Recent improvement in long-term survival after a COPD hospitalisation.

BACKGROUND: Evidence-based international guidelines on chronic obstructive pulmonary disease (COPD), and their corresponding recommendations, were established to improve individual COPD prognosis, and ultimately to improve survival. The aim of this study was to determine whether the long-term mortality after discharge from a COPD hospitalisation has improved recently, and the effect of co-morbidity treatment in improving COPD prognosis. METHODS: In a prospective cohort study design of two cohorts 7 years apart, patients discharged from the same university hospital after a COPD exacerbation were followed-up, and their outcomes compared. Demographic and clinical variables, as well as lung function, were collected with the same protocol by the same investigators. Comprehensive assessments of co-morbidities and treatments were undertaken. Kaplan-Meier survival curves were estimated, and outcomes were compared by means of Cox regression methods. RESULTS: Overall, 135 participants in the 1996-7 cohort and 181 participants in the 2003-4 cohort were studied. Both cohorts were comparable in their baseline demographic and clinical variables, and median follow-up was 439 days. The 3-year mortality was lower in the 2003-4 cohort (38.7%) than in the 1996-7 cohort (47.4%) (p=0.017), and the RR of death after adjustment for gender, age, body mass index, co-morbidities, lung function and mMRC (modified Medical Research Council scale) dyspnoea was 0.66 (95% CI 0.45 to 0.97). Long-term survival improved in the second cohort for patients with COPD with heart failure or cancer (p<0.001). CONCLUSIONS: A recent trend towards better prognosis of patients with COPD after hospital discharge is described and is likely to be associated with better management and treatment of COPD and co-morbidities.

Pseudomonas aeruginosa in patients hospitalised for COPD exacerbation: a prospective study.

Risk factors for Pseudomonas aeruginosa (PA) isolation in patients hospitalised for chronic obstructive pulmonary disease (COPD) exacerbation remain controversial. The aim of our study was to determine the incidence and risk factors for PA isolation in sputum at hospital admission in a prospective cohort of patients with acute exacerbation of COPD. We prospectively studied all patients with COPD exacerbation admitted to our hospital between June 2003 and September 2004. Suspected predictors of PA isolation were studied. Spirometry tests and 6-min walking tests were performed 1 month after the patients were discharged. High-resolution computed tomography (HRCT) was performed in a randomised manner in one out of every two patients to quantify the presence and extent of bronchiectasis. Patients were followed up during the following year for hospital re-admissions. A total of 188 patients were included, of whom 31 (16.5%) had PA in sputum at initial admission. The BODE (body mass index, airflow obstruction, dyspnoea, exercise capacity) index (OR 2.18, CI 95% 1.26-3.78; p = 0.005), admissions in the previous year (OR 1.65, CI 95% 1.13-2.43; p = 0.005), systemic steroid treatment (OR 14.7, CI 95% 2.28-94.8; p = 0.01), and previous isolation of PA (OR 23.1, CI 95% 5.7-94.3; p<0.001) were associated with PA isolation. No relationship was seen between bronchiectasis in HRCT and antibiotic use in the previous 3 months. PA in sputum at hospital admission is more frequent in patients with poorer scoring on the BODE index, previous hospital admissions, oral corticosteroids and prior isolation of PA.

The bronchodilator test in chronic obstructive pulmonary disease: interpretation methods.

The objective of the study was to evaluate the best method for interpreting the bronchodilator test (BDT). Five formulas for expressing the BDT results were analyzed and compared: changes experienced by maximum expiratory volume in 1s (FEV(1)) and forced vital capacity (FVC) measured in milliliters, in percentage with respect to the baseline, in percentage with respect to the predicted, in percentage with respect to the possible, and in standardized residuals. Ninety-eight chronic obstructive pulmonary disease (COPD) patients were submitted to a respiratory function test on two different days. On each occasion three spirometries were conducted: basal, post-placebo and post bronchodilator. As a gold standard, a normality interval was defined using the variability experienced with the placebo between the two days of the study. The best formulas according to their sensitivity, specivity and area under receiver operating characteristic (ROC) curve were the "standardized residuals", with a cut point of .3, and the "percentage with respect to the predicted" with a cut point of 6%.

Prognostic assessment of mortality and hospitalizations of outpatients with advanced chronic obstructive pulmonary disease. Usefulness of the CODEX index. / Valoración pronóstica de mortalidad y hospitalizaciones en pacientes ambulatorios con EPOC avanzada. Utilidad del índice CODEX.

OBJECTIVES: To validate the CODEX index in outpatients with advanced chronic obstructive pulmonary disease (COPD). PATIENTS AND METHODS: We studied all patients with COPD treated in a chronic respiratory disease unit. We calculated the BODEX and CODEX indices and their relationship with mortality, hospitalisations or both and performed an analysis by number of events (mortality and/or readmissions), using the Cox proportional hazards analysis. RESULTS: We included 80 patients (90% men) with a mean age of 73.4 years. The mean follow-up was 656 days, with an interquartile range (25-75%) of 417-642 days. Seventeen patients died (21%) and 57 (71.3%) required hospitalisation for COPD. The CODEX index was significantly related to mortality (P<.008; HR: 1.56; 95% CI: 1.1-2.15), hospitalisations (P<.01; HR: 1.35; 95% CI: 1.13-1.62) and the combined variable (P<.03; HR: 1.27; 95% CI: 1.1-1.5). The BODEX index was not associated with mortality (P=.17) but was associated with hospitalisation (P<.001; HR: 1.4; 95% CI: 1.15-1.73) and the combined variable (P<.03; HR: 1.2; 95% CI: 1.02-1.34). There were 187 events during follow-up. Both the CODEX (P<.001; HR: 1.17; 95% CI: 1.1-1.27) and BODEX (P<.02; HR: 1.12; 95% CI: 1.02-1.23) indices were related to the number of events. However, after adjusting for the interaction between the 2 indices, only the CODEX index maintained statistical significance for the combined variable for patients (P<.03) and in the analysis by number of events (P<.001). CONCLUSIONS: Both the CODEX and BODEX indices are useful for predicting hospitalisations, although the prognostic ability of the CODEX index is greater than that of the BODEX index, both for mortality and hospitalisations.

Age-dependence of Schneiderian psychotic symptoms in bipolar patients.

Psychotic symptoms frequently occur in bipolar disorder, especially in younger patients. However, whether the association with younger age also extends to psychotic symptoms that have traditionally been associated with schizophrenia, such as Schneiderian first-rank symptoms (FRSs), is unclear. This study examined FRSs in bipolar I patients and their relationship to age and gender. The sample comprised 103 consecutive inpatients who met DSM IV criteria for bipolar disorder, manic or mixed. FRSs were rated with the Scale for the Assessment of Positive Symptoms (SAPS). Interaction between FRSs and gender and FRSs and age was assessed using logistic regression. A high rate of FRSs in manic and mixed patients was found with a higher frequency in men (31%) than in women (14%; P=0.038). A monotonic increase in the association between FRSs and younger age was apparent (odds ratios (OR) over five levels: 1.42; 1.00-2.01). These results confirm previous findings that FRSs are not specific to schizophrenia and suggest in addition that a dimension of nuclear psychotic experiences of developmental origin extends across categorically defined psychotic disorders.

Principal components of mania.

OBJECTIVE: An alternative to the categorical classification of psychiatric diseases is the dimensional study of the signs and symptoms of psychiatric syndromes. To date, there have been few reports about the dimensions of mania, and the existence of a depressive dimension in mania remains controversial. The aim of this study was to investigate the dimensions of manic disorder by using classical scales to study the signs and symptoms of affective disorders. METHODS: One-hundred and three consecutively admitted inpatients who met DSM IV criteria for bipolar disorder, manic or mixed were rated with the Young Mania Rating Scale (YMRS) and the Hamilton Depression Rating Scale (HDRS-21). A principal components factor analysis of the HDRS-21 and the YMRS was carried out. RESULTS: Factor analysis showed five independent and clinically interpretable factors corresponding to depression, dysphoria, hedonism, psychosis and activation. The distribution of factor scores on the depressive factor was bimodal, whereas it was unimodal on the dysphoric, hedonism and activation factors. Finally, the psychosis factor was not normally distributed. LIMITATIONS: Patients of the sample were all medicated inpatients. CONCLUSIONS: Mania seems to be composed of three core dimensions, i.e. hedonism, dysphoria and activation, and is frequently accompanied by a psychotic and a depressive factor. The existence of a depressive factor suggests that it is essential to evaluate depression during mania, and the distribution of the depressive factor supports the existence of two different states in mania.

Use of olanzapine in dysphoric mania.

BACKGROUND: The simultaneous presentation of both manic and depressive symptoms has long been recognized. Nevertheless, a variable prevalence of dysphoric mania has been reported. The aim of this study was to estimate the prevalence of dysphoric mania among hospitalized patients and to assess the effectiveness of olanzapine in this type of patients. METHODS: Eighty-six patients who met DSM-IV criteria for mania were evaluated at admission with a protocol that included McElroy's criteria for dysphoric mania [Am. J. Psychiatry 149 (1992) 1633]. Treatment was administered according to clinical need, using mood stabilizers combined with antipsychotics. Sequential assessments were conducted throughout the study. RESULTS: Forty-four patients (51.2%) fulfilled McElroy's criteria for dysphoric mania. Fourteen of these dysphoric patients were treated with olanzapine in combination with mood-stabilizers. All patients improved in manic symptoms but patients treated with olanzapine improved significantly more than those treated with other antipsychotics in depressive symptoms. LIMITATIONS: The lack of randomization is a methodological limitation of this study, so these findings should be considered as preliminary. CONCLUSIONS: Dysphoric symptoms are common in this population of manic patients. Olanzapine in combination with mood-stabilizers may be effective in these patients. Additional controlled studies are needed to replicate these results.

Study of the influence of electroconvulsive therapy on the regional cerebral blood flow by HMPAO-SPECT.

STUDY OBJECTIVE: The aim of this preliminary study is to investigate the regional blood flow in response to ECT (electroconvulsive therapy) and to identify any responsive-pattern to the treatment. STUDY DESIGN: Single longitudinal prospective study of cohorts. SUBJECTS: For this preliminary study ten patients, female sex, mean age 70.8 years with major mood disorder (CID-10 investigation criteria) were studied after signature consent. INTERVENTIONS: The intervention consisted in the administration of bilateral brief pulse ECT three times a week, during 6 to 12 sessions according to the standards of the Psychiatric Department of the Santiago Hospital in Victoria. MEASUREMENT: Clinical evaluation of depression was evaluated by Hamilton Depression Scale, Montgomery and Asberg Scale, Newcastle Scale and regional cerebral blood flow (rCBF) using the HMPAO-SPECT. RESULTS: The pattern of distribution on the regional cerebral flow during the ECT showed changes from the basal pattern in all patients. All patients had a relative increased perfusion of the temporal lobes and basal ganglia. Other changes from the basal study were areas of decreased perfusion of the occipital lobe (6 patients) and parietal lobe (3 patients). CONCLUSIONS: Brain perfusion SPECT study of the patients with major depression shows changes during ECT. Further analysis are needed to understand the relationship between mechanisms of treatment and recovery in affective illness.

[Comparison between automatic and manual analysis in the diagnosis of obstructive sleep apnea-hypopnea syndrome]. / Comparación entre el análisis automático y manual de la polisomnografía convencional en el diagnóstico del síndrome de apnea-hipopnea obstructiva del sueño.

OBJECTIVE: To compare automatic and manual analysis of neurological and respiratory variables obtained with the SomnoStar alpha 4100, a 16-channel polysomnographic system. PATIENTS AND METHOD: Twenty-eight patients suspected of obstructive sleep apnea-hypopnea syndrome were enrolled and given conventional polysomnographic tests. The order of automatic and manual reading of respiratory episodes, sleep stages, and arousals was randomized. We assessed agreement with the intraclass correlation coefficient and plotted standardized differences against standardized means, using the Bland-Altman method. RESULTS: Poor agreement was observed between the 2 types of analysis of sleep stages, especially for REM and deep sleep stages. Agreement was good for apneic episodes among the respiratory variables; however, automatic analysis underestimated hypopneas. If manual analysis is considered the gold standard at the apnea-hypopnea index cut point greater than 10, automatic analysis obtained a sensitivity of 55%, a specificity and positive predictive value of 100%, a negative predictive value of 47%, and an overall diagnostic yield of 67.8%. CONCLUSIONS: The automatic analysis of the SomnoStar 4100 system provides an unsatisfactory reading of sleep stages and respiratory episodes, especially hypopneas.

[The perception of improvement in asthma]. / Percepción de mejoría en el asma.

BACKGROUND: The capacity of stable asthma patients to recognize the presence of air flow obstruction, treatment improvement and daily variations was studied. METHODS: Placebo and 500 micrograms of inhaled terbutaline for two consecutive days were administered to 39 patients. The subjective impressions were compared with spirometric results. RESULTS: Thirty patients presented obstruction of which 7 reported to be asymptomatic and 9 presented normal spirometry of which 3 reported to be symptomatic. Fifty-four percent (21) did not correctly recognize whether they improved with the medication either of the two days. Eleven patients reported improvement with placebo without significant spirometric changes. Eighteen preferred terbutaline and 5 the placebo while 16 were indifferent out of whom 7 (43%) had improved with only the bronchodilator. The FEV1 difference between the two days was > 10% in 18 patients of which this was not perceived in 10. CONCLUSIONS: Objective controls are necessary for the evaluation and follow up of patients with stable asthma.

[The differential diagnosis between pleural exudates and transudates: the value of cholesterol]. / Diagnóstico diferencial entre exudados y trasudados pleurales: valor del colesterol.

BACKGROUND: The evaluation of a patient with pleural effusion depends on its classification as exudate or transudate. Many criteria have been established but none has a 100% sensitivity and specificity. The aim of the present study was to assess the value of the cholesterol level to differentiate between exudate and transudate and to establish its utility as compared with other differential criteria. METHODS: 104 patients with pleural effusion of well defined etiology, permitting their classification into 56 exudates and 48 transudates, were evaluated. In all, Light's criteria were established and cholesterol values in pleural effusion and serum were measured and compared. RESULTS: Using the lactate dehydrogenase level (LDH) in pleural fluid (PF) and the ratios of LDH and proteins in PF and serum, 100% of exudates and 83% of transudates were correctly classified. A cholesterol level of 40 mg/dl or higher best separated exudates and transudates, with a sensitivity of 96% and a specificity of 92% for exudates. A ratio of 0.3 or higher between cholesterol levels in PF and serum was shown to have a high sensitivity (96%) and lower specificity (85%) for exudates. The highest specificity (92%) was achieved when the protein ratio in PF and serum was combined with PF cholesterol. CONCLUSIONS: The cholesterol level in pleural fluid and the ratio between this value and that in serum are highly useful parameters to differentiate between exudates and transudates.

[Macroscopic fungi from Sierra de Quila, Jalisco, Mexico: diversity and fungal similarity]. / Hongos macroscópicos de la Sierra de Quila, Jalisco, México: diversidad y similitud fungística.

Diversity and similarity of macrofungi of Sierra de Quila, Jalisco, México were analized in three different kinds of vegetation. Fungal diversity in the area is high. The pine-oak and cloud forests, were more diverse in their community structure than the oak forest. Similarity among the three kinds of vegetation was low, there are few species share among them; pine-oak and cloud forests show higher affinity than oak forests. This pattern of similarity is a general condition for others regions with environmental conditions similar to Sierra de Quila.

[Post-hospital mortality in patients re-admitted due to COPD. Utility of BODE index]. / Mortalidad posthospitalaria en pacientes reingresadores por EPOC. Utilidad del índice BODE.

BACKGROUND: The BODE index can accurately predict mortality in ambulatory patients with COPD, although its utility in hospitalized patients is unknown. MATERIAL AND METHODS: We prospectively evaluated all patients hospitalized during one year for acute exacerbation of COPD with one or more admissions in the previous year. On discharge, previous functional dependence, comorbidity, depression and quality of life, among other variables, were evaluated. Body mass index, 6-minute walking test, dyspnea scale and spirometry with a post-bronchodilator test were performed on the last day of hospitalization and the BODE index was calculated using these data. RESULTS: A total of 66 patients were included, with a mean age of 71.6 +/- 8.9 years. Of these patients, 42 (63.6%) died before the end of the study (median follow-up 1,490 days). A higher mortality was observed among the oldest patients (p < 0.004), those with more comorbidities (p < 0.05), worse score on the BODE index (p < 0.006; OR 1.3; CI 95%: 1.07-1.54) and the dyspnea scale (p < 0.008). Functional dependence (p < 0.02), and pCO2 > 45 mmHg at discharge (p < 0.001) were also significant predictors of mortality. In the multivariate analysis, only hypercapnia (p < 0.004; OR 3.48; CI 95% 1.49-8.14) and the BODE index (p < 0.0005; OR 1.47; CI 95%: 1.18-1.82) were independent predictors of mortality. CONCLUSIONS: The BODE index measured at hospital discharge is an accurate and reliable predictor of mortality in patients who require several admissions for acute exacerbations of COPD.