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Introduction: The prevalence of alpha-1 antitrypsin deficiency (AATD) in Macaronesia (i.e., Azores, Madeira, Canary Islands, and Cape Verde archipelagos) is poorly known. Our goal was to update it by selecting the most reliable available articles. Method: Literature search using MEDLINE, Embase (via Ovid), and Google Scholar, until December 2023, for studies on prevalence of AATD in the general population and in screenings, published in peer-reviewed journals. Results: Three studies carried out in the general population of Madeira, La Palma, and Cape Verde, and three screenings carried out in La Palma (2) and Gran Canaria (1) were selected. The frequencies of PI*S in the general population showed an ascending gradient, from South to North, with values (per thousand) of 35 in Cape Verde, 82 in La Palma, and 180 in Madeira. The PI*Z frequencies showed this same gradient, with values of 2 × 1,000 in Cape Verde, 21 in La Palma, and 25 in Madeira. Screenings detected high percentages of defective alleles, including several rare and null alleles, some unique to these islands. Conclusion: The frequencies of PI*S and PI*Z in Madeira are comparable to the highest in the world. Those of the Canary Islands are similar to those of the peninsular population of Spain, and contrast with the low rates of Cape Verde. Screenings detected high numbers of deficient alleles. These results support the systematic investigation of AATD in clinically suspected patients and in relatives of index cases, to reduce underdiagnosis and apply early preventive and therapeutic measures in those affected. [ABSTRACT FROM AUTHOR]

Background: Alpha-1 antitrypsin deficiency (AATD) is an underdiagnosed condition despite being one of the most common inherited disorders in adults that is associated with an increased risk of developing chronic obstructive pulmonary disease (COPD). The aim was to evaluate the frequency of performing AAT levels and associated factors in COPD patients in an audit conducted in 2021–2022, as well as to compare with a previous audit conducted in 2014–2015. Methods: EPOCONSUL 2021 is a cross-sectional audit that evaluated the outpatient care provided to COPD patients in respiratory clinics in Spain based on available data from medical registries. Results: 4225 patients with a diagnosis of COPD from 45 centers were audited in 2021. A total of 1670 (39.5%) patients underwent AAT determination. Being treated at a specialized COPD outpatient clinic (OR 1.88, p = 0.007), age ≤ 55 years old (OR 1.84, p = 0.007) and a FEV1 < 50% (OR 1.86, p < 0.001) were associated with a higher likelihood of being tested for AAT, while Charlson index ≥ 3 (OR 0.63, p < 0.001) and genotyping of AATD availability (OR 0.42, p < 0.001) showed a statistically significant negative association. The analysis of cases included in respiratory units that participated in both audits showed an increase in the proportion of cases with AAT serum level testing available (adjusted OR 2.81, p < 0.001). The percentage of individuals with serum AAT levels < 60 mg/dL (a severe AATD) was 4%. Conclusions: Our analysis identifies significant improvements in adherence to the recommendation to test AAT levels in COPD patients, performed in 4 out of 10 patients, being more likely at younger ages and with higher COPD severity, and with a detection of severe AATD of 4% among those tested, suggesting that clinicians still perform AAT testing in COPD patients selectively. Therefore, efforts are still needed to optimize AATD screening and establish new early detection strategies to reduce morbidity and mortality in these patients. [ABSTRACT FROM AUTHOR]

Inhaled bronchodilator therapy with long-acting muscarinic antagonists (LAMAs) and long-acting β2-agonists (LABAs) in combination is currently the mainstay of treatment for chronic obstructive pulmonary disease (COPD). Treatment guidelines recommend the addition of inhaled corticosteroids (ICS) to LABA/LAMA only in patients with a history of frequent/severe exacerbations and high blood eosinophil counts, or in those with concomitant asthma. Despite this, real-world data suggest that clinicians are not adhering to this guidance and that ICS are frequently overused. This is possibly due to the incorrect assumption that when LABA/LAMA therapy is not sufficient, adding an ICS to the treatment regimen is the logical next step. In this narrative review, we describe global and country-specific guideline recommendations from Germany, Spain, and Japan and compare these with real-world data on LABA/LAMA and ICS use in clinical practice. We also provide a clinical guide to the use of add-on therapies with LABA/LAMA for different patient phenotypes, including (1) patients still symptomatic (but not exacerbating) despite LABA/LAMA treatment; (2) patients still exacerbating despite LABA/LAMA treatment who have high blood eosinophil counts; and (3) patients still exacerbating despite LABA/LAMA treatment who do not have high blood eosinophils or concomitant asthma. Plain language summary: What are the options for patients with COPD when LABA/LAMA is not enough? Treatment guidelines for chronic obstructive pulmonary disease (COPD) recommend dual bronchodilator therapy for the majority of patients, consisting of an inhaled combination of long-acting β2-agonist (LABA) and long-acting muscarinic antagonist (LAMA). Patients whose COPD is not well controlled on LABA/LAMA require further clinical intervention, which may or may not involve treatment with additional drugs. Data from observational studies reflecting routine clinical practice suggest that inhaled corticosteroids (ICS) are often added to LABA/LAMA, even though treatment guidelines recommend only adding ICS in a specific group of patients with a history of exacerbations and high levels of eosinophils (a type of inflammatory cell) in the blood, or in those with current asthma. As long-term ICS use may be associated with an increased risk of side effects such as pneumonia, it is important to avoid overuse of ICS. When a patient's COPD is not well controlled on LABA/LAMA, other treatable conditions should first be ruled out, and factors such as medication adherence, inhaler technique, and co-existing health conditions should also be considered. This review gives advice on what follow-up options physicians should consider when LABA/LAMA is not providing adequate control of a patient's COPD. Specifically, recommendations are given for three different patient profiles: 1. Patients who still have symptoms of COPD (but no acute/sudden worsenings of symptoms, known as exacerbations). 2. Patients who have exacerbations, as well as high levels of eosinophils in the blood. 3. Patients who have exacerbations, but without high levels of eosinophils in the blood or current asthma. [ABSTRACT FROM AUTHOR]

Background: The objective of this analysis is to evaluate tobacco use and the level of chronic obstructive pulmonary disease (COPD) knowledge among the general adult population in Spain and to compare these results to those obtained in the 2011 survey. Methods: A cross-sectional, observational, epidemiological study was conducted by telephone interviews and stratified by sex, age, and setting. The study design was identical to that of the study conducted in 2011. Results: Of a total of 89,601 phone contacts, there were 6534 respondents. The average age was 61.5 years. With respect to smoking, 30.9% reported being former smokers and 14.7% were current smokers, 63.6% of whom reported having attempted to quit. Among the current smokers, 19.7% claimed to use electronic cigarettes, although 88% believe these pose a health risk. No significant differences were found in smoking prevalence or frequency of attempts to quit according to residential setting (rural/urban). The highest prevalence of current smoking in men was recorded in the 55–64 years age range (31.6%), while in women it was from 45 to 54 years (34.6%). Smoking has decreased with respect to 2011, from 21.1% to 16.1% in men and from 17.9% to 13.2% in women, with a clear variability according to region. Of the population surveyed, 32.5% had spontaneous knowledge about COPD, with significant geographic variability. The most frequent sources of information about the disease were social media and the Internet (39.6%), followed by the media (35.2%). Conclusions: The prevalence of tobacco use in adults has considerably decreased and there is greater knowledge about COPD in Spain, although there is significant variability according to region, which could explain the geographic variability in the prevalence of COPD. Strategies are needed to increase COPD education and awareness and to reinforce smoking prevention measures among women. [ABSTRACT FROM AUTHOR]

Background: Patients with alpha-1 antitrypsin deficiency (AATD), commonly categorized as a rare disease, have been affected by the changes in healthcare management brought about by COVID-19. This study's aim was to identify the changes that have taken place in AATD patient care as a result of the COVID-19 pandemic in Spain and to propose experts' recommendations aimed at ensuring humanized and quality care for people with AATD in the post-pandemic situation. Methods: A qualitative descriptive case study with a holistic single-case design was conducted, using focus groups with experts in AATD clinical management, including 15 health professionals with ties to the Spanish health system (12 pneumologists and 2 hospital pharmacists from 11 different hospitals in Spain) and 1 patient representative. Results: COVID-19 has had a major impact on numerous aspects of AATD clinical patient management in Spain, including diagnostic, treatment, and follow-up phases. The experts concluded that there is a need to strengthen coordination between Primary Care and Hospital Care and improve the coordination processes across all the organizations and actors involved in the healthcare system. Regarding telemedicine and telecare, experts have concluded that it is necessary to promote this methodology and to develop protocols and training programs. Experts have recommended developing personalized and precision medicine, and patient participation in decision-making, promoting self-care and patient autonomy to optimize their healthcare and improve their quality of life. The possibility of monitoring and treating AATD patients from home has also been proposed by experts. Another result of the study was the recommendation of the need to ensure that plasma donations are made on a regular basis by a sufficient number of healthy individuals. Conclusion: The study advances knowledge by highlighting the challenges faced by health professionals and changes in AATD patient management in the context of the COVID-19 pandemic. It also proposes experts' recommendations aimed at ensuring humanized and quality care for people with AATD in the post-pandemic situation. This work could serve as a reference study for physicians on their daily clinical practice with AATD patients and may also provide guidance on the changes to be put in place for the post-pandemic situation. [ABSTRACT FROM AUTHOR]

Factors such as seeking medical attention for respiratory symptoms and health professionals ordering spirometry come into play in the underdiagnosis of chronic obstructive pulmonary disease (COPD). The objective of this study was to analyze seeking medical attention and the use of spirometry in individuals with chronic respiratory symptoms and to compare these results with those obtained in the 2005 and 2011 surveys. Material and Methods: A cross-sectional, observational, epidemiological study was conducted via phone interview in December 2020 in Spain, with a representative sample from 17 autonomous communities. The study design was identical to that of the studies carried out in 2005 and 2011 to evaluate the changes that have occurred in seeking medical attention and performing spirometry in Spain, as well as the variability between autonomous communities. Results: From 89,601 phone contacts, a total of 6534 respondents were obtained. A total of 24.8% reported having some chronic respiratory symptom, and 17.9% reported a respiratory disease. Only 51.6% of those who had some chronic respiratory symptom had seen their doctor, which was less likely among current smokers (OR: 0.599, 95% CI: 0.467–0.769, p < 0.001) and those living in a rural setting (OR: 0.797, 95% CI: 0.651–0.975, p = 0.027). A total of 68.7% of the individuals who saw a doctor reported having undergone spirometry, most frequently males (OR: 1.535, 95% CI: 2.074–1.136, p < 0.005), former smokers (OR: 1.696, 95% CI: 2.407–1.195, p < 0.003), and those seen by a pulmonologist (OR: 6.151, 95% CI: 8.869–4.265, p < 0.001). With respect to the 2005 survey, more frequent use of spirometry has been observed (42.6 vs. 68.7%), without any change in seeking medical attention for respiratory symptoms. There is a clear variability according to the autonomous community (p < 0.05). Conclusions: Many individuals with chronic respiratory symptoms do not seek medical attention and although the use of spirometry has increased in the past 15 years, it is still an important area that needs improving in the primary care setting, especially among women. Both of these factors can be determinants in the underdiagnosis of COPD and its variability between autonomous communities. [ABSTRACT FROM AUTHOR]

Background: Blood eosinophils are considered a biomarker for the treatment of chronic obstructive pulmonary disease (COPD). Population-based studies are needed to better understand the determinants of the blood eosinophil count (BEC) in individuals with and without COPD.Methods: EPISCAN II is a multicentre, cross-sectional, population-based epidemiological study aimed at investigating the prevalence and determinants of COPD in Spain. Study subjects were randomly selected from the general population, and COPD was defined by a post-bronchodilator FEV1/FVC < 0.7. For the pre-specified outcomes related to BEC, the first 35 COPD and 35 non-COPD subjects were consecutively recruited in 12 of the participating centres with the objective of analysing 400 individuals in each group. Baseline BEC and its association with demographic, clinical and functional variables were analysed.Results: A total of 326 COPD and 399 non-COPD subjects were included in the analysis. The mean age (standard deviation [SD]) was 63.2 years (11.0), 46.3% were male, and 27.6% were active smokers. BEC was significantly higher in individuals with COPD [192 cells/μL (SD: 125) vs. 160 cells/μL (SD: 114); p = 0.0003]. In a stepwise multivariate model, being male, active smoker and having a previous diagnosis of asthma were independently associated with having a higher BEC.Conclusions: This population-based study estimated the distribution of eosinophils in the healthy adult population and concluded that COPD patients have a significantly higher BEC. Male sex, active smoking and concomitant asthma were significantly associated with a higher BEC. [ABSTRACT FROM AUTHOR]

Chronic obstructive pulmonary disease (COPD) is the leading cause of hospitalization for chronic respiratory illness in Spain. In recent years hospital admissions due to bronchiectasis have been increasing, although it is not known whether this is in proportion to COPD hospitalizations. Our main objective was to analyze the temporal evolution of discharges due to COPD, bronchiectasis, and their combination, and secondly, to assess their impact on in-hospital mortality and healthcare costs. We performed a retrospective study, based on the analysis of the Minimum Basic Data Set (MBDS) of hospital discharges using data from Spanish Ministry of Health with diagnostic codes of COPD or bronchiectasis between 2004 and 2015. We found 3 356 186 discharges with a diagnosis of COPD or bronchiectasis. After exclusions, 1 386 430 episodes were analyzed: 85.2% with COPD, 8.4% bronchiectasis, and 6.4% with both pathologies. Mean age of patients was 74.8 (10.9) years and with a male predominance of 80.1%. The increase in the annual number of discharges was greater in the two groups with bronchiectasis: 48.8% in the bronchiectasis group and 55.4% in the mixed group, compared to 6.6% in the COPD group. The mean length of stay was greater in both groups with bronchiectasis (p < 0.001), while in-hospital mortality was higher in the COPD group (p < 0.001). Similarly, the annual increase of costs was more evident in the two groups with bronchiectasis. Conclusions: Hospitalizations and health costs for bronchiectasis have increased in recent years significantly more than for COPD. Supplemental data for this aricle can be accessed here. [ABSTRACT FROM AUTHOR]

Copyright of Revista Española de Quimioterapia is the property of Sociedad Espanola de Quimioterapia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: COPD prevalence is highly variable and geographical altitude has been linked to it, yet with conflicting results. We aimed to investigate this association, considering well known risk factors.Methods: A pooled analysis of individual data from the PREPOCOL-PLATINO-BOLD-EPI-SCAN studies was used to disentangle the population effect of geographical altitude on COPD prevalence. Post-bronchodilator FEV1/FVC below the lower limit of normal defined airflow limitation consistent with COPD. High altitude was defined as >1500 m above sea level. Undiagnosed COPD was considered when participants had airflow limitation but did not report a prior diagnosis of COPD.Results: Among 30,874 participants aged 56.1 ± 11.3 years from 44 sites worldwide, 55.8% were women, 49.6% never-smokers, and 12.9% (3978 subjects) were residing above 1500 m. COPD prevalence was significantly lower in participants living at high altitude with a prevalence of 8.5% compared to 9.9%, respectively (p < 0.005). However, known risk factors were significantly less frequent at high altitude. Hence, in the adjusted multivariate analysis, altitude itself had no significant influence on COPD prevalence. Living at high altitude, however, was associated with a significantly increased risk of undiagnosed COPD. Furthermore, subjects with airflow limitation living at high altitude reported significantly less respiratory symptoms compared to subjects residing at lower altitude.Conclusion: Living at high altitude is not associated with a difference in COPD prevalence after accounting for individual risk factors. However, high altitude itself was associated with an increased risk of undiagnosed COPD. [ABSTRACT FROM AUTHOR]

Background: Determining physicians' awareness about alpha-1 antitrypsin (AAT) deficiency (AATD) may help to explain the discrepancy between the observed and expected number of patients diagnosed with this disease. This study was designed to assess the opinions on knowledge, practice pattern and attitude regarding AATD among physicians in Spain and Portugal. Methods: An online anonymous survey was performed on pulmonologists (n = 100), internal medicine specialists (IMS) (n = 100) and primary care physicians (PCP) (n = 176). Of the total number of physicians, 221 were from Spain, and 155 were from Portugal. Physicians answered 21 questions related to their personal and professional profile, knowledge regarding AATD and chronic obstructive pulmonary disease (COPD), performance and attitude about AATD, and use of augmentation therapy. Responses were ranked on a 4-point scale indicating the level of agreement. In addition, some of the responses were rated as either "low" or "high" indicating the level of knowledge the respondent felt he/she possessed. Results: Only 14 % of physicians reported to "know very well" about AATD (3.3 [SD 0.6] for pulmonologists vs. 2.64 [SD 0.60] for IMS and 2.48 [SD 0.71] for PCP; p < 0.001). Only 45.2 % of physicians correctly answered "<50 mg/dL" as the threshold value of serum AAT to be considered severe AATD (55.0 % of pulmonologists vs. 47.0 % of IMS and 38.6 % of PCP; p = 0.001). Choice of the correct answer did not agree with those physicians self-declaring a high level of AATD knowledge (51.2 %). A total of 43.9 % of physicians correctly identified all diseases or conditions in a list associated or not with AATD. A similar trend was detected when identifying which conditions would be responsive to augmentation therapy (<50 %). Only 15.8 % of specialists performed AATD testing in all patients with COPD (27.0 % pulmonologists, 12.6 % PCP; p = 0.001). Conclusion: The results suggest that a knowledge gap may be contributing to the underdiagnosis of AATD. Physicians in Spain and Portugal showed a marked lack of awareness of their shortcomings in knowledge about AATD, and in general did not follow guidelines and recommendations for AATD testing. [ABSTRACT FROM AUTHOR]

Background: We aimed to estimate the monetary value of informal care of disabled people with chronic obstructive pulmonary disease (COPD) in Spain and to identify the main determinants of the time involved in informal caregiving. Methods: We used the Survey on Disabilities, Autonomy and Dependency carried out in Spain in 2008 to obtain information on disabled individuals with COPD and their informal caregivers. Assessment of informal caregiving time was performed using the proxy good method. A statistical multivariate analysis (ordered probit model) was performed to study the determinants of informal care provided. Results: It was estimated that 220,892 disabled people with COPD received informal care. The total annual number of caregiving hours was 694.44 million, with an estimated monetary value between 4,981 and 8,254 million EUR. Based on the condition of having received informal care, the cost of informal care per disabled person with COPD ranged from 24,549 to 40,681 EUR per year (depending on the shadow price applied). This value varies significantly depending on the degree of dependency; it ranged from 17,089 EUR per person annually for non-dependents to 33,033 EUR for those who were greatly dependent (under the most conservative scenario). Degree of dependency and the formal care received were the main variables that explained the variability of informal caregiving time provided. Conclusions: The results partially reveal the high hidden social costs, and the association between the level of dependency and the time provided by the caregivers. This information should be a useful tool to design policies that focus on improving caregivers' well-being. [ABSTRACT FROM AUTHOR]

Background: The Living with COPD (LCOPD), COPD and Asthma Fatigue Scale (CAFS), and COPD and Asthma Sleep Impact Scale (CASIS) are instruments developed to assess the overall impact of chronic obstructive pulmonary disease (COPD) on daily life, fatigue, and sleep impairment, respectively. Objectives: To assess the usefulness of these instruments and to identify factors associated with the concepts they measure. Method: The questionnaires were administered to patients with moderate to severe COPD. Descriptive analyses of sociodemographic and clinical data were performed, and bivariate and multivariate analyses were used to identify factors associated with the overall impact of COPD on patients' lives, fatigue, and sleep impairment. Results: A total of 408 patients was included (mostly males, 91.2%), with an average age of 68 years (SD = 9.3). Statistically significant differences were observed in the scores of the three questionnaires with regard to level of education, presence of chronic cough or expectoration, level of dyspnea, number of exacerbations, physical activity level, presence of depression and anxiety, and number of treatments indicated for COPD. The LCOPD and CAFS questionnaires also discriminated between different levels of airflow obstruction and, in the case of CAFS, age and gender. Linear regression showed that level of dyspnea, physical activity, and presence of anxiety were significantly related to the LCOPD, CAFS and CASIS scores. The presence of depression was significant in the LCOPD and CAFS questionnaires and chronic cough was significant in the CAFS questionnaire. Conclusions: The LCOPD, CAFS, and CASIS instruments are valid and useful in understanding the overall impact of COPD on daily life, fatigue, and sleep impairment in patients with moderate to severe COPD. Copyright © 2012 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

After the development of the COPD Strategy of the National Health Service in Spain, all scientific societies, patient organisations, and central and regional governments formed a partnership to enhance care and research in COPD. At the same time, the Spanish Society of Pneumology and Thoracic Surgery (SEPAR) took the initiative to convene the various scientific societies involved in the National COPD Strategy and invited them to participate in the development of the new Spanish guidelines for COPD (Guía Española de Ia EPOC; Ge5EPOC). Probably the more innovative approach of GesEPOC is to base treatment of stable COPD on clinical phenotypes, a term which has become increasingly used in recent years to refer to the different clinical forms of COPD with different prognostic implications. The proposed phenotypes are: (A) infrequent exacerbators with either chronic bronchitis or emphysema; (B) overlap COPD-asthma; (C) frequent exacerbators with emphysema predominant; and (D) frequent exacerbators with chronic bronchitis predominant. The assessment of severity has also been updated with the incorporation of multidimensional indices. The severity of the obstruction, as measured by forced expiratory volume in 1 second, is essential but not sufficient. Multidimensional indices such as the BODE index have shown excellent prognostic value. If the 6-minute walking test is not performed routinely, its substitution by the frequency of exacerbations (BODEx index) provides similar prognostic properties. This proposal aims to achieve a more personalised management of COPD according to the clinical characteristics and multidimensional assessment of severity. [ABSTRACT FROM AUTHOR]

Copyright of Archivos de Bronconeumología (English Edition) is the property of Sociedad Espanola de Neumologia y Cirugia Toracica (SEPAR) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Archivos de Bronconeumología (English Edition) is the property of Sociedad Espanola de Neumologia y Cirugia Toracica (SEPAR) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: A spirometrically-defined restrictive ventilatory defect is a common finding when performing spirometry. Aims: We aimed to determine the frequency, geographical variation, individual consequences, and 'severity' of the restrictive ventilatory defect. Methods: A population-based study was conducted in Spain. The response rate from 11 participating centres was 88.9%, totalling 3,802 participants. A restrictive ventilatory defect was defined according to pre-bronchodilator spirometry as forced expiratory volume in 1s/forced vital capacity (FEV1/FVC) ⩾0.70 and a predicted FVC <80%, in accordance with current American Thoracic Society/European Respiratory Society guidelines. Results: The prevalence of a restrictive ventilatory defect was 12.7% (95% CI 9.7% to 15.7%), with the highest in Seville (19.4%) and Burgos (18.5%) and the lowest in Oviedo (5.2%) and Madrid-La Princesa (5.7%) (p<0.001). Although most of the participants (97.1%) with a restrictive ventilatory defect were objectively considered 'mild' by spirometry (%predicted FVC 50-80%), they reported more phlegm, dyspnoea, and wheezing than healthy control participants (p<0.001), and scored worse in all St George's Respiratory Questionnaire domains of quality of life and activities of daily living (p<0.001). Interestingly, they scored similarly to participants with chronic obstructive pulmonary disease (COPD) in both (p=0.102 and p=0.217). In a multivariate analysis, older age, male gender, heavy smoking, low education, and high body mass index were independently associated with having a restrictive ventilatory defect. Conclusions: A restrictive ventilatory defect in spirometry is a common finding (12.7%) with a highly variable geographical distribution (range 3.7) whose population burden is important in terms of quality of life and activities of daily living and similar to that of an obstructive pattern compatible with COPD. [ABSTRACT FROM AUTHOR]

Copyright of Archivos de Bronconeumología (English Edition) is the property of Sociedad Espanola de Neumologia y Cirugia Toracica (SEPAR) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Archivos de Bronconeumología (English Edition) is the property of Sociedad Espanola de Neumologia y Cirugia Toracica (SEPAR) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Archivos de Bronconeumología (English Edition) is the property of Sociedad Espanola de Neumologia y Cirugia Toracica (SEPAR) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Archivos de Bronconeumología (English Edition) is the property of Sociedad Espanola de Neumologia y Cirugia Toracica (SEPAR) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Our objective was to assess the 5-year cost effectiveness of bronchodilator therapy with tiotropium, salmeterol or ipratropium for chronic obstructive pulmonary disease (COPD) from the perspective of the Spanish National Health System (NHS). A probabilistic Markov model was designed wherein patients moved between moderate, severe or very severe COPD and had the risk of exacerbation and death. Probabilities were derived from clinical trials. Spanish healthcare utilisation, costs and utilities were estimated for each COPD and exacerbation state. Outcomes were exacerbations, exacerbation-free months, quality-adjusted life years (QALYs), and cost(-effectiveness). The mean (SE) 5-year number of exacerbations was 3.50 (0.14) for tiotropium, 4.16 (0.40) for salmeterol and 4.71 (0.54) for ipratropium. The mean (SE) number of QALYs was 3.15 (0.08), 3.02 (0.15) and 3.00 (0.20), respectively. Mean (SE) 5-year costs were €6,424 (€305) for tiotropium, €5,869 (€505) for salmeterol, and €5,181 (€682) for ipratropium (2005 values). Ipratropium and tiotropium formed the cost-effectiveness frontier, with tiotropium being preferred when willingness to pay (WTP) exceeded €639 per exacerbation-free month and €8,157 per QALY. In Spain, tiotropium demonstrated the highest expected net benefit for ratios of the willingness to pay per QALY, well within accepted limits. [ABSTRACT FROM AUTHOR]

Copyright of Archivos de Bronconeumología (English Edition) is the property of Sociedad Espanola de Neumologia y Cirugia Toracica (SEPAR) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Impaired health status may be a risk factor for frequent exacerbations and hospital admission and, in turn, exacerbations and admissions may further impair the health status of patients with COPD. We have investigated the variables associated with frequent exacerbations (3 or more per year) and admission, with particular interest in health status, in a cohort of ambulatory patients with moderate to severe COPD attended by chest physicians in Spain. A total of 227 investigators included 1057 patients with a mean predicted FEV1 of 41.8%. The mean total score on the St. George's Respiratory Questionnaire (SGRQ) was 47.9 units, and 300 patients (28.4%) had 3 or more exacerbations the previous year and 344 (32.6%) were admitted at least once during the same period. In multivariate analysis only the SGRQ total score was significantly associated with both frequent exacerbations (OR = 1.04; 95% CI = 1.01-2.12; p<0.0001) and admission (OR = 1.01; 95% CI = 1.00-1.02; p = 0.0008). Other variables significantly associated with frequent exacerbations were chronic mucus hypersecretion, increased baseline dyspnea, comorbidity, GOLD stage IV and treatment with inhaled corticosteroids. Variables associated with admission were lower educational level, increased number of exacerbations, use of long-term oxygen therapy and use of short acting beta-2 agonists. An impaired health status is associated with an increased number of exacerbations and with admission to hospital in the previous year. These results, together with previous studies, confirm that impairment in health status in COPD is both a marker of risk for, and a consequence of, frequent exacerbations and admissions. [ABSTRACT FROM AUTHOR]

Objectives: To ascertain the prevalence, diagnostic level, and treatment of COPD in Spain through a multicenter study comprising seven different geographic areas. Design and participants: This is an epidemiologic, multicenter, population-based study conducted in seven areas of Spain. A total of 4,035 men and women (age range, 40 to 69 years) who were randomly selected from a target population of 236,412 subjects participated in the study. Interventions: Eligible subjects answered the European Commission for Steel and Coal questionnaire. Spirometry was performed, followed by a bronchodilator test when bronchial obstruction was present. Results: The prevalence of COPD was 9.1% (95% confidence interval [CI], 8.1 to 10.2%), 15% in smokers (95% CI, 12.8 to 17.1%), 12.8% in ex-smokers (95% CI, 10.7 to 14.8%), and 4.1% in nonsmokers (95% CI, 3.3 to 5.1%). The prevalence in men was 14.3% (95% CI, 12.8 to 15.9%) and 3.9% in women (95% CI, 3.1 to 4.8%). Marked differences were observed between sexes in smoking; the percentage of nonsmokers was 23% in men and 76.3% in women (p < 0.0001). The prevalence of COPD varied among the areas, ranging from 4.9% (95% CI, 3.2 to 7.0%) in the area of the lowest prevalence to 18% (95% CI, 14.8 to 21.2%) in the area of the highest. There was no previous diagnosis of COPD in 78.2% of cases (284 of 363). Only 49.3% of patients with severe COPD, 11.8% of patients with moderate COPD, and 10% of patients with mild COPD were receiving some kind of treatment for COPD. Multivariate analysis showed that individuals had a higher probability of having received a previous diagnosis of COPD if they lived in urban areas, were of male gender, were > 60 years old, had higher educational levels, had > 15 pack-year smoking history, or had symptoms of chronic bronchitis. Conclusions: COPD is a very frequent disease in Spain, and presents significant geographic variations and a very Iow level of previous diagnosis and treatment, even in the most advanced cases. [ABSTRACT FROM AUTHOR]

Introduction: We aim to describe the changes in prevalence and risk factors associated to chronic obstructive pulmonary disease (COPD) in Spain, comparing three population-based studies conducted in three timepoints., Methods: We compared participants from IBERPOC conducted in 1997, EPISCAN conducted in 2007 and EPISCAN II in 2017. COPD was defined as a postbronchodilator FEV 1 /FVC (forced expiratory volume in 1s/forced vital capacity) ratio <0.70, according to GOLD criteria; subsequently, also as the FEV 1 /FVC below the lower limit of normal (LLN)., Results: COPD prevalence in the population between 40 and 69 years decreased from 21.6% (95% CI 20.7%-23.2%) in 1997 to 8.8% (95% CI 8.2%-9.5%) in 2017, a 59.2% decline (p<0.001). In 2007, the prevalence was 7.7% (95% CI 6.8%-8.7%) with an upward trend of 1.1 percentage points in 2017 (p=0.073). Overall COPD prevalence decreased in men and women, although a significant increase was observed in the last decade in females (p<0.05). Current smokers significantly increased in the last decades (25.4% in 1997, 29.1% in 2007 and 23.4% in 2017; p<0.001). Regrettably, COPD underdiagnosis was constantly high, 77.6% in 1997, 78.4% in 2007, and to 78.2% in 2017 (p=0.95), higher in younger ages (40-49 yrs and 50-59 yrs) and also higher in women than in men in all three studies (p<0.05)., Conclusions: We report a significant reduction of 59.2% in the prevalence of COPD in Spain from 1997 to 2017 in subjects aged 40-69 years. Our study highlights the significant underdiagnosis of COPD, particularly sustained in women and younger populations., (Copyright © 2022 SEPAR. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction: Identifying the variables that guide decision-making in relation to the use of inhaled corticosteroids (ICS) can contribute to the appropriate use of these drugs. The objective of this study was to identify the clinical variables that physicians consider most relevant for prescribing or withdrawing ICS in COPD., Methods: A cross-sectional survey was conducted in Spain from November 2020 to May 2021. Therapeutic decisions on the use of ICS in 11 hypothetical COPD patient profiles were collected using an online survey answered by specialists with experience in the management of patients with COPD. Mixed-effects logistic regression was used to analyze the impact of patients' characteristics in the therapeutic decision for prescribing ICS or proceeding to its withdrawal., Results: A total of 74 pulmonologists agreed to collaborate in the survey and answered the questionnaire. The results showed great variability, with only 2 profiles achieving consensus for starting or withdrawing the treatment. The frequency and severity of exacerbations influenced the decision to prescribe ICS in a dose-response fashion (1 exacerbation odds ratio (OR) = 1.86, 95% confidence interval (CI) 1.02 to 3.43, two exacerbations OR = 11.6, 95% CI: 4.47 to 30.2 and three OR = 123, 95% CI: 25 to 601). Similarly, increasing blood eosinophils and history of asthma were associated with ICS use. On the other hand, pneumonia reduced the probability of initiating treatment with ICS (OR = 0.54 [0.29 to 0.98]). Lung function and dyspnea degree did not influence the clinician's therapeutic decision. The results for withdrawal of ICS were similar but in the opposite direction., Conclusion: In accordance with guidelines, exacerbations, blood eosinophils and history of asthma or pneumonia are the factors considered by pulmonologist for the indication or withdrawal of ICS. However, the agreement in prescription or withdrawal of ICS when confronted with hypothetical cases is very low, suggesting a great variability in clinical practice., Competing Interests: The authors meet criteria for authorship as recommended by the International Committee of Medical Journal Editors (ICMJE). The authors did not receive payment related to the development of the manuscript. MM has received speaker fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, Menarini, Rovi, Bial, Sandoz, Zambon, Kamada, CSL Behring, Grifols and Novartis, consulting fees from AstraZeneca, Atriva Therapeutics, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Bial, Gebro Pharma, CSL Behring, Laboratorios Esteve, Ferrer, Mereo Biopharma, Verona Pharma, Spin Therapeutics, ONO Pharma, pH Pharma, Palobiofarma SL, Takeda, Novartis, Sanofi and Grifols and research grants from Grifols. FG has received economic compensation for consulting, lectures at various congresses and scientific training sessions, manuscript writing and support for attending meetings from Boehringer Ingelheim, GSK, Novartis, Astrazeneca, Chiesi, Pfizer, Esteve and Rovi. CRR reports no disclosure related to this paper. XP has received speaker fees from Boehringer Ingelheim, GlaxoSmithKline, Rovi and Chiesi. EMM has received economic compensation for consulting, lectures, presentations, manuscript writing, educational events, support for attending meetings, participation in data safety monitoring or advisory board from Boehringer Ingelheim, Glaxo Smith Kline, Novartis, Aflofarm, Bial, Chiesi, Meranini and GSK. CG has received economic compensation for consulting, support for attending meetings from Chiesi, Boehringer Ingelheim, Glaxo Smith Kline, Novartis, Meranini, Ferrer and Teva. CA has received speaker fees and/or consulting fees from Boehringer Ingelheim, Pfizer, AstraZeneca, Novartis, Chiesi, Faes farma, Esteve and GlaxoSmithKline. CF has received economic compensation by GOC Health Consulting for statistical analysis. SA has received economic compensation for support for attending meetings, other sessions and consulting from Novartis, Astra Zeneca, Menarini, GSK, Boeringer Ingelheim, Chiesi, Mundipharma, FAES, Pfizer and Teva. BA reports personal fees from GSK, grants, personal fees and non-financial support from Novartis, personal fees and non-financial support from Boehringer Ingelheim, personal fees and non-financial support from Chiesi, grants, personal fees and non-financial support from Laboratorios BIAL, Menarini, personal fees from Gebro, Astra- Zeneca, and Gilead, outside the submitted work. In addition, has a patent P201730724 pending. EN has received economic compensation for consulting, lectures, presentations, manuscript writing and educational events from Novartis, Boehringer Ingelheim, Chiesi and Glaxo Smith Kline. MB reports personal fees from Grifols, Menarini, CSL Behring, GSK, Boehringer Ingelheim, and Novartis, outside the submitted work. The authors report no other conflicts of interest in this work., (© 2022 Miravitlles et al.)

The aim of this observational, retrospective study was to describe characteristics, treatment patterns, and adherence among patients with asthma who initiated multiple-inhaler triple therapy (MITT) in Catalonia, Spain. This study used data of patients initiating MITT in 2016 from the SIDIAP (Information System for Research in Primary Care) database, which covers ~80% of the Catalonian population (5.8 million). Of 1,204 patients initiating MITT, 361 (30.0%) stepped down (discontinued ≥ 1 and continued ≥1 MITT component) and 89 (7.4%) stopped all three components of MITT for a period of 60 days during the following 12 months. In the follow-up period, 196 (16.3%) patients were considered adherent to MITT (>0.8 proportion of days covered [PDC]), with a mean (standard deviation) PDC of 0.52 (0.51) days. Given the low adherence and substantial rates of step down/discontinuation among patients initiating MITT, there is an urgent need to implement strategies to improve treatment adherence/persistence., (© 2022. The Author(s).)

Purpose: Inhaled corticosteroids (ICS) are frequently used to treat chronic obstructive pulmonary disease (COPD) outside the current recommendations. Our aim was to describe ICS use in COPD patients and to identify factors associated with ICS use among COPD patients treated within primary care in Spain., Patients and Methods: This was a cross-sectional, non-interventional and multicenter study of patients with COPD treated in primary care. Patient characteristics and exacerbations were described in terms of ICS use among the overall cohort, and among those with spirometry confirmed COPD (post-bronchodilator forced expiratory volume in 1 second [FEV 1 ]/forced vital capacity [FVC] ratio <70%). Multivariable logistic regression was used to identify factors associated with ICS use., Results: A total of 901 patients were included, of which 47.9% (n = 432) were treated with ICS. A total of 240 patients (26.6%) experienced moderate/severe exacerbations in the prior year, while 309 (34.3%) during the previous two years. History of asthma totaled 11.6% (n = 105). The most frequent phenotype was non-exacerbator (51.6%), and the proportion of patient with moderate or severe exacerbations was significantly higher among ICS treated patients compared to non-treated: 37.5% versus 16.6% during the previous year (p < 0.001), and 46.8% versus 22.8% during the previous 2-years (p < 0.001), respectively. Patient characteristics were similar among spirometry confirmed patients and the overall population. Factors significantly associated with ICS use were a history of asthma (OR = 4.39, 95% CI: 2.67-7.26), the presence of moderate or severe exacerbations in the last year (OR = 2.52, 95% CI: 1.81-3.49), followed by higher mMRC and higher CAT score., Conclusion: Nearly half of patients in primary care in Spain are treated with ICS, despite most of them being non-exacerbators. History of asthma, exacerbations, and worse dyspnea and CAT scores are associated with ICS use., Competing Interests: Marc Miravitlles has received speaker fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, GlaxoSmithKline, Menarini, Rovi, Bial, Sandoz, Zambon, CSL Behring, Grifols and Novartis, consulting fees from AstraZeneca, Atriva Therapeutics, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Bial, Gebro Pharma, CSL Behring, Laboratorios Esteve, Ferrer, Mereo Biopharma, Verona Pharma, Spin Therapeutics, ONO Pharma, pH Pharma, Palobiofarma SL, Takeda, Novartis, Sanofi and Grifols and research grants from Grifols. Miguel Roman-Rodriguez has received speaker fees from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Menarini, Bial, consulting fees from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and research grants from AstraZeneca in the last 3 years. Xavier Ribera is an employee of Boehringer Ingelheim Spain. John Ritz is an employee of Syneos Health – Boehringer Ingelheim Pharmaceuticals Inc. José Luis Izquierdo has received honoraria for consultancy, projects, and talks from AstraZeneca, Bayer, Boehringer Ingelheim, Chiesi, Glaxo, Grifols, Smith Kline, Menarini, Novartis, Orion, Pfizer, Sandoz, Teva, and Zambon. The authors report no other conflicts of interest in this work., (© 2022 Miravitlles et al.)

Objective: The aim of this study was to analyze current data on the population's level of knowledge about COPD and to evaluate certain diagnostic interventions, such as the use of spirometry., Material and Methods: An epidemiological, observational, cross-sectional study by telephone interview, with random dialing of landline telephone numbers, was conducted in November 2019, in a nationally representative sample of adults over 40 years of age., Results: From a total of 51,079 telephone calls, a total of 1920 individuals responded. Mean age was 61.9 years and 31.6% were men. Overall, 19.4% were current smokers and 13.4% reported respiratory disease (5% reported COPD). In total, 27.9% had spontaneous knowledge of COPD, which is a relative increase from the 17% observed in 2011. The most frequent information channel was the media (35.5%), with a significant presence of social networks and the Internet (25.7%). Almost one fifth (18.1%) had chronic respiratory symptoms. Of these, 59.3% had requested medical care, and 66.2% had undergone spirometry. Spirometry was performed less frequently in subjects treated in primary care compared to respiratory medicine departments (51.9% versus 79.1%; P < .001)., Conclusions: Knowledge of COPD is still scarce, and strategies are needed to increase awareness and the importance of assessing respiratory symptoms and increased use of spirometry., (Copyright © 2020 SEPAR. Published by Elsevier España, S.L.U. All rights reserved.)

Objective: The objective of this study was to assess the non-adherence level of Spanish clinical practice to guideline recommendations for the treatment of chronic obstructive pulmonary disease (COPD) and to estimate the potential impact on pharmaceutical expenditure resulting from transitioning current treatment patterns according to guidelines., Methods: A model was developed to compare current prescribing patterns with two alternative scenarios: the first aligned with the Global Initiative for Chronic Obstructive Lung Disease (GOLD 2020) recommendations, and the second with the Spanish Guidelines for COPD (GesEPOC 2017). Current treatment practice was obtained from publications that describe treatment patterns by pulmonology departments in Spain. The economic impact between patterns was calculated from the perspective of the Spanish National Health System (NHS), considering the annual pharmacological costs of COPD inhaled maintenance therapy. Two additional analyses were performed: one that included current prescribing patterns of patients managed by pulmonology and primary care centers in Spain (published aggregated data); and another that only considered the appropriate use of inhaled corticosteroids (ICS) treatment according to guidelines., Results: It was estimated that 54% and 38% of patients were not treated in line with GOLD and GesEPOC recommendations, respectively, mainly due to a broader use of ICS-based therapies. Adapting treatment to recommendations could provide a potential annual cost-saving of €17,792,022 (according to GOLD) and €5,881,785 (according to GesEPOC). In scenario analysis 1, a 26% of non-adherence to GesEPOC guideline was observed with a potential annual pharmacological cost-saving of €2,707,554. In scenario analysis 2, considering only inappropriate use of ICS treatment, an annual cost-saving of €17,863,750 (according to GOLD) and €9,904,409 (according to GesEPOC) was calculated., Conclusion: More than a third of treatments for COPD patients in Spain are not prescribed in accordance with guideline recommendations. The adaptation of clinical practice to guideline recommendations could provide important cost-savings for the Spanish NHS., Competing Interests: Dr Marc Miravitlles has received speaker fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, GlaxoSmithKline, Menarini, Rovi, Bial, Sandoz, Zambon, CSL Behring, Grifols and Novartis, consulting fees from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Gebro Pharma, CSL Behring, Laboratorios Esteve, Ferrer, Mereo Biopharma, Verona Pharma, Spin Therapeutics, Palobiofarma SL, pH Pharma, Novartis, Sanofi and Grifols, and research grants from Grifols. Alexandra Solé, Helena Aguilar and Ana Ampudia are employees of Boehringer Ingelheim, S.A. Jaume Costa-Samarra, Maria Mallén-Alberdi and Diana Nieves work for an independent research entity, Oblikue Consulting, and have received remuneration for their contribution to the development of the draft. The authors affirm that the results of the research described in this manuscript, as well as the analysis and interpretation thereof, were the result of the free expression of opinions and the agreement of the publication’s co-authors, and that there were no conflicts, either to obtain or disclose said results., (© 2021 Miravitlles et al.)

Background: The cost of chronic obstructive pulmonary disease (COPD) in Spain has been studied from different perspectives, but parameters such as the patient's phenotype have seldom been considered. Our aim was to describe the disease burden of COPD patients with frequent exacerbator phenotype, treated with triple therapy., Methods: An observational, multicenter study was carried out from December 2017 to November 2018 in pulmonology services among patients ≥40 years with COPD confirmed diagnosis receiving triple therapy (ICS/LAMA/LABA) and history of ≥2 moderate or ≥1 severe exacerbation in the 12 months prior to the inclusion visit. COPD-related healthcare resources were collected over a 12-months period prior to the inclusion visit: pharmacological and non-pharmacological treatments, medical and ER visits, hospitalizations, tests and productivity loss. Costs were updated to €2019. Patients were classified according to blood eosinophil levels: <150 cells/µL and ≥150 cells/µL., Results: A total of 306 patients were included (77.1% men), with mean age of 69.9 years. Mean COPD exacerbation rate was 2.5/patient/year and 51.3% of patients had ≥150 cells/µL eosinophil level. On average, for the total population, COPD-related visits/patients/year were 6.2. Resource use in moderate exacerbation was higher in patients with eosinophils ≥150 cells/µL, whereas in severe exacerbation was higher in patients with eosinophils <150cells/µL. According to eosinophil levels, total annual mean (SD) costs/patient accounted for €8382 (9863) and €5144 (5444) for patients with eosinophils <150 cells/µL and ≥150 cells/µL, respectively., Conclusion: The impact of exacerbating COPD patients treated with triple therapy in Spain is large, especially among those with eosinophils <150 cells/µL., Competing Interests: Bernardino Alcázar-Navarrete reports grants and personal fees from GSK, grants, personal fees and non-financial support from Novartis AG, personal fees and non-financial support from Boehringer Ingelheim, personal fees and non-financial support from Chiesi, Laboratories FAES, and Gilead, grants, personal fees and non-financial support from Laboratorios Menarini, personal fees from Gebro, personal fees from Astra- Zeneca, personal fees from Laboratorios Rovi, personal fees from Laboratorios Ferrer. Francisco García-Rio has received speaker fees from Boehringer Ingelheim, Pfizer, Chiesi, GlaxoSmithKline, Menarini, Novartis and Rovi, and consulting fees from Boehringer Ingelheim, Pfizer, GlaxoSmithKline and Novartis. Guadalupe Sánchez and Andrea García, are GSK employees. Esther Mariscal was a GSK employee when the study was conducted. Maribel Cuesta and Estefany Uría, are employees of Oblikue Consulting and were involved in data monitoring board, study design, manuscript preparation, and statistical analysis for GlaxoSmithKline. Marc Miravitlles has received speaker fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, Menarini, Rovi, Bial, Sandoz, Zambon, CSL Behring, Grifols and Novartis, consulting fees from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Bial, Gebro Pharma, Kamada, CSL Behring, Laboratorios Esteve, Ferrer, Mereo Biopharma, Verona Pharma, TEVA, Spin Therapeutics, pH Pharma, Novartis, Sanofi and Grifols and research grants from and Grifols. The authors report no other conflicts of interest in this work., (© 2021 Alcázar-Navarrete et al.)

Background: Recent data from real world clinical practices on the use of Triple Therapy (TT) in patients with COPD are scarce., Methods: Observational population-based study with longitudinal follow-up in patients with COPD identified in a primary care electronic medical records database in Catalonia, covering 80% of the general population. The aims were to characterize COPD patients who initiated TT and to describe treatment pathways before and after TT initiation. Time to and probability of step down or complete discontinuation of TT was described using restricted mean survival time and Kaplan-Meier analysis., Results: A total of 34,018 COPD patients initiated TT during the study period. Of them, 23,867 (70.1%) were GOLD A/B. 18,453 (54.2%) were non-exacerbators, 9931 (29.2%) infrequent exacerbators, 5634 (16.5%) frequent exacerbators and 1923 (5.6%) had asthma-COPD overlap. Drugs most frequently used prior to initiation of TT were long-acting antimuscarinics (22.5%) and combination of long-acting beta2 agonists/inhaled corticosteroids (15.2%). A total of 11,666 (34.3%) stepped down and 1091 (3.2%) discontinued TT during follow-up. Step down following TT was more likely in patients with severe COPD, especially during the first year; however, discontinuation was more common among patients with mild COPD., Conclusion: Most patients initiating treatment with TT were non exacerbators and continued on the same treatment over time regardless severity of disease. Stepping down was more frequent in severe patients, while discontinuation was more common among mild patients. Overall, it appears that TT is extensively used in primary care for treatment of patients with COPD., (Copyright © 2020 SEPAR. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: There is controversy regarding the role of blood eosinophil levels as a biomarker of exacerbation risk in chronic obstructive pulmonary disease (COPD). Our aim was to quantify blood eosinophil levels and determine the risk of exacerbations associated with these levels and their variability., Methods: Observational, retrospective, population-based study with longitudinal follow-up in patients with COPD identified in a primary care electronic medical record database in Catalonia, Spain, covering 80% of the general population. Patients were classified into 4 groups using the following cut-offs: (a) <150cells/μl; (b) ≥150 and <300cells/μl; (c) ≥300 and <500cells/μl; (d) ≥500cells/μl., Results: A total of 57,209 patients were identified with a mean age of 70.2 years, a mean FEV1(% predicted) of 64.1% and 51.6% had at least one exacerbation the previous year. The number of exacerbations in the previous year was higher in patients with the lowest and the highest eosinophil levels compared with the intermediate groups. During follow-up the number of exacerbations was slightly higher in the group with the lowest blood eosinophil levels and in those with higher variability in eosinophil counts, but ROC curves did not identify a reliable threshold of blood eosinophilia to discriminate an increased risk of exacerbations., Conclusions: Our results do not support the use of blood eosinophil count as a reliable biomarker of the risk of exacerbation in COPD in a predominantly non-exacerbating population. Of note was that the small group of patients with the highest variability in blood eosinophils more frequently presented exacerbations., (Copyright © 2020 SEPAR. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Two previous national epidemiological studies, IBERPOC in 1997 and EPISCAN in 2007, determined the COPD burden in Spain. Changes in demographics and exposure to risk factors demand the periodic update of COPD prevalence and its determinants., Methods: EPISCAN II aimed to estimate the prevalence of COPD in the general population aged 40 years or older in all 17 regions of Spain. A random population screening sample, requiring 600 participants per region performed a questionnaire plus post-bronchodilator (post-BD) spirometry., Results: A total of 12,825 subjects were initially contacted, and 9433 (73.6%) agreed to participate, of whom 9092 performed a valid spirometry. Baseline characteristics were: 52.6% women, mean±SD age 60±11 years, 19.8% current- and 34.2% former-smokers. The prevalence of COPD measured by post-BD fixed ratio FEV 1 /FVC<0.7 was 11.8% (95% C.I. 11.2-12.5) with a high variability by region (2.4-fold). Prevalence was 14.6% (95% C.I. 13.5-15.7) in males and 9.4% (95% C.I. 8.6-10.2) in females; according to the lower limit of normal (LLN) was 6.0% (95% C.I. 5.5-6.5) overall, by sex being 7.1% (95% C.I. 6.4-8.0) in males and 4.9% (95% C.I. 4.3-5.6) in females. Underdiagnosis of COPD was 74.7%. Cases with COPD were a mean of seven years older, more frequently male, of lower attained education, and with more smokers than the non-COPD population (p<0.001). However, the number of cigarettes and pack-years in non-COPD participants was substantial, as it was the reported use of e-cigarettes (7.0% vs. 5.5%) (p=0.045). There were also significant social and clinical differences including living alone, previous respiratory diagnoses, more comorbidities measured with the Charlson index, greater BODE and COTE scores, cognitive impairment, and depression (all p<0.001)., Conclusions: COPD remains prevalent in Spain and frequently underdiagnosed., (Copyright © 2020 SEPAR. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: The objective of this analysis was the evaluation of a new national circuit used for diagnosing alpha1 antitrypsin deficiency (AATD) based on multiplex technology using online registration and mail posted samples from dried blood spots (DBS) and buccal swabs., Methods: This is an observational, ongoing study conducted in Spain since March 2018. Samples are coded on a web platform and sent by postal mail to the central laboratory. Allele-specific genotyping for the 14 most common mutations was done with the Luminex 200 Instrument System. Gene sequencing was done if none of the mutations were found and the AAT serum level was <60mg/dl, or by request from the clinician in charge., Results: At the time of the present report, 5803 (92.9%) samples were processed, 4984 (85.9%) from buccal swab and 819 (14.1%) from DBS. The prevalence of the frequent allele combinations were: MS 19.0%, MZ 14.4%, SS 2.9%, SZ 3.7%, and ZZ: 1.4%. Globally, Z carriers represented 20.0% and S carriers 26.6% of this population, with differences seen between regions. 209 (3.6%) were identified carrying rare alleles, 12 (0.2%) carrying null alleles and 14 (0.3%) new mutations were described. Respiratory diseases other than COPD, including poorly controlled asthma or bronchiectasis, also presented AATD mutations., Conclusions: The availability of a diagnostic system based on the simultaneous testing of 14 genetic variants from buccal swabs or DBS sent by postal mail and with web registration has proven to be useful, and the system can improve the timely diagnosis of AATD., (Copyright © 2020 SEPAR. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: The concept of clinical control has been proposed as an instrument for evaluating patients with COPD. However, the possible association between clinical control, reduced symptom severity and HRQoL has yet to be confirmed., Methods: This multicentre, prospective and observational study was carried out in 15 pulmonology clinics in Spain. The patients were followed up for six months, with a baseline visit (V0), followed by visits at three months (V1) and six months (V2). Clinical control was determined at V1, with the application of both clinical criteria and the COPD assessment test (CAT). All patients reported their symptoms by a validated symptom diary (E-RS) using a portable device, and their HRQoL was assessed using the EQ5D questionnaire. The relationship between clinical control and E-RS and HRQoL during follow-up was assessed with t -test., Results: A total of 126 patients were screened. After application of the inclusion/exclusion criteria, 93 were finally included (mean age 66 ± 8 years, 84.9% male), with a mean FEV 1 predicted of 49.8% ± 16.5%. Of these patients, 44 (47.3%) achieved clinical control at V1, according to CAT criteria, and 50 (53.8%), according to clinical criteria. The E-RS scores differed between controlled and uncontrolled patients at all time points, both according to CAT (mean differences of -4.6, -5.6 and -6.2 units at V0, V1 and V2, respectively, p<0.005 for all comparisons) and to clinical criteria (mean differences of -3.3, -5-6 and -4.99 units, respectively, p<0.005 for all comparisons). The controlled patients also presented a significantly better HRQoL, measured by the EQ5D questionnaire (mean difference 0.13 and 0.10 at V2 by CAT or clinical criteria, respectively, p<0.05)., Conclusion: Clinical control in patients with COPD, whether measured by CAT or by clinical criteria, is associated with a lower symptom load and a better HRQoL., Competing Interests: Dr. Alcázar-Navarrete reports grants, non-financial support and personal fees from GSK, grants, personal fees and non-financial support from Novartis AG, personal fees and non-financial support from Boehringer Ingelheim, personal fees and non-financial support from Chiesi, grants, personal fees and non-financial support from Laboratorios Menarini, personal fees from Gebro, personal fees and non-financial support from Astra-Zeneca, personal fees from Laboratorios Rovi, personal fees from Laboratorios Ferrer, grants, personal fees, non-financial support from Menarini, outside the submitted work. Dra. Fuster has nothing to disclose. Dra García-Sidro reports personal fees from GSK, Pfizer, Novartis AG, Menarini, Boehringer Ingelheim, Astra-Zeneca, Gebro and Laboratorios Rovi, outside the submitted work. Dr. García Rivero has nothing to disclose. Dr. Abascal-Bolado has nothing to disclose. Dr. Pallarés-Sanmartín has received lecture fees, consultancy fees and/or support for conference attendance from various pharmaceutical companies such as Novartis, GlaxoSmithKline, Chiesi, Boehringer Ingelheim, Mundipharma, Menarini, Laboratorios Esteve, Astra Zeneca, Teva Pharmaceutical, Ferrer, Rovi, Bial, Faes Farma, ALK Abelló and Gebro Pharma outside the submitted work. Dr. Marquez- Martín has nothing to disclose. Dr. Valido Morales has received lecture fees, consultancy fees and/or support for conference attendance from various pharmaceutical companies, such as GlaxoSmithKline, Chiesi, Boehringer Ingelheim, Menarini, Pfizer, Novartis, Laboratorios Esteve, Teva Pharmaceutical, Ferrer, Rovi, Astra Zeneca, Bial, Grifols, Faes Farma and Gebro Pharma, outside the submitted work. Dr. Callejas González has received lecture fees, consultancy fees and/or support for conference attendance from various pharmaceutical companies, such as GlaxoSmithKline, Chiesi, Boehringer Ingelheim, Mundipharma, Menarini, Pfizer, Novartis, Laboratorios Esteve, Teva Pharmaceutical, Ferrer, Rovi, Roche, Astra Zeneca, Bial, Actelion, Grifols, CSL Behring, Faes Farma and Gebro Pharma, and reports personal fees from GlaxoSmithKline, personal fees from Chiesi, personal fees from Boehringer Ingelheim, personal fees from Mundipharma, personal fees from Menarini, personal fees from Pfizer, personal fees from Novartis, personal fees from Laboratorios Esteve, personal fees from Teva Pharmaceutical, personal fees from Ferrer, personal fees from Rovi, personal fees from Roche, personal fees from Astra Zeneca, personal fees from Bial, personal fees from Actelion, personal fees from Grifols, personal fees from CSL Behring, personal fees from Faes Farma, personal fees from Gebro Pharma, outside the submitted work. Dra. Palop reports personal fees from Astra Zeneca, GlaxoSmithKline, Chiesi, Boehringer -Ingelheim, Novartis, Teva, Menarini, Rovi, outside the submitted work. Dr. JA Riesco reports grants and personal fees from GSK, grants, personal fees and non-financial support from Pfizer, Novartis AG, Menarini, personal fees and non-financial support from Boehringer Ingelheim, personal fees and non-financial from Astra-Zeneca, Grants and personal fees from Gebro, personal fees from Laboratorios Rovi, outside the submitted work. Dr. Golpe reports personal fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Menarini, Rovi, Zambon, Grifols, Novartis, Ferrer, Gebro Pharma, Laboratorios Esteve and GlaxoSmithKline, outside the submitted work. Dr. Soler-Cataluña reports speaking fees from Laboratorio Esteve, Mundipharma, grants, personal fees, speaking fees from AstraZeneca, grants, personal fees, non-financial support from Boehringer Ingelheim, personal fees from Bial, personal fees from Ferrer, personal fees, non-financial support from Menarini, personal fees, non-financial support from Novartis, personal fees from Rovi and Teva; consulting fees from AirLiquide, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Laboratorios Esteve, Mundipharma grants, personal fees from Chiesi, personal fees from Ferrer, grants, personal fees from; research grants from GlaxoSmithKline and Boehringer Ingelheim, outside the submitted work. Marc Miravitlles has received speaker fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, Menarini, Rovi, Bial, Sandoz, Zambon, CSL Behring, Grifols and Novartis, consulting fees from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Bial, Gebro Pharma, Kamada, CSL Behring, Laboratorios Esteve, Ferrer, Mereo Biopharma, Verona Pharma, TEVA, Spin Therapeutics, pH Pharma, Novartis, Sanofi and Grifols and research grants from GlaxoSmithKline and Grifols; reports personal fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, Menarini, Rovi, Bial, Sandoz, Zambon, CSL Behring, Grifols and Novartis, personal fees from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Bial, Gebro Pharma, Kamada, CSL Behring, Laboratorios Esteve, Ferrer, Mereo Biopharma, Verona Pharma, TEVA, Spin Therapeutics, pH Pharma, Novartis, Sanofi and Grifols, grants from GlaxoSmithKline and Grifols., outside the submitted work. The authors report no other potential conflicts of interest for this work., (© 2020 Alcazar-Navarrete et al.)

Purpose: On March 16, 2020, the Spanish government declared a state of alarm due to the rapid spread of coronavirus disease 2019 (COVID-19). Patients with chronic obstructive pulmonary disease (COPD) were restricted to remain confined at home, and medical visits were cancelled for 3 months. The impact of this lockdown on the manifestations of COPD and the quality-of-life of these patients has not been explored., Patients and Methods: One hundred patients with COPD were interviewed by telephone from May 2-18, 2020. The interviews included questions about the lockdown, missed medical appointments, fears of the disease, possible COVID-19 infection, and exacerbations of COPD suffered during this period and their management. In addition, the COPD Assessment Test, the Hospital Anxiety and Depression, and the 5-Dimension Euro Quality-of-Life questionnaires were administered., Results: Sixty-four (64%) patients claimed to have strictly complied with the lockdown, and only 42 (42%) stated they had left home at least once during lockdown. Only one patient (1%) was hospitalized due to COVID-19, and 13 (13%) patients presented an exacerbation of COPD self-managed at home with no admissions due to exacerbation of COPD during this period. A medical consultation or complementary test was cancelled in 90% of the patients, but 61% had a medical telephone visit with a high degree of satisfaction (mean 9.3/10). Most patients declared that their feeling regarding lung disease and general health was similar or even better during lockdown (82% and 81%, respectively)., Conclusion: Our results indicate that in general lockdown had a low impact on COPD patients. Only one patient was affected by COVID-19, but moderate exacerbations of COPD were not infrequent. Although many medical visits and test were cancelled, patients were very satisfied with the medical telephone visits., Competing Interests: Marc Miravitlles has received speaker fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, Menarini, Rovi, Bial, Sandoz, Zambon, CSL Behring, Grifols, and Novartis, consulting fees from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Bial, Gebro Pharma, Kamada, CSL Behring, Laboratorios Esteve, Ferrer, Mereo Biopharma, Verona Pharma, TEVA, Spin Therapeutics, pH Pharma, Novartis, Sanofi, and Grifols, and research grants from GlaxoSmithKline and Grifols, outside the submitted work, and reports no other potential conflicts of interest in this work. The remaining authors have no conflicts of interest to disclose for this work., (© 2020 Pleguezuelos et al.)

Introduction: Chronic obstructive pulmonary disease (COPD) is associated with increased lung and systemic inflammation. We aimed to identify associations between easy-to-obtain blood biomarkers and the frequency and severity of exacerbations., Methods: Cross-sectional, multicentre study performed in four centres in Spain, Italy, Bulgaria, and Slovenia. Blood samples were obtained for blood cell count, C-reactive protein (CRP), alpha-1 antitrypsin (AAT) and fibrinogen analysis. The neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR) and eosinophil/basophil ratio (EBR) were calculated. Firstly, patients were divided into clinical phenotypes according to the Spanish guidelines of COPD, and secondly, patients were classified into 2 groups: non-exacerbators (≤1 ambulatory exacerbation in the previous year) and exacerbators (≥2 ambulatory exacerbations or 1 hospitalisation in the previous year). A multivariate stepwise logistic regression model was performed to identify laboratory parameters associated with exacerbators., Results: A total of 355 patients with a mean age 66 years (SD=8.9) were included, and 64% were male. The mean FEV1% (forced expiratory volume in the first second) was 55% (SD=20%), and the mean COPD Assessment Test (CAT) score was 15.6 (SD=7.9). One hundred ninety-six (55.2%) patients were classified in the non-exacerbator group, and 159 (44.8%) were exacerbators. Patients in the exacerbators group presented lower haemoglobin levels (p=0.019) and ERB (p= 0.023) but higher CRP levels (p=0.001). In the multivariate analysis, females, higher levels of CRP, lower FEV1% and low EBR were independently related to exacerbators., Conclusion: Female sex, having a more severe impairment of lung function, higher CRP levels and a lower EBR are associated with an exacerbator phenotype in COPD., Competing Interests: Alexa Nuñez and Viviana Marras are co-first authors in this study. Alexa Nuñez is the recipient of a Rio Hortega contract in the 2019 Strategic Action Health Call from the Instituto de Salud Carlos III for the years 2020-2022. Viviana Marras from the University of Sassari (Italy) was the recipient of an Erasmus Placement for a short stay at the Pneumology Department of University Hospital Valld’Hebron (Barcelona, Spain). Miriam Barrecheguren is the recipient of a Rio Hortega contract in the 2017 Strategic Action Health Call from the Instituto de Salud Carlos III for the years 2018-2019. Matevz Harlander has received speaker or consulting fees from AstraZeneca, Berlin-Chemie, Menarini, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis and Teva, all unrelated to this manuscript. Evgeni Mekov has received speaker or consulting fees from Astra Zeneca and Chiesi, all unrelated to this manuscript. Cristina Esquinas has received speaker fees from CSL Behring. Matjaz Turel has received speaker or consulting fees from AstraZeneca, Berlin-Chemie, Menarini, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis and Teva, all unrelated to this manuscript. David Lestan has received speaker or consulting fees from Boehringer Ingelheim and Roche, all unrelated to this manuscript. Rosen Petkov has received speaker or consulting fees from Astra Zeneca and Boehringer Ingelheim, all unrelated to this manuscript. Nikolay Yanev has received speaker or consulting fees from Astra Zeneca, Boehringer Ingelheim, Berlin Chemie and Chiesi, all unrelated to this manuscript. Pietro Pirina has received speaker fees from Chiesi, Menarini, Novartis, Mundifarma, Glaxo Smith Kline, all unrelated to this manuscript. Marc Miravitlles has received speaker or consulting fees from AstraZeneca, Bial, Boehringer Ingelheim, Chiesi, Cipla, CSL Behring, Laboratorios Esteve, Ferrer, Gebro Pharma, GlaxoSmithKline, Grifols, Kamada, Menarini, Mereo Biopharma, Novartis, pH Pharma, Rovi, Sanofi, Sandoz, TEVA, Verona Pharma and Zambon, and research grants from GlaxoSmithKline and Grifols, unrelated to this manuscript. Miriam Barrecheguren has received speaker fees from Grifols, Menarini, CSL Behring, GSK and consulting fees from GSK, Novartis and Gebro Pharma. The authors report no other conflicts of interest in this work., (© 2020 Nuñez et al.)

Background: Low plasma level of alpha1-antitrypsin (AAT) is an established risk factor for early-onset chronic obstructive lung disease (COPD). However, less attention is given to the levels of AAT in the general population., Methods: This is a part of a multicentre, population-based study conducted at 11 sites throughout Spain. Plasma levels of AAT were available for 837 persons with a mean (SD) age of 58.05 (11.3) years: 328-smokers, 272-ex-smokers and 237 non-smokers. Out of 837, 303 (36.2%) had a diagnosis of COPD, 222 (26.5%) had respiratory symptoms but no COPD, and 312 (37.3%) were healthy controls., Results: In the whole cohort, the mean level of plasma AAT was 1.51 (0.47)g/L. Levels were higher in COPD patients [1.55 (0.45)g/L] and individuals with respiratory symptoms [1.57 (0.47)g/L] than in controls [1.43 (0.47)g/L], p<0.001, a finding which persisted after correction for age and CRP. Plasma AAT levels were negatively associated with FEV1/FVC ratio, after adjustment for age, sex, smoking status, CRP, TNFα, fibrinogen and albumin. The risk for COPD was significantly associated with higher AAT levels in univariate and multivariate models, with odds ratios of 1.8 and 1.5, respectively. In the univariate and multivariate models smoking status, gender, and CRP levels were also associated with COPD probability, demonstrating that they act independently., Conclusion: Increased circulating levels of AAT, similarly to CRP and other markers of systemic inflammation, is an important feature of COPD. Our results highlight a complex interrelationship between levels of AAT and health of respiratory system., (Copyright © 2019 SEPAR. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Community-acquired pneumonia (CAP) is treated with penicillin in some northern European countries., Objectives: To evaluate whether high-dose penicillin V is as effective as high-dose amoxicillin for the treatment of non-severe CAP., Design: Multicentre, parallel, double-blind, controlled, randomized clinical trial., Setting: 31 primary care centers in Spain., Participants: Patients from 18 to 75 years of age with no significant associated comorbidity and with symptoms of lower respiratory tract infection and radiological confirmation of CAP were randomized to receive either penicillin V 1.6 million units, or amoxicillin 1000mg three times per day for 10 days., Main Measurements: The main outcome was clinical cure at 14 days, and the primary hypothesis was that penicillin V would be non-inferior to amoxicillin with regard to this outcome, with a margin of 15% for the difference in proportions. EudraCT register 2012-003511-63., Results: A total of 43 subjects (amoxicillin: 28; penicillin: 15) were randomized. Clinical cure was observed in 10 (90.9%) patients assigned to penicillin and in 25 (100%) patients assigned to amoxicillin with a difference of -9.1% (95% CI, -41.3% to 6.4%; p=.951) for non-inferiority. In the intention-to-treat analysis, amoxicillin was found to be 28.6% superior to penicillin (95% CI, 7.3-58.1%; p=.009 for superiority). The number of adverse events was similar in both groups., Conclusions: There was a trend favoring high-dose amoxicillin versus high-dose penicillin in adults with uncomplicated CAP. The main limitation of this trial was the low statistical power due to the low number of patients included., (Copyright © 2017 Elsevier España, S.L.U. All rights reserved.)

Introduction: The EPISCAN study, published in 2007, was an update of the results of the 1997 IBERPOC study. Changes in demographics and exposure to risk factors demand the periodic update of prevalence and determining factors in COPD. This article is a summary of the protocol and tools used in EPISCAN II., Materials and Methods: The primary objective of EPISCAN II is to estimate the prevalence of COPD among the general population aged 40 years or more in the 17 autonomous communities of Spain. The sample size requires 600 participants (300 men and 300 women) per center, selected by screening 10,200 participants in a short visit (questionnaire plus forced post-bronchodilator spirometry). Of these, 800 (400 with COPD and 400 without COPD) will also perform a long visit (including a walking test, blood tests, determination of diffusion, pulse oximetry and bioimpedance, and low radiation CT)., Results: The first participant was recruited on 28 February 2017. As of 22 November 2017, a total of 3,581 participants had been included, of whom 422 had already performed the long visit. It is estimated that the field work will be completed by December 2018. The new imaging data, biomarkers, and information on new exposures, such as electronic cigarettes and environmental pollution, will help us re-quantify the burden of COPD., Conclusions: EPISCAN II will provide updated information on prevalence and determinants of COPD in Spain, allowing for the comparison of spirometric results and other factors associated with COPD among the 17 autonomous communities., (Copyright © 2018 SEPAR. Publicado por Elsevier España, S.L.U. All rights reserved.)

Purpose: The aim of this study was to evaluate the impact of morning symptoms in COPD using the Capacity of Daily Living during the Morning (CDLM) questionnaire and to determine the clinical variables that are related to CDLM scores., Methods: This was an observational, cross-sectional, and multicenter study conducted in stable COPD patients. CDLM scores ranged from 0 to 5 and were transformed into a qualitative variable according to tertile values to compare patient characteristics. A multivariate linear regression model was used to identify the clinical variables related to CDLM scores., Results: A total of 605 patients were included in the study; the mean age (SD) was 68 years (9.1) and mostly were male (80.8%). The mean post-bronchodilator FEV 1 % was 53.4% (19.2%), and the mean BODEx (body mass index, airway obstruction, dyspnea, exacerbation) score was 3.2 (2.0). The mean COPD assessment test (CAT) score was 16.6 (8.3), and the mean CDLM score was 4.2 (0.9). First tertile patients, that is, those with a higher impact in the morning, were older, had more respiratory symptoms, more dyspnea, a lower FEV 1 %, lower CAT and BODEx scores, and more exacerbations. We found a ceiling effect on the CDLM scores: 194 (32%) patients scored 5.00 and no patients scored 0. On multivariate analysis, higher CAT and BODEx scores, a lower FEV 1 %, and use of long-term oxygen therapy (LTOT) were all independently related to lower CDLM scores., Conclusion: Morning respiratory symptoms are associated with more severe airflow obstruction, lower CAT and BODEx scores, and LTOT. The ceiling effect of the CDLM questionnaire does not allow it to discriminate well between low and high impact of morning symptoms., Competing Interests: Disclosure Miriam Barrecheguren has received speaker fees from Grifols, Menarini, and GSK; and consultancy fees from Novartis and Gebro Pharma. Myriam Calle has received speaker fees from Boehringer Ingelheim, AstraZeneca, GlaxoSmithKline, Menarini, and Novartis. Ricard Casamor is a full-time employee of Novartis-Pharmaceuticals. Marc Miravitlles has received honoraria from Novartis for conducting the FENEPOC study; speaker fees from Boehringer Ingelheim, Chiesi, Cipla, Menarini, Rovi, Bial, Grifols, and Novartis; consultancy fees from Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Bial, Gebro Pharma, CSL Behring, Laboratorios Esteve, Mereo Biopharma, Verona Pharma, pH Pharma, Novartis, and Grifols; and research grants from GlaxoSmithKline and Grifols, outside the submitted work. The authors report no other conflicts of interest in this work.

Introduction: The objective of this study was to analyze the clinical characteristics of COPD patients attending general respiratory clinics, adherence to clinical guidelines, classification accuracy, and therapeutic management., Method: Multicenter, cross-sectional study, with the primary objective of describing the number, intensity, and variability of symptoms in COPD patients. Data were collected in 2015 by 300 pulmonologists who evaluated a total of 3,010 patients, of which 2,669 (88.6%) were eligible for analysis., Results: A total of 22% were active smokers, notably 21% and 17% of GOLD groups C and D, and 17% and 19% of exacerbators in the GesEPOC classification; 62.3% had associated comorbidities. The diagnostic process was characterized by limited use of tests such as diffusion capacity or lung volumes, even in the more severe GOLD groups or the GesEPOC exacerbator phenotypes. The use of multidimensional scales, such as BODE (12%), and specific rehabilitation protocols was also rare. Treatment was based on different combinations of bronchodilators and inhaled corticosteroids. Methylxanthines were used in very few patients (7%)., Conclusions: A large proportion of COPD patients seen in respiratory clinics have non-complex disease and pulmonology tests are rarely performed. Our study confirms a slight change in treatments and the frequent association with comorbidities that can modify the clinical presentation of the patient., (Copyright © 2018 SEPAR. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: Evaluate cardiac, metabolic, and ventilatory changes during a training session with whole-body vibration training (WBVT) with 3 different frequencies in patients with chronic obstructive pulmonary disease (COPD)., Methods: This was a prospective, interventional trial in outpatients with severe COPD. Participants performed 3 vertical WBVT sessions once a week using frequencies of 35, 25 Hz and no vibration in squatting position (isometric). Cardiac, metabolic, and ventilator parameters were monitored during the sessions using an ergospirometer. Changes in oxygen pulse response (VO 2 /HR) at the different frequencies were the primary outcome of the study., Results: Thirty-two male patients with a mean forced expiratory volume in 1 second of 39.7% completed the study. Compared to the reference of 35 Hz, VO 2 /HR at no vibration was 10.7% lower ( P =0.005); however, no statistically significant differences were observed on comparing the frequencies of 35 and 25 Hz. The median oxygen uptake (VO 2 ) at 25 Hz and no vibration was 9.43% and 13.9% lower, respectively, compared to that obtained at 35 Hz (both comparisons P <0.0001). The median expiratory volume without vibration was 9.43% lower than the VO 2 at the end of the assessment at 35 Hz vibration ( P =0.002)., Conclusion: Vertical WBVT training sessions show greater cardiac, metabolic, and respiratory responses compared with the squat position. On comparing the 2 frequencies used, we observed that the frequency of 35 Hz provides higher cardiorespiratory adaptation., Competing Interests: Disclosure Marc Miravitlles received speaker fees from Boehringer Ingelheim, Chiesi, Cipla, Menarini, Rovi, Bial, CSL Behring, Grifols and Novartis, consulting fees from Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Bial, Gebro Pharma, CSL Behring, Laboratorios Esteve, Mereo Biopharma, Verona Pharma, pH Pharma, Novartis and Grifols and research grants from GlaxoSmithKline and Grifols, all outside of the submitted work. The authors report no other conflicts of interest in this work.

Purpose: Psychiatric patients present an elevated rate of smoking, and the smoking habit is related to a high morbidity and mortality in this collective. The aim of this study was to determine the prevalence of smoking in patients admitted for psychiatric disorders and its relationship with respiratory disease, the prevalence of COPD, and alterations in the quality of life., Patients and Methods: A cross-sectional, observational study was conducted and detailed information on smoking and respiratory symptomatology was obtained. The study participants underwent the following tests: spirometry with bronchodilator test, Fagerström test, determination of physical activity using the LCADL questionnaire, and evaluation of quality of life with the EuroQoL-5 Dimensions EQ-5D questionnaire., Results: Two hundred seventy-six patients (mean age 56.8 years) were included: 155 with schizophrenia (87.7% smokers), 46 with depressive or anxiety disorders (54.3% smokers), and 49 and 25 with intellectual disability and dementia (43.2% smokers), respectively. The mean Fagerström test score was 5.75 points. Smokers presented with cough (47.6%), expectoration (41.4%), and chronic bronchitis (36.6%). The prevalence of COPD in the total population was 28.9%. The EQ-5D and LCADL scores were better in smokers because of their younger age and lesser psychiatric involvement. A high prevalence of smoking was observed in the psychiatric population studied, and 28.9% were diagnosed with COPD., Conclusion: Smokers presented many more respiratory symptoms and chronic bronchitis but did not present a worse quality of life or physical activity due to their younger age and milder psychiatric involvement., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: Alpha-1-Antitrypsin (AAT) deficiency (AATD) is a hereditary disorder that manifests primarily as pulmonary emphysema and liver cirrhosis. The clinically most relevant mutation causing AATD is a single nucleotide polymorphism Glu342Lys (Z-mutation). Despite the recommendation to test every COPD patient, the condition remains severely underdiagnosed with a delay of several years between first symptoms and diagnosis. The Grifols' AlphaKit® QuickScreen is a novel qualitative point-of-care (POC) in vitro screening test developed for the detection of the Z AAT protein in capillary whole blood. The objective of this prospective, international, multi-center, diagnostic, interventional real-world study was to assess the performance of this device for the detection of AATD in test-naïve COPD patients., Methods: 1044 test-naïve COPD patients were recruited from 9 centers in Spain and 10 centers in Germany, ranging from primary to tertiary care. To evaluate the performance of the test, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated compared with the gold standard (genotyping)., Results: Genotyping and phenotyping of all 1019 evaluable samples revealed 4.12% of patients as carriers of at least one Z-allele, while 0.29% carried the homozygous genotype Pi*ZZ. The evaluation of the test's ability to detect the PiZ protein yielded the following results: specificity 97.8%, sensitivity 73.8%, negative predictive value 98.9%, and positive predictive value 58.5%. All false negatives (n = 11) were heterozygote Pi*MZ samples., Conclusions: The tested device can be used as an appropriate tool to exclude AATD in primary care and in the overall COPD population, except in patients with a high a-priori- probability of AATD.

Background: Alpha-1 antitrypsin deficiency (AATD) is the most common hereditary disorder in adults, but is under-recognized. In Spain, the number of patients diagnosed with AATD is much lower than expected according to epidemiologic studies. The objectives of this study were to assess the frequency and determinants of testing serum α1-antitrypsin (AAT) levels in COPD patients, and to describe factors associated with testing., Methods: EPOCONSUL is a cross-sectional clinical audit, recruiting consecutive COPD cases over one year. The study evaluated serum AAT level determination in COPD patients and associations between individual, disease-related, and hospital characteristics., Results: A total of 4,405 clinical records for COPD patients from 57 Spanish hospitals were evaluated. Only 995 (22.5%) patients had serum AAT tested on some occasion. A number of patient characteristics (being male [OR 0.5, p < 0.001], ≤55 years old [OR 2.38, p<0.001], BMI≤21 kg/m2 [OR 1.71, p<0.001], FEV1(%)<50% [OR 1.35, p<0.001], chronic bronchitis [OR 0.79, p < 0.001], Charlson index ≥ 3 [OR 0.66, p < 0.001], or history or symptoms of asthma [OR 1.32, p<0.001]), and management at a specialized COPD outpatient clinic [OR 2.73,p<0.001] were identified as factors independently associated with ever testing COPD patients for AATD. Overall, 114 COPD patients (11.5% of those tested) had AATD. Of them, 26 (22.8%) patients had severe deficiency. Patients with AATD were younger, with a low pack-year index, and were more likely to have emphysema (p<0.05)., Conclusion: Testing of AAT blood levels in COPD patients treated at outpatient respiratory clinics in Spain is infrequent. However, when tested, AATD (based on the serum AAT levels ≤100 mg/dL) is detected in one in five COPD patients. Efforts to optimize AATD case detection in COPD are needed., Competing Interests: Boehringer Ingelheim gave financial support with a donation for to carry out the study. The financing entity did not participate in the design of the study, data collection, analysis, publication or preparation of this manuscript. Myriam Calle Rubio received speaker fees from Boehringer Ingelheim, AstraZeneca, GlaxoSmithKline, Menarini, and Novartis and consulting fees from GlaxoSmithKline, Gebro Pharma and Novartis. This does not alter our adherence to PLOS ONE policies on sharing data and materials.