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Calvin You Jia Chen,1 Min Sen Yew,2 John Arputhan Abisheganaden,3 Huiying Xu3 1Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; 2Department of Cardiology, Tan Tock Seng Hospital, Singapore, Singapore; 3Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, SingaporeCorrespondence: Huiying XuDepartment of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, Singapore, 308433, Tel +65 6256 6011Email Huiying_xu@ttsh.com.sgPurpose: Influenza infection is an important cause of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Clinical features predicting influenza PCR positivity are unknown. We aim to identify predictors of influenza PCR positivity in AECOPD.Patients and Methods: A retrospective study of AECOPD cases admitted between 1st January 2016 to 30 June 2017 with combined nasal/throat swabs sent for influenza PCR (Xpert Xpress Flu/RSV) within 24 hours of admission was performed. Clinical parameters and investigations within 24 hours of admission were retrieved from electronic medical records.Results: Influenza PCR were sent for 925 AECOPD cases (mean age 75 years, 87.9% male). There were 90 PCR positive cases (68 Influenza A, 22 Influenza B). Influenza PCR positive cases had higher temperatures, higher heart rates, lower white cell and lower eosinophil counts. Age, gender, COPD severity, comorbidities and smoking status were similar in both groups. There were no differences in blood pressure, oxygen status, neutrophil or lymphocyte counts, C reactive protein, procalcitonin or chest X-ray consolidation between groups. Higher temperature, higher heart rate, white cell count in the lowest quartile (Q1 < 8.1 x109/L) and non-eosinophilic exacerbations predicted influenza PCR positivity on univariate logistic regression and these factors remained significant after multivariate adjustment (temperature adjusted odds ratio [adj OR] 1.324 [1.009– 1.737], p = 0.043; heart rate adj OR 1.017 [1.004– 1.030], p = 0.011; white cell count Q1 adj OR 3.330 [1.690– 6.562], p = 0.001; eosinophilic exacerbations adj OR 0.390 [0.202– 0.756], p = 0.005).Conclusion: Higher temperature, higher heart rate, low white cell count (especially when < 8.1 x109/L) and non-eosinophilic exacerbations are independent predictors of influenza PCR positivity in AECOPD cases.Keywords: chronic obstructive pulmonary disease, exacerbation, influenza, eosinophil

Background: Sensitisation to Aspergillus fumigatus is linked to worse outcomes in patients with COPD; however, its prevalence and clinical implications in domestic (residential) settings remains unknown., Methods: Individuals with COPD (n=43) recruited in Singapore had their residences prospectively sampled and assessed by shotgun metagenomic sequencing including indoor air, outdoor air and touch surfaces (a total of 126 specimens). The abundance of environmental A. fumigatus and the occurrence of A. fumigatus (Asp f) allergens in the environment were determined and immunological responses to A. fumigatus allergens determined in association with clinical outcomes including exacerbation frequency. Findings were validated in 12 individuals (31 specimens) with COPD in Vancouver, Canada, a climatically different region., Results: 157 metagenomes from 43 homes were assessed. 11 and nine separate Aspergillus spp . were identified in Singapore and Vancouver, respectively. Despite climatic, temperature and humidity variation, A. fumigatus was detectable in the environment from both locations. The relative abundance of environmental A. fumigatus was significantly associated with exacerbation frequency in both Singapore (r=0.27, p=0.003) and Vancouver (r=0.49, p=0.01) and individuals with higher Asp f 3 sensitisation responses lived in homes with a greater abundance of environmental Asp f 3 allergens (p=0.037). Patients exposed and sensitised to Asp f 3 allergens demonstrated a higher rate of COPD exacerbations at 1-year follow-up (p=0.021)., Conclusion: Environmental A. fumigatus exposure in the home environment including air and surfaces with resulting sensitisation carries pathogenic potential in individuals with COPD. Targeting domestic A. fumigatus abundance may reduce COPD exacerbations., Competing Interests: Conflict of interest: P.Y. Tiew and A. Tee have served on advisory boards for GlaxoSmithKline and AstraZeneca, outside the submitted work. M.S. Koh reports grant support from AstraZeneca, and honoraria for lectures and advisory board meetings paid to her hospital (Singapore General Hospital) from GlaxoSmithKline, AstraZeneca, Novartis, Sanofi, Boehringer Ingelheim and Roche, outside the submitted work. F.T. Chew reports grants from the National University of Singapore, Singapore Ministry of Education Academic Research Fund, Singapore Immunology Network, National Medical Research Council (NMRC) (Singapore), Biomedical Research Council (BMRC) (Singapore), National Research Foundation (NRF) (Singapore), Singapore Food Agency (SFA), and the Agency for Science Technology and Research (A*STAR) (Singapore), during the conduct of the study, and consulting fees from Sime Darby Technology Centre, First Resources Ltd, Genting Plantation, Olam International, Musim Mas and Syngenta Crop Protection, outside the submitted work. P.Y. Tiew reports grants from Singapore Ministry of Health's National Medical Research Council under its Transition Award (MOH- 001275-00). S.H. Chotirmall reports support for the present study from Singapore Ministry of Health's National Medical Research Council under its Clinician-Scientist Individual Research Grant (MOH-001356), Singapore Ministry of Health's National Medical Research Council under its Clinician Scientist Award (MOH-000710), Open Fund Individual Research Grant (MOH-000955) and Singapore Ministry of Education under its AcRF Tier 1 Grant (RT1/22), consultancy fees from CSL Behring, Boehringer Ingelheim and Pneumagen Ltd, payment or honoraria for lectures, presentations, manuscript writing or educational events from AstraZeneca and Chiesi Farmaceutici, and participation on a data safety monitoring board or advisory board with Inovio Pharmaceuticals Inc. and Imam Abdulrahman Bin Faisal University. J.M. Leung and C. Carlsten report grants from Canada Research Chairs program. The remaining authors have no potential conflicts of interest to disclose., (Copyright ©The authors 2024.)

Background/objectives: Qualitative research can be laborious and time consuming, presenting a challenge for practitioners and policymakers seeking rapid, actionable results. Data collection, transcription and analysis are the main contributors to the resource-intensive nature. OpenAI's Chat Generative Pre-trained Transformer (ChatGPT), have demonstrated potential to aid in data analysis. Our study aimed to compare themes generated by ChatGPT (3.5 and 4.0) with traditional human analysis from in-depth interviews., Methods: Three transcripts from an evaluation study to understand patients' experiences at a community eye clinic were used. Transcripts were first analysed by an independent researcher. Next, specific aims, instructions and de-identified transcripts were uploaded to ChatGPT 3.5 and ChatGPT 4.0. Concordance in the themes was calculated as the number of themes generated by ChatGPT divided by the number of themes generated by the researcher. The number of unrelated subthemes and time taken by both ChatGPT were also described., Results: The average time taken per transcript was 11.5 min, 11.9 min and 240 min for ChatGPT 3.5, ChatGPT 4.0 and researcher respectively. Six themes were identified by the researcher: (i) clinic's accessibility, (ii) patients' awareness, (iii) trust and satisfaction, (iv) patients' expectations, (v) willingness to return and (vi) explanation of the clinic by referral source. Concordance for ChatGPT 3.5 and 4.0 ranged from 66 to 100%., Conclusion: Preliminary results showed that ChatGPT significantly reduced analysis time with moderate to good concordance compared with current practice. This highlighted the potential adoption of ChatGPT to facilitate rapid preliminary analysis. However, regrouping of subthemes will still need to be conducted by a researcher., (© 2024. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Adherence to treatment plans is crucial for patients with diabetic foot ulcers (DFUs) to achieve positive outcomes. With limited understanding of nonadherence and its impacts on care outcomes, this study aimed to explore the reasons and factors associated with nonadherence in an integrated diabetic limb salvage (DLS) programme and evaluate its effects on care outcomes. This study included 2798 DFU patients who were enrolled in an integrated DLS programme across multiple institutions in central and northern Singapore from 2020 to 2021. Reasons for nonadherence were obtained via telephone interviews. Factors associated with nonadherence were identified using multiple logistic regression. Differences in one-year outcomes, including minor and major lower extremity amputation (LEA), mortality, LEA-free survival, and healthcare utilisation between adherent and nonadherent patients, were examined based on a significance level of P  < .05. Nonadherence was observed in 40.2% of patients, with higher rates among younger patients, Malays and Indians, and those with higher HbA1c levels. Patient-related factors were the most commonly reported reasons for missed appointments (50.4%). Compared to adherent patients, nonadherent patients exhibited a relatively higher minor LEA rate (13.0% vs 10.2%, OR = 1.18, 95% CI: 0.93, 1.51), lower mortality rate (8.6% vs18.1%, OR = 0.50, 95% CI: 0.39, 0.65), higher overall LEA-free survival (76.4% vs 71.1%, OR = 1.27, 95% CI: 1.06, 1.53), and more hospitalisations (IRR = 1.22, 95% CI: 1.11, 1.33) and emergency visits (IRR = 1.27, 95% CI: 1.16, 1.39). While nonadherent patients showed relatively higher minor LEA rates and more healthcare utilisation, they also exhibited lower mortality and higher LEA-free survival. This suggests that nonadherence in this population may be associated with complex patient characteristics and behaviours that warrant further investigation to tailor interventions effectively., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Artificial Intelligence (AI) is transforming systematic reviews (SRs) in health research by automating processes such as study screening, data extraction, and quality assessment. This perspective highlights recent advancements in AI tools that enhance efficiency and accuracy in SRs. It discusses the benefits, challenges, and future directions of AI integration, emphasising the need for human oversight to ensure the reliability of AI outputs in evidence synthesis and decision-making in healthcare., (© 2024. The Author(s).)

Background: Individuals with chronic lung disease (CLD) are more susceptible to respiratory viral infections; however, significant heterogeneity exists in the literature on CLD and COVID-19 outcomes. Data are lacking on outcomes with newer variants (eg, Omicron) and in vaccinated and boosted populations., Research Question: What are the outcomes of SARS-CoV-2 infection in individuals with CLD during Delta and Omicron transmission in a highly vaccinated and boosted population-based cohort?, Study Design and Methods: Outcomes of Delta and Omicron SARS-CoV-2 infection in a highly vaccinated and boosted cohort of adult Singaporeans with CLD (including asthma, COPD, bronchiectasis, and pulmonary fibrosis) were contrasted against matched population control participants. Calendar time-scale Cox regressions were used to compare risk of infection, COVID-19-related hospitalizations, and severe COVID-19 disease, adjusting for sociodemographic factors and comorbidities., Results: Overall, 68,782 individual patients with CLD and 534,364 matched population control participants were included. By the end of the Omicron wave, 92.7% of patients with CLD were boosted. Compared with control participants, patients with CLD showed higher risk of SARS-CoV-2 infection, COVID-19-related hospitalization, and severe COVID-19 during both the Delta wave (infection: adjusted hazards ratio [aHR], 1.22 [95% CI, 1.17-1.28]; hospitalization: aHR, 1.76 [95% CI, 1.61-1.92]; severe COVID-19: aHR, 1.75 [95% CI, 1.50-2.05]) and Omicron wave (infection: aHR, 1.15 [95% CI, 1.14-1.17]; hospitalization: aHR, 1.82 [95% CI, 1.74-1.91]; severe COVID-19: aHR, 2.39 [95% CI, 2.18-2.63]). During Omicron, significantly higher risk of infection, hospitalization, and severe COVID-19 was observed among patients with asthma (severe COVID-19: aHR, 1.31 [95% CI, 1.10-1.55]) and COPD (severe COVID-19: aHR, 1.36 [95% CI, 1.12-1.66]) compared with control participants. Severe exacerbation (requiring hospitalization) in the preceding year was associated with higher risk of poorer outcomes (Delta, severe COVID-19: aHR, 9.84 [95% CI, 6.33-15.28]; Omicron, severe COVID-19: aHR, 19.22 [95% CI, 15.35-24.06]). Risk was attenuated in the boosted group, with numerically lower HRs against hospitalization and severe COVID-19 in the four-dose group compared with the three-dose group., Interpretation: Increased risk of COVID-19-related hospitalization and severe COVID-19 was observed among patients with CLD compared with matched population control participants during Delta and Omicron predominance. Boosting attenuated serious COVID-19 outcomes., Competing Interests: Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: S. H. C. reports relationships with CSL Behring LLC, Pneumagen, Boehringer Ingelheim GmbH, Inovio Pharmaceuticals, Inc., and Imam Abdulrahman Bin Faisal University that include board membership and relationships with AstraZeneca Pharmaceuticals LP and Chiesi Pharmaceuticals, Inc., that include speaking and lecture fees. None declared (L. E. W., J. Y. J. T., C. J.C., J. A. A., D. C. B. L., K. B. T.)., (Copyright © 2024 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

This study assessed the cost-effectiveness of continuous positive airway pressure treatment for obstructive sleep apnea in Singapore from a health system perspective. The analysis evaluated a 5-year care pathway using a Markov model, considering per-patient costs of treatment, health system cost savings of obstructive sleep apnea and attributed conditions, the effectiveness measured in disability-adjusted life years with a discount rate of 3% and a weighted 5-year continuous positive airway pressure adherence of 74.1% from Singapore studies. Per-patient costs of treatment were from a large public hospital in Singapore. Efficacy of continuous positive airway pressure treatment, health system costs and disability-adjusted life years were obtained from literature; costs are in US dollars. We conducted probabilistic sensitivity analysis, one-way sensitivity analysis and what-if analysis. Based on a willingness-to-pay threshold of US $50,000 per disability-adjusted life year in USA, continuous positive airway pressure therapy was highly cost-effective, with an incremental cost-effectiveness ratio of $13,822 per disability-adjusted life year averted. Compared with the annual total costs of $856 for patients with continuous positive airway pressure treatment diagnosed by an inpatient sleep study, the total costs for those diagnosed by a home sleep test were $625, resulting in a remarkable 27% reduction per patient per year. One-way sensitivity analysis indicated that costs of treatment, effectiveness of continuous positive airway pressure treatment and adherence had a higher impact on the cost-effectiveness of continuous positive airway pressure therapy. The what-if analysis suggested that for continuous positive airway pressure treatment to be cost-effective, adherence rate should be at least 16.1%. These findings provide valuable insights for policymakers in making informed decisions on funding diagnosis and continuous positive airway pressure therapy within Singapore's healthcare system., (© 2024 European Sleep Research Society.)

Rationale: Chronic infection and inflammation shapes the airway microbiome in bronchiectasis. Utilizing whole-genome shotgun metagenomics to analyze the airway resistome provides insight into interplay between microbes, resistance genes, and clinical outcomes. Objectives: To apply whole-genome shotgun metagenomics to the airway microbiome in bronchiectasis to highlight a diverse pool of antimicrobial resistance genes: the "resistome," the clinical significance of which remains unclear. Methods: Individuals with bronchiectasis were prospectively recruited into cross-sectional and longitudinal cohorts ( n  = 280), including the international multicenter cross-sectional Cohort of Asian and Matched European Bronchiectasis 2 (CAMEB 2) study ( n  = 251) and two independent cohorts, one describing patients experiencing acute exacerbation and a further cohort of patients undergoing Pseudomonas aeruginosa eradication treatment. Sputum was subjected to metagenomic sequencing, and the bronchiectasis resistome was evaluated in association with clinical outcomes and underlying host microbiomes. Measurements and Main Results: The bronchiectasis resistome features a unique resistance gene profile and increased counts of aminoglycoside, bicyclomycin, phenicol, triclosan, and multidrug resistance genes. Longitudinally, it exhibits within-patient stability over time and during exacerbations despite between-patient heterogeneity. Proportional differences in baseline resistome profiles, including increased macrolide and multidrug resistance genes, associate with shorter intervals to the next exacerbation, whereas distinct resistome archetypes associate with frequent exacerbations, poorer lung function, geographic origin, and the host microbiome. Unsupervised analysis of resistome profiles identified two clinically relevant "resistotypes," RT1 and RT2, the latter characterized by poor clinical outcomes, increased multidrug resistance, and P. aeruginosa. Successful targeted eradication in P. aeruginosa -colonized individuals mediated reversion from RT2 to RT1, a more clinically favorable resistome profile demonstrating reduced resistance gene diversity. Conclusions: The bronchiectasis resistome associates with clinical outcomes, geographic origin, and the underlying host microbiome. Bronchiectasis resistotypes link to clinical disease and are modifiable through targeted antimicrobial therapy.

Background: Variable clinical outcomes are reported with fungal sensitisation in chronic obstructive pulmonary disease (COPD), and it remains unclear which fungi and what allergens associate with the poorest outcomes. The use of recombinant as opposed to crude allergens for such assessment is unknown., Methods: A prospective multicentre assessment of stable COPD (n=614) was undertaken in five hospitals across three countries: Singapore, Malaysia and Hong Kong. Clinical and serological assessment was performed against a panel of 35 fungal allergens including crude and recombinant Aspergillus and non- Aspergillus allergens. Unsupervised clustering and topological data analysis (TDA) approaches were employed using the measured sensitisation responses to elucidate if sensitisation subgroups exist and their related clinical outcomes., Results: Aspergillus fumigatus sensitisation was associated with increased exacerbations in COPD. Unsupervised cluster analyses revealed two "fungal sensitisation" groups. The first was characterised by Aspergillus sensitisation and increased exacerbations, poorer lung function and worse prognosis. Polysensitisation in this group conferred even poorer outcome. The second group, characterised by Cladosporium sensitisation, was more symptomatic. Significant numbers of individuals demonstrated sensitisation responses to only recombinant (as opposed to crude) A. fumigatus allergens f 1, 3, 5 and 6, and exhibited increased exacerbations, poorer lung function and an overall worse prognosis. TDA validated these findings and additionally identified a subgroup within Aspergillus -sensitised COPD of patients with frequent exacerbations., Conclusion: Aspergillus sensitisation is a treatable trait in COPD. Measuring sensitisation responses to recombinant Aspergillus allergens identifies an important patient subgroup with poor COPD outcomes that remains overlooked by assessment of only crude Aspergillus allergens., Competing Interests: Conflict of interest: P.Y. Tiew received honoraria for lectures and advisory board meetings paid to her hospital (Singapore General Hospital) from AstraZeneca, GlaxoSmithKline and Boehringer Ingelheim, outside the submitted work. M.S. Koh received research grant support from AstraZeneca, and honoraria for lectures and advisory board meetings paid to her hospital (Singapore General Hospital) from GlaxoSmithKline, AstraZeneca, Novartis, Sanofi and Boehringer Ingelheim, outside the submitted work. K. Tsaneva-Atanasova reports EPSRC grant EP/T017856/1. F.T. Chew reports personal fees for consultancy from Sime Darby Technology Centre, First Resources Ltd, Genting Plantation and Olam International, outside the submitted work. S.H. Chotirmall is on advisory boards for CSL Behring, Pneumagen Ltd and Boehringer Ingelheim, serves on a data and safety monitoring board for Inovio Pharmaceuticals Inc. and Imam Abdulrahman Bin Faisal University, and has received personal fees from AstraZeneca, all outside of the submitted work. All other authors have no conflicts of interest to declare., (Copyright ©The authors 2023.)

Neisseria species are frequently identified in the bronchiectasis microbiome, but they are regarded as respiratory commensals. Using a combination of human cohorts, next-generation sequencing, systems biology, and animal models, we show that bronchiectasis bacteriomes defined by the presence of Neisseria spp. associate with poor clinical outcomes, including exacerbations. Neisseria subflava cultivated from bronchiectasis patients promotes the loss of epithelial integrity and inflammation in primary epithelial cells. In vivo animal models of Neisseria subflava infection and metabolipidome analysis highlight immunoinflammatory functional gene clusters and provide evidence for pulmonary inflammation. The murine metabolipidomic data were validated with human Neisseria-dominant bronchiectasis samples and compared with disease in which Pseudomonas-, an established bronchiectasis pathogen, is dominant. Metagenomic surveillance of Neisseria across various respiratory disorders reveals broader importance, and the assessment of the home environment in bronchiectasis implies potential environmental sources of exposure. Thus, we identify Neisseria species as pathobionts in bronchiectasis, allowing for improved risk stratification in this high-risk group., Competing Interests: Declaration of interests J.D.C. has received research grants from GSK, BI, AZ, Gilead Sciences, Grifols, and Insmed and has received personal fees from GSK, BI, AZ, Chiesi, Grifols, Napp, Novartis, Insmed, and Zambon, all outside the submitted work. S.H.C. is on advisory boards for CSL Behring, Pneumagen, and BI, serves on Data and Safety Monitoring Boards for Inovio Pharmaceuticals and Imam Abdulrahman Bin Faisal University, and has received personal fees from AZ, all outside of the submitted work., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Allergic bronchopulmonary aspergillosis (ABPA) is associated with frequent exacerbations and poor outcomes in chronic respiratory disease, but remains underdiagnosed. The role of fungal sensitization in bronchiectasis-COPD overlap (BCO) is unknown., Research Question: What is the occurrence and clinical relevance of Aspergillus sensitization and ABPA in BCO when compared with individuals with COPD or bronchiectasis without overlap?, Study Design: Prospective, observational, cross-sectional study., Methods: We prospectively recruited 280 patients during periods of clinical stability with bronchiectasis (n = 183), COPD (n = 50), and BCO (n = 47) from six hospitals across three countries (Singapore, Malaysia, and Scotland). We assessed sensitization responses (as specific IgE) to a panel of recombinant Aspergillus fumigatus allergens and the occurrence of ABPA in relationship to clinical outcomes., Results: Individuals with BCO show an increased frequency and clinical severity of ABPA compared with those with COPD and bronchiectasis without overlap. BCO-associated ABPA is associated with more severe disease, higher exacerbation rates, and lower lung function when compared with ABPA occurring in the absence of overlap. BCO with a severe bronchiectasis severity index (BSI; > 9) is associated significantly with the occurrence of ABPA that is unrelated to underlying COPD severity., Conclusions: BCO demonstrates a high frequency of ABPA that is associated with a severe BSI (> 9) and poor clinical outcomes. Clinicians should maintain a high index of suspicion for the potential development of ABPA in patients with BCO with high BSI., (Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Objectives: The Integrated Care for Advanced REspiratory Disorders (ICARE) service is a stay-in, post-acute care program for hospitalized patients with chronic, nonmalignant lung diseases. It provides palliative rehabilitation-a novel model integrating functional rehabilitation with early palliative care. We compare reduction of health care utilization among ICARE participants vs matched controls receiving usual care., Design: This is a prospective, propensity score-matched study. Primary outcomes were reduction in hospital readmissions and length of stay and emergency department (ED) visits, comparing the period 6 months before and after ICARE, or 6 months before and after hospital discharge (for controls). Secondary outcomes included 6-minute walking distance (6MWD) and Modified Barthel Index (MBI)., Setting: Participants were matched 1:1 to controls by age, respiratory diagnosis, socioeconomic strata, index hospitalization length of stay, frailty, and recent admissions into intensive care unit or noninvasive ventilation units., Methods: Multidisciplinary interventions focused on symptom relief, functional rehabilitation, targeted comorbidity management, and postdischarge care coordination., Results: One hundred pairs of patients were matched. Participants were older adults (mean age 73.9 ± 8.2 years) with prolonged index hospitalization (median 12.0 days; interquartile range 7-18). Overall, 57% had high Hospital Frailty Risk Scores and 71% had overlapping respiratory diagnoses, the most common commonest being COPD (89%), followed by interstitial lung disease (54%) and bronchiectasis (28%). Small reductions in health care utilization were observed among controls. ICARE was associated with a further 9.1 ± 19.9 days' reduction in hospitalization length of stay (P < .001), 0.8 ± 1.9 lesser admission (P < .001), and 0.6 ± 2.2 fewer ED visits (P < .02). Participants with longest index hospitalization were observed to have greatest reduction in length of stay. 6MWD and MBI scores improved by 41.0 ± 60.2 m and 12.3 ± 11.6 points, respectively (both P < .001). Greater improvement was observed in patients with lower baseline 6MWD and MBI scores. Prescription of slow-release opioids rose from 9% to 49%. Treatment for anxiety and depression rose from 5% to 19%., Conclusions and Implications: Integrating palliative care with postexacerbation functional rehabilitation was associated with short-term reduction in health care utilization, improved functional capacity, and increased treatment of dyspnea, anxiety, and depression., (Copyright © 2021 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)