Impact of the iCODEX tool in routine clinical practice in Spain.

INTRODUCTION: The prognosis of COPD patients can be calculated using multidimensional indexes that improve the predictive capacity of the individual variables. The CODEX index can be calculated using iCODEX, a digital support tool available on the web and in an app. The aim of this study was to evaluate how the usefulness and applicability of iCODEX and its recommendations in routine clinical practice are perceived by specialists in internal medicine, pneumology, and primary care. METHODS: A cross-sectional study was conducted from November 2019 to February 2020 with the participation of specialists in internal medicine, primary care, and pneumology. All respondents completed a survey consisting of 104 questions on their perception of the iCODEX tool. RESULTS: Overall, 335 physicians responded. Of these, 95.2% had no difficulty accessing the tool and 83.1% were quite or very satisfied with it. Regarding the applicability and implementation of iCODEX recommendations in routine clinical practice, respondents reported that the recommendations were generally applicable: most questions obtained a median score of ≥ 4 out of 5. The recommendations with the greatest expected clinical benefit are listed. CONCLUSIONS: Our study shows that the iCODEX tool is easy for participating specialists to use and identifies the recommendations that have the greatest clinical impact in areas such as lung obstruction, severe exacerbations, exercise, smoking, and patient follow-up.

[Sarcopenia index in hospitalized patients with chronic obstructive pulmonary disease exacerbation]. / Índice de sarcopenia en pacientes hospitalizados por agudización de la enfermedad pulmonar obstructiva crónica.

Sarcopenia (loss of muscle mass and function) implies a worse prognosis. However, its diagnosis is complex and is not made in routine clinical care. A biomarker has been proposed as a surrogate estimator of skeletal muscle mass, the so-called sarcopenia index ([serum creatinine/cystatine C] x100) which is associated with prognostic features in various diseases including patients with stable chronic obstructive pulmonary disease (COPD). The aim of our study was to prospectively evaluate the potential clinical and prognostic information of this biomarker in COPD exacerbation. This is a one-year prospective study of consecutive patients admitted for COPD exacerbation. A total of 89 patients, 70 men (79%) and 19 women (21%) were included. Those with lower values of the sarcopenia index had a higher level of dyspnoea and a longer hospitalization. In the correlation analysis, the index had statistically significant values with FEV1 (r = 0.23), PaCO2 (r = -0.30), bicarbonate (r = -0.31), dyspnoea (r = -0.25) and length of admission (r = -0.30). In patients admitted for COPD exacerbation, the sarcopenia index was related to prognostic characteristics, so that lower values were associated with longer duration of hospital admission, more dyspnoea and greater functional impairment. As this is an index associated with muscle mass, its determination may identify patients who could be the subject of a differentiated therapeutic plan.

La presencia de sarcopenia (pérdida de masa y función muscular) implica peor pronóstico. Sin embargo, su diagnóstico es complejo y no se realiza en la atención clínica habitual. Se ha propuesto un biomarcador como estimador subrogado de la masa muscular esquelética, el denominado índice de sarcopenia ([creatinina sérica/cistatina C] x100) que se asocia a características pronósticas en diversas enfermedades incluyendo pacientes con enfermedad pulmonar obstructiva crónica (EPOC) estable. El objetivo de nuestro estudio ha sido evaluar de forma prospectiva la potencial información clínica y pronóstica de este biomarcador en agudización de la EPOC. Se trata de un estudio prospectivo, durante un año, de los pacientes consecutivos que ingresan por agudización de su EPOC. Se incluyeron 89 pacientes, 70 varones (79%) y 19 mujeres (21%). Aquellos con valores disminuidos del índice de sarcopenia tenían más disnea y requerían una internación más prolongada. En el análisis de correlación se obtuvo valores con significación estadística del índice con FEV1 (r = 0.23), PaCO2 (r = -0.30) y bicarbonato (r = -0.31), y con la disnea (r = -0.25) y la duración del ingreso (r =- 0.30). En los ingresados por agudización de la EPOC el índice de sarcopenia se relacionó con características pronósticas, de modo que los valores inferiores se asociaron a mayor duración de la internación, más disnea y mayor afectación funcional. Al tratarse de un índice asociado a la masa muscular, su determinación podría identificar a pacientes a incluir en un plan terapéutico diferenciado.

Insights into Chronic Obstructive Pulmonary Disease as Critical Risk Factor for Cardiovascular Disease.

In patients with chronic obstructive pulmonary disease (COPD), cardiovascular comorbidities are highly prevalent and associated with considerable morbidity and mortality. This coincidence is increasingly seen in the context of a "cardiopulmonary continuum" rather than being simply attributed to shared risk factors, in particular, cigarette smoking. Both disease entities are centrally linked to systemic inflammation as well as aging, arterial stiffness, and several common biomarkers that led to the development of pulmonary hypertension, left ventricular diastolic dysfunction, atherosclerosis, and reduced physical activity and exercise capacity. For these reasons, COPD should be considered an independent factor of high cardiovascular risk, and efforts should be directed to early identification of cardiovascular disease (CVD) in COPD patients. Assessment of the overall cardiovascular risk is especially important in patients with severe exacerbation episodes, and the same therapeutic target levels for glycosylated hemoglobin, low-density lipoprotein cholesterol (LDL-C), or blood pressure than those recommended by clinical practice guidelines for patients at high cardiovascular risk, should be achieved. In this review, we will discuss the most recent evidence of the role of COPD as a critical cardiovascular risk factor and try to find new insights and potential prevention strategies for this disease.

Spanish clinical practice consensus in internal medicine on chronic obstructive pulmonary disease patients with comorbidities (miEPOC).

Background: Chronic obstructive pulmonary disease (COPD) is one of the diseases that leads to a higher number of hospitalizations in internal medicine departments. These patients are usually older and have greater multimorbidity than COPD patients hospitalized in other departments, which hinders the implementation of clinical guidelines necessarily focused on the management of a single disease.Aims: To ascertain the opinion of Spanish internists on the management of COPD in scenarios in which the available evidence is sparse and to produce a consensus document designed to assist in decision-making in COPD patients with comorbidities treated in internal medicine services.Methods: After identifying the clinical areas of greatest uncertainty by consensus, a survey was designed with 89 questions on the epidemiology and diagnosis of COPD, its management both in stable phase and during decompensation, and the treatment of the associated comorbidities in outpatients and inpatients. The consensus process was carried out using the Delphi method in an anonymized two-round process.Results: The survey was completed by 67 internists experienced in the clinical management of COPD. Of all the questions posed, a consensus was reached for 51 (57.3%) in the first round and for 67 (75.3%) in the second round. The result of the process is a series of 67 suggestions that may assist in the care of these patients.Conclusions: Our study allows us to ascertain the views of a large number of internists experienced in the management of COPD and to learn how the recommendations for guidelines are applied in clinical practice.

Management of the COPD Patient with Comorbidities: An Experts Recommendation Document.

Background: Chronic obstructive pulmonary disease (COPD) is associated with multiple comorbidities, which impact negatively on patients and are often underdiagnosed, thus lacking a proper management due to the absence of clear guidelines. Purpose: To elaborate expert recommendations aimed to help healthcare professionals to provide the right care for treating COPD patients with comorbidities. Methods: A modified RAND-UCLA appropriateness method consisting of nominal groups to draw up consensus recommendations (6 Spanish experts) and 2-Delphi rounds to validate them (23 Spanish experts) was performed. Results: A panel of Spanish internal medicine experts reached consensus on 73 recommendations and 81 conclusions on the clinical consequences of the presence of comorbidities. In general, the experts reached consensus on the issues raised with regard to cardiovascular comorbidity and metabolic disorders. Consensus was reached on the use of selective serotonin reuptake inhibitors in cases of depression and the usefulness of referring patients with anxiety to respiratory rehabilitation programmes. The results also showed consensus on the usefulness of investigating the quality of sleep, the treatment of pain with opioids and the evaluation of osteoporosis by lateral chest radiography. Conclusion: This study provides conclusions and recommendations that are intended to improve the management of the complexity of patients with COPD and important comorbidities, usually excluded from clinical trials.

Índice de sarcopenia en pacientes hospitalizados por agudización de la enfermedad pulmonar obstructiva crónica / Sarcopenia index in hospitalized patients with chronic obstructive pulmonary disease exacerbation

Resumen La presencia de sarcopenia (pérdida de masa y función muscular) implica peor pronóstico. Sin embargo, su diagnóstico es complejo y no se realiza en la atención clínica habitual. Se ha propuesto un biomarcador como estimador subrogado de la masa muscular esquelética, el denominado índice de sarcopenia ([creatinina sérica/cistatina C] x100) que se asocia a características pronósticas en diversas enfermedades incluyendo pacientes con enfermedad pulmonar obstructiva crónica (EPOC) estable. El objetivo de nuestro estudio ha sido evaluar de forma prospectiva la potencial información clínica y pronóstica de este biomarcador en agudización de la EPOC. Se trata de un estudio prospectivo, durante un año, de los pacientes consecutivos que ingresan por agudización de su EPOC. Se incluyeron 89 pacientes, 70 varones (79%) y 19 mujeres (21%). Aquellos con valores disminuidos del índice de sarcopenia tenían más disnea y requerían una internación más prolongada. En el análisis de correlación se obtuvo valores con significación estadística del índice con FEV1 (r = 0.23), PaCO (r = -0.30) y bicarbonato (r = -0.31), y con la disnea (r = -0.25) y la duración del ingreso (r =0.30). En los ingresados por agudización de la EPOC el índice de sarcopenia se relacionó con características pronósticas, de modo que los valores inferiores se asociaron a mayor duración de la internación, más disnea y mayor afectación funcional. Al tratarse de un índice asociado a la masa muscular, su determinación podría identificar a pacientes a incluir en un plan terapéutico diferenciado.

Abstract Sarcopenia (loss of muscle mass and function) implies a worse prognosis. However, its diagnosis is complex and is not made in routine clinical care. A biomarker has been proposed as a surrogate estimator of skeletal muscle mass, the so-called sarcopenia index ([serum creatinine/cystatine C] x100) which is associated with prognostic features in various diseases including patients with stable chronic obstructive pulmonary disease (COPD). The aim of our study was to prospectively evaluate the potential clinical and prognostic information of this biomarker in COPD exacerbation. This is a one-year prospective study of consecutive patients admitted for COPD exacerbation. A total of 89 patients, 70 men (79%) and 19 women (21%) were included. Those with lower values of the sarcopenia index had a higher level of dyspnoea and a longer hospitalization. In the correlation analysis, the index had statistically significant values with FEV1 (r = 0.23), PaCO (r = -0.30), bicarbonate (r = -0.31), dyspnoea (r = -0.25) and length of admission (r = -0.30). In patients admitted for COPD exacerbation, the sarcopenia index was related to prognostic characteristics, so that lower values were associated with longer duration of hospital admission, more dyspnoea and greater functional impairment. As this is an index associated with muscle mass, its determination may identify patients who could be the subject of a differentiated therapeutic plan.

COPD patients with and without metabolic syndrome: clinical and functional differences.

Chronic obstructive pulmonary disease (COPD) and the metabolic syndrome (MetS) are considered public health challenges of the 21st century. The coexistence of MetS in COPD patients and any clinical differences between COPD patients with and without MetS have not been extensively studied. We aimed to describe the clinical characteristics of patients with MetS and COPD. An observational, multicenter study of 375 patients hospitalized for a COPD exacerbation with spirometric confirmation was performed. We measured the components of the MetS and collected comorbidity information using the Charlson index and other conditions. Dyspnea, use of steroids, exacerbations, and hospitalizations were also investigated. The overall prevalence of MetS in COPD patients was 42.9 %, was more frequent in women (59.5 %) than men (40.8 %), p = 0.02, but with no differences in age and smoking history. COPD patients with MetS had greater % predicted FEV1, more dyspnea, and more comorbidity and used more inhaled steroids (all p < 0.05). Diabetes, osteoporosis, coronary artery disease, and heart failure were more frequent in patients with MetS. They had been hospitalized more frequently for any cause but not for COPD. In multivariate analysis, the presence of MetS was independently associated with greater FEV1, inhaled steroids use, osteoporosis, diabetes, and heart failure. MetS is a frequent condition in COPD patients, and it is associated with greater FEV1, more dyspnea, and more comorbidities.

[Clinical profile and treatment of elderly patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease in Spanish Internal Medicine services. ECCO study]. / Características clínicas y tratamiento de los pacientes ancianos hospitalizados por descompensación de enfermedad pulmonar obstructiva crónica en los servicios de Medicina Interna españoles. Estudio ECCO.

BACKGROUND AND OBJECTIVE: Hospitalizations for chronic obstructive pulmonary disease (COPD) occur mostly in elderly patients. We describe the characteristics and treatment of elderly patients hospitalized for COPD in Internal Medicine Services, compared with the younger age group. PATIENTS AND METHODS: Observational, prospective, multicenter study. We compared the differences between patients older than 80 years and the rest regarding comorbidity, severity of COPD, previous admissions, length of stay and treatment prescribed. Comorbidity was assessed by the Charlson index and a questionnaire was designed for this purpose. RESULTS: We included 398 subjects, 353 men (89%) with a mean age of 73.7 years (SD 8.8), of whom about 107 (26.9%) were older than 80 years. These patients had less severe COPD according to the GOLD classification (P<.02). Although the overall morbidity was similar in both groups, elderly patients had greater presence of arrhythmias (P<.01), left ventricular hypertrophy (P<.01) and received more diuretics (P<.05). Dyspnoea, length of stay and mortality were similar between both populations. Home oxygen therapy prior to and use of inhaled corticosteroids and oxygen therapy was lower in older patients, even when they were clinically indicated. CONCLUSIONS: A quarter of patients hospitalized for COPD in Internal Medicine Services are over 80 years. Although they present less obstruction, they have a similar degree of dyspnea, increased cardiac morbidity and their treatment is less consistent with the recommendations of the guidelines.