists of pertinent articles. One reviewer performed data extraction, and two assessed the quality of the studies that described measurement properties, using the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN) checklist.

 Results:

Of 654 reports, 41 met the study criteria. Five types of arm exercise tests were identified: arm ergometry, ring shifts, dowel lifts, proprioceptive neuromuscular facilitation, and activities of daily living. Four studies assessed the measurement properties of the unsupported upper-limb exercise test (UULEX), the 6-min pegboard and ring test (6PBRT), a test involving weight shifts, and the grocery-shelving task (GST). Validity studies were of fair to good quality, whereas reliability studies were of poor quality.

 Conclusions:

Arm ergometry may be the best method for measuring peak supported arm exercise capacity and endurance. The UULEX, 6PBRT, and GST may better reflect activities of daily living and should be the tests of choice to measure peak unsupported arm exercise capacity (UULEX) and arm function (6PBRT and GST).

Severity Scoring in the Critically Ill: Part 1

This review examines the use of scoring systems to assess ICU performance. APACHE (Acute Physiology and Chronic Health Evaluation), MPM (mortality probability model), and SAPS (simplified acute physiology score) are the three major ICU scoring systems in use today. Central to all three is the use of physiologic data for severity adjustment. Differences in the size, nature, and time horizon of the data set translate into minor differences in accuracy and difficulty of data abstraction. APACHE IV provides ICU and hospital predictions for mortality and length of stay, whereas MPM and SAPS only provide hospital mortality predictions (although new algorithms generated from MPM data elements may predict ICU length of stay adequately). The primary use of scoring systems is for assessing ICU performance, with the ratio of actual-to-predicted outcomes in the study cohort providing performance comparisons to the reference ICUs. The reliability of scoring system predictions depends on the completeness and accuracy of the abstracted data; accordingly, ICUs must implement robust data quality control processes. CIs of the ratios are inversely related to sample size, and care must be taken to avoid overinterpreting changes in outcomes. ICU structural and process issues also can affect scoring system performance measures. Despite good discrimination and calibration, scoring systems are used in only 10% to 15% of US ICUs. Without ICU performance data, there is little hope of improving quality and reducing costs. Current demands for transparency and computerization of documentation are likely to drive future use of ICU scoring systems.

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