COPD classification models and mortality prediction capacity

Metabolic syndrome, genetic susceptibility, and risk of chronic obstructive pulmonary disease: The UK Biobank Study

AIM

To investigate the effect of metabolic syndrome (MetS), genetic predisposition, and their interactions, on the risk of developing chronic obstructive pulmonary disease (COPD).

METHODS

Cohort analyses included 287 868 participants from the UK Biobank Study. A genetic risk score for COPD was created using 277 single nucleotide polymorphisms. Cox proportional hazard models were used to evaluate the hazard ratios (HRs) with 95% confidence intervals (CIs) for COPD in relation to exposure factors.

RESULTS

During 2 658 936 person-years of follow-up, 5877 incident cases of COPD were documented. Compared with participants without MetS, those with MetS had a higher risk of COPD (HR 1.24, 95% CI 1.17-1.32). Compared to participants with low genetic predisposition, those with high genetic predisposition had a 17% increased risk of COPD. In the joint analysis, compared with participants without MetS and low genetic predisposition, the HR for COPD for those with MetS and high genetic predisposition was 1.50 (95% CI 1.36-1.65; P < 0.001). However, no significant interaction between MetS and genetic risk was found.

CONCLUSIONS

Metabolic syndrome was found to be associated with an increased risk of COPD, regardless of genetic risk. It is crucial to conduct further randomized control trials to determine whether managing MetS and its individual components can potentially reduce the likelihood of developing COPD.

RETRO-POPE: A Retrospective, Multicenter, Real-World Study of All-Cause Mortality in COPD

Purpose

The Phenotypes of COPD in Central and Eastern Europe (POPE) study assessed the prevalence and clinical characteristics of four clinical COPD phenotypes, but not mortality. This retrospective analysis of the POPE study (RETRO-POPE) investigated the relationship between all-cause mortality and patient characteristics using two grouping methods: clinical phenotyping (as in POPE) and Burgel clustering, to better identify high-risk patients.

Patients and Methods

The two largest POPE study patient cohorts (Czech Republic and Serbia) were categorized into one of four clinical phenotypes (acute exacerbators [with/without chronic bronchitis], non-exacerbators, asthma-COPD overlap), and one of five Burgel clusters based on comorbidities, lung function, age, body mass index (BMI) and dyspnea (very severe comorbid, very severe respiratory, moderate-to-severe respiratory, moderate-to-severe comorbid/obese, and mild respiratory). Patients were followed-up for approximately 7 years for survival status.

Results

Overall, 801 of 1,003 screened patients had sufficient data for analysis. Of these, 440 patients (54.9%) were alive and 361 (45.1%) had died at the end of follow-up. Analysis of survival by clinical phenotype showed no significant differences between the phenotypes (P=0.211). However, Burgel clustering demonstrated significant differences in survival between clusters (P<0.001), with patients in the "very severe comorbid" and "very severe respiratory" clusters most likely to die. Overall survival was not significantly different between Serbia and the Czech Republic after adjustment for age, BMI, comorbidities and forced expiratory volume in 1 second (hazard ratio [HR] 0.80, 95% confidence interval [CI] 0.65-0.99; P=0.036 [unadjusted]; HR 0.88, 95% CI 0.7-1.1; P=0.257 [adjusted]). The most common causes of death were respiratory-related (36.8%), followed by cardiovascular (25.2%) then neoplasm (15.2%).

Conclusion

Patient clusters based on comorbidities, lung function, age, BMI and dyspnea were more likely to show differences in COPD mortality risk than phenotypes defined by exacerbation history and presence/absence of chronic bronchitis and/or asthmatic features.

Comparison of clinical scoring to predict mortality risk in mild-to-moderate idiopathic pulmonary fibrosis

BACKGROUND

During the last decade, a number of clinical scores, such as Gender-Age-Physiology (GAP) Index, TORVAN Score and Charlson Comorbidity Index (CCI), have been separately used to measure comorbidity burden in idiopathic pulmonary fibrosis (IPF). However, no previous study compared the prognostic value of these scores to assess mortality risk stratification in IPF patients with mild-to-moderate disease.

METHODS

All consecutive patients with mild-to-moderate IPF who underwent high-resolution computed tomography, spirometry, transthoracic echocardiography and carotid ultrasonography at our Institution, between January 2016 and December 2018, were retrospectively analyzed. GAP Index, TORVAN Score and CCI were calculated in all patients. Primary endpoint was all-cause mortality, whereas secondary endpoint was the composite of all-cause mortality and rehospitalizations for all-causes, over medium-term follow-up.

RESULTS

Seventy IPF patients (70.2±7.4 yrs, 74.3% males) were examined. At baseline, GAP Index, TORVAN Score and CCI were 3.4±1.1, 14.7±4.1 and 5.3±2.4, respectively. A strong correlation between coronary artery calcification (CAC) and common carotid artery (CCA) intima-media thickness (IMT) (r=0.88), CCI and CAC (r=0.80), CCI and CCA-IMT (r=0.81), was demonstrated in the study group. Follow-up period was 3.5±1.2 years. During follow-up, 19 patients died and 32 rehospitalizations were detected. CCI (HR 2.39, 95% CI: 1.31-4.35) and heart rate (HR 1.10, 95% CI: 1.04-1.17) were independently associated with primary endpoint. CCI (HR 1.54, 95% CI: 1.15-2.06) predicted secondary endpoint, also. A CCI ≥6 was the optimal cut-off for predicting both outcomes.

CONCLUSIONS

Due to the increased atherosclerotic and comorbidity burden, IPF patients with CCI ≥6 at an early-stage disease have poor outcome over medium-term follow-up.

Assessment of Work Ability of Patients with COPD in Relation to the Workplace

Context

Chronic obstructive pulmonary disease (COPD) is one of the most common chronic lung diseases and is an important cause of mortality and morbidity in the world. Chronic obstructive pulmonary disease is a heterogeneous and multisystemic disease. Aims of the study was to assess workability of patients with COPD in relation to the workplace.

Settings and Design

Prospective study.

Methods and Material

The study was conducted on 150 patients with COPD. Each patient was examined by an occupational medicine specialist and a standardized COPD Questionnaire was completed. A physical examination was performed with special emphasis on auscultatory findings on the lungs. Spirometric testing was performed. Using the statistical methods, the results of the parameters of temporary (number of lost working days) and permanent incapacity (exercised right to some kind of disability) of the examined group were analyzed.

Statistical Analysis Used

Descriptive statistics. SPSS 10.0. Results of the study showed that out of 150 patients, 48.67% had preserved working capacity for jobs. There are mostly jobs without special working conditions. Out of 150 patients, 51.33% had reduced working capacity for jobs.

Conclusions

These are mostly workplaces with special working conditions, where respondents are exposed to the harmfulness of the workplace. Reduced working capacity was found in 51.33% of examined simple.

Differences in Survival of Patients With COPD According to the New GesEPOC 2021 Classification of Phenotypes

Introduction

Chronic obstructive pulmonary disease (COPD) is a respiratory pathology with high prevalence, morbidity and mortality. The Spanish COPD guideline (GesEPOC) recommends individualizing treatment according to phenotypes. The phenotype classification was updated in 2021. This study aimed to determine the survival of patients by this new classification and compare the predictive capacity of mortality compared to the previous version.

Methods

This observational study of COPD patients involved prospective follow-up for 6 years. Demographic and clinical data were collected at the beginning and evolutionary data at the end of the study. Patients were classified according to GesEPOC 2017 and GesEPOC 2021. Univariate survival analysis and multivariate analysis identified mortality risk factors.

Results

Of the 273 patients, 243 (89.0%) were male. Ninety-three patients (34.1%) died during follow-up. Regarding phenotypes, 190 patients (69.6%) were non-exacerbators, 69 (25.3%) belonged to the non-eosinophilic exacerbator phenotype and 14 (5.1%) were of the eosinophilic exacerbator phenotype. Compared with non-exacerbator patients, those with the non-eosinophilic exacerbator phenotype had lower survival (p = 0.009). Risk factors independently associated with mortality were older age (p < 0.001), non-eosinophilic exacerbator phenotype (p = 0.017) and a high Charlson index score (p < 0.001). The new classification presented a worse ability to predict mortality than the previous version (area under the curve 0.632 vs 0.566, p = 0.018).

Conclusion

Patients with the non-eosinophilic exacerbator phenotype had worse prognoses. This phenotype, advanced age and high comorbidity were mortality risk factors. The GesEPOC 2021 classification predicts mortality worse than the 2017 version. These data must be considered for more individualized management of COPD patients.

Deep Learning Prediction of Survival in Patients with Chronic Obstructive Pulmonary Disease Using Chest Radiographs

Background Preexisting indexes for predicting the prognosis of chronic obstructive pulmonary disease (COPD) do not use radiologic information and are impractical because they involve complex history assessments or exercise tests. Purpose To develop and to validate a deep learning-based survival prediction model in patients with COPD (DLSP) using chest radiographs, in addition to other clinical factors. Materials and Methods In this retrospective study, data from patients with COPD who underwent postbronchodilator spirometry and chest radiography from 2011-2015 were collected and split into training (n = 3475), validation (n = 435), and internal test (n = 315) data sets. The algorithm for predicting survival from chest radiographs was trained (hereafter, DLSP_CXR), and then age, body mass index, and forced expiratory volume in 1 second (FEV₁) were integrated within the model (hereafter, DLSP_integ). For external test, three independent cohorts were collected (n = 394, 416, and 337). The discrimination performance of DLSP_CXR was evaluated by using time-dependent area under the receiver operating characteristic curves (TD AUCs) at 5-year survival. Goodness of fit was assessed by using the Hosmer-Lemeshow test. Using one external test data set, DLSP_integ was compared with four COPD-specific clinical indexes: BODE, ADO, COPD Assessment Test (CAT), and St George's Respiratory Questionnaire (SGRQ). Results DLSP_CXR had a higher performance at predicting 5-year survival than FEV₁ in two of the three external test cohorts (TD AUC: 0.73 vs 0.63 [P = .004]; 0.67 vs 0.60 [P = .01]; 0.76 vs 0.77 [P = .91]). DLSP_CXR demonstrated good calibration in all cohorts. The DLSP_integ model showed no differences in TD AUC compared with BODE (0.87 vs 0.80; P = .34), ADO (0.86 vs 0.89; P = .51), and SGRQ (0.86 vs 0.70; P = .09), and showed higher TD AUC than CAT (0.93 vs 0.55; P < .001). Conclusion A deep learning model using chest radiographs was capable of predicting survival in patients with chronic obstructive pulmonary disease. © RSNA, 2022 Online supplemental material is available for this article.

Development and validation of a multivariable mortality risk prediction model for COPD in primary care

Risk stratification of chronic obstructive pulmonary disease (COPD) patients is important to enable targeted management. Existing disease severity classification systems, such as GOLD staging, do not take co-morbidities into account despite their high prevalence in COPD patients. We sought to develop and validate a prognostic model to predict 10-year mortality in patients with diagnosed COPD. We constructed a longitudinal cohort of 37,485 COPD patients (149,196 person-years) from a UK-wide primary care database. The risk factors included in the model pertained to demographic and behavioural characteristics, co-morbidities, and COPD severity. The outcome of interest was all-cause mortality. We fitted an extended Cox-regression model to estimate hazard ratios (HR) with 95% confidence intervals (CI), used machine learning-based data modelling approaches including k-fold cross-validation to validate the prognostic model, and assessed model fitting and discrimination. The inter-quartile ranges of the three metrics on the validation set suggested good performance: 0.90–1.06 for model fit, 0.80–0.83 for Harrel’s c-index, and 0.40–0.46 for Royston and Saurebrei’s \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$R_D^2$$\end{document}RD2 with a strong overlap of these metrics on the training dataset. According to the validated prognostic model, the two most important risk factors of mortality were heart failure (HR 1.92; 95% CI 1.87–1.96) and current smoking (HR 1.68; 95% CI 1.66–1.71). We have developed and validated a national, population-based prognostic model to predict 10-year mortality of patients diagnosed with COPD. This model could be used to detect high-risk patients and modify risk factors such as optimising heart failure management and offering effective smoking cessation interventions.

Changes in health-related quality of life as a marker in the prognosis in COPD patients

Chronic obstructive pulmonary disease (COPD) is understood as a complex, heterogeneous and multisystem airway obstructive disease. The association of deterioration in health-related quality of life (HRQoL) with mortality and hospitalisation for COPD exacerbation has been explored in general terms. The specific objectives of this study were to determine whether a change in HRQoL is related, over time, to mortality and hospitalisation. Overall, 543 patients were recruited through Galdakao Hospital's five outpatient respiratory clinics. Patients were assessed at baseline, and the end of the first and second year, and were followed up for 3 years. At each assessment, measurements were made of several variables, including HRQoL using the St George's Respiratory Questionnaire (SGRQ). The cohort had moderate obstruction (forced expiratory volume in 1 s 55% of the predicted value). SGRQ total, symptoms, activity and impact scores at baseline were 39.2, 44.5, 48.7 and 32.0, respectively. Every 4-point increase in the SGRQ was associated with an increase in the likelihood of death: "symptoms" domain odds ratio 1.04 (95% CI 1.00-1.08); "activity" domain OR 1.12 (95% CI 1.08-1.17) and "impacts" domain OR 1.11 (95% CI 1.06-1.15). The rate of hospitalisations per year was 5% (95% CI 3-8%) to 7% (95% CI 5-10%) higher for each 4-point increase in the separate domains of the SGRQ. Deterioration in HRQoL by 4 points in SGRQ domain scores over 1 year was associated with an increased likelihood of death and hospitalisation.

A new, three-dimensional approach to the GOLD COPD assessment tool

BACKGROUND

The 2-dimensional, 4-quadrant 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) COPD A-D assessment tool (GOLD₂₀₁₇) does not include lung function variables to classify patients into different risk groups. The previous 2011 tool (GOLD₂₀₁₁) classified cases in the upper-quadrants (higher risk groups) regardless of whether they had a history of exacerbations or worse lung function. We hypothesized that a modified, three-dimensional classification (GOLD_3D) that separately includes assessment of lung function and exacerbations history would improve the ability to predict adverse events.

METHODS

A total of 1303 COPD patients were included in a historical cohort study. The ability of GOLD_3D to predict outcomes (all-cause death and hospitalizations due to severe exacerbation) was compared with GOLD₂₀₁₇ and GOLD₂₀₁₁.

RESULTS

Mean follow-up was 45.0 ± 28.0 months. Two hundred and twenty-eight patients (17.5%) died and 337 (25.9%) subjects suffered at least a severe exacerbation that required hospital admission. The area under the receiver-operating characteristics curve for mortality prediction was slightly but significantly higher for GOLD_3D than for GOLD₂₀₁₁. The area under the curve for prediction of severe exacerbations was significantly higher for GOLD_3D than for GOLD₂₀₁₁ and GOLD₂₀₁₇. A worse ventilatory obstruction was associated in most cases with a higher mortality risk and a higher exacerbation risk for the GOLD2017 A-D groups.

CONCLUSIONS

The proposed GOLD_3D classification system upgrades the previous ones, and is advantageous in predicting future adverse events.

Alpha1-antitrypsin Disease, Treatment and Role for Lung Volume Reduction Surgery

Chronic obstructive pulmonary usually is subcategorized into 2 groups: chronic bronchitis and emphysema. The main cause of chronic bronchitis and emphysema is smoking; however, alpha1-antitrypsin also has been seen to cause emphysema in patients who are deficient. As symptoms and lung function decline, treatment modalities, such as lung volume reduction surgery, have been used in individuals with chronic obstructive pulmonary disease and upper lobe predominant emphysema. This article analyzes multiple published series where lung volume reduction surgery has been used in individuals with alpha1-antitrypsin deficiency and their overall outcomes.

[Incidence of severe exacerbation in patients diagnosed with diabetes and chronic obstructive pulmonary disease: Cohort study]

Objetivo

Estimar en una cohorte de pacientes diagnosticados de EPOC y diabetes la incidencia de hospitalizaciones por exacerbación grave de la EPOC y sus factores asociados.

Diseño

Estudio prospectivo de cohorte.

Emplazamiento

Centros de Atención Primaria de Lleida ciudad (en total 7 centros).

Participantes

Se estudiaron 761 pacientes codiagnosticados de EPOC y diabetes. Los criterios de inclusión fueron pacientes de ambos sexos, igual o mayores de 40 años, residentes en el área geográfica de Lleida ciudad, con el diagnóstico de EPOC según los criterios de la guía GOLD, con espirometría reciente y una fracción FEV₁/FVC < 0,7; diagnosticados de DM2 según la guía de la International Diabetes Federation. Los criterios de exclusión fueron padecer alguna enfermedad física o psíquica grave.

Mediciones principales

Las variables del estudio fueron: el sexo, la edad, su área básica de salud en Lleida, índice de masa corporal, perímetro de cintura, hábito tabáquico y enólico, hipertensión arterial, insuficiencia cardiaca, insuficiencia renal crónica, FEV₁, FEV₁/FVC, categorización GOLD, HbA1c. Se registró la vacuna antigripal y antineumocócica. La variable dependiente fue la exacerbación grave. En el análisis estadístico la asociación de la variable dependiente con las variables independientes se determinó mediante el cálculo de la hazard ratio (HR) con el intervalo de confianza del 95%. La HR se estimó de forma ajustada mediante modelos de regresión de Cox no condicional.

Resultados

La incidencia de hospitalización por exacerbación grave de la EPOC fue del 9,98%; se objetivó un aumento del riesgo de exacerbación grave en pacientes diagnosticados de insuficiencia cardiaca (HR = 2,27; p = 0,002), y con una menor fracción de FEV₁/FVC. La vacuna antigripal y antineumocócica presentaron un papel protector débil sin ser estadísticamente significativa.

Conclusión

Se documenta una incidencia de exacerbaciones elevada en los pacientes codiagnosticados de EPOC y DM2. La insuficiencia cardiaca y una menor fracción FEV₁/FVC podrían aumentar el riesgo de exacerbación.

The Relation Between Clinical Phenotypes, GOLD Groups/Stages and Mortality in COPD Patients - A Prospective Multicenter Study

Introduction

The concept of phenotyping emerged, reflecting specific clinical, pulmonary and extrapulmonary features of each particular chronic obstructive pulmonary disease (COPD) case. Our aim was to analyze prognostic utility of: “Czech“ COPD phenotypes and their most frequent combinations, ”Spanish” phenotypes and Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages + groups in relation to long-term mortality risk.

Methods

Data were extracted from the Czech Multicenter Research Database (CMRD) of COPD. Kaplan-Meier (KM) estimates (at 60 months from inclusion) were used for mortality assessment. Survival rates were calculated for the six elementary “Czech” phenotypes and their most frequent and relevant combinations, “Spanish” phenotypes, GOLD grades and groups. Statistically significant differences were tested by Log Rank test. An analysis of factors underlying mortality risk (the role of confounders) has been assessed with the use of classification and regression tree (CART) analysis. Basic factors showing significant differences between deceased and living patients were entered into the CART model. This showed six different risk groups, the differences in risk were tested by a Log Rank test.

Results

The cohort (n=720) was 73.1% men, with a mean age of 66.6 years and mean FEV₁ 44.4% pred. KM estimates showed bronchiectases/COPD overlap (HR 1.425, p=0.045), frequent exacerbator (HR 1.58, p<0.001), cachexia (HR 2.262, p<0.001) and emphysematous (HR 1.786, p=0.015) phenotypes associated with higher mortality risk. Co-presence of multiple phenotypes in a single patient had additive effect on risk; combination of emphysema, cachexia and frequent exacerbations translated into poorest prognosis (HR 3.075; p<0.001). Of the “Spanish” phenotypes, AE CB and AE non-CB were associated with greater risk of mortality (HR 1.787 and 2.001; both p=0.001). FEV₁% pred., cachexia and chronic heart failure in patient history were the major underlying factors determining mortality risk in our cohort.

Conclusion

Certain phenotypes (“Czech” or “Spanish”) of COPD are associated with higher risk of death. Co-presence of multiple phenotypes (emphysematous plus cachectic plus frequent exacerbator) in a single individual was associated with amplified risk of mortality.

Pattern of comorbidities and 1-year mortality in elderly patients with COPD hospitalized in internal medicine wards: data from the RePoSI Registry

Currently, chronic obstructive pulmonary disease (COPD) represents the fourth cause of death worldwide with significant economic burden. Comorbidities increase in number and severity with age and are identified as important determinants that influence the prognosis. In this observational study, we retrospectively analyzed data collected from the RePoSI register. We aimed to investigate comorbidities and outcomes in a cohort of hospitalized elderly patients with the clinical diagnosis of COPD. Socio-demographic, clinical characteristics and laboratory findings were considered. The association between variables and in-hospital, 3-month and 1-year follow-up were analyzed. Among 4696 in-patients, 932 (19.8%) had a diagnosis of COPD. Patients with COPD had more hospitalization, a significant overt cognitive impairment, a clinically significant disability and more depression in comparison with non-COPD subjects. COPD patients took more drugs, both at admission, in-hospital stay, discharge and 3-month and 1-year follow-up. 14 comorbidities were more frequent in COPD patients. Cerebrovascular disease was an independent predictor of in-hospital mortality. At 3-month follow-up, male sex and hepatic cirrhosis were independently associated with mortality. ICS-LABA therapy was predictor of mortality at in-hospital, 3-month and 1-year follow-up. This analysis showed the severity of impact of COPD and its comorbidities in the real life of internal medicine and geriatric wards.

Health status can predict diaphragmatic muscle thickness in COPD: pilot study

Abstract Introduction: Among the systemic implications of chronic obstructive pulmonary disease (COPD) there are changes in the diaphragm and impact on health status. However, there are few studies on the possible relationship between these variables, and whether health status could predict diaphragmatic muscle thickness (DMT). Objective: To investigate whether there is a relationship between DMT and the prognostic mortality index Body Mass-Index, Airway Obstruction, Dyspnea and Exercise Capacity (BODE), dyspnea and health status, and to investigate whether health status can predict DMT in patients with COPD entering a pulmonary rehabilitation program. Methods: This is a pilot study with a cross-sectional design. Diaphragmatic muscle thickness was evaluated using ultrasound; health status through the COPD Assessment Test (CAT); the sensation of dyspnea by the modified Medical Research Council scale; and mortality, using the BODE index. Results: The sample consisted of 13 patients (68.69 ± 9.3 years) classified as having moderate to severe COPD. There was a strong and inverse correlation between diaphragmatic muscle thickness and health status (r = -0.735; p = 0.004). Simple regression analysis demonstrated that health status influenced diaphragmatic muscle thickness (β = -0.002; IC 95% - 0.004 to -0.001; p = 0.004), explaining 49% of the variance. However, no correlations were observed between diaphragmatic muscle thickness with dyspnea (r = 0.005; p = 0.985) or with the BODE mortality index (r = -0.219; p = 0.472). Conclusion: This pilot study demonstrated a strong inverse correlation between health status and DMT. In addition, health status was able to predict DMT in patients with COPD.

Mortality prediction in chronic obstructive pulmonary disease comparing the GOLD 2015 and GOLD 2019 staging: a pooled analysis of individual patient data

In 2019, The Global Initiative for Chronic Obstructive Lung Disease (GOLD) modified the grading system for patients with COPD, creating 16 subgroups (1A–4D). As part of the COPD Cohorts Collaborative International Assessment (3CIA) initiative, we aim to compare the mortality prediction of the 2015 and 2019 COPD GOLD staging systems.

We studied 17 139 COPD patients from the 3CIA study, selecting those with complete data. Patients were classified by the 2015 and 2019 GOLD ABCD systems, and we compared the predictive ability for 5-year mortality of both classifications.

In total, 17 139 patients with COPD were enrolled in 22 cohorts from 11 countries between 2003 and 2017; 8823 of them had complete data and were analysed. Mean±sd age was 63.9±9.8 years and 62.9% were male. GOLD 2019 classified the patients in milder degrees of COPD. For both classifications, group D had higher mortality. 5-year mortality did not differ between groups B and C in GOLD 2015; in GOLD 2019, mortality was greater for group B than C. Patients classified as group A and B had better sensitivity and positive predictive value with the GOLD 2019 classification than GOLD 2015. GOLD 2015 had better sensitivity for group C and D than GOLD 2019. The area under the curve values for 5-year mortality were only 0.67 (95% CI 0.66–0.68) for GOLD 2015 and 0.65 (95% CI 0.63–0.66) for GOLD 2019.

The new GOLD 2019 classification does not predict mortality better than the previous GOLD 2015 system.

GOLD 2019 staging system created 16 subgroups. GOLD 2015 and GOLD 2019 are not strong predictors of mortality, and do not have sufficient discriminatory power to be used as a tool for risk classification of mortality in patients with COPD.https://bit.ly/3idBuaN

Integrating Comorbidities and Phenotype-Based Medicine in Patient-Centered Medicine in COPD

Despite recent notable innovations in the management of chronic obstructive pulmonary disease (COPD), no major advances in patient-centered medicine have been achieved. Current guidelines base their proposals on the average results from clinical trials, leading to what could be termed ‘means-based’ medical practice. However, the therapeutic response is variable at the patient level. Additionally, the variability of the clinical presentation interacts with comorbidities to form a complex clinical scenario for clinicians to deal with. Consequently, no consensus has been reached over a practical approach for combining comorbidities and disease presentation markers in the therapeutic algorithm. In this context, from the patients’ first visit, the clinician faces four major dilemmas: (1) establishing the correct diagnosis of COPD as opposed to other airway diseases, such as bronchial asthma; (2) deciding on the initial therapeutic approach based on the clinical characteristics of each case; (3) setting up a study strategy for non-responding patients; (4) pursuing a follow-up strategy with two well-defined periods according to whether close or long-term follow-up is required. Here, we will address these major dilemmas in the search for a patient-centered approach to COPD management and suggest how to combine them all in a single easy-to-use strategy.

Predictive factors over time of health-related quality of life in COPD patients

Background

Health-related quality of life (HRQoL) should be seen as a tool that provides an overall view of the general clinical condition of a COPD patient. The aims of this study were to identify variables associated with HRQoL and whether they continue to have an influence in the medium term, during follow-up.

Methods

Overall, 543 patients with COPD were included in this prospective observational longitudinal study. At all four visits during a 5-year follow-up, the patients completed the Saint George’s Respiratory Questionnaire (SGRQ), pulmonary function tests, the 6-min walk test (6MWT), and a physical activity (PA) questionnaire, among others measurements. Data on hospitalization for COPD exacerbations and comorbidities were retrieved from the personal electronic clinical record of each patient at every visit.

Results

The best fit to the data of the cohort was obtained with a beta-binomial distribution. The following variables were related over time to SGRQ components: age, inhaled medication, smoking habit, forced expiratory volume in one second, handgrip strength, 6MWT distance, body mass index, residual volume, diffusing capacity of the lung for carbon monoxide, PA (depending on level, 13 to 35% better HRQoL, in activity and impacts components), and hospitalizations (5 to 45% poorer HRQoL, depending on the component).

Conclusions

Among COPD patients, HRQoL was associated with the same variables throughout the study period (5-year follow-up), and the variables with the strongest influence were PA and hospitalizations.

Do Benefits Outweigh Risks for Corticosteroid Therapy in Acute Exacerbation of Chronic Obstructive Pulmonary Disease in People with Diabetes Mellitus?

Chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM) are chronic health conditions with significant impacts on quality and extent of life. People with COPD and DM appear to have worse outcomes in each of the comorbid conditions. Treatment with corticosteroids in acute exacerbation of COPD (AECOPD) has been shown to reduce treatment failure and exacerbation relapse, and to shorten length of hospital stay, but not to affect the inexorable gradual worsening of lung function. Treatment with corticosteroids can lead to a wide spectrum of side effects and complications, including worsening hyperglycemia and deterioration of diabetes control in those with pre-existing DM. The relationship between COPD and DM is rather complex and accumulating evidence indicates a distinct phenotype of the comorbid state. Several randomized controlled trials on corticosteroid treatment in AECOPD excluded people with DM or did not report on outcomes in this subgroup. As such, the perceived benefits of corticosteroids in AECOPD in people with DM have not been validated. In people with COPD and DM, the detrimental side effects of corticosteroids are guaranteed, while the benefits are not confirmed and only presumed based on extrapolation from the general COPD population. Therefore, the potential for harm when prescribing corticosteroids for AECOPD in people with DM cannot be excluded.

Advance care planning in COPD: guidance development for healthcare professionals

OBJECTIVES

To examine current practices, attitudes and levels of confidence related to advance care planning (ACP) in patients with chronic obstructive pulmonary disease (COPD) among healthcare professionals working in Ireland. This will inform future clinical guidance development.

METHODS

A cross-sectional survey of healthcare professionals.

RESULTS

There were 143 participants (109 general practitioners, 25 nurses, 7 physiotherapists and 2 consultant physicians). The majority (82%, n=117) cared for patients with COPD weekly, but only 23% (n=33) had initiated ACP with a patient with COPD over the previous 6 months. Overall, 59% (n=85) answered ≥6 of 8 general knowledge questions correctly. Participants demonstrated positive attitudes towards ACP (mean score 3.6/5.0), but confidence levels were low (2.2/4.0). Most thought ACP was appropriate for patients with severe or very severe COPD (71%, n=101%, and 91%, n=130, respectively) but were unsure or felt that it was not appropriate for those with mild-moderate COPD. However, almost all participants (97%, n=139) stated that if a patient expressed a desire to have ACP discussions, they would comply. Topics most likely to be discussed related to diagnosis and treatment options. Death and end-of-life issues were rarely discussed. The death of a family member or friend and participation in support groups were identified as new 'triggers' for initiating ACP.

CONCLUSIONS

Targeted education to improve general knowledge and confidence levels among healthcare professionals, together with initiatives to increase public awareness of ACP so that patients themselves might be more inclined to start the discussion, may help increase the uptake of ACP for this patient group.