Chronic obstructive pulmonary disease (COPD) remains a major public health problem. It is the fourth leading cause of chronic morbidity and mortality in the United States, and is projected to rank fifth in 2020 in burden of disease worldwide, according to a study published by the World Bank/World Health Organization. Yet, COPD remains relatively unknown or ignored by the public as well as public health and government officials. In 1998, in an effort to bring more attention to COPD, its management, and its prevention, a committed group of scientists encouraged the U.S. National Heart, Lung, and Blood Institute and the World Health Organization to form the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Among the important objectives of GOLD are to increase awareness of COPD and to help the millions of people who suffer from this disease and die prematurely of it or its complications. The first step in the GOLD program was to prepare a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD, published in 2001. The present, newly revised document follows the same format as the original consensus report, but has been updated to reflect the many publications on COPD that have appeared. GOLD national leaders, a network of international experts, have initiated investigations of the causes and prevalence of COPD in their countries, and developed innovative approaches for the dissemination and implementation of COPD management guidelines. We appreciate the enormous amount of work the GOLD national leaders have done on behalf of their patients with COPD. Despite the achievements in the 5 years since the GOLD report was originally published, considerable additional work is ahead of us if we are to control this major public health problem. The GOLD initiative will continue to bring COPD to the attention of governments, public health officials, health care workers, and the general public, but a concerted effort by all involved in health care will be necessary.

https://www.who.int/respiratory/copd/GOLD_WR_06.pdf

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary.

OBJECTIVE — To systematically review the incidence of posttransplantation diabetes (PTD), risk factors for its development, prognostic implications, and optimal management. RESEARCH DESIGN AND METHODS — We searched databases (MEDLINE, EMBASE, the Cochrane Library, and others) from inception to September 2000, reviewed bibliographies in reports retrieved, contacted transplantation experts, and reviewed specialty journals. Two reviewers independently determined report inclusion (original studies, in all languages, of PTD in adults with no history of diabetes before transplantation), assessed study methods, and extracted data using a standardized form. Meta-regression was used to explain between-study differences in incidence. RESULTS — Nineteen studies with 3,611 patients were included. The 12-month cumulative incidence of PTD is lower (10% in most studies) than it was 3 decades ago. The type of immunosuppression explained 74% of the variability in incidence (P 0.0004). Risk factors were patient age, nonwhite ethnicity, glucocorticoid treatment for rejection, and immunosuppression with high-dose cyclosporine and tacrolimus. PTD was associated with decreased graft and patient survival in earlier studies; later studies showed improved outcomes. Randomized trials of treatment regimens have not been conducted. CONCLUSIONS — Physicians should consider modification of immunosuppressive regimens to decrease the risk of PTD in high-risk transplant recipients. Randomized trials are needed to evaluate the use of oral glucose-lowering agents in transplant recipients, paying particular attention to interactions with immunosuppressive drugs. Diabetes Care 25:583–592, 2002

A systematic review of the literature

Representatives from many countries serve as a network for the dissemination and implementation of programs for diagnosis, management, and prevention of COPD. The GOLD Board of Directors is grateful to the many GOLD National Leaders who participated in discussions of concepts that appear in GOLD reports.

Global initiative for chronic obstructive lung disease.

This new edition of Ann Bowling's well-known and highly respected text has been thoroughly revised and updated to reflect key methodological developments in health research. It is a comprehensive, easy to read, guide to the range of methods used to study and evaluate health and health services. It describes the concepts and methods used by the main disciplines involved in health research, including: demography, epidemiology, health economics, psychology and sociology.The research methods described cover the assessment of health needs, morbidity and mortality trends and rates, costing health services, sampling for survey research, cross-sectional and longitudinal survey design, experimental methods and techniques of group assignment, questionnaire design, interviewing techniques, coding and analysis of quantitative data, methods and analysis of qualitative observational studies, and types of unstructured interviewing. With new material on topics such as cluster randomization, utility analyses, patients' preferences, and perception of risk, the text is aimed at students and researchers of health and health services. It has also been designed for health professionals and policy makers who have responsibility for applying research findings in practice, and who need to know how to judge the value of that research.

Research Methods in Health. Investigating health and health services

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is characterised by both an accelerated decline in lung function and periods of acute deterioration in symptoms termed exacerbations. The aim of this study was to investigate whether these are related. METHODS: Over 4 years, peak expiratory flow (PEF) and symptoms were measured at home daily by 109 patients with COPD (81 men; median (IQR) age 68.1 (63-74) years; arterial oxygen tension (PaO(2)) 9.00 (8.3-9.5) kPa, forced expiratory volume in 1 second (FEV(1)) 1.00 (0.7-1.3) l, forced vital capacity (FVC) 2.51 (1.9-3.0) l); of these, 32 (29 men) recorded daily FEV(1). Exacerbations were identified from symptoms and the effect of frequent or infrequent exacerbations (> or < 2.92 per year) on lung function decline was examined using cross sectional, random effects models. RESULTS: The 109 patients experienced 757 exacerbations. Patients with frequent exacerbations had a significantly faster decline in FEV(1) and peak expiratory flow (PEF) of -40.1 ml/year (n=16) and -2.9 l/min/year (n=46) than infrequent exacerbators in whom FEV(1) changed by -32.1 ml/year (n=16) and PEF by -0.7 l/min/year (n=63). Frequent exacerbators also had a greater decline in FEV(1) if allowance was made for smoking status. Patients with frequent exacerbations were more often admitted to hospital with longer length of stay. Frequent exacerbations were a consistent feature within a patient, with their number positively correlated (between years 1 and 2, 2 and 3, 3 and 4). CONCLUSIONS: These results suggest that the frequency of exacerbations contributes to long term decline in lung function of patients with moderate to severe COPD.

https://thorax.bmj.com/content/thoraxjnl/57/10/847.full.pdf

Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease

Resumen Las hospitalizaciones por exacerbacion aguda de EPOC (EAEPOC) generan un elevado consumo de recursos sanitarios, frecuentes reingresos y una alta mortalidad. El estudio MAG-1 pretende identificar aquellos puntos criticos y mejorables en el proceso asistencial de la EAEPOC que requiere ingreso hospitalario. Metodologia Estudio observacional, de revision de historias clinicas de pacientes ingresados en hospitales de la red publica por EAEPOC. Los centros se clasificaron en 3 grupos segun el numero de altas/ano. Se analizaron datos demograficos y descriptivos del ano previo, tratamiento farmacologico, atencion durante la hospitalizacion y proceso de alta, asi como mortalidad y reingresos a los 30 y 90 dias. Resultados Se estudio a 910 pacientes (83% varones), con una edad media de 74,3 (+10,1) anos y una tasa de respuesta del 70%. Solo constaba el habito tabaquico actual en un 45% de los casos y de estos un 9,8% eran fumadores activos. En un 31% de los casos no constaban datos espirometricos previos. La mediana de la estancia fue de 7 dias (RIQ: 4-10), aumentando con la complejidad del centro. La mortalidad observada desde el ingreso a los 90 dias fue del 12,4% con una tasa de reingresos del 49%. Se observo una relacion inversa entre los dias de estancia hospitalaria y las readmisiones a 90 dias. Conclusiones En un elevado numero de historias clinicas no consta adecuadamente el habito tabaquico ni las pruebas de funcion pulmonar. La estancia media aumenta con la complejidad del hospital, aunque mayores estancias parecen asociarse con menor mortalidad en el seguimiento.

Auditoría clínica de los pacientes que ingresan en el hospital por agudización de EPOC. Estudio MAG-1

Long-term mechanical ventilation in amyotrophic lateral sclerosis

Over the last 20 years, advances in the treatment of patients with chronic obstructive pulmonary disease (COPD) have improved survival even among patients in the most advanced stages of the disease, such as those requiring domiciliary oxygen therapy.1,2 This improvement—in principle a positive development—has given rise to considerable clinical problems associated with the establishment of a therapeutic ceiling and the difficulty of determining prognosis in some of these patients. In this situation, the clinician should consider introducing palliative care, that is, care aimed at improving symptom control, communication, physical activity, and emotional support, in order to achieve the best possible quality of life for the patient. Palliative care is generally associated with the advanced stages of a disease’s natural history, but in the case of COPD it is important to emphasize it does not necessarily mean that death is imminent. The lack of a generally accepted definition for “end-stage COPD” makes it difficult to compare studies.3 Table 1 defines the basic concepts. Improving the management of advanced-stage COPD not only has a direct impact on the quality of care received by the patient, but also has a positive effect on the health care system as a whole in that it reduces hospital admissions shifts the burden of care from the hospital to the community, and reduces unnecessary and unscheduled admissions to intensive care units.4 Many patients with COPD remain undiagnosed, and some of those diagnosed do not fulfill the accepted criteria, and it is therefore extremely difficult to establish how many patients actually have very severe COPD, though it is estimated that the proportion may range between 3% and 15% of the total.5,6 The concern with broadening the clinician’s approach beyond actions taken primarily to prolong the patient’s life has developed more recently in the context of COPD in comparison with other diseases. Nonetheless, and despite the lack of precise definitions and the unpredictability of this disease, this broader approach should be an indispensable component of good practice in pulmonology. Figure 1 summarizes the final stages of life in patients with COPD.

[Recommendations for end-of-life care in patients with chronic obstructive pulmonary disease].

Resumen El acceso a una espirometria de calidad es un objetivo imprescindible para poder minimizar el infradiagnostico de las enfermedades respiratorias, especialmente en las mas frecuentes, como la EPOC y el asma. Este objetivo es alcanzable a corto plazo pero requiere la integracion simultanea de estrategias diversas: formacion de los profesionales que deben realizar la espirometria, definicion de estandares para la transmision de la informacion, programa de control de calidad requerimientos tecnicos en las adquisiciones de aparatos y la correcta interpretacion de los resultados. El presente trabajo muestra la utilizacion de estandares para el intercambio electronico de informacion clinica. Para normalizar el tratamiento de los datos relacionados con la espirometria y permitir el intercambio de informacion se ha utilizado el estandar CDA R2 (Clinical Document Architecture, Release 2) de HL7 (Health Level Seven) version 3. HL7 es un producto de HL7 International, una organizacion no lucrativa que se dedica a la produccion de estandares en el ambito de la salud para facilitar la interoperabilidad. La definicion de este estandar, ademas, es imprescindible para asegurar la adopcion del mismo por parte de los fabricantes de espirometros. Mediante este proceso se ponen las bases para facilitar el acceso a la espirometria desde todos los ambitos asistenciales y, a su vez, es un elemento tecnico fundamental para disenar los programas de control de calidad de las exploraciones.

Joan Escarrabill

Papers

Auditoría clínica de los pacientes que ingresan en el hospital por agudización de EPOC. Estudio MAG-1

Long-term mechanical ventilation in amyotrophic lateral sclerosis

[Recommendations for end-of-life care in patients with chronic obstructive pulmonary disease].

Requerimientos técnicos de los espirómetros en la estrategia para garantizar el acceso a una espirometría de calidad

Recomendaciones sobre la atención al final de la vida en pacientes con EPOC