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The purpose of this study was to have a nationwide snapshot of the characteristics of patients hospitalized in Internal Medicine Units (IMUs) for exacerbation of chronic obstructive pulmonary disease (COPD), and to assess applicability and contents of a specific Hospital Discharge Form for the patient with exacerbation of COPD discharged from IMUs. This was a prospective study in 44 IMUs in Italy, enrolling patients hospitalized with a diagnosis of COPD exacerbation. Information concerning clinical characteristics of patients, and treatment for COPD at discharge was collected. Specific documents for monitoring of clinical conditions and adherence to therapies as well as a form including individual indications for clinical controls, instrumental tests, etc. were provided upon discharge. Four hundred and seventy-two patients were enrolled (68% male). According to GOLD classification 2015, patients with classes A to D were 12%, 27%, 31%, and 30%, respectively. Triple therapy was prescribed in 14% of GOLD A and 51% of GOLD D patients. Around 10% of patients for each GOLD class received no specific therapy. The vast majority of patients (85%) received instructions on the correct use of inhalers, and in most cases (85%), the quality of counseling was considered optimal/adequate. Indication for performing chest X-ray, spirometry, or blood gas analysis following discharge was addressed to 29%, 59% and 52.1% of patients, respectively. The follow-up sheet for COPD used in our study was shown as applicable. This highlighted the need for greater awareness and more standardized procedures within IMUs in the post-discharge phase.

Sepsis-induced organ dysfunction may be occult; therefore, its presence should be considered in any patient presenting with infection. Conversely, unrecognized infection may be the cause of new-onset organ dysfunction. Any unexplained organ dysfunction should thus raise the possibility of underlying infection. Severe sepsis is a heterogeneous clinical entity with a wide spectrum of manifestations and severity, and over half of patients never receive care in an Intensive Care Unit (ICU). Due to ageing of the population, patients with severe sepsis are frequently admitted to general wards and, given the standard diagnostic approach, treatment must be tailored to the single patient, taking into account the burden of comorbidities. From Internal Medicine Wards the single patient could be transferred to ICU, but again admitted to our Units, due to his/her frailty, to complete the path of cure. First of all, we have to be aware of the illness and more, according to the recent literature, that, generally speaking, limits invasiveness, to be able to take care of this kind of patients.

Chronic obstructive pulmonary disease (COPD) is one of the most frequent pathologies among patients hospitalized in Internal Medicine (IM) Departments. COPD is frequently associated with concomitant diseases, which represent major causes of death, and affect disease management. Objectives of our study are to assess the prevalence of COPD patients in IM, to evaluate their comorbidity status, and to describe their complexity, by means of the validated multidimensional prognostic index (MPI) score. COMPLEXICO is an observational, prospective, multicenter study, enrolling consecutive patients hospitalized for any cause in IM, with diagnosis of COPD documented by spirometry. A total of 1002 patients in 43 IM Units in Italy were enrolled. The prevalence of COPD in IM was found to be 18.1%, and 72.8% of patients had at least three chronic diseases other than COPD. The mean MPI was 0.43±0.15, and according to a stratification algorithm 31.8% of patients were classified as having low-risk, 58.9% moderate-risk and 9.3% severe-risk of adverse outcome. More than two-thirds of COPD patients in our study present moderate to severe risk of poor outcome according to the MPI stratification.

Chronic obstructive pulmonary disease (COPD) is one of the main causes for admission to an internal medicine ward, due to exacerbations of the disease itself or to comorbidities leading to dyspnea as an intriguing symptom. In many cases, a diagnosis of COPD is made only on clinical grounds, but well-accepted guidelines strongly suggest measuring the lung function to diagnose and stage such a common disease. Problems with the equipment, its use and data interpretation lead to underuse spirometry in general and in patients in internal medicine in particular.

Low adherence with prescribed treatments is very common in chronic diseases and represents a significant barrier to optimal management, with both clinical and economic consequences. In chronic obstructive pulmonary disease (COPD), poor adherence, also in terms of premature discontinuation of therapy or improper use of inhaler devices, leads to increased risk of clinical deterioration. By contrast, adherence to appropriate long-term maintenance therapy is associated with improved quality of life and significantly lower risks of hospitalization and re-hospitalization, resulting in important health benefits for the individual patient and a reduction in costs for the national health services. In considering strategies to improve adherence, three main aspects should be addressed: i) patient education; ii) pharmacological alternatives and correct use of inhalers; and iii) adherence to COPD guidelines for appropriate therapy. In this field, healthcare providers play a critical role in helping patients understand the nature of their disease and its management, explaining the potential benefits and adverse effects of treatment, and teaching or checking the correct inhalation technique. These are important issues for patient management, particularly in the immediate aftermath of hospital discharge, because the high risk of re-admission is mainly due to inadequate treatment. Thus, discharge procedure should be considered a key element in the healthcare continuum from the hospital to primary care. This implies an integrated model of care delivery by all relevant health providers. In this context, we developed a structured COPD discharge form that we hope will improve the management of COPD patients, particularly in the aftermath of hospital discharge.

BACKGROUND COPD affects over 5% of the adult population, and it is the only major cause of mortality that is increasing worldwide. Patients with COPD don’t die usually of respiratory failure: indeed lung cancer and cardiovascular diseases are the leading causes of mortality in patients with mild to moderate COPD. Pulmonary and systemic inflammations are prominent. Inhaled corticosteroids have little effect on the rate of decline of lung function, but they reduce the frequency of exacerbations, especially when combined with an inhaled long-acting beta-agonist. AIM OF THE STUDY The combination of the long-acting beta-agonist salmeterol (SM) and the inhaled corticosteroid fluticasone propionate (FP) would reduce mortality among patients with COPD, as compared with usual care. The primary end-point was the time to death from any cause by 3 years. Secondary end-points were the frequency of exacerbations and health status. PATIENTS AND METHODS Of 8,554 patients recruited, 6,184 underwent randomization; the mean age was 65 years, and the mean value of postbronchodilator FEV1 was 44% of the predicted value. This double-blind study was conducted in 444 centers of 42 countries. After a 2-week run-in period, eligible patients were randomly assigned to treatment with the combination of SM at a dose of 50 μg and FP at a dose of 500 μg or SM alone at a dose of 50 μg, FP alone at a dose of 500 μg, or placebo, all taken as a dry powder with the use of an inhaler bid for 3 years. RESULTS There were 875 deaths within 3 years after randomization. The proportions of deaths from any cause at 3 years were 12.6% in the combination therapy group, 15.2% in the placebo group, 13.5% in the SM group, and 16.0% in the FP group. The absolute risk reduction for death in the combination-therapy group as compared with the placebo group was 2.6%, and the hazard ratio was 0.825 (95% confidence interval [CI], 0.681 to 1.002; p = 0.052), corresponding to a reduction in the risk of death at any time in the 3 years of 17.5% (95% CI, –0.2 to 31.9). DISCUSSION In this trial, the reduction in mortality from any cause did not meet the level of statistical significance (p = 0.052), but the treatment with the combination regimen resulted in significantly fewer exacerbations and improved health status and lung function, as compared with placebo. Mortality could be influenced mainly by factors unresponsive to the study drugs, or it is possible that this study was underpowered to detect this effect. There was also a high withdrawal rate, which was highest among patients in the placebo group. CONCLUSIONS Even though p = 0.052 is not statistically significant, 126 deaths for every 1,000 treated in the combination-therapy group, after 3 years, instead of 152 in the placebo group, is anyway an important result? Further investigation is needed in future large, prospective trials.