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Javier de Miguel-Díez,1 Rodrigo Jiménez-García,2 Valentín Hernández-Barrera,2 José M de Miguel-Yanes,3,4 Manuel Méndez-Bailón,5 Ana López-de-Andres2 1Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain; 2Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain; 3Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain; 4Facultad de Medicina, Universidad Complutense De Madrid (UCM), Madrid, Spain; 5Internal Medicine Department, Hospital Universitario Clínico San Carlos, Facultad De Medicina, Universidad Complutense de Madrid (UCM), Madrid, SpainCorrespondence: Rodrigo Jiménez-GarcíaPreventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Avenida de Atenas s/n, Alcorcón, Madrid 28922, SpainTel +34 91 4888853Email rodrigo.jimenez@urjc.esBackground: To describe trends and outcomes during admission for solid organ transplants, excluding lungs, in people with or without COPD in Spain (2001–2015).Methods: We used national hospital discharge data to select all hospital admissions for kidney, heart and liver transplants. We estimated admission rates stratified by COPD status. We analyzed the Charlson Comorbidity Index, therapeutic procedures and outcomes.Results: We identified 52,020 admissions (33,293 for kidney transplant, 3,937 for heart transplant and 14,790 for liver transplant). Patients with COPD accounted for 2.5%, 4.2% and 3.5% of kidney, heart and liver transplant patients, respectively. The number of kidney and liver transplants increased among COPD patients over the study period, whereas the number of heart transplants remained stable. In all cases, COPD patients were significantly older and had more coexisting medical conditions than those without COPD. Among patients who underwent a kidney transplant, there were no significant differences in the clinical characteristics analyzed between the groups, but the overall in-hospital mortality (IHM) rate was significantly higher in COPD patients than in those without COPD (2.22% vs 0.58%, p=0.008). There were no differences for any of the study variables or for the IHM rate in patients who underwent a heart transplant (14.63% in both groups). Among patients who underwent a liver transplant, COPD patients had lower prevalences of infection and complications than those without COPD. The IHM rate was also significantly lower in COPD patients than in non-COPD controls who underwent a liver transplant (4.07% vs 8.91%, p=0.002).Conclusion: COPD prevalence in patients undergoing renal, heart and liver transplants is lower than it has been described in the general population. However, we did not find differences in the clinical characteristics analyzed between COPD and non-COPD patients. Furthermore, the IHM rate was only higher in COPD patients who underwent a kidney transplant but not in those undergoing a heart or liver transplant.Keywords: solid organ transplant, COPD, comorbidities, in-hospital mortality

Rodrigo Jimenez-Garcia,1 José Luis del Barrio,1 Valentín Hernandez-Barrera,1 Javier de Miguel-Díez,2 Isabel Jimenez-Trujillo,1 María Angeles Martinez-Huedo,3 Ana Lopez-de-Andres1 1Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain; 2Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain; 3Preventive Medicine and Public Health, Unidad de Docencia, Hospital Universitario La Paz, Madrid, Spain Background: The objective of the study was to study the association between low back pain (LBP), neck pain (NP), and diabetes while controlling for many sociodemographic characteristics, comorbidities, and lifestyle variables. The study also aimed to identify which of these variables is independently associated with LBP and NP among diabetes sufferers. Methods: A case–control study using data taken from the European Health Interview Surveys for Spain was conducted in 2009/2010 (n=22,188) and 2014 (n=22,842). We selected subjects ≥40 years of age. Diabetes status was self-reported. One non-diabetic control was matched by the year of survey, age, and sex for each diabetic case. The presence of LBP and NP was defined as the affirmative answer to both of the questions: “Have you suffered chronic LBP/NP over the last 12 months?” and “Has your physician confirmed the diagnosis?” Independent variables included demographic and socioeconomic characteristics, health status variables, lifestyles, and pain characteristics. Results: The prevalence of NP (32.2% vs 26.8%) and LBP (37.1% vs 30.3%) was significantly higher among those suffering from diabetes. Multivariable analysis showed that diabetes was associated with a 1.19 (95% CI 1.04–1.36) and 1.20 (95% CI 1.06–1.35) higher risk of NP and LBP. Among diabetic subjects, being female, concomitant mental or respiratory disorders, being obese, and physically inactive are variables associated with suffering from these pains. Those suffering NP had 8 times higher risk of reporting LBP than those without NP and the same association is found among those suffering from LBP. Conclusion: The prevalence and intensity of NP and LBP are high among people with diabetes, affecting them significantly more than their age- and sex-matched non-diabetic controls. Specific preventive and educational strategies must be implemented to reduce the incidence, severity, and negative effect on the quality of NP and LBP among diabetic patients. Keywords: low back pain, neck pain, diabetes, survey

Javier de Miguel-Díez,1 Rodrigo Jiménez-García,2 Valentín Hernández-Barrera,2 Pilar Carrasco-Garrido,2 Héctor Bueno,3 Luis Puente-Maestu,1 Isabel Jimenez-Trujillo,2 Alejandro Alvaro-Meca,2 Jesús Esteban-Hernandez,2 Ana López de Andrés21Pneumology Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain; 2Preventive Medicine and Public Health Teaching and Research Unit, Department of Health Sciences, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain; 3Centro Nacional de Investigaciones Cardiovasculares, Instituto de investigación i+12, Cardiology Department, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, SpainBackground: People with COPD suffering from coronary artery disease are frequently treated with revascularization procedures. We aim to compare trends in the use and outcomes of these procedures in COPD and non-COPD patients in Spain between 2001 and 2011.Methods: We identified all patients who had undergone percutaneous coronary interventions (PCIs) and coronary artery bypass graft (CABG) surgeries, using national hospital discharge data. Discharges were grouped into: COPD and no COPD.Results: From 2001 to 2011, 428,516 PCIs and 79,619 CABGs were performed. The sex and age-adjusted use of PCI increased by 21.27% per year from 2001 to 2004 and by 5.47% per year from 2004 to 2011 in patients with COPD. In-hospital mortality (IHM) among patients with COPD who underwent a PCI increased significantly from 2001 to 2011 (odds ratio 1.11; 95% confidence interval 1.03–1.20). Among patients with COPD who underwent a CABG, the sex and age-adjusted CABG incidence rate increased by 9.77% per year from 2001 to 2003, and then decreased by 3.15% through 2011. The probability of dying during hospitalization in patients who underwent a CABG did not change significantly in patients with and without COPD (odds ratio, 1.06; 95% confidence interval 0.96–1.17).Conclusion: The annual percent change in PCI procedures increased in COPD and non-COPD patients. We found a decrease in the use of CABG procedures in both groups. IHM was higher in patients with COPD who underwent a PCI than in those without COPD. However, COPD did not increase the probability of dying during hospitalization in patients who underwent a CABG.Keywords: COPD, percutaneous coronary intervention, coronary artery bypass graft surgery, hospitalization, length of stay, in-hospital mortality

Marta Fuentes-Alonso,1 Ana López-de-Andrés,2 Domingo Palacios-Ceña,3 Rodrigo Jimenez-Garcia,4 Marta Lopez-Herranz,5 Valentin Hernandez-Barrera,2 Napoleon Perez-Farinos,6 Zichen Ji,1 Javier de-Miguel-Diez1 1Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain; 2Department of Medical Specialties and Public Health, Universidad Rey Juan Carlos, Madrid, Spain; 3Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Research Group of Humanities and Qualitative Research in Health Science of Universidad Rey Juan Carlos (Hum&QRinHS), Universidad Rey Juan Carlos, Madrid, Spain; 4Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain; 5Faculty of Nursing, Physiotherapy and Podology, Universidad Complutense de Madrid, Madrid, Spain; 6Department of Public Health and Psychiatry, Faculty of Medicine, Universidad de Málaga, Málaga, SpainCorrespondence: Ana López-de-AndrésDepartment of Medical Specialties and Public Health, Universidad Rey Juan Carlos, Av Atenas s/n, Alcorcon, Madrid 28922, SpainEmail ana.lopez@urjc.esObjective: We aimed to assess whether patients suffering from COPD have a higher prevalence of chronic back pain (neck and low back pain) than age-, sex-, and residence-matched non-COPD controls. We also aimed to identify which variables are associated with chronic neck pain (CNP) and chronic low back pain (CLBP) among COPD patients.Methods: We carried out a retrospective case–control study using data obtained from the Spanish National Health Survey conducted in 2017.Results: We analyzed data from 1034 COPD and 1034 matched non-COPD controls. The prevalence of CNP and CLBP was 38.20% and 45.16%, respectively, among COPD patients and 22.82% and 28.34% for non-COPD controls, respectively (p< 0.001 for both). Multivariable analysis showed that COPD patients had a 1.62-fold (95% CI 1.50– 1.74) higher risk of CNP and a 1.83-fold (95% CI 1.73– 1.91) higher risk of CLBP than non-COPD controls. Experiencing one type of pain greatly increased the risk of having the other. Factors associated with the presence of both types of pain among COPD patients included female sex, “fair/poor/very poor” self-rated health, migraine or frequent headache and use of pain medication. Being aged from 70 to 79 years was a risk factor for CLBP, and suffering from a mental disorder was a risk factor for CNP.Conclusion: The prevalence of CNP and CLBP was significantly higher among COPD patients than among non-COPD controls after adjusting for age, sex and other relevant clinical variables. Our findings add new data to the knowledge of chronic pain in COPD patients.Keywords: COPD, neck pain, low back pain, comorbidities, pain medication

Zichen Ji,1,2 Julio Hernández-Vázquez,3 Irene Milagros Domínguez-Zabaleta,1 Ziyi Xia,2 José María Bellón-Cano,4 Virginia Gallo-González,1 Ismael Ali-García,3 Carmen Matesanz-Ruiz,3 Ana López-de-Andrés,5 Rodrigo Jiménez-García,6 María Jesús Buendía-García,3 Ángela Gómez-Sacristán,7 Walther Iván Girón-Matute,1,2,7 Luis Puente-Maestu,1,2,7 Javier de Miguel-Díez1,2,7 1Pulmonology Service, Gregorio Marañón General University Hospital, Madrid, Spain; 2Faculty of Medicine, Complutense University of Madrid, Madrid, Spain; 3Pulmonology Section, Infanta Leonor University Hospital, Madrid, Spain; 4Research Support Service, Gregorio Marañón Health Research Institute, Madrid, Spain; 5Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain; 6Public Health and Maternal and Child Health Department, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain; 7Gregorio Marañón Health Research Institute, Madrid, SpainCorrespondence: Zichen JiPulmonology Service, Gregorio Marañón University General Hospital, Madrid 28007, SpainTel +34 617 882 547Email jizich72@gmail.comBackground: Chronic obstructive pulmonary disease (COPD) usually occurs alongside other conditions. Few studies on comorbidities have taken into account the phenotypes of COPD patients. The objective of this study is to evaluate the prevalence of comorbidities included in the Charlson index and their influence on the survival of patients with COPD, taking phenotypes into account.Methods: An observational study was conducted on a group of 273 patients who had COPD and underwent spirometry in the first half of 2011, with a median prospective follow-up period of 68.15 months. The survival of these patients was analyzed according to the presence of various comorbidities.Results: Of the 273 patients, 93 (34.1%) died within the follow-up period. An increased presence of chronic ischemic heart disease (CIHD), chronic heart failure (CHF), chronic kidney disease (CKD), and malignancy was found in deceased patients. All of these conditions shorten the survival of COPD patients globally; however, when considering phenotypes, only CHF influences the exacerbator with chronic bronchitis phenotype, CKD influences the non-exacerbator phenotype, and malignancy influences the positive bronchodilator test (BDT) and exacerbator with chronic bronchitis phenotypes. In the multivariate model, advanced age (hazard ratio, HR: 1.05; p=0.001), CHF (HR: 1.74; p=0.030), and the presence of malignancy (HR: 1.78; p=0.010) were observed as independent mortality risk factors.Conclusion: The survival is shorter in the presence of CIHD in overall COPD patients and also CHF, CKD, and malignancy for certain phenotypes. It is important to pay attention to these comorbidities in the comprehensive care of COPD patients.Keywords: COPD, phenotypes, comorbidities, risk factors, mortality, survival

Virginia Moya-Álvarez,1 Juan Luis Quevedo-Marín,2 Zichen Ji,3 Cristina Navarro-Jiménez,4 Rodrigo Jiménez-García,5 Ana López-de-Andrés,6 Alfonso Pérez-Trullén,7 Javier de Miguel-Díez3 1Faculty of Medicine, Francisco de Vitoria University, Madrid 28223, Spain; 2Rey Juan Carlos University, Madrid 28922, Spain; 3Pulmonology Service, Gregorio Marañón University General Hospital, Madrid 28007, Spain; 4Pulmonology Service, El Escorial Hospital, Madrid 28200, Spain; 5Public Health and Maternal and Child Health Department, Faculty of Medicine, Complutense University of Madrid, Madrid 28040, Spain; 6Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Madrid 28922, Spain; 7Pulmonology Service, Lozano Blesa University Clinical Hospital, Zaragoza 50009, SpainCorrespondence: Javier de Miguel-DíezPulmonology Service, Gregorio Marañón, University General Hospital, Madrid 28007, SpainTel +34 91 586 88 00Email jdemigueldiez@telefonica.netIntroduction: The Global Organization of Lung Disease (GOLD) classifies patients with chronic obstructive pulmonary disease (COPD) taking into account the symptoms. The modified Medical Research Council’s dyspnea scale (mMRC) and the COPD assessment test (CAT) are used to assess these symptoms. In this study, we analyze the concordance of GOLD classification using mMRC and CAT.Patients and Methods: This is an observational study of a cohort of 169 patients with COPD, who were classified following the GOLD 2017 recommendations, using both mMRC and CAT. A concordance analysis was applied, and a ROC curve was generated to identify the CAT score that best concorded with the mMRC scale.Results: The concordance for the GOLD groups classified by CAT and mMRC was moderate (kappa 0.492). For mMRC score of 1 and 2, a CAT score of ≥ 9 and ≥ 16 showed the maximum value of the Youden index, respectively. By reclassifying the patients with the new cut-off points obtained, the best concordance was obtained between the cut-off point for CAT of 16 and for mMRC of 2, followed by CAT of 9 and mMRC of 1.Conclusion: Because of the deficient concordance between CAT and mMRC, we propose the use of new cut-off points in future updates of the GOLD strategy.Keywords: chronic obstructive pulmonary disease, COPD, Global Organization of Lung Disease, GOLD, dyspnea, modified Medical Research Council, mMRC, COPD assessment test, CAT

Javier de Miguel-Díez,1 Ana López-de-Andres,2 Valentín Hernández-Barrera,2 José M de Miguel-Yanes,3 Manuel Méndez-Bailón,4 Rodrigo Jiménez-García2 1Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain; 2Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain; 3Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Madrid, Spain; 4Internal Medicine Department, Hospital Universitario Clínico San Carlos, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Madrid, Spain Purpose: To describe trends from 2001 to 2015 in incidence and in-hospital outcomes of patients suffering or not suffering from COPD who had undergone lung transplantation (LTx) in Spain. Methods: We used the Spanish National Hospital Discharge Database to select all admissions for LTx. Incidence was estimated overall and according to the presence of COPD. Outcomes included infections, complications, length of hospital stay and in-hospital mortality (IHM). Results: We identified 2,896 admissions for LTx. Admission rates rose in COPD sufferers and non-COPD sufferers over time, with higher rates among COPD patients. COPD and non-COPD patients were older, but mean age was higher in COPD patients. Although there was a male predominance among patients, the proportion of women significantly increased over time in the COPD population. COPD patients had lower Charlson Comorbidity Index values than non-COPD patients (score ≥1, 25.83% and 31.6%, P

Julio Hernández Vázquez,1 Ismael Ali García,1 Rodrigo Jiménez-García,2 Alejandro Álvaro Meca,2 Ana López de Andrés,2 Carmen Matesanz Ruiz,1 María Jesús Buendía García,1 Javier de Miguel Díez3 1Respiratory Department, Hospital Universitario Infanta Leonor, Madrid, Spain; 2Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain; 3Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain Background: The aim of the study was to analyze the characteristics and survival of a group of patients with COPD according to their clinical phenotype.Patients and methods: The study population was selected from patients undergoing scheduled spirometry between January 1, 2011 and June 30, 2011 at the respiratory function laboratory of a teaching hospital and comprised those with a previous and confirmed diagnosis of COPD and forced expiratory volume in the first second (FEV1) of

Ana López-de-Andrés,1 José Luis del Barrio,1 Valentín Hernández-Barrera,1 Javier de Miguel-Díez,2 Isabel Jimenez-Trujillo,1 María Angeles Martinez-Huedo,3 Rodrigo Jimenez-García1 1Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain; 2Respiratory Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain; 3Preventive Medicine and Public Health Department, Teaching and Research Unit, University Hospital La Paz, Madrid, Spain Aims: To investigate the association between migraine and diabetes mellitus while controlling for several socio-demographic characteristics, comorbidities, and lifestyle variables. We also aimed to identify which of these variables are associated with migraine among diabetics.Patients and methods: We conducted a cross-sectional study using data taken from the European Health Interview Surveys for Spain conducted in 2009/10 (n=22,188) and 2014 (n=22,842). We selected those subjects ≥40 years of age. Diabetes status was self-reported. One non-diabetic control was matched by the year of survey, age, and sex for each diabetic case. The presence of migraine was defined as the affirmative answer to both of the following questions: “Have you suffered migraine or frequent headaches over the last 12 months?” and “Has your physician confirmed the diagnosis?”. Independent variables included demographic and socio-economic characteristics, health status variables, lifestyle, and pain characteristics.Results: The prevalence of migraine was significantly higher among those suffering from diabetes (14.9% vs. 13.0%; p=0.021). The multivariable analysis showed that diabetes was not associated with a higher risk of migraine (adjusted OR 1.06; 95%CI 0.89–1.25). Among diabetic subjects, female sex, suffering concomitant mental disorders, respiratory disorders, neck pain, and low back pain were variables associated with suffering from migraine.Conclusion: We found no significant differences in the prevalence of migraine between ­diabetics and non-diabetic age- and sex-matched controls after controlling for possible confounders. Keywords: diabetes, headache, survey, self-rated health, comorbidities, pain medication

Javier de Miguel Díez,1 Jorge Chancafe Morgan,1 Rodrigo Jiménez García2 1Pulmonology Department, Gregorio Maranon University Hospital, Complutense University of Madrid, Madrid, Spain; 2Preventive Medicine and Public Health Teaching and Research Unit, Department of Health Sciences, Rey Juan Carlos University, Madrid, Spain Abstract: Chronic obstructive pulmonary disease (COPD) is commonly associated with heart failure (HF) in clinical practice since they share the same pathogenic mechanism. Both conditions incur significant morbidity and mortality. Therefore, the prognosis of COPD and HF combined is poorer than for either disease alone. Nevertheless, usually only one of them is diagnosed. An active search for each condition using clinical examination and additional tests including plasma natriuretic peptides, lung function testing, and echocardiography should be obtained. The combination of COPD and HF presents many therapeutic challenges. The beneficial effects of selective ß1-blockers should not be denied in stable patients who have HF and coexisting COPD. Additionally, statins, angiotensin-converting enzyme inhibitors, and angiotensin-receptor blockers may reduce the morbidity and mortality of COPD patients. Moreover, caution is advised with use of inhaled ß2-agonists for the treatment of COPD in patients with HF. Finally, noninvasive ventilation, added to conventional therapy, improves the outcome of patients with acute respiratory failure due to hypercapnic exacerbation of COPD or HF in situations of acute pulmonary edema. The establishment of a combined and integrated approach to managing these comorbidities would seem an appropriate strategy. Additional studies providing new data on the pathogenesis and management of patients with COPD and HF are needed, with the purpose of trying to improve quality of life as well as survival of these patients. Keywords: chronic obstructive pulmonary disease, heart failure