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Introduction: The lack of adherence is involved in treatment failure. The aim of the study is to assess adherence and clinical and bacteriological effectiveness of nebulized treatment with sodium colistimethate (Promixin®) inhaled by I-neb® device in patients with non-cystic fibrosis bronchiectasis colonized by Pseudomonas aeruginosa (PsA). Patients and Methods: A prospective, multicenter, observational, longitudinal study of a cohort of adults treated for at least 6 months with Promixin®. Compliance data were collected with the computer platform Insight. Lung function data, sputum bacteriology and number of exacerbations and hospital admission in the previous year and after treatment were analysed. Results: 106 patients, 57 males (53.8%), average age 64.0 ± 14.6 years. The post-infectious aetiology was the most frequent and PsA was the only isolated pathogen in 84% of cases. The mean treatment time was 26.8 ± 16.7 months (6.1 to 63.9). Proper nebulizer management was 96.6 ± 7.8% and real adherence 84.3±20.2%. Relevant clinical data are collected in the. Conclusions: In our cohort, nebulizer management and real adherence to treatment with Promixin® were excellent with an improvement in lung function, number of exacerbations and need for admission to hospital.

Objectives: At the moment no studies have evaluated a clinical audit of clinical practice in chronic obstructive pulmonary disease (COPD) in the outpatient visits so far. This work is a first pilot project that aims to assess the variability of clinical practice for COPD in this care setting through a clinical audit. Methods: Pilot medical record audit conducted in specialised outpatient Pneumology clinic from 9 public hospitals in Andalusia (Spain) between October 2013 and September 2014. The project goal was to audit 80 cases per centre distributed over the year. The information was collected by standardized questionnaire with 182 variables. The data are described in means and inter-hospital ranges to evaluate between centres variability. Results: During study analysed 621 stories. Patients were mostly men, in the seventh decade of life, with a percentage of current smokers of 26.2%, a considerable number of comorbidities and mostly the urban area. The data indicate that health care is generally correct as average but indicating areas for improvement in some points and considerable variability between centres with significant differences (p Conclusions: Health care COPD patients in outpatient Pneumology clinics shows considerable variability that probably cannot be explained only by the patient9s clinical condition. Future studies should elucidate which factors influence this variability.

Introduction: The source of systemic inflammation keeps being an unanswered question in COPD pathogenesis.Of all the mediators described in COPD,there are three main biological pathways,namely lung inflammation(IL-8,MCP-1,NF-κβ,IFN-γ),systemic inflammation(SAA1,SAA2,SAA4,PCR)and protease/antiprotease imbalance(MMP-9,MMP-12).On the other hand,simvastatin has been shown to have some anti-inflammatory effect with some clinical implications.The aim of this study was evaluate the response to inflammatory cytokine(IL-1)in epithelial cells,fibroblasts and lung endothelial and its possible inhibition with simvastatin. Methods: Commercial cell lines from bronchial epithelial cells(CRL-4011),human lung fibroblasts(MRC-5),and vascular pulmonary cells(C-12282)were used.After a dose response study,the dose of 10ng/ml of IL-1 and 30uM of simvastatin were the selected for the rest of the experiments.These cells were cultured with IL-1 and simvastatin for 24, 48 and 72 hours;the simvastatin was added 45 minutes before,following study protocols.The pellet was extracted for measuring gene expression by RT-PCR.Gene and protein expression are explored. Results: The different cell types activated three pathways involved in COPD.After IL-1 challenge,fibroblasts had a significantly higher expression than epithelial and endothelial cells to IL-8, MCP-1,SAA1 and SAA2 (p Conclusions: The different cell types of the lung tissue respond at inflammatory cytokine with gene expression involved in pathogenic pathways of COPD.However,this activation is not reversed with statins such as simvastatin.

Jose Luis Lopez-Campos,1,2,* Alberto Fernandez-Villar,3,* Carmen Calero-Acuña,1 Cristina Represas-Represas,3 Cecilia Lopez-Ramírez,1 Virginia Leiro Fernández,3 Juan Jose Soler-Cataluña,2,4 Ricard Casamor5 On behalf of the On-Sint study group 1Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/Universidad de Sevilla, Sevilla, Spain; 2CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; 3Servicio de Neumología, Instituto de Investigación Biomédica de Vigo (IBIV), Complexo Hospitalario de Vigo, Vigo, Spain; 4Servicio de Neumología Hospital Arnau de Vilanova, Valencia, Spain; 5Departamento Médico de Novartis Farmacéutica, Barcelona, Spain *These authors contributed equally to this work Background: The COPD Assessment Test (CAT) has been recently developed to quantify COPD impact in routine practice. However, no relationship with other measures in the Global Initiative for Obstructive Lung Disease (GOLD) strategy has been evaluated. The present study aimed to evaluate the relationship of the CAT with other GOLD multidimensional axes, patient types, and the number of comorbidities.Methods: This was a cross-sectional analysis of the Clinical presentation, diagnosis, and course of chronic obstructive pulmonary disease (On-Sint) study. The CAT score was administered to all participants at the inclusion visit. A GOLD 2011 strategy consisting of modified Medical Research Council scale (MRC) scores was devised to study the relationship between the CAT, and GOLD 2011 axes and patient types. The relationship with comorbidities was assessed using the Charlson comorbidity index, grouped as zero, one to two, and three or more.Results: The CAT questionnaire was completed by 1,212 patients with COPD. The CAT maintained a relationship with all the three axes, with a ceiling effect for dyspnea and no distinction between mild and moderate functional impairment. The CAT score increased across GOLD 2011 patient types A–D, with similar scores for types B and C. Within each GOLD 2011 patient type, there was a considerably wide distribution of CAT values.Conclusion: Our study indicates a correlation between CAT and the GOLD 2011 classification axes as well as the number of comorbidities. The CAT score can help clinicians, as a complementary tool to evaluate patients with COPD within the different GOLD patient types. Keywords: chronic obstructive pulmonary diseases, multidimensional evaluation, comorbidities

Alberto Fernández-Villar,1 José Luis López-Campos,2,3 Cristina Represas Represas,1 Lucía Marín Barrera,3 Virginia Leiro Fernández,1 Cecilia López Ramírez,3 Ricard Casamor4 1Department of Pneumology, Complexo Hospitalario de Vigo, Instituto de Investigación Biomédica de Vigo, Vigo, 2Medical-Surgical Unit of Respiratory Diseases, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, 3Centro de Investigación Biomédica en Red de Respiratorio, Instituto de Salud Carlos III, Madrid, 4Medical Department, Novartis Farmacéutica, Barcelona, Spain Background: The purpose of this study was to evaluate the frequency of inadequate diagnosis and factors predictive of this in patients with chronic obstructive pulmonary disease (COPD) participating in the On-Sint study. Methods: The On-Sint cohort was recruited for a multicenter observational study in which 356 physicians (71.6% from primary care) included adult patients who had been diagnosed with COPD. Patients’ clinical and functional information since diagnosis and details for the recruiting physicians were collected from patient files and at the inclusion visit. We performed a multivariate analysis to evaluate the influence of these variables on diagnostic inadequacy (absence of postbronchodilator forced expiratory volume in one second/forced vital capacity [FEV1/FVC]

Objetivo La ventilacion mecanica domiciliaria se aplica a pacientes con insuficiencia respiratoria cronica y grave, lo que tiene un impacto considerable en su calidad de vida. El objetivo de este trabajo ha sido realizar una traduccion y adaptacion transcultural para la poblacion espanola del cuestionario Severe Respiratory Insuficiency (SRI), el primer cuestionario de calidad de vida relacionada con la salud especifico para estos pacientes. Metodos Intervinieron 4 traductores bilingues aleman-espanol siguiendo el metodo de la traduccion y retrotraduccion. Despues de cada paso se realizaron reuniones con los traductores para obtener una version unica antes de continuar. Al final del proceso se realizo una prueba piloto para valorar su comprensibilidad. El proceso de traduccion se evaluo en dificultad y naturalidad, mediante una escala entre 1 (minimo) y 10 (maximo), asi como en equivalencia de los items con la version original. Resultados Se obtuvieron 3 versiones en espanol. La dificultad de la traduccion fue considerablemente baja para la traduccion (media ± desviacion estandar 1,4 ± 0,6) y la retrotraduccion (2,2 ± 1,1). La naturalidad de los items fue muy elevada y mejoro con las sucesivas versiones (version 1: 8,4; version 2: 8,7; version 3: 9,1; p Conclusiones La traduccion del cuestionario siguiendo el metodo de la traduccion-retrotraduccion ha dado una version espanola equiparable a la original y asequible para los pacientes. Actualmente se esta llevando a cabo la validacion del cuestionario mediante un estudio multicentrico.

Background Previous analyses of lung cancer mortality were based on models of death rates within one time period, assuming that rates increase or decrease with time at a constant rate. The aim of this work is to analyse recent changes in lung cancer mortality trends in Andalusia (Spain) during the period of 1975–2000 using joinpoint regression models. Patients and methods Mortality data were obtained from the Death Registry of Andalusia. For each gender, age group-specific and standardised (overall and truncated) rates were calculated by the direct method (using the world standard population). The joinpoint analysis was used to identify the best-fitting points where a statistically significant change in the trend occurred. Results Lung cancer is the leading cause of cancer mortality in men, with an increasing trend up to 1994. After that year, rates began to decrease significantly (–1.8% yearly from 1994 to 2000). Standardised rates in women exhibited a downward trend until the early 1990s, after which they levelled off (overall standardised rates) or increased significantly (truncated rates 35–64 years). Conclusions An increase in lung cancer mortality has been observed in young women. There seems to be a relationship with the prevalence in smoking in men and women.

Fundamento Y Objetivos Valorar la eficacia de la ventilacion no invasiva (VNI) en la enfermedadpulmonar obstructiva cronica (EPOC) en fracaso respiratorio agudo (FRA) y saber si hay diferenciasen los resultados en funcion del lugar de aplicacion. Material Y Metodo Se realizo un metaanalisis de ensayos controlados aleatorizados (ECA) publicadosen Medline, EMBASE, Registro de Ensayos Clinicos Controlados de la ColaboracionCochrane y Teseo hasta junio de 2002. Se efectuo una seleccion de los ECA en EPOC con FRAy pH sanguineo 45 mmHg, con VNI frente a tratamiento estandar, y seanalizaron mortalidad, tasa de intubacion y dias de estancia. La validez y calidad de los ECAfueron analizadas por dos investigadores con la escala de Jadad. Realizamos metaanalisis diferentespara los estudios de unidades de cuidados intensivos (UCI) y planta. Resultados Se incluyeron 5 ECA de UCI y 4 de planta. Se encontro una reduccion de la mortalidad(UCI, odds ratio [OR] = 0,35; intervalo de confianza [IC] del 95%, 0,15–0,82; n = 166; p= 0,02; planta, OR = 0,40; IC del 95%, 0,21–0,75; n = 330; p = 0,005) y del numero de intubaciones(UCI, OR = 0,18; IC del 95%, 0,10–0,35; n = 219; p Conclusiones La VNI reduce la mortalidad y la necesidad de intubacion en pacientes con EPOCen FRA cuando se aplica tanto en UCI como en planta. En la UCI la VNI reduce tambien losdias de hospitalizacion.

Despite widespread recommendations to use standardized questionnaires and multidimensional indices for the assessment of patients with chronic obstructive pulmonary disease (COPD), few data are available on the application of these tools in clinical practice. This study evaluates the attitude of physicians participating in the On-Sint cohort toward the use of health status questionnaires and multidimensional indices, as well as toward the frequency of visits and spirometry in primary care and specialized care.During the constitution of the On-Sint cohort, the participating physicians were surveyed about their clinical practice. They were questioned on the frequency of spirometry and visits and on the use of various questionnaires and indices. The health status questionnaires assessed were St. George's respiratory questionnaire, chronic respiratory questionnaire, airways questionnaire 20 and COPD assessment test (CAT). Physicians were also asked about the use of the medical research council (MRC) dyspnea scale and multidimensional indices such as body mass index, airflow obstruction, dyspnea, exercise capacity (BODE).Of the 356 physicians who participated in the study, 258 (72.5 %) completed the investigator's questionnaire (185 primary care, 73 specialized care). Nonscheduled visits were inversely proportional to the severity of COPD. Overall, 34.1% reported using health status questionnaires, mainly CAT (20.9%). We found differences between primary and specialized care in the use of multidimensional indices (84.9% vs 47.6%; P 0.001). Of all the participants, 33.3% reported using the MRC scale and 28.7% the BODE index.Multidimensional indices and questionnaires are not commonly used with some differences between primary care and specialized care physicians. There is a considerable variability in the frequency of follow-up visits and spirometry.

Background Previous studies have demonstrated significant variability in the processes of care and outcomes of chronic obstructive pulmonary disease (COPD) exacerbations. The AUDIPOC is a Spanish nationwide clinical audit that identified large between-hospital variations in care and clinical outcomes. Here, we test the hypothesis that these variations can be attributed to either patient characteristics, hospital characteristics and/or the so-called hospital-clustering effect, which indicates that patients with similar characteristics may experience different processes of care and outcomes depending on the hospital to which they are admitted. Methods A clinical audit of 5178 COPD patients consecutively admitted to 129 Spanish public hospitals was performed, with a 90-day follow-up. Multilevel regression analysis was conducted to model the probability of patients experiencing adverse outcomes. For each outcome, an empty model (with no independent variables) was fitted to assess the clustering effect, followed by a model adjusted for the patient- and hospital-level covariables. The hospital-clustering effect was estimated using the intracluster correlation coefficient (ICC); the cluster heterogeneity was estimated with the median odds ratio (MOR), and the coefficients of predictors were estimated with the odds ratio (OR). Results In the empty models, the ICC (MOR) for inpatient mortality and the follow-up mortality and readmission were 0.10 (1.80), 0.08 (1.65) and 0.01 (1.24), respectively. In the adjusted models, the variables that most represented the patients’ clinical conditions and interventions were identified as outcome predictors and further reduced the hospital variations. By contrast, the resource factors were primarily unrelated with outcomes. Conclusions This study demonstrates a noteworthy reduction in the observed crude between-hospital variation in outcomes after accounting for the hospital-cluster effect and the variables representing patient's clinical conditions. This emphasises the predictor importance of the patients’ clinical conditions and interventions, and understates the impacts of hospital resources and organisational factors. Authors thank all participating institutions for their willingness to contribute to medical research aimed at reducing medical practice variations, improving the quality of care provided. Supported by the Spanish Ministry of Health, Instituto de Salud Carlos III, FIS project numbers: PI07/90129, PI07/90309, PI07/90486, PI07/90503, PI07/90516, PI07/90721, PI08/90129, PI08/90578, PI08/90251, PI08/90529, PI08/90129, PI07/90403, PI08/90447, PI08/90457, PI08/90486 and PI08/90550, the Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES) and the Spanish Society of Respiratory and Thoracic Surgey (SEPAR).

Objective Appropriate use of antibiotics in the management of hospitalised patients with COPD exacerbations is defined within the GOLD strategy. This paper analyses the factors associated with antibiotic prescribing in patients to better understand how prescribing may be improved. Methods The European COPD audit was a study of clinical care in 384 hospitals from 13 European countries between 2010 and 2011 enrolling 16018 patients. Those admitted to hospital due to a clinician-made diagnosis of exacerbation of COPD at the time of discharge were audited. We defined antibiotic prescribing compliance as consistent with the GOLD 2010 recommendations. Two different multivariate models were used to evaluate factors associated with the prescription of antibiotics and the guideline-compliant prescriptions. Results Overall 86% of admissions were given antibiotics but only 61.4% cases met the GOLD recommendations. Antibiotics were more likely to be given in hospital and at discharge if received prior to admission. Antibiotic prescription was more likely in patients who met the GOLD recommendations and in those with radiological consolidation but there was also a significant use of antibiotics in patients who did not meet either criterion. Patients cared for on a Respiratory Ward were more likely to receive GOLD compliant antibiotic management. Conclusions The present study describes the audited in-hospital antibiotic prescription for COPD exacerbation across different European countries. In general, there is an apparent overuse of antibiotics likely to be associated with both patient and practice-related variables.

Despite its accepted role, a number of controversies persist regarding the use of antibiotics for exacerbations of chronic obstructive pulmonary disease (COPD). The adequate selection of patients, the identification of biomarkers for treatment response, the adequacy to disease and exacerbation severities or the short-term impact on the exacerbation outcome in different settings remain some of the aspects under current debate (1,2). One specific topic that warrants investigation is the potential long-term impact of antibiotic prescription during exacerbations, specifically on the prevention of subsequent exacerbations. The question about whether a specific treatment during the exacerbation can have an impact on the long term preventing future acute episodes is intriguing. Beyond the potential rationale behind, the topic results to be not easy to face, since a number of factors associated with subsequent exacerbations or with re-admissions after an index event are well-known (3).

BACKGROUND The European COPD Audit initiated by the European Respiratory Society (ERS) evaluated the management of hospital admissions due to exacerbation of chronic obstructive pulmonary disease (COPD) in several European countries. Data on the treatment of severe acute exacerbations of COPD (AECOPDs) in Switzerland are scarce. OBJECTIVES In light of the GOLD 2010 guidelines, this work aims to examine the quality of care for AECOPD and to provide specific recommendations for the management of severe AECOPD in Switzerland. METHODS A total of 295 patients requiring hospital admission to 19 Swiss hospitals due to exacerbation of COPD during a predefined 60 days in 2011 were included in the study. We compared the Swiss data to the official GOLD 2010 recommendations and to the results of the other European countries. RESULTS Approximately 43% of the Swiss patients with severe AECOPD were current smokers at hospital admission, compared to 33% of the patients in other European countries (p < 0.001). In Switzerland and in Europe, spirometry data were not available for most patients at hospital admission (65 and 60%, respectively; p = 0.08). In comparison to other European countries, antibiotics were prescribed 14% less often in Switzerland (p < 0.001). Only 79% of the patients in the Swiss cohort received treatment with a short-acting bronchodilator at admission. CONCLUSIONS Considering the overall high standard of health care in Switzerland, in light of the GOLD 2010 guidelines we are able to make 7 recommendations to improve and standardize the management of severe AECOPD for patients treated in Switzerland.

Little is known about the longitudinal changes associated with using the 2013 update of the multidimensional GOLD strategy for chronic obstructive pulmonary disease (COPD).To determine the COPD patient distribution of the new GOLD proposal and evaluate how this classification changes over one year compared with the previous GOLD staging based on spirometry only.We analyzed data from the CHAIN study, a multicenter observational Spanish cohort of COPD patients who are monitored annually. Categories were defined according to the proposed GOLD: FEV1%, mMRC dyspnea, COPD Assessment Test (CAT), Clinical COPD Questionnaire (CCQ), and exacerbations-hospitalizations. One-year follow-up information was available for all variables except CCQ data.At baseline, 828 stable COPD patients were evaluated. On the basis of mMRC dyspnea versus CAT, the patients were distributed as follows: 38.2% vs. 27.2% in group A, 17.6% vs. 28.3% in group B, 15.8% vs. 12.9% in group C, and 28.4% vs. 31.6% in group D. Information was available for 526 patients at one year: 64.2% of patients remained in the same group but groups C and D show different degrees of variability. The annual progression by group was mainly associated with one-year changes in CAT scores (RR, 1.138; 95%CI: 1.074-1.206) and BODE index values (RR, 2.012; 95%CI: 1.487-2.722).In the new GOLD grading classification, the type of tool used to determine the level of symptoms can substantially alter the group assignment. A change in category after one year was associated with longitudinal changes in the CAT and BODE index.

Summary Background Non-invasive ventilation and exercise training might prove beneficial in the management of COPD patients. Objetive to compare the combined use of exercise training and non-invasive ventilation with the two interventions separately in chronic respiratory failure due to chronic obstructive pulmonary disease. As primary objective exercise capacity and secondary objectives gas exchange, peripheral muscle strength, BODE index, quality of life and systemic inflammatory response. Methods Forty-five patients with severe chronic obstructive pulmonary disease were randomized into three groups for an intervention of 12 weeks: exercise training alone, ventilation alone and combined treatment. We assessed exercise capacity, pulmonary function, BODE index, perception of dyspnoea, quality of life and several biomarkers. Results All exercise capacity parameters improved after training and the combined treatment. In addition, peripheral muscle strength and six-minute walk distance increased after ventilation. We found differences between the combined group and the ventilation group in submaximal effort and in oxygen consumption. Changes in respiratory function were observed in blood gases that improved after ventilation and the combined treatment, with differences between these groups. BODE index, perception of dyspnoea and quality of life improved in all three groups without differences between groups. Levels of interleukin 8 and tumour necrosis factor α decreased after ventilation, and interleukin 8, C-reactive protein and surfactant protein D decreased after training, while all four of these markers fell after the combined treatment. No differences between groups were found. Conclusions The combination of ventilation and exercise training had greater benefits than the separate treatments: improvements were observed in both blood gases and the levels of more biomarkers decreased. In addition, submaximal exercise capacity increased in all groups. The improvements seen in BODE index, perception of dyspnoea and quality of life were similar in all groups.

Background Chronic systemic inflammatory syndrome has been implicated in the pathobiology of extrapulmonary manifestations of chronic obstructive pulmonary disease (COPD). We aimed to investigate which cell types within lung tissue are responsible for expressing major acute-phase reactants in COPD patients and disease-free (“resistant”) smokers. Methods An observational case–control study was performed to investigate three different cell types in surgical lung samples of COPD patients and resistant smokers via expression of the C-reactive protein (CRP) and serum amyloid A (SAA1, SAA2 and SAA4) genes. Epithelial cells, macrophages and fibroblasts from the lung parenchyma were separated by magnetic microbeads (CD326, CD14 and anti-fibroblast), and gene expression was evaluated by RT-PCR. Results The sample consisted of 74 subjects, including 40 COPD patients and 34 smokers without disease. All three cell types were capable of synthesizing these biomarkers to some extent. In fibroblasts, gene expression analysis of the studied biomarkers demonstrated increased SAA2 and decreased SAA1 in patients with COPD. In epithelial cells, there was a marked increase in CRP, which was not observed in fibroblasts or macrophages. In macrophages, however, gene expression of these markers was decreased in COPD patients compared to controls. Conclusions These results provide novel information regarding the gene expression of CRP and SAA in different cell types in the lung parenchyma. This study revealed differences in the expression of these markers according to cell type and disease status and contributes to the identification of cell types that are responsible for the secretion of these molecules.

This report shows the results of a nation-wide survey on spirometry to assess regional differences.Observational cross-sectional study conducted by means of a telephone survey in 805 primary care (PC) and specialized centers (SC) in all regions. The survey contacted technicians in charge of spirometry and consisted of 36 questions related to the test.The results showed major differences between regions. Most centers had 1-2 spirometers. The number of spirometry tests per week ranged from 2 to 8.9 in PC and between 34.3 and 98.3 in SC. Some training had been given in most centers (63.6-100% in PC and 60.0-100% in SC) but not on a regular basis. Most centers used several short-acting bronchodilators for the bronchodilation test, but with insufficient inhalations (2.0-3.8 in PC and 2.0-3.3 in SC) and frequently incorrect waiting time (29.4-83.3% PC and 33.3-87.5% in SC). Daily calibration was not performed in all centers (0-100% in PC and 66.7-100% in SC). Significant inter-regional differences in spirometry quality criteria were observed, with 6 or more criteria met in 9.1-84.6% of PC centers and 37.5-100% in SC.Our results show the current situation of spirometry in primary and specialized care in Spain, highlighting considerable variability and areas for improvement. This information should be considered by health officials to improve the quality and accessibility of such tests.

Objective. The aim of the study was to describe echocardiographic abnormalities in patients with rheumatoid arthritis, concurrent systemic comorbidities, rheumatologic clinical activity, serologic markers of rheumatoid arthritis, and inflammatory activity. Methods. In an observational, cross-sectional study, rheumatoid arthritis outpatients were included (n=105). Conventional transthoracic echocardiographic variables were compared between patients with arthritis and non-RA controls (n=41). For rheumatoid arthritis patients, articular activity and rheumatologic and inflammatory markers were obtained. Results. Ventricular dysfunction was found in 54.3% of the population: systolic (18.1%), diastolic (32.4%), and/or right (24.8%), with lower ejection fraction (P<0.0001). Pulmonary hypertension was found in 46.9%. Other echocardiographic findings included increased left atrial diameter (P=0.01), aortic diameter (P=0.01), ventricular septum (P=0.01), left ventricular posterior wall (P=0.013), and right ventricular (P=0.01) and atrial diameters compared to control subjects. Rheumatoid factor and anti-CCP antibodies levels were significantly elevated in cases with ventricular dysfunction. Angina and myocardial infarction, diabetes, and dyslipidemia were the main risk factors for ventricular dysfunction. Conclusions. Ventricular dysfunction is common in rheumatoid arthritis and associated with longer disease duration and increased serologic markers of rheumatoid arthritis. Screening for cardiac abnormalities should be considered in this kind of patients.

A problem arises in cases of CAO in patients who have not been active smokers. In these cases, following the definition of COPD, other factors such as passive smoking or exposure to other inhaled irritants play a major role. Indeed, a number of previous studies have established passive smoking or biomass exposure as causes of CAO and therefore COPD [7, 8] . In those cases when the patient has not been exposed to inhaled toxins, a differential diagnosis of CAO should be made, including asthma, bronchiectasis and infectious diseases such as pulmonary tuberculosis (TB). These disorders are also associated with CAO, and there is some debate about whether TB should be considered a risk factor for COPD. The confusion is partly explained because epidemiological studies of the prevalence of COPD have exclusively used the results of spirometry to detect one case, forgetting the other pillar of the diagnosis, namely chronic exposure to inhaled fumes. Moreover, in these studies, CAO equals COPD [9] . In the present issue of Respiration, Allwood et al. [10] performed a systematic review of the peer-reviewed literature on the association between pulmonary TB and the development of CAO. After their search, 19 observational studies met the eligibility criteria. In the analysis, all but two of these works reported a positive association beThe concept of chronic obstructive pulmonary disease (COPD) has been evolving over recent decades. Although earlier studies provided descriptions of emphysema and chronic bronchitis [1] , the CIBA symposium landmark meeting in 1959 [2] established the foundation for COPD. As defined in the Global Initiative for Obstructive Lung Disease strategy [3] , COPD is characterized by a persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and lungs to noxious particles or gases. According to this definition, there are two sine qua non conditions for establishing a diagnosis. The first is the demonstration of chronic airflow obstruction (CAO). This non-reversible airway obstruction must be demonstrated by pulmonary function tests with the patient in a stable condition and after performing a bronchodilator test [3] . The second condition is that CAO has to result as a consequence of prolonged exposure to inhaled noxious particles or gases, because the enhanced chronic inflammatory response to these inhalants causes the disease and the pathological alterations described [4] . In this context, tobacco smoke is the leading inhaled toxin, and thus, the main risk factor for the development of COPD [5] . COPD and tobacco have been invariably associated in numerous epidemiological studies described in the literature [6] . Published online: June 11, 2013

Background: Bronchial variability in COPD patients may be a phenotypic feature associated with clinical characteristics and differential treatment response. Objectives: We analysed whether symptoms, quality of life and exercise capacity varied in COPD patients as a function of bronchodilator test results. Further, we compared response to an exercise programme in the groups. Methods: A positive bronchodilator test result was defined as FVC and/or FEV1>12% plus >200 ml improvement after 400 μg salbutamol. We studied 198 COPD patients, 94 with positive reversibility and 104 with negative reversibility. Training sessions were carried out on three non-consecutive days each week for 12 weeks, and consisted of a combination of resistance and strength training. Subjects were evaluated on two consecutive days at baseline, and at the end of the 12-week training programme. Results: Those with positive reversibility had shorter time—to-exhaustion on the endurance test (19.1±12.6 min versus 24.5±14.5 min in negative reversibility patients; p

Chronic obstructive pulmonary disease (COPD) has traditionally been considered an inexorably progressive disease, associated with a constant increase of symptoms that occur as the forced expiratory volume in 1 second (FEV1) worsens, only intermittently interrupted by exacerbations. However, this paradigm has been challenged in recent decades by the available evidence. Recent studies have pointed out that COPD-related symptoms are not consistently perceived by patients in the same way, showing not only seasonal variation, but also changes in symptom perception during a week or even within a single day. According to the available data, patients experience the biggest increase in respiratory symptoms during the first hours of the early morning, followed by the nighttime. This variation over time is of considerable importance, since it impacts on daily life activities and health-related quality of life, as measured by a recently developed ad hoc questionnaire. Additionally, recent clinical trials have suggested that the use of rapid-onset long-acting bronchodilators may have an impact on morning symptoms, despite their current use as maintenance treatment for a determined period. Although this hypothesis is to be validated in future long-term clinical trials comparing fast-onset versus slow-onset inhaled drugs in COPD, it may bring forward a new concept of long-term bronchodilator therapy. At the present time, the two available long-acting, fast-onset bronchodilators used in the treatment of COPD are formoterol and the recently marketed indacaterol. Newer drugs have also been shown to have a rapid onset of action in preclinical studies. Health care professionals caring for COPD patients should consider this variation in the perception of symptoms during their clinical interview as a potential new target in the long-term treatment plan.

With the publication of the new guidelines (The Global Initiative for Chronic Obstructive Lung Disease 2011 and Guía Española de la COPD) on chronic obstructive pulmonary disease (COPD), the pharmacological treatment of this disease has changed substantially. In this article, the evidence supporting the use of pharmacological groups in COPD is summarized and the place of each of these drugs among the new therapeutic strategies is established. Although short-acting bronchodilators have been used as maintenance therapy for COPD for many years, few clinical trials are available on the efficacy and safety of these agents, whose role was defined at the very early stages of treatment. The introduction of long-acting bronchodilators, administered every 12 or 24 h, led to an increase in therapeutic effects and an improvement in both treatment adherence and dosage; therefore, both guidelines consider these drugs as the standard therapy for all types of patients and clinical phenotypes. The combination of long-acting bronchodilators from different families has been established as a new therapeutic approach for patients with persistent symptoms despite an appropriate bronchodilator treatment. Anti-inflammatory therapy with inhaled corticosteroids has been discussed at length, and is considered in the current guidelines as the treatment of choice in patients with a high risk of exacerbations associated with an impaired lung function or previous exacerbations, or presenting with phenotypes that are susceptible to the effect of corticosteroids. Roflumilast is a novel drug with a clearly defined indication. Finally, further evidence about other therapies, such as antibiotics or mucolytics, is emerging that will help define their appropriate use in selected patients. At present, pharmacological management of COPD is being re-evaluated. As long as we are able to apply the new treatment approaches to the clinical reality of our patients we will achieve greater benefits in both the short and the long term with a reduction in potential complications.

Background Adherence to clinical practice guidelines is far from optimal for most of the chronic diseases. Spain has implemented a phenotype based chronic obstructive pulmonary disease (COPD) guideline and there is scarce data about the follow-up of this guideline. The aim of this study is to evaluate the suitability of the pharmacological treatment for COPD to the Spanish Guidelines (GesEPOC) recommendations in patients with COPD recruited at respiratory clinics around Spain.

Jose Luis López-Campos,1,2 María Abad Arranz,1 Carmen Calero Acuña,1,2 Fernando Romero Valero,3 Ruth Ayerbe García,4 Antonio Hidalgo Molina,3 Ricardo I Aguilar Perez-Grovas,4 Francisco García Gil,5 Francisco Casas Maldonado,6 Laura Caballero Ballesteros,5 María Sánchez Palop,6 Dolores Pérez-Tejero,7 Alejandro Segado,7 Jose Calvo Bonachera,8 Bárbara Hernández Sierra,8 Adolfo Doménech,9 Macarena Arroyo Varela,9 Francisco González Vargas,10 Juan J Cruz Rueda10 1Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, 2Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, 3Hospital Universitario Puerta del Mar, Cádiz, 4Hospital Juan Ramón Jiménez, Huelva, 5Hospital Universitario Reina Sofía, Córdoba, 6Hospital Universitario San Cecilio, Granada, 7Hospital Infanta Margarita, Cabra, Córdoba, 8Hospital Torrecárdenas, Almería, 9Hospital Regional Universitario de Málaga, 10Hospital Universitario Virgen de las Nieves, Granada, Spain Introduction: This study is an analysis of a pilot COPD clinical audit that evaluated adherence to guidelines for patients with COPD in a stable disease phase during a routine visit in specialized secondary care outpatient clinics in order to identify the variables associated with the decision to step-up or step-down pharmacological treatment.Methods: This study was a pilot clinical audit performed at hospital outpatient respiratory clinics in the region of Andalusia, Spain (eight provinces with over eight million inhabitants), in which 20% of centers in the area (catchment population 3,143,086 inhabitants) were invited to participate. Treatment changes were evaluated in terms of the number of prescribed medications and were classified as step-up, step-down, or no change. Three backward stepwise binominal multivariate logistic regression analyses were conducted to evaluate variables associated with stepping up, stepping down, and inhaled corticosteroids discontinuation.Results: The present analysis evaluated 565 clinical records (91%) of the complete audit. Of those records, 366 (64.8%) cases saw no change in pharmacological treatment, while 99patients (17.5%) had an increase in the number of drugs, 55 (9.7%) had a decrease in the number of drugs, and 45 (8.0%) noted a change to other medication for a similar therapeutic scheme. Exacerbations were the main factor in stepping up treatment, as were the symptoms themselves. In contrast, rather than symptoms, doctors used forced expiratory volume in 1second and previous treatment with long-term antibiotics or inhaled corticosteroids as the key determinants to stepping down treatment.Conclusion: The majority of doctors did not change the prescription. When changes were made, a number of related factors were noted. Future trials must evaluate whether these therapeutic changes impact clinically relevant outcomes at follow-up. Keywords: quality of care, outpatient care, treatment strategies, follow-up, respiratory diseases, airway diseases

Our aim is to assess the impact on respiratory function and exercise capacity of a respiratory rehabilitation program (RR) compared with a program of home mechanical ventilation (HMV) and the summation of both interventions. Methods: 45 COPD patients with severe functional impairment and in situations of hypercapnic respiratory failure were prospectively randomized to 3 groups: RR (12 weeks in 40-minute sessions that included strength training and resistance), HMV (12 weeks BiPAP mode) and RR-HMV (combination of the two interventions). Patients underwent pulmonary function tests. Exercise capacity was measured with a measurement of peripheral muscle strenght (PMS) using the one repetition maximum (1 RM) and maximal cardiopulmonary exercise testing performed on a cycle ergometer. Submaximal test of endurance was measure with cycle ergometer at 70% load. Results: Neither HMV or RR produced changes in respiratory function tests, except for the blood gases that improved after HMV (PaCO2 significant improvement with a decrease of 4 mmHg, p = 0.008) and in the combined with improvement in PaO2 (increase of more than 3 mmHg, p = 0.02) and PaCO2 (decrease of 5 mmHg, p

Our aim is to assess the impact on BODE index, quality of live and inflammatory parameters (IP) of a respiratory rehabilitation program (RR) compared with a program of home mechanical ventilation (HMV) and the summation of both interventions. Methods: 45 COPD patients with severe functional impairment and in situations of hypercapnic respiratory failure were prospectively randomized to 3 groups: RR (12 weeks in 40-minute sessions that included strength training and resistance), HMV (12 weeks BiPAP mode) and RR-HMV (combination of the two interventions). The patients underwent diferents components of BODE index, quality of live (CRDQ) and IP: C Reactive Protein (CRP), Tumor Necrosis Factor-α (TNF-α), Interleucin-6 (IL-6), IL-8 and Surfanctan D Protein (SDP). Results: HMV group improved BODE index significantly by decreasing median 2 points (p = 0.003). Also get statistically significant improvement in quality of life index CRDQ (in total and its four components). IP improved significantly by decreasing TNF-α and IL-8. RR group obtained the same results in BODE index, and CRDQ. IP significantly improved by lowering CRP, IL-8, SDP and C3. RR-HMV group improves BODE index significantly when going from 5 to 3.5 (p = 0.001). CRDQ in total and components of dyspnea, fatigue and disease control. Significantly improved IP by lowering CRP, TNF-α, SDP and prealbumin. Conclusions: HMV and the RR produced improvement in the BODE index and quality of life as well as when the two interventions are given together without finding differences when applied independently. The combination of both intervention control more IP than each other separately.

This present paper describes the method and the organization of the study known as the COPD History Assessment In SpaiN (CHAIN), whose main objective is to evaluate the long-term natural history of a chronic obstructive pulmonary disease (COPD) patient cohort from a multidimensional standpoint and to identify clinical phenotypes, in comparison with another non-COPD control cohort.CHAIN is a multicenter, observational study of prospective cohorts carried out at 36 Spanish hospitals. Both cohorts will be followed-up during a 5-year study period with complete office visits every 12 months and telephone interviews every 6 months in order to evaluate exacerbations and the vital state of the subjects. The recruitment period for cases was between 15 January 2010 and 31 March 2012. At each annual visit, information will be collected on: (i) clinical aspects (socio-economic situation, anthropometric data, comorbidities, smoking, respiratory symptoms, exacerbations, quality of life, anxiety-depression scale, daily life activities, treatments); (ii) respiratory function (spirometry, blood gases, hyperinflation, diffusion, respiratory pressures); (iii) BODE index (main study variable); (iv) peripheral muscle function, and (v) blood work-up (including IgE and cardiovascular risk factors). In addition, a serum bank will be created for the future determination of biomarkers. The data of the patients are anonymized in a database with a hierarchical access control in order to guarantee secure information access. The CHAIN study will provide information about the progression of COPD and it will establish a network of researchers for future projects related with COPD.

Recognizing the clinical heterogeneity of COPD suggests a specific therapeutic approach directed by the so-called clinical phenotypes of the disease. The Spanish COPD Guidelines (GesEPOC) is an initiative of SEPAR, which, together with the scientific societies involved in COPD patient care, and the Spanish Patient Forum, has developed these new clinical practice guidelines. This present article describes the severity classification and the pharmacological treatment of stable COPD. GesEPOC identifies four clinical phenotypes with differential treatment: non-exacerbator, mixed COPD-asthma, exacerbator with emphysema and exacerbator with chronic bronchitis. Pharmacological treatment of COPD is based on bronchodilation in addition to other drugs depending on the clinical phenotype and severity. Severity is established by the BODE/BODEx multidimensional scales. Severity can also be approximated by assessing airflow obstruction, dyspnea, level of physical activity and history of exacerbations. GesEPOC is a new, more individualized approach to COPD treatment according to the clinical characteristics of the patients.

We sought to investigate whether the serum concentrations of several inflammatory biomarkers are related to the cyclooxygenase-2 (COX2) - 765G>C polymorphism in chronic obstructive pulmonary disease (COPD) and a control group of non-COPD smokers. Serum inflammatory markers (CRP, SAA, CXCL8, and sICAM-1) were measured by ELISA in 144 patients with COPD and in 55 control subjects. Genomic DNA was extracted from peripheral blood leukocytes, and the COX2 - 765G>C (rs20417) polymorphism was genotyped. After adjustment for age and active smoking, CRP and SAA concentrations were associated with the COX2 polymorphism in controls (p= 0.041 and 0.014, respectively) but not in COPD patients. The CXCL8 and sICAM-1 concentrations were not associated with the COX2 polymorphism for either cases or controls. The results of the present study indicate that there is a relationship between the COX2 - 765G>C polymorphism and the concentrations of CRP and SAA in non-COPD smokers and that this relationship does not exist in COPD patients. © 2011 Elsevier B.V., This study was financially supported by grants from the Fundación Neumosur (project number 03/2006) and the Consejería de Innovación, Ciencia y Empresa, Junta de Andalucía (project number P08-CVI-3891).

Introduction: Exacerbations of Chronic Obstructive Pulmonary Disease (COPD) that require hospital admission have a major impact on the progression of disease and generate high health costs. Method: A multi-center, cross-sectional, observational study was conducted with the aim to identify factors associated with hospital admission in patients with COPD. We obtained data of socio-demographic and anthropometric characteristics, quality of life, respiratory symptoms, anxiety and depression, physical activity and pulmonary function tests. We analyzed their association with hospital admission with a multivariate analysis using a logistic regression model. Results: We analyzed 127 patients, 50 (39%) of whom had been hospitalized. 93.7% were men, mean age 67 years (SD=9) and a FEV1 of 41.9% (SD=15.3). In the first model obtained, the baseline SpO2, the BODE index and emergency room (ER) visits were associated with hospital admission and the area under the ROC curve (AUC) was 0.809. In a second model we included only variables readily available (without the 6 min walking test) and only the SpO2 and previous visits to the ER were significant with an AUC ROC 0.783. Conclusions: Hospital admission for exacerbation of COPD is associated with poor SpO2, higher BODE index score and a greater number of visits to the ER. In case you do not have the 6 min walking test, the other two variables offer a similar discriminative ability.

OBJECTIVE To use lung cancer mortality rates from 1979 to 2008 in Andalusia, southern Spain (population >8,000,000), to provide an estimate of the future number of deaths for the period 2009-2028. DESIGN The numbers of lung cancer deaths from 1979 to 2008 were obtained from the Andalusian Institute for Statistics (AIS). Data were arranged in 5-year age groups using an age-period-cohort model. Age-standardised rates (ASR) per 100, 000 were calculated for males and females. Population projections for Andalusia 2009-2028 were downloaded from the AIS database. RESULTS In males, the ASR varied from 46.1 in 2004-2008 to 34.6 in 2024-2028, with a projected 33% decrease. In females, the ASR varied from 4.9 in 2004-2008 to 8.9 per 100,000 in 2024-2028, with a projected 45% increase. This reflects an annual change of -1.3% for males and of +2.7% for females for the period 2009-2028. The sex ratio is projected to drop from a male:female ratio of 11 (1979-1983) to 3.8 (2024-2028). CONCLUSIONS Our projections emphasise the significance of a continuously increasing trend in female lung cancer mortality, with a drop in the projected sex ratio.

Recent studies have found cyclooxygenase-2 (COX-2) and its polymorphisms to be associated with sarcoidosis, being it significantly decreased in alveolar macrophages, with no information on the relationship between these polymorphisms and the rest of cells in bronchoalveolar layage (BAL). The present study aimed to investigate the potential association between COX-2 gene polymorphisms and the BAL cell profile including the CD4/CD8 ratio.This observational cross-sectional study involved six hospitals in Spain. Patients diagnosed with sarcoidosis with a BAL performed were included. The following variables were recorded: age, gender, initial diagnostic methods, serum angiotensin-converting enzyme levels, pulmonary function tests, radiological stage, and the cellularity and CD4/CD8 ratio from BAL. Genotyping of four COX-2 polymorphisms (COX2.5909TG, COX2.8473TC, COX2.926GC, and COX2.3050GC) was undertaken on DNA extracted from peripheral blood lymphocytes using fluorescent hybridization probes. The relationship between the polymorphisms and the cellularity was done by means of a multiple linear regression, adjusting for gender.A total of 51 sarcoid patients (23 males, mean age: 45 +/- 15 years) were studied. CD4/CD8 ratio was significantly higher among homozygote allele C carriers of the polymorphism COX2.8473TC (CC 11.2 +/- 5.5 vs. CT+TT 4.4 +/- 3.5; p = 0.022; beta = 7.43; 95% CI 1.38 - 13.48). Although several differences were observed in other cell groups, they did not reach the statistical significance level.In patients diagnosed with sarcoidosis, there seems to be a relationship between COX2.8473 polymorphism and CD4/CD8 ratio from BAL.

Aquaporin-1 (AQP1) is the main water channel responsible for water transport through many epithelia and endothelia. The latest evidence pointed toward an important role of this protein also in gas permeation, angiogenesis, cell proliferation and migration. In the present work we studied the expression of AQP1 by immunohistochemical staining of 92 lung biopsies from patients diagnosed with a pleuro-pulmonary tumor (71 lung and 21 pleural neoplasms). AQP1 expression was analyzed comparing the results among the different histological patterns and against 9 control cases (5 parenchyma and 4 healthy pleura). Clear staining of AQP1 was detected in 39 of the 92 tumors analyzed. In parenchyma, AQP1 was more frequently detected in primary lung adenocarcinomas (55%, P0.001); in contrast, small cell carcinomas were the least AQP1 expressive tumors studied (93% of negative staining, P0.05). Carcinomas analyzed in pleura (mesotheliomas and metastatic adenocarcinomas) also revealed strong expression of AQP1. High expression of this protein was detected in small capillaries in areas near or surrounding the tumor, and novel intense AQP1 immunostaining was detected over thicker alveolar walls in alveoli inside or next to the tumoral tissue regardless of the tumor type. An important role of AQP1 in tumor angiogenesis is sustained by the abundant expression of this protein in the endothelia of tumor capillaries. Further studies are necessary to elucidate the potential pathophysiological role of this protein in pleuro-pulmonary neoplasms.

Assessment of patients with COPD has changed in the last few years by adding subjective patient evaluations to traditional measurements based on pulmonary function. One of the most recently studied variables is symptom variability during the day and, specifically, patients' perceptions of these symptoms in the first few hours of the day. To evaluate this feature, two new symptom questionnaires, the Capacity of Daily Living in the Morning (CDLM) questionnaire and the Global Chest Symptoms Questionnaire (GCSQ), have recently been developed. Recent studies have begun to provide data on the effect of the available treatments on these morning symptoms, yielding information on the rapidity of action of budesonide/formoterol with a significant and nearly clinically relevant effect on morning activities. Confirmation of these results could lead to future strategies designed to earlier symptomatic improvement, which could lead to greater treatment adherence.

Exacerbations of chronic obstructive pulmonary disease (COPD) re important because they have an impact on morbidity, mortality nd healthcare costs. So far the diagnosis and treatment of exacerations remains relatively homogeneous rules that apply equally o all exacerbations are based on bronchodilators, systemic coricosteroids and antibiotics as pillars of treatment.1 However, as ith the expression of the disease in the stable phase, exacerbaions have a rich and different clinical expression with different ubtypes being identified with prognostic implications.2 In this ontext, the presence of pulmonary consolidation in a patient with n exacerbation of COPD is a subject of ongoing controversy. According to previous guides,3 the community-acquired pneuonia was included among the causes of exacerbation in the past. owever, currently, it is considered an infectious comorbidity, learly distinct from an exacerbation.1 In this regard, several quesions can be identified. If we consider that the 2 processes are ompletely different, then does the exacerbation of COPD have istinguishing features compared to community-acquired pneuonia? In the present issue of Archivos de Bronconeumologia, Boixeda t al.4 analysed a group of 124 patients with COPD requiring hosital admission for lower respiratory tract infection, comparing hose with pulmonary condensation versus those without. With he cautiousness derived from an observational study with some mbalance between groups and the limitations of a bivariate analyis, the authors find differences between the 2 conditions in various linical and laboratory parameters. Interestingly, the yield of spuum culture is similar in both process and the outcome too. The cute phase reactants such as C-reactive protein, the serum alpha1 and in the proteinogram or fibrinogen are highly increased in

Las exacerbaciones de la enfermedad pulmonar obstructiva cronica (EPOC) son importantes, ya que tienen un impacto en la morbimortalidad y en el coste sanitario. Hasta el momento el diagnostico y el tratamiento de las exacerbaciones sigue unas reglas relativamente homogeneas que se aplican a todas las agudizaciones por igual, y que se basan en la prescripcion de broncodilatadores, corticoides sistemicos y antibioterapia como pilares del tratamiento1. Sin embargo, al igual que ocurre con la expresion de la enfermedad en fase estable, las agudizaciones tienen una diferente y rica expresion clinica en la que diferentes subtipos se estan identificando con implicaciones en el pronostico2. En este contexto, la presencia de una consolidacion pulmonar en un paciente con una agudizacion de EPOC constituye un tema de actual controversia. Anteriormente, segun algunas guias3, la neumonia adquirida en la comunidad era incluida dentro de las causas de exacerbacion. Sin embargo, actualmente, se considera una comorbilidad infecciosa, diferenciandola claramente de la agudizacion1. Ante esta cuestion cabe hacerse algunas preguntas. Si consideramos que ambos procesos son completamente distintos, ?tiene la agudizacion de la EPOC algunas caracteristicas diferenciadoras frente a la neumonia de la comunidad? En el presente numero de Archivos de Bronconeumologia, Boixeda et al.4 analizan un grupo de 124 pacientes con EPOC que precisaron ingreso hospitalario por una infeccion respiratoria baja, comparando aquellos con condensacion pulmonar frente a los que no la tenian. Con la prudencia derivada de un estudio observacional con disbalance entre grupos y las limitaciones de un analisis bivariante, los autores encuentran diferencias entre ambos en diversas caracteristicas clinicas y analiticas. Curiosamente, la rentabilidad del cultivo del esputo es similar en ambos procesos y el pronostico tambien. Los reactantes de fase aguda, como la proteina C reactiva, la banda alfa 1 del proteinograma o el fibrinogeno estan muy aumentados en los pacientes con condensacion radiologica. En este

Introduction and objectives The major cost to health services of COPD care is hospital admission for exacerbation. Reducing length of stay (LOS) will reduce cost, yet there is wide variability across patients and hospitals. We test the hypothesis that these variations may be attributed to either patient characteristics, hospital characteristics and/or the so-called hospital-clustering effect, which indicates that patients with similar characteristics may experience different processes of care and outcomes depending on the hospital to which they are admitted. Methods The European COPD Audit which was carried out in 432 hospitals from 13 countries, included data from 16,018 patients admitted over an 8 week period. The recorded variables included information on the patient and disease characteristics, resources available and clinical practice. Variables in each category associated with LOS were evaluated by a multivariate multilevel analysis and expressed as odds ratios (OR). Results Mean LOS was 8.7 days (median: 7, standard deviation: 8.3, interquartile range: 4–11). Factors associated with an LOS higher than the median (see figure) were clinical with the highest impact in patients with use of mechanical ventilation (OR: 4.74) and higher oxygen flows (OR 2.63). In-hospital treatments, comorbidities and patient-related variables including GOLD class IV (OR 1.77) were also significant. These relationships were maintained with respect to longer LOS (> 21 days). Neither the day of admission, nor any of the resource variables were associated with significant differences in LOS. The crude variability of LOS between the different countries was reduced after accounting for these clinical factors and the clustering effect. Conclusions This study demonstrates a noteworthy reduction in the observed crude inter-hospital variation in LOS after accounting for the hospital-cluster effect and patient related variables. This emphasises the predictor importance of the patients’ clinical conditions and interventions, and understates the impacts of hospital resources and organisational factors. This “real-life” reflection may highlight some valid learning points that may help us to determine which achievable strategies are most relevant to improve outcomes.

In recent decades, the diagnosis of chronic obstructive ulmonary disease (COPD) has been veering from simple oneimensional schemes to more complex strategies based on ultidimensional approaches or on phenotypes. The latest update f the GOLD1 strategy recommends the use of three questionnaires or the assessment of the patient’s situation: the COPD Assessment est (CAT),2 the modified Medical Research Council (MRC) dyspnea cale,3 and the Clinical COPD Questionnaire (CCQ).4 The inclusion of hese three different questionnaires in the GOLD strategy to assess he impact of the disease in patients has provoked an interesting ebate on the multidimensional assessment of the disease. In order to verify the equivalence of these questionnaires, sevral authors have conducted observational studies, describing a eality that was intuitively perceived by the clinician: the results f these questionnaires, while individually valid in assessing the mpact of the disease, are not superimposable. In this respect, some tudies have highlighted a lack of agreement between CAT and RC,5 while others report the discrepancies between the MRC nd the St. George’s respiratory questionnaire.6 The differences are educed by changing the cutoff for the MRC questionnaire in the OLD classification. Thus, Jones et al.7 suggest that if patients with nd without dyspnea (MRC grade 0) are separated, the distribuion of patients over the various GOLD types is very similar to that btained using CAT with the current cutoff values. The idea behind these studies is that if the classification perentages with both scales in a given patient cohort agree, then they ould all be used interchangeably for categorizing COPD patients. owever, as Jones et al.7 point out, concordance in the distribuion of GOLD types does not necessarily mean that patients who btain the same scores on the different questionnaires using these ew cutoff values will be exactly the same. In this respect, it should

En las ultimas decadas, el diagnostico de la enfermedad pulonar obstructiva cronica (EPOC) ha ido virando desde esquemas encillos unidimensionales hasta estrategias mas complejas basanose en aproximaciones multidimensionales o en fenotipos. En a ultima actualizacion de la estrategia GOLD1 se recomienda ealizar una valoracion de la situacion del paciente mediante l uso de 3 cuestionarios: el COPD Assessment Test (CAT)2, la scala de disnea modificada del Medical Research Council (MRC)3 el Clinical COPD Questionnaire (CCQ)4. La designacion de estos cuestionarios diferentes para evaluar el impacto de la enferedad en los pacientes en la estrategia GOLD ha suscitado una ontroversia interesante en la evaluacion multidimensional de la nfermedad. Con objeto de comprobar la equivalencia de los cuestionarios, iversos autores han realizado estudios observacionales donde e describe una realidad previamente intuida por el clinico: que stos cuestionarios, aun siendo validos de manera aislada en la valuacion del impacto de la enfermedad, tienen resultados no uperponibles entre si. En este sentido, algunos trabajos han mosrado esta falta de concordancia entre CAT y MRC5, al igual que se a observado para la relacion de la MRC con el cuestionario respiraorio de St George6. Esta diferencia disminuye al cambiar el punto e corte para el cuestionario MRC en la clasificacion GOLD. De esta anera, Jones et al.7 sugieren que una separacion de los pacientes ue no tienen disnea (grado 0 de la MRC) frente a los que si la tienen ace que los pacientes se distribuyan en tipos GOLD en porcentajes uy parecidos a cuando se emplea el CAT con sus actuales puntos e corte.

There is little information regarding the clinical management of hospital inpatients diagnosed with exacerbation of Chronic Obstructive Pulmonary Disease (COPD). AUDIPOC is a clinical audit dealing with the clinical management of COPD in Spain.To examine the adequacy and validity of the instruments used to measure the variables proposed by AUDIPOC Spain (Preliminary Study) and to verify the viability of AUDIPOC in a complex environment with hospitals of different sizes, resources, and organizational layout (Pilot Study).The Preliminary Study took place in 4 hospitals and studied 213 cases. The Pilot Study took place in 30 hospitals of 6 Autonomous Communities (i.e. Regions) and studied 1203 cases.The results of both studies contributed to the improvement of the design, methods and organization of the AUDIPOC work. Some of the improvements include better training of those responsible at a hospital level, a new classification of hospitals, the incorporation of new variables and the creation of a Bureau for the Coordination and Management of the Project.The AUDIPOC study is viable. It aims to recruit 10000 patients across 142 hospitals from all the Regions of Spain.