Geographical differences in chronic obstructive pulmonary disease mortality trends by sex, Spain, 1980-2021

BACKGROUND: To analyse changes in trends in mortality due to chronic obstructive pulmonary disease (COPD) in Spain by Autonomous Community (AC) and sex during the period 1980-2021.METHODS: Data on population and COPD death records (International Classification of Diseases, 10th edition, codes J40â-"J44 and J47) were retrieved from the National Institute of Statistics for the study period. Age-standardised mortality rates by AC and sex were assessed using joinpoint regression models.RESULTS: There were 562,668 deaths due to COPD (423,855 in men and 138,813 in women), with an average annual increase of 1.6%. COPD deaths in men increased in most ACs, except for Asturias (â-"0.5% per year). The Canary Islands (14% per year) and Madrid (6.5% per year) had the highest increases. In women, the figures show a wide range of values at the AC level (from a â-"1.4% decrease to 7.9% increase). Nationally, the sex ratio increased from 1980 to 2021. In men, six ACs showed a significant decrease, while in women only two ACs showed a significant decrease.CONCLUSION: A steady decrease in COPD mortality was observed in most ACs for men, while a different trend was observed in women in several ACs. Despite past and ongoing tobacco control initiatives, this condition remains a leading cause of death.

Step-Up and Step-Down Treatment Approaches for COPD: A Holistic View of Progressive Therapies

Recent advances in inhaled drugs and a clearer definition of the disease have made the task of managing COPD more complex. Different proposals have been put forward which combine all the available treatments and the different clinical presentations in an effort to select the best therapeutic options for each clinical context. As COPD is a chronic progressive disease, the escalation of therapy has traditionally been considered the most natural way to tackle it. However, the notion of COPD as a constantly progressing disease has recently been challenged and, in specific areas, this points to the possibility of a de-escalation in treatment. In this context, the clinician requires simple, specific recommendations to guide these changes in treatment in their daily clinical practice. To accomplish this, the first step must be a correct evaluation and an accurate initial preliminary diagnosis of the patient's condition. Thereafter, the first escalation in therapy must be introduced with caution as the disease progresses, since clinical trials are not designed with clinical decision-making in mind. During this escalation, three possibilities are open to change the current treatment for a different one within the same family, to increase non-pharmacological interventions or to increase the pharmacological therapies. Beyond that point, a patient with persistent symptoms represents a complex clinical scenario which requires a specialized approach, including the evaluation of different respiratory and non-respiratory comorbidities. Unfortunately, there are few de-escalation studies available, and these are mainly observational in nature. The debate on de-escalation in pharmacological treatment, therefore, involves two main discussion points: the withdrawal of bronchodilators and the withdrawal of inhaled steroids. Altogether, the scheme for modifying treatment must be more personalized than just adding molecules, and the therapeutic response and its conditioning factors should be evaluated at each step before proceeding further.

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

Extrafine Beclometasone Dipropionate/Formoterol Fumarate vs Double Bronchodilation Therapy in Patients with COPD: A Historical Real-World Non-Inferiority Study

Purpose

This study aimed to evaluate the non-inferiority of initiating extrafine beclometasone dipropionate/formoterol fumarate (BDP/FF) versus double bronchodilation (long-acting beta-agonists [LABA]/long-acting muscarinic antagonists [LAMA]) among patients with a history of chronic obstructive pulmonary disease (COPD) exacerbations.

Patients and Methods

A historical cohort study was conducted using data from the UK's Optimum Patient Care Research Database. Patients with COPD ≥40 years at diagnosis were included if they initiated extrafine BDP/FF or any LABA/LAMA double therapy as a step-up from no maintenance therapy or monotherapy with inhaled corticosteroids (ICS), LAMA, or LABA and a history of ≥2 moderate/severe exacerbations in the previous two years. The primary outcome was exacerbation rate from therapy initiation until a relevant therapy change or end of follow-up. Secondary outcomes included rate of acute respiratory events, acute oral corticosteroids (OCS) courses, and antibiotic prescriptions with lower respiratory indication, modified Medical Research Council score (mMRC) ≥2, and time to first pneumonia diagnosis. The non-inferiority boundary was set at a relative difference of 15% on the ratio scale. Five potential treatment effect modifiers were investigated.

Results

A total of 1735 patients initiated extrafine BDP/FF and 2450 patients initiated LABA/LAMA. The mean age was 70 years, 51% were male, 41% current smokers, and 85% had FEV₁ <80% predicted. Extrafine BDP/FF showed non-inferiority to LABA/LAMA for rate of exacerbations (incidence rate ratio [IRR] = 1.01 [95% CI 0.94-1.09]), acute respiratory events (IRR = 0.98 [0.92-1.04]), acute OCS courses (IRR = 1.01 [0.91-1.11]), and antibiotic prescriptions (IRR = 0.99 [0.90-1.09]), but not for mMRC (OR = 0.93 [0.69-1.27]) or risk of pneumonia (HR = 0.50 [0.14-1.73]). None of the a priori defined effect modifier candidates affected the comparative effectiveness.

Conclusion

This study found that stepping up to extrafine BDP/FF from no maintenance or monotherapy was not inferior to stepping up to double bronchodilation therapy in patients with a history of exacerbations.

Differential biomarker profiles between unprovoked venous thromboembolism and cancer

BACKGROUND

The relationship between cancer and venous thromboembolic disease (VTD) are complex because the activated coagulation factors are not only involved in thrombosis but also in malignant processes, such as angiogenesis and metastasis.

OBJECTIVE

To compare phenotypes of extracellular vesicles (EVs), and levels of D-dimer, soluble P-selectin (sP-selectin) and antigenic tissue factor (TF) between unprovoked VTD patients, who did not develop cancer during one-year follow-up, and those with advanced stage of cancer but not associated with VTD.

METHODS

A prospective study in which we included 138 unprovoked VTD patients and 67 advanced cancer patients, who did not develop thrombosis. Levels of EVs of different cellular origin (platelet, endothelium and leukocyte), EVs positive for tissue factor (TF) and P-selectin glycoprotein ligand 1 were quantified by flow cytometry. D-dimer, soluble P-selectin (sP-selectin) and antigenic TF were determined by ELISA.

RESULTS

TF-positive EVs, D-dimer, and sP-selectin were markedly elevated in unprovoked VTD patients compared to cancer patients without association with thrombosis.

CONCLUSIONS

Levels of TF-positive EVs, D-dimer and sP-selectin are able to discriminate between unprovoked VTD patients not related to cancer and cancer patients not associated with VTD. These results could lead to the application of EVs as biomarkers of both diseases. Key messages: Circulating EVs, specifically TF-positive EVs, in combination with plasmatic markers of hypercoagulable states, such as D-dimer, sP-selectin and antigen TF, are able to discriminate between cancer patients without thrombosis and patients with unprovoked VTD. Research fields could be opened. Future studies will assess if these biomarkers together serve as predicting thrombotic events in cancer populations.

Expression of aquaporins in bronchial tissue and lung parenchyma of patients with chronic obstructive pulmonary disease

Background: Aquaporins AQP1 and AQP5 are highly expressed in the lung. Recent studies have shown that the expression of these proteins may be mechanistically involved in the airway inflammation and in the pathogenesis of chronic obstructive pulmonary disease (COPD). The aim of this study was to investigate the expression of AQP1 and AQP5 in the bronchial tissue and the lung parenchyma of patients with COPD and COPD-resistant smokers. Methods: Using a case–control design, we selected a group of 15 subjects with COPD and 15 resistant smokers (smokers without COPD) as a control, all of whom were undergoing lung resection surgery due to a lung neoplasm. We studied the expression of AQP1 and AQP5 in the bronchial tissue and the lung parenchyma by means of immunohistochemistry and reverse-transcription real-time polymerase chain reaction. Tissue expression of AQP1 and AQP5 was semi-quantitatively assessed in terms of intensity and expression by immunohistochemistry using a 4-point scale ranging from 0 (none) to 3 (maximum). Results: There were no significant differences in gene expression between COPD patients and resistant smokers both in the bronchial tissue and in the lung parenchyma. However, AQP1 gene expression was 2.41-fold higher in the parenchyma of smokers with COPD compared to controls, whereas the AQP5 gene showed the opposite pattern, with a 7.75-fold higher expression in the bronchus of smokers with COPD compared with controls. AQP1 and AQP5 proteins were preferentially expressed in endothelial cells, showing a higher intensity for AQP1 (66.7% of cases with an intensity of 3, and 93.3% of subjects with an extension of 3 among patients with COPD). Subtle interstitial disease was associated with type II pneumocyte hyperplasia and an increased expression of AQP1. Conclusions: This study provides pilot observations on the differences in AQP1 and AQP5 expression between COPD patients and COPD-resistant smokers. Our findings suggest a potential role for AQP1 in the pathogenesis of COPD.

Relationship between the endothelial dysfunction and the expression of the β1-subunit of BK channels in a non-hypertensive sleep apnea group

STUDY OBJECTIVES

Vascular damage must be diagnosed early in patients with hypertension. In this regard, endothelial dysfunction (ED) is an early sign of vascular disease and a predictor of cardiovascular diseases. In obstructive sleep apnea (OSA), intermittent hypoxia triggers ED, but mechanisms are not clear. In this context, it has been described that BK channels regulates arterial tone and that chronic and intermittent hypoxia downregulates the expression of the BK channel β1-subunit facilitating vasoconstriction. Thus, we investigated the relationship among hypoxemia, ED, and mRNA expression of the β1-subunit in patients with severe OSA. We aimed to assess (1) ED in non-hypertensive patients with OSA using laser-Doppler flowmetry, (2) BK β1-subunit mRNA expression, and (3) the impact of continuous positive airway pressure (CPAP) treatment on ED and β1-subunit regulation.

METHODS

OSA patients underwent 24-hour blood pressure monitoring to exclude hypertension. Laser-Doppler flowmetry was performed to assess ED, and β1-subunit mRNA expression was evaluated using a blood test of peripheral blood leukocytes at baseline and after 3 months of CPAP treatment.

RESULTS

In normotensive patients with OSA, endothelial function correlated with the severity of OSA. CPAP improved endothelial function in normotensive OSA patients and the speed of the arterial response was significantly correlated with β1-subunit mRNA expression. β1-subunit mRNA expression at baseline correlated inversely with its change after CPAP.

CONCLUSIONS

Sleep apnea is related to ED in normotensive patients with OSA. CPAP therapy improves endothelial function and regulates β1-subunit mRNA expression.

Mixed Th2 and non-Th2 inflammatory pattern in the asthma-COPD overlap: a network approach

Introduction

The asthma–chronic obstructive pulmonary disease (COPD) overlap (ACO) is a clinical condition that combines features of those two diseases, and that is difficult to define due to the lack of understanding of the underlying mechanisms. Determining systemic mediators may help clarify the nature of inflammation in patients with ACO.

Objectives

We aimed at investigating the role and interaction of common markers of systemic inflammation (IL-6, IL-8, and tumor necrosis factor-α), Th2-related markers (periostin, IL-5, and IL-13), and IL-17 in asthma, COPD, and ACO.

Methods

This is a cross-sectional study of patients aged ≥40 years with a post-bronchodilator forced expiratory volume in the first second/forced vital capacity <0.70 recruited from outpatient clinics in tertiary hospitals with a clinical diagnosis of asthma, COPD, or ACO. ACO was defined by a history of smoking >10 pack-years in a patient with a previous diagnosis of asthma or by the presence of eosinophilia in a patient with a previous diagnosis of COPD. Clinical, functional, and inflammatory parameters were compared between categories using discriminant and network analysis.

Results

In total, 109 ACO, 89 COPD, and 94 asthma patients were included. Serum levels (median [interquartile range]) of IL-5 were higher in asthma patients than in COPD patients (2.09 [0.61–3.57] vs 1.11 [0.12–2.42] pg/mL, respectively; p=0.03), and IL-8 levels (median [interquartile range]) were higher in COPD patients than in asthma patients (9.45 [6.61–13.12] vs 7.03 [4.69–10.44] pg/mL, respectively; p<0.001). Their values in ACO were intermediate between those in asthma and in COPD. Principal component and network analysis showed a mixed inflammatory pattern in ACO in between asthma and COPD. IL-13 was the most connected node in the network, with different weights among the three conditions.

Conclusion

Asthma and COPD are two different inflammatory conditions that may overlap in some patients, leading to a mixed inflammatory pattern. IL-13 could be central to the regulation of inflammation in these conditions.

Seasonal variability in clinical care of COPD outpatients: results from the Andalusian COPD audit

OBJECTIVES

Clinical practice in chronic obstructive pulmonary disease (COPD) can be influenced by weather variability throughout the year. To explore the hypothesis of seasonal variability in clinical practice, the present study analyzes the results of the 2013-2014 Andalusian COPD audit with regard to changes in clinical practice according to the different seasons.

METHODS

The Andalusian COPD audit was a pilot clinical project conducted from October 2013 to September 2014 in outpatient respiratory clinics of hospitals in Andalusia, Spain (8 provinces with more than 8 million inhabitants) with retrospective data gathering. For the present analysis, astronomical seasons in the Northern Hemisphere were used as reference. Bivariate associations between the different COPD guidelines and the clinical practice changes over the seasons were explored by using binomial multivariate logistic regression analysis with age, sex, Charlson comorbidity index, type of hospital, and COPD severity by forced expiratory volume in 1 second as covariates, and were expressed as odds ratio (OR) with 95% confidence intervals (CIs).

RESULTS

The Andalusian COPD audit included 621 clinical records from 9 hospitals. After adjusting for covariates, only inhaler device satisfaction evaluation was found to significantly differ according to the seasons with an increase in winter (OR, 3.460; 95% CI, 1.469-8.151), spring (OR, 4.215; 95% CI, 1.814-9.793), and summer (OR, 3.371; 95% CI, 1.391-8.169) compared to that in autumn. The rest of the observed differences were not significant after adjusting for covariates. However, compliance with evaluating inhaler satisfaction was low.

CONCLUSION

The various aspects of clinical practice for COPD care were found to be quite homogeneous throughout the year for the variables evaluated. Inhaler satisfaction evaluation, however, presented some significant variation during the year. Inhaler device satisfaction should be evaluated during all clinical visits throughout the year for improved COPD management.

Distribution and Outcomes of a Phenotype-Based Approach to Guide COPD Management: Results from the CHAIN Cohort

Rationale

The Spanish guideline for COPD (GesEPOC) recommends COPD treatment according to four clinical phenotypes: non-exacerbator phenotype with either chronic bronchitis or emphysema (NE), asthma-COPD overlap syndrome (ACOS), frequent exacerbator phenotype with emphysema (FEE) or frequent exacerbator phenotype with chronic bronchitis (FECB). However, little is known on the distribution and outcomes of the four suggested phenotypes.

Objective

We aimed to determine the distribution of these COPD phenotypes, and their relation with one-year clinical outcomes.

Methods

We followed a cohort of well-characterized patients with COPD up to one-year. Baseline characteristics, health status (CAT), BODE index, rate of exacerbations and mortality up to one year of follow-up were compared between the four phenotypes.

Results

Overall, 831 stable COPD patients were evaluated. They were distributed as NE, 550 (66.2%); ACOS, 125 (15.0%); FEE, 38 (4.6%); and FECB, 99 (11.9%); additionally 19 (2.3%) COPD patients with frequent exacerbations did not fulfill the criteria for neither FEE nor FECB. At baseline, there were significant differences in symptoms, FEV₁ and BODE index (all p<0.05). The FECB phenotype had the highest CAT score (17.1±8.2, p<0.05 compared to the other phenotypes). Frequent exacerbator groups (FEE and FECB) were receiving more pharmacological treatment at baseline, and also experienced more exacerbations the year after (all p<0.05) with no differences in one-year mortality. Most of NE (93%) and half of exacerbators were stable after one year.

Conclusions

There is an uneven distribution of COPD phenotypes in stable COPD patients, with significant differences in demographics, patient-centered outcomes and health care resources use.

Determinants for changing the treatment of COPD: a regression analysis from a clinical audit

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 99 patients (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 1 second 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.

Factors Associated with Depression in COPD: A Multicenter Study

INTRODUCTION

Depression is a prevalent comorbidity in COPD and has an impact on the prognosis of these patients, thereby making it important to study the factors associated with depression in patients with COPD.

METHOD

A multicenter, observational and cross-sectional study was conducted to study the factors associated with depression in patients with COPD measured by the hospital anxiety and depression (HAD) questionnaire. We analyzed anthropometric variables and the number of exacerbations in the previous year and calculated the 6-min walking test and the body mass index, airflow obstruction, dyspnea, and exercise (BODE) index. All the patients completed the quality of life EQ-5D and the LCADL physical activity questionnaires. The relationship of these variables with depression was evaluated with two multiple logistic regression models.

RESULTS

One hundred fifteen patients were evaluated (93 % male) with a mean age of 66.9 years (SD 8.8) and a mean FEV1 % of 44.4 % (SD 15.7 %). 24.3 % presented symptoms of depression (HAD-D > 8). These latter patients had worse lung function, greater dyspnea, reduced exercise capacity, a higher score in the BODE index, poorer quality of life, reduced physical activity, and more exacerbations. In the first logistic regression model, quality of life and the BODE index were associated with depression (AUC: 0.84; 0.74-0.94). In the second model including the variables in the BODE index, quality of life and dyspnea measured with the MRC scale (AUC: 0.87; 0.79-0.95) were associated with depression.

CONCLUSIONS

Nearly one-quarter of the patients with COPD in this study presented clinically significant depression associated with worse quality of life, reduced exercise capacity, greater dyspnea, and a higher score in the BODE index.

Defining the Asthma-COPD Overlap Syndrome in a COPD Cohort

BACKGROUND

Asthma-COPD overlap syndrome (ACOS) has been recently described by international guidelines. A stepwise approach to diagnosis using usual features of both diseases is recommended although its clinical application is difficult.

METHODS

To identify patients with ACOS, a cohort of well-characterized patients with COPD and up to 1 year of follow-up was analyzed. We evaluated the presence of specific characteristics associated with asthma in this COPD cohort, divided into major criteria (bronchodilator test > 400 mL and 15% and past medical history of asthma) and minor criteria (blood eosinophils > 5%, IgE > 100 IU/mL, or two separate bronchodilator tests > 200 mL and 12%). We defined ACOS by the presence of one major criterion or two minor criteria. Baseline characteristics, health status (COPD Assessment Test [CAT]), BMI, airflow obstruction, dyspnea, and exercise capacity (BODE) index, rate of exacerbations, and mortality up to 1 year of follow-up were compared between patients with and without criteria for ACOS.

RESULTS

Of 831 patients with COPD included,125 (15%) fulfilled the criteria for ACOS, and 98.4% of them sustained these criteria after 1 year. Patients with ACOS were predominantly male (81.6%), with symptomatic mild to moderate disease (67%), who were receiving inhaled corticosteroids (63.2%). There were no significant differences in baseline characteristics, and only survival was worse in patients with non-ACOS COPD after 1 year of follow-up (P < .05).

CONCLUSIONS

The proposed ACOS criteria are present in 15% of a cohort of patients with COPD and these patients show better 1-year prognosis than clinically similar patients with COPD with no ACOS criteria.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT01122758; URL: www.clinicaltrials.gov.

Understanding variation in length of hospital stay for COPD exacerbation: European COPD audit

Chronic obstructive pulmonary disease (COPD) care across Europe has high heterogeneity with respect to cost and the services available. Variations in length of stay (LOS) may be attributed to patient characteristics, resource and organisational characteristics, and/or the so-called hospital cluster effect. The European COPD Audit in 13 countries included data from 16 018 hospitalised patients. The recorded variables included information on patient and disease characteristics, and resources available. Variables associated with LOS were evaluated by a multivariate, multilevel analysis. Mean±sd LOS was 8.7±8.3 days (median 7 days, interquartile range 4-11 days). Crude variability between countries was reduced after accounting for clinical factors and the clustering effect. The main factors associated with LOS being longer than the median were related to disease or exacerbation severity, including GOLD class IV (OR 1.77) and use of mechanical ventilation (OR 2.15). Few individual resource variables were associated with LOS after accounting for the hospital cluster effect. This study emphasises the importance of the patients' clinical severity at presentation in predicting LOS. Identifying patients at risk of a long hospital stay at admission and providing targeted interventions offers the potential to reduce LOS for these individuals. The complex interactions between factors and systems were more important that any single resource or organisational factor in determining differences in LOS between hospitals or countries.

Determinants of between-hospital variations in outcomes for patients admitted with COPD exacerbations: findings from a nationwide clinical audit (AUDIPOC) in Spain

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.

Antibiotic Prescription for COPD Exacerbations Admitted to Hospital: European COPD Audit

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.

The lung cancer epidemic in Spanish women: an analysis of mortality rates over a 37-year period

BACKGROUND

Lung cancer continues to be the leading cause of cancer-related mortality in the European Union (EU) and deaths from lung cancer have been projected to escalate to epidemic proportions amongst females over the next years. We examined lung cancer mortality rates in men and women from Andalusia (Spain) over a 37-year period [1975-2012].

METHODS

Longitudinal epidemiological study analyzing lung cancer mortality trends in males and females. Data on lung cancer mortality in Andalusia for the period 1975-2012 were obtained from the official cause-of-death publications of the Institute of Statistics of Andalusia. For each sex, age-standardized (European standard population) mortality rates (ASR) from lung cancer were calculated for all ages and truncated at 30-64, 65-74, and >75 years using the direct method. Standardized rate trends by age and sex were estimated by joinpoint regression analysis.

RESULTS

In men, the ASR steadily increased through the period 1993-1995, reaching a peak of 145.72 deaths/100,000 people. Subsequently, lung cancer deaths decreased to a rate of 125.47 in the 2011-2012 period. A moderate increase was seen in women until the late 1990s and early 2000s. Thereafter, a very notable rise was observed in females for all age groups, the only exception being older subjects. The sex differences decreased from 8.6:1 in the 1975-1977 period to 6.8:1 in the 2011-2012 period.

CONCLUSIONS

Lung cancer mortality rates decreased significantly in Andalusian men from 1975 to 2012. More importantly, we demonstrate for the first time the beginning of the lung cancer epidemics in Andalusian women as previously predicted for this area.

Expression of aquaporins in bronchial tissue and lung parenchyma of patients with chronic obstructive pulmonary disease

Background

Aquaporins AQP1 and AQP5 are highly expressed in the lung. Recent studies have shown that the expression of these proteins may be mechanistically involved in the airway inflammation and in the pathogenesis of chronic obstructive pulmonary disease (COPD). The aim of this study was to investigate the expression of AQP1 and AQP5 in the bronchial tissue and the lung parenchyma of patients with COPD and COPD-resistant smokers.

Methods

Using a case–control design, we selected a group of 15 subjects with COPD and 15 resistant smokers (smokers without COPD) as a control, all of whom were undergoing lung resection surgery due to a lung neoplasm. We studied the expression of AQP1 and AQP5 in the bronchial tissue and the lung parenchyma by means of immunohistochemistry and reverse-transcription real-time polymerase chain reaction. Tissue expression of AQP1 and AQP5 was semi-quantitatively assessed in terms of intensity and expression by immunohistochemistry using a 4-point scale ranging from 0 (none) to 3 (maximum).

Results

There were no significant differences in gene expression between COPD patients and resistant smokers both in the bronchial tissue and in the lung parenchyma. However, AQP1 gene expression was 2.41-fold higher in the parenchyma of smokers with COPD compared to controls, whereas the AQP5 gene showed the opposite pattern, with a 7.75-fold higher expression in the bronchus of smokers with COPD compared with controls. AQP1 and AQP5 proteins were preferentially expressed in endothelial cells, showing a higher intensity for AQP1 (66.7% of cases with an intensity of 3, and 93.3% of subjects with an extension of 3 among patients with COPD). Subtle interstitial disease was associated with type II pneumocyte hyperplasia and an increased expression of AQP1.

Conclusions

This study provides pilot observations on the differences in AQP1 and AQP5 expression between COPD patients and COPD-resistant smokers. Our findings suggest a potential role for AQP1 in the pathogenesis of COPD.

A comprehensive, national survey of spirometry in Spain: current bottlenecks and future directions in primary and secondary care

BACKGROUND

We aimed to evaluate the availability and practice of spirometry, training of technicians, and spirometer features and maintenance in Spain in both primary care (PC) and secondary care (SC) centers.

METHODS

We used a nationwide, cross-sectional, 36-item telephone survey of health-care centers in Spain to target the technician in charge of conducting spirometries in PC and SC centers where outpatient respiratory patients are routinely evaluated. The questions surveyed for resources, training, spirometer use, bronchodilator tests, and spirometer features and maintenance.

RESULTS

Of a total of 1,259 centers screened, 605 PC centers (21.2% of the PC centers in Spain) and 200 SC centers (24.9% of the SC centers in Spain) were surveyed. The response rate was 85.4% for PC centers and 75.1% for SC centers. All together, 19% of screened centers did not have a spirometer or were not using it. The number of spirometers per center and spirometries conducted per week was higher in SC centers than in PC centers (P &lt; .001). Most centers received training for conducting spirometries, but this was periodically done in &lt; 40%. Most centers used two inhalations of salbutamol for the bronchodilator test, but the international criteria of a positive test was considered only in 55.8% of PC and 52.8% of SC centers. Calibration of the spirometer was never done in 10.5% of PC and 3.1% of SC centers.

CONCLUSIONS

This survey maps for the first time, to our knowledge, the current situation of spirometry in Spain, identifying bottlenecks and suggesting future directions applicable in both PC and SC centers and elsewhere.

Mortality trends in chronic obstructive pulmonary disease in Europe, 1994-2010: a joinpoint regression analysis

BACKGROUND

Findings from studies done over the past 20 years suggest that mortality from chronic obstructive pulmonary disease (COPD) is decreasing worldwide, but little information is available for trends in Europe. We aimed to describe COPD mortality trends by sex and calendar year for the period of 1994 to 2010.

METHODS

We extracted data for COPD deaths between 1994 and 2010 in the 27 countries in the European Union (EU) from the statistical office of the EU (Eurostat), using the International Classification of Diseases 10 (ICD-10) codes J40-J44 and J47. We estimated age-standardised mortality rates (ASR), and analysed data using joinpoint regression, for women and men in the EU overall and by individual country for each year. We used the standard European population as the reference and present our findings as deaths per 100,000 person-years. We compared findings for each country with the EU average by calculating standardised rate ratios (SRR) and 95% CIs.

FINDINGS

Between 1994 and 2010, there were 2,348,184 recorded COPD deaths in the EU. COPD mortality was higher in men than in women throughout the study period in all EU countries. In the EU overall, deaths per 100,000 population decreased in men almost linearly from 90·07 in 1994 to 61·33 in 2010, and in women from 26·99 in 1994 to 25·15 in 2010, representing a narrowing in gender gap over the study period. Several countries had a higher SRR mortality than the EU average-eg, Ireland, Hungary, and Belgium for men and Denmark, the UK, and the Netherlands for women. Our joinpoint regression analysis identified no statistically significant changes in the trend for the whole EU, but several countries had changing trends over the study period. In men, we recorded a 2·56% constant and statistically significant decrease in ASRs in the EU. Five countries had an increase in ASR. Overall, in women, we recorded a 0·76% statistically significant decrease in ASRs. 14 countries had an increase in ASR.

INTERPRETATION

Our findings indicate a downward trend in COPD mortality in Europe between 1994 and 2010. The data also suggest a narrowing of the gap between COPD mortality in men and in women. The wide heterogeneity in mortality rates within European countries could serve as a reference to allow informed policy making.

FUNDING

None.

Characteristics of subjects who died of chronic obstructive pulmonary disease in Andalusia in 2010 and 2011

BACKGROUND

The place of death is an important consideration in the end-of-life care of patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVE

This study aimed to describe the place of death for patients with COPD in Andalusia (Spain) and the determinants of death at home compared to death outside of home.

DESIGN

This observational study analyzed place of death from death certificates for the years 2010 and 2011 in Andalusia, Spain (over 8 million inhabitants, 17.8% of the Spanish population).

MEASUREMENTS

Death certificates obtained from the Institute of Statistics and Cartography of Andalusia were used to describe where patients with COPD died. All deaths with ICD-10 codes J40 to J44 or J47 (International Classification of Diseases, Tenth Revision) were included for the years 2010 and 2011. Upon review of the death certificates, the following data were recorded: age, sex, marital status, rural areas, and place of death.

RESULTS

Out of a total of 119,589 decedents, the research team retrieved the place of death for 4983 subjects. The chance of dying at home was higher for COPD patients aged ≥ 89 years and for females. Married and widowed persons had a greater likelihood of dying at home than singles. Moreover, the likelihood of death at home was higher for individuals residing in rural areas.

CONCLUSIONS

Age, sex, marital status, and rural areas of residence determine where COPD patients will end their life in Andalusia. Knowledge about place of death and its determinants will facilitate the planning of health care palliative services.

Impact of bronchodilator responsiveness on quality of life and exercise capacity in patients with COPD

BACKGROUND

Bronchial variability in COPD patients may be a phenotypic feature associated with clinical characteristics and differential treatment response. We analyzed whether symptoms, quality of life, and exercise capacity varied in COPD patients as a function of bronchodilator test results, and compared responses to an exercise program.

METHODS

A positive bronchodilator test result was defined as FVC and/or FEV1 improvement of > 12% plus > 200 mL after 400 μg of salbutamol. We studied 198 COPD subjects: 94 with positive reversibility, and 104 with negative reversibility. Training sessions were carried out on 3 non-consecutive days each week, for 12 weeks, and consisted of a combination of resistance and strength training. Subjects were evaluated on 2 consecutive days at baseline, and at the end of the 12-week training program.

RESULTS

Those with positive reversibility had shorter time to exhaustion in the endurance test (19.1 ± 12.6 min vs 24.5 ± 14.5 min, P = .03), shorter shuttle walk test distance (380.6 ± 158.2 m vs 438.5 ± 149.1 m, P = .02), and lower Chronic Respiratory Disease Questionnaire scores (18.7 ± 4.6 vs 19.8 ± 4.3, P = .01). There were no significant differences in peak exercise, peripheral muscle strength, dyspnea, or improvement after exercise training.

CONCLUSIONS

Compared to COPD subjects with negative reversibility, those with positive reversibility walked for shorter distances, and had shorter endurance times and worse quality of life, but the improvements after exercise training were similar.

C-reactive protein and serum amyloid a overexpression in lung tissues of chronic obstructive pulmonary disease patients: a case-control study

BACKGROUND

Although researchers have consistently demonstrated systemic inflammation in chronic obstructive pulmonary disease (COPD), its origin is yet unknown. We aimed to compare the lung bronchial and parenchymal tissues as potential sources of major acute-phase reactants in COPD patients and resistant smokers.

METHODS

Consecutive patients undergoing elective surgery for suspected primary lung cancer were considered for the study. Patients were categorized as COPD or resistant smokers according to their spirometric results. Lung parenchyma and bronchus sections distant from the primary lesion were obtained. C-reactive protein (CRP) and serum amyloid A (SAA1, SAA2 and SAA4) gene expressions were evaluated by RT-PCR. Protein levels were evaluated in paraffin embedded lung tissues by immunohistochemistry and in serum samples by nephelometry.

RESULTS

Our study included 85 patients with COPD and 87 resistant smokers. In bronchial and parenchymal tissues, both CRP and SAA were overexpressed in COPD patients. In the bronchus, CRP, SAA1, SAA2, and SA4 gene expressions in COPD patients were 1.89-fold, 4.36-fold, 3.65-fold, and 3.9-fold the control values, respectively. In the parenchyma, CRP, SAA1, and SAA2 gene expressions were 2.41-, 1.97-, and 1.76-fold the control values, respectively. Immunohistochemistry showed an over-stained pattern of these markers on endovascular cells of COPD patients. There was no correlation with serum protein concentration.

CONCLUSIONS

These results indicate an overexpression of CRP and SAA in both bronchial and parenchymal tissue in COPD, which differs between both locations, indicating tissue/cell type specificity. The endothelial cells might play a role in the production of theses markers.

Lung cancer mortality in Spain: estimating the future burden to the year 2028

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.

Clinical and polygraphic evolution of sleep-related breathing disorders in adolescents

It has been suggested that sleep-related breathing disorders (SRBD) involve a continuum that develops over the course of life. If modifiable factors could be identified, the progression of SRBD could perhaps be addressed early in life. Although some studies have looked at the evolution of SRBD in pre-pubertal children, very few studies obtained data in adolescents. Anthropometric, clinical and polygraphic variables were collected during a 4-yr follow-up study among 148 normal adolescents after initial cross-sectional analysis. From a total of 267 adolescents studied at baseline (mean+/-sd age 14.3+/-2.1 yrs), 148 (55.4%) were followed up for 4 yrs. During follow-up, there were no significant changes in snoring and polygraphic parameters. However, a tendency toward weight gain with centrally distributed fat was observed. Habitual snorers had a significantly higher body mass index and more centrally distributed fat than nonsnorers. Males had a higher snoring prevalence and a higher number of respiratory events than females. Snoring at baseline, male sex and poor academic performance were significant predictors of snoring at follow-up. Snoring tends to persist during adolescence and male sex acts as a risk factor. A relationship between snoring and academic performance was observed. These findings may have implications for long-term management of sleep-related breathing disorders.

Lung cancer mortality trends by geographical area in Spanish women, 1980-2005

OBJECTIVE

To provide up-to-date information and analyse recent changes in lung cancer mortality trends among women.

DESIGN

The present study analysed subjects by geographical area in Spain during the period 1980-2005 using joinpoint regression models. Age-standardised mortality rates (ASR) for lung cancer were computed from death certificate data obtained from the official authorities in Spain. Joinpoint regression analysis was used to identify the years when significant changes in the linear slope of the temporal trend occurred.

RESULTS

The overall ASR changed during the period studied from 5.7 per 100,000 women in 1980 to 8.2/100,000 in 2005, with an average annual increase of 1.7%. Joinpoint regression analysis detected different trends in most Spanish communities. These changes occurred in the late 1980s or early 1990s. ASR among those women aged 35-64 years doubled during the period of study, from 5.6 in 1980 to 11.3 in 2005.

CONCLUSIONS

Time trends in lung cancer mortality among women are increasing sharply, especially in the age group 35-64 years, indicating the start of an epidemic phenomenon of lung cancer in women.

Factors related to quality of life in patients receiving home mechanical ventilation

OBJECTIVES

The objective of this study was to evaluate factors associated with health-related quality of life (HRQOL) among patients receiving home mechanical ventilation (HMV).

METHODS

Observational, cross-sectional study. Patients receiving HMV were recruited from hospital outpatients facilities at five participating centers; a single follow-up visit was scheduled. The Spanish version of the Severe Respiratory Insufficiency (SRI) Questionnaire was used and the following variables were collected: socio-demographic status, previous medical history (Charlson-Age Comorbidity Index), current symptoms, administration of questionnaires, pulmonary function tests (PFT), current ventilatory support, and oxygen therapy.

RESULTS

One hundred and fifteen patients (57 males and 58 females, mean age 62+/-13 years) were investigated. The reasons for HMV were as follows: thoracic cage abnormalities (33 patients), obesity hypoventilation syndrome (37 patients), neuromuscular disorders (18 patients), sequelae of tuberculosis (12 patients), and chronic obstructive pulmonary disease (15 patients). In a bivariate approach, dyspnea, the number of hospitalizations, and the number of emergency room admissions in last year were the main predictors of each HRQOL dimension. Multivariate analysis showed that dyspnea, FEV(1)/FVC, and the number of hospitalizations in the previous year were independently associated with HRQOL.

CONCLUSIONS

HRQOL of patients receiving HMV is influenced by many factors, especially by dyspnea and the number of admissions. An obstructive pattern in the PFT also influences HRQOL. These findings may have therapeutic implications.

Age-period-cohort analysis of lung cancer mortality rates in Andalusia, 1975-2004

Our objective is to describe lung cancer mortality trends in Andalusia, Spain, during the period 1975-2004 using age-period-cohort analysis (APC). For each gender, age-standardised (European Standard Population) mortality rates from lung cancer were computed based on the causes of death on the death certificates from the official registry of vital statistics in Andalusia. In men, after climbing considerably from 1975 to 1994, adjusted lung cancer mortality rates, have been declining by 0.8% per year since 1994. For women, the mortality from lung cancer was almost constant but tended to increase after 1994 (average annual increase of 2.1%). Among males, the cohort effect was steadily and appreciably upwards to the cohort born around 1905, then levelled off, and declined in the youngest generations. An increasing period effect was also observed until 1995. For females, cohort values decreased until the cohort born around 1930, then levelled off, and increased for women born since 1940. Period effect trend was downward until 1990, and upward thereafter. In conclusion, the cohort effect observed for women born since 1940 suggests the start of a lung cancer epidemic associated with a higher prevalence of smokers in women. The decrease in prevalence of smokers among males and the decrease in mortality in younger age groups suggest that the trend initiated in 1994 will continue as long as smoking prevalence continues to decrease.

Factors related to variability in long-term oxygen therapy prevalence

OBJECTIVE

To analyse the variability of long term oxygen therapy (LTOT) prevalence according to several organisational and population factors.

METHODS

Prospective multicentre survey in 29 public hospitals (population 6,796,964) recording data on the organisational structure of the participating centres and factors related to LTOT prevalence. Official figures were also obtained from local health authorities on the prevalence and cost of LTOT.

RESULTS

The overall prevalence of LTOT was 184 per 100000 population (range 71-473). There was a specific unit or staff member for LTOT supervision in 17 (58.6%) centres, giving a lower prevalence (169 vs. 237/ 100000; P = 0.03). The altitude of the participating centres (median 92 m, mean 275 m; range 4-848 m) was found to influence LTOT prevalence (r = 0.73; P = 0.005). In the linear regression analysis, the coefficient of determination for altitude was 0.504. Other factors, such as percentage of population aged over 65 years, the attitude of prescribers towards patients with low adherence, current smokers or those with a PaO2 = 61 mmHg, were not related to LTOT prevalence.

CONCLUSIONS

Altitude and the existence of a specific unit or staff member for LTOT supervision significantly influence LTOT prevalence.

Joinpoint regression analysis of lung cancer mortality, Andalusia 1975–2000

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.

Mortality from non-malignant respiratory diseases in Andalusia, Spain, 1975-1997

This study aims to assess mortality trends of nonmalignant respiratory diseases from 1975 through 1997 in the population of Andalusia (a region of Spain in the southwest, population 7,000,000). The death records containing codes 460-519 of the International Classification of Diseases, Eighth Revision (ICD-8) and Ninth Revision (ICD-9) in effect through the 23-year period were used in this study. Deaths from nonmalignant respiratory diseases accounted for 12.4 and 10% of all deaths in males and females in 1975 and for 12.1 and 8.3% in 1997. Crude death rates decreased from 107.5 to 102.7 per 100,000 amongst men, and from 76.9 to 62.2 per 100,000 amongst women. Age-adjusted death rates decreased from 167.6 to 111.6 per 100,000 in men and from 84.4 to 41.2 per 100,000 in women. Age-adjusted death rate by potential years of life lost decreased from 5.8 to 2.4 per 1000 in men and from 2.4 to 0.8 per 1000 in women. Total percentage of change, adjusted by age, showed a decrease of 24.3% in men and 45.9% in women. Gender-adjusted rates for each category of nonmalignant respiratory disorders showed an upward trend of obstructive lung diseases in men and a downward trend of diseases of the upper airways and pneumonia both in men and women. Specific death rates by age groups for 1975-1985 and 1986-1997 showed an increased in mortality in infants under 1 year of age and in abrupt decrease up to the age of 50 followed by an exponential increase up to the age of 85.

[Effects of ranitidine on regenerating parietal cells. A stereologic study]

In this work, we have carried out a stereological and morphological study in order to verify the effects of Ranitidine on regenerating parietal cells. We have used a control group and operated or non-operated groups treated with 2, 10 and 50 mg/kg/day Ranitidine. In operated groups an ulcer was provoked by cauterization with a metallic plate in the gastric fundus. Groups treated with high doses of Ranitidine showed an increase in the connective tissue of the gastric mucosa. The stereological study in treated groups shows a decrease in the parietal volume density, and an increase in the cellular profile. Changes detected in the parietal volume density would originate a decrease in the production of CIH.

[The effects of pirenzepine on regenerating parietal cells]

In this work, we have carried out a stereological and ultrastructural study in order to verify the action of pirenzepine on regenerating parietal cells. We have used a control group and operated or nonoperated groups treated with 1, 5 and 25 mg/kg/day pirenzepine. In operated groups an ulcer was provoked by cauterization with a metallic plate in the gastric fundus. Parietal cells in operated groups showed mitochondria with altered crests, a fine granular matrix and a large number of tubulo-vesicles. The comparative stereological analysis demonstrates a generalized decrease in the mitochondria, canaliculi and lysosomal volume density, and an increase in the tubulo-vesicle volume density. Changes detected in these cellular structures would originate a decrease in the production of HCl [correction of ClH].

[Histophysiologic aspects of the remnant intestine of rats subjected to partial resection of the small intestine]

The effect of small bowel resection on the morphology, mucous secretion and alkaline phosphatase activity of the remnant intestine was studied five months after surgical operation. Distal small bowel resection produced hyperplasia and infiltration of lymphocytes. The intestinal neutral and acid mucosubstances, and the alkaline phosphatase activity were increased in resected animals, whilst the sulphomucins content of goblet cells was unaltered. The serum alkaline phosphatase activity two and five months after resection was also increased.

Permeability and changes in carbohydrate moiety in rat endometrial epithelium during oestrus as revealed by ruthenium red

We have used four different methods of ruthenium red (RuR) staining (RuR-Lumen, RuR-Glu, Glu/CB-RuR and RuR-OsO4) in order to study the permeability of the uterine epithelial cells of the rat during oestrus. The best results were obtained with the application of RuR-OsO4, and this test was used for the statistical analysis. In addition, the dialyzed iron and diamine test (HID) techniques corroborated the nature of the acid glycoconjugate part of luminal surface of the uterine epithelium stained by the RuR. By means of the Thiéry technique we detected the presence of neutral glycoconjugates. These results, together with statistical analysis, lead us to suggest a) that the uterine epithelial cells present a greater permeability to RuR during early oestrus (Stage II) than during the later part (Stage III) and b) that sulphate group-bearing glycoconjugates decrease in the course of the oestrus, whereas the neutral glycoconjugates remain constant.