[Curriculum reform at the Pontificia Universidad Católica de Chile School of Medicine]. / Reforma curricular de la carrera de Medicina de la Pontificia Universidad Católica de Chile.

The career of Medicine at the Pontificia Universidad Católica de Chile was established from the beginning (1929), with a classical Flexner curriculum design. In seven years, the career is divided in three cycles: basic sciences, clinics and internship. It obtained Chilean accreditation and fulfilled American Association of Medical Colleges accreditation requirements. Changes in the Chilean epidemiological profile and health system, and new teaching methods in medicine, stimulated a process of deep curricular analysis, identifying strengths and weaknesses of the medical career. The curricular strengths were well-developed scientific and clinical components, fully committed students and faculties, well defined learning objectives and excellent clinical campuses. Curricular weaknesses included a poor vertical and horizontal integration, few student centered methodologies and a weak emphasis concerning doctor’s professionalism. Subsequently, the whole community of teachers, students and medical educators worked on the design of a new curriculum, establishing a new graduate profile and designed it oriented by learning objectives, of six years of duration, with an optimized course sequence that melds basic science and clinical concepts, with strong emphasis on humanities and professionalism. It prioritizes an early contact with patients from the first year and expands teaching methods. The main objective of this process was to achieve a new curriculum with an integrative structure. This was implemented in 2015 with an approved protocol to evaluate the outcomes.

Instability in the COPD diagnosis upon repeat testing vary with the definition of COPD.

BACKGROUND: A low FEV1/FVC from post-bronchodilator spirometry is required to diagnose COPD. Both the FEV1 and the FVC can vary over time; therefore, individuals can be given a diagnosis of mild COPD at one visit, but have normal spirometry during the next appointment, even without an intervention. METHODS: We analyzed two population-based surveys of adults with spirometry carried out for the same individuals 5-9 years after their baseline examination. We determined the factors associated with a change in the spirometry interpretation from one exam to the next utilizing different criteria commonly used to diagnose COPD. RESULTS: The rate of an inconsistent diagnosis of mild COPD was 11.7% using FEV1/FVC <0.70, 5.9% using FEV1/FEV6

Comorbilidades y estado de salud en individuos con y sin EPOC en 5 ciudades de América Latina: Estudio PLATINO / Comorbidities and Health Status in Individuals With and Without COPD in Five Latin American Cities: The PLATINO Study

INTRODUCCIÓN: La enfermedad pulmonar obstructiva crónica (EPOC) se asocia a comorbilidades que influyen en el estado de salud y en el pronóstico de los pacientes. El estudio PLATINO aporta datos sobre comorbilidades autorreportadas y percepción del estado general de salud (EGS) en la EPOC. MÉTODOS: PLATINO es un estudio poblacional, sobre prevalencia de EPOC en 5 ciudades de Latinoamérica. El diagnóstico de EPOC se realizó según el criterio de GOLD (FEV1/FVC < 0,70 post-broncodilatador). Se recogió información sobre las siguientes comorbilidades: cardíaca, hipertensión, diabetes, accidente cerebrovascular (ACV), úlcera y asma. El EGS se evaluó mediante el cuestionario SF-12, con la pregunta: «En general ¿diría usted que su salud es: excelente, muy buena, buena, regular o pobre?». Sumando las comorbilidades, se elaboró un índice de comorbilidad. RESULTADOS: Sobre una población total de 5.314 individuos se realizó diagnóstico de EPOC en 759. Las comorbilidades reportadas en orden decreciente fueron: cualquier tipo de enfermedad cardiovascular, hipertensión, úlcera péptica, enfermedad cardíaca, diabetes, ACV, asma y cáncer de pulmón. Los sujetos con EPOC tuvieron mayor índice de comorbilidad, prevalencia de cáncer de pulmón (p < 0,0001) y asma (p < 0,0001), así como mayor tendencia a hipertensión (p = 0,0652) y ACV (p = 0,0750). Los factores asociados a comorbilidad en EPOC fueron la edad, el índice de masa corporal (IMC) y el género femenino. Con el deterioro del EGS aumenta el número de comorbilidades. CONCLUSIONES: En población no seleccionada los individuos con EPOC presentan más comorbilidades. La edad, el sexo femenino y mayor IMC son los principales factores asociados a comorbilidad en estos pacientes. Independientemente de la condición de EPOC, un mayor número de comorbilidades se asocia a peor EGS (AU)

INTRODUCTION: Comorbidities are common in patients with chronic obstructive pulmonary disease (COPD), and have a significant impact on health status and prognosis. The PLATINO study provides data on self-reported comorbidities and perceived health status in COPD subjects. METHODS: PLATINO is a population-based study on COPD prevalence in five Latin American cities. COPD diagnosis was defined by GOLD criteria (FEV1/FVC<0.70 post-bronchodilator). Information was collected on the following comorbidities: heart disease, hypertension, diabetes, cerebrovascular disease, peptic ulcer and asthma. Health status was evaluated using the SF-12 questionnaire, derived from the question: "In general, would you say your health is excellent, very good, good, fair or poor?" A simple comorbidity score was calculated by adding the total number of comorbid conditions. RESULTS: Of a total population of 5314 individuals, 759 had COPD. Reported comorbidities by decreasing frequency were: any cardiovascular disease, hypertension, peptic ulcer, heart disease, diabetes, cerebrovascular disease, asthma and lung cancer. COPD patients had a higher comorbidity score and prevalence of lung cancer (P<0.0001) and asthma (P<0.0001), as well as a higher tendency to have hypertension (P=0.0652) and cerebrovascular disease (P=0.0750). Factors associated with comorbidities were age, body mass index (BMI) and female gender. The number of comorbidities increased as the health status deteriorated. CONCLUSIONS: In the PLATINO population-based study, COPD individuals had an increased number of comorbidities. Age, female gender and higher BMI were the factors associated with comorbidity in these patients. Comorbid conditions were associated with impaired health status, independently of the COPD status (AU)

Comorbidities and health status in individuals with and without COPD in five Latin American cities: the PLATINO study.

INTRODUCTION: Comorbidities are common in patients with chronic obstructive pulmonary disease (COPD), and have a significant impact on health status and prognosis. The PLATINO study provides data on self-reported comorbidities and perceived health status in COPD subjects. METHODS: PLATINO is a population-based study on COPD prevalence in five Latin American cities. COPD diagnosis was defined by GOLD criteria (FEV1/FVC<.70 post-bronchodilator). Information was collected on the following comorbidities: heart disease, hypertension, diabetes, cerebrovascular disease, peptic ulcer and asthma. Health status was evaluated using the SF-12 questionnaire, derived from the question: «In general, would you say your health is excellent, very good, good, fair or poor?¼. A simple comorbidity score was calculated by adding the total number of comorbid conditions. RESULTS: Of a total population of 5314individuals, 759 had COPD. Reported comorbidities by decreasing frequency were: any cardiovascular disease, hypertension, peptic ulcer, heart disease, diabetes, cerebrovascular disease, asthma and lung cancer. COPD patients had a higher comorbidity score and prevalence of lung cancer (P<.0001) and asthma (P<.0001), as well as a higher tendency to have hypertension (P=.0652) and cerebrovascular disease (P=.0750). Factors associated with comorbidities were age, body mass index (BMI) and female gender. The number of comorbidities increased as the health status deteriorated. CONCLUSIONS: In the PLATINO population-based study, COPD individuals had an increased number of comorbidities. Age, female gender and higher BMI were the factors associated with comorbidity in these patients. Comorbid conditions were associated with impaired health status, independently of the COPD status.

The chronic bronchitis phenotype in subjects with and without COPD: the PLATINO study.

Little information exists regarding the epidemiology of the chronic bronchitis phenotype in unselected chronic obstructive pulmonary disease (COPD) populations. We examined the prevalence of the chronic bronchitis phenotype in COPD and non-COPD subjects from the PLATINO study, and investigated how it is associated with important outcomes. Post-bronchodilator forced expiratory volume in 1 s/forced vital capacity <0.70 was used to define COPD. Chronic bronchitis was defined as phlegm on most days, at least 3 months per year for ≥ 2 yrs. We also analysed another definition: cough and phlegm on most days, at least 3 months per year for ≥ 2 yrs. Spirometry was performed in 5,314 subjects (759 with and 4,554 without COPD). The proportion of subjects with and without COPD with chronic bronchitis defined as phlegm on most days, at least 3 months per year for ≥ 2 yrs was 14.4 and 6.2%, respectively. Using the other definition the prevalence was lower: 7.4% with and 2.5% without COPD. Among subjects with COPD, those with chronic bronchitis had worse lung function and general health status, and had more respiratory symptoms, physical activity limitation and exacerbations. Our study helps to understand the prevalence of the chronic bronchitis phenotype in an unselected COPD population at a particular time-point and suggests that chronic bronchitis in COPD is possibly associated with worse outcomes.

Acute bronchodilator responsiveness in subjects with and without airflow obstruction in five Latin American cities: the PLATINO study.

BACKGROUND: Acute bronchodilator responsiveness is an area of discussion in COPD. No information exists regarding this aspect of the disease from an unselected COPD population. We assessed acute bronchodilator responsiveness and factors influencing it in subjects with and without airway obstruction in an epidemiologic sample. METHODS: COPD was defined by GOLD criteria (post-bronchodilator FEV(1)/FVC<0.70). In this analysis, subjects with pre-bronchodilator FEV(1)/FVC <0.70 but > or =0.70 post-bronchodilator were considered to have reversible obstruction. Bronchodilator responsiveness after albuterol 200microg was assessed using three definitions: a) FVC and/or FEV(1) increment > or =12% plus > or =200mL over baseline; b) FEV(1)> or =15% increase over baseline; and c) FEV(1) increase > or =10% of predicted value. RESULTS: There were 756 healthy respiratory subjects, 481 subjects with reversible obstruction and 759 COPD subjects. Depending on the criterion used the proportion of person with acute bronchodilator responsiveness ranged between 15.0-28.2% in COPD, 11.4-21.6% in reversible obstructed and 2.7-7.2% in respiratory healthy. FEV(1) changes were lower (110.6+/-7.40 vs. 164.7+/-11.8mL) and FVC higher (146.5+/-14.2mL vs. -131.0+/-19.6mL) in COPD subjects compared with reversible obstructed. Substantial overlap in FEV(1) and FVC changes was observed among the groups. Acute bronchodilator responsiveness in COPD persons was associated with less obstruction and never smoking. CONCLUSIONS: Over two-thirds of persons with COPD did not demonstrate acute bronchodilator responsiveness. The overall response was small and less than that considered as significant by ATS criteria. The overlap in FEV(1) and FVC changes after bronchodilator among the groups makes it difficult to determine a threshold for separating them.

Prevalence of smoking and incidence of initiation in the Latin American adult population: the PLATINO study.

BACKGROUND: The PLATINO project was launched in 2002 in order to study the prevalence of chronic obstructive pulmonary disease (COPD) in Latin America. Because smoking is the main risk factor for COPD, detailed data on it were obtained. The aim of this paper was to evaluate the prevalence of smoking and incidence of initiation among middle-aged and older adults (40 years or older). Special emphasis was given to the association between smoking and schooling. METHODS: PLATINO is a multicenter study comprising five cross-sectional population-based surveys of approximately 1,000 individuals per site in Sao Paulo (Brazil), Santiago (Chile), Mexico City (Mexico), Montevideo (Uruguay) and Caracas (Venezuela). The outcome variable was smoking status (never, former or current). Current smokers were those who reported to smoke within the previous 30 days. Former smokers were those who reported to quit smoking more than 30 days before the survey. Using information on year of birth and age of smoking onset and quitting, a retrospective cohort analysis was carried out. Smoking prevalence at each period was defined as the number of subjects who started to smoke during the period plus those who were already smokers at the beginning of the period, divided by the total number of subjects. Incidence of smoking initiation was calculated as the number of subjects who started to smoke during the period divided by the number of non-smokers at its beginning. The independent variables included were sex, age and schooling. RESULTS: Non-response rates ranged from 11.1% to 26.8%. The prevalence of smoking ranged from 23.9% (95%CI 21.3; 26.6) in Sao Paulo to 38.5% (95%CI 35.7; 41.2) in Santiago. Males and middle-aged adults were more likely to smoke in all sites. After adjustment for age, schooling was not associated with smoking. Using retrospective cohort analysis, it was possible to detect that the highest prevalence of smoking is found between 20-29 years, while the highest incidence is found between 10-19 years. Age of smoking onset tended to decline over time among females. CONCLUSION: The prevalence of smoking varied considerably across sites, but was lower among countries with national anti-smoking campaigns.

Frequency of self-reported COPD exacerbation and airflow obstruction in five Latin American cities: the Proyecto Latinoamericano de Investigacion en Obstruccion Pulmonar (PLATINO) study.

BACKGROUND: Recurrent exacerbations are common in COPD patients. Limited information exists regarding exacerbation frequency in COPD patients from epidemiologic studies. We examined the frequency of self-reported exacerbations and the factors influencing exacerbation frequency among COPD patients in a population-based study conducted in Latin America. METHODS: We used a post-bronchodilator FEV(1)/FVC ratio of < 0.70 to define COPD. Exacerbation was self-reported and defined by symptoms (deterioration of breathing symptoms that affected usual daily activities or caused missed work). RESULTS: Spirometry was performed in 5,314 subjects. There were 759 subjects with airflow limitation; of these, 18.2% reported ever having had an exacerbation, 7.9% reported having an exacerbation, and 6.2% reported having an exacerbation requiring at least a doctor visit within the past year. The proportion of individuals with an exacerbation significantly increased by Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages, from 4.2% in stage 1 to 28.9% in stages 3 and 4. The self-reported exacerbation rate was 0.58 exacerbations per year. The rate of exacerbations requiring at least a doctor visit and length of stay in hospital due to exacerbations also increased as COPD severity progressed. The factors associated with having an exacerbation in the past year were dyspnea, prior asthma diagnosis, receiving any respiratory therapy, and disease severity of GOLD stages 3 and 4. CONCLUSIONS: The proportion of individuals with airflow limitation and self-reported exacerbation increases as the disease severity progresses. Dyspnea, prior asthma diagnosis, receiving any respiratory therapy, and more severe obstruction were significantly associated with having an exacerbation in the past year.

Health status perception and airflow obstruction in five Latin American cities: the PLATINO study.

BACKGROUND: COPD is a highly prevalent disease but underdiagnosed, undertreated and possibly under-recognized by patients. Limited information exists regarding patients' perception of COPD severity. We compared patients' general health status perception, degree of breathlessness and physical activity limitation with the severity of their respiratory condition measured by airway obstruction, in a population-based sample. METHODS: We used postbronchodilator FEV(1)/FVC<0.70 to define COPD. Patients' perception of their general health status was derived from the question "in general you would say that your health is: excellent, very good, good, fair or poor?" RESULTS: Spirometry was performed in 5314 subjects: an FEV(1)/FVC ratio below 0.70 was found in 759 subjects. In persons with COPD, general health status decreased with increasing GOLD stages. Over one-half of subjects with stage 2 and one third of those with stages 3 and 4 reported their health status as good to excellent. There was also a disparity between airway obstruction severity and breathlessness intensity. Although the more severe COPD stages were frequently associated with significant compromise of work and everyday activities, patients often tended to provide an optimistic self evaluation of their health status. CONCLUSIONS: The discrepancy observed between general health status, dyspnea severity, physical activity limitation and airway obstruction most likely reflect patients' underperception of disease severity, emphasizing the need for improving case-finding measures and multi-component evaluation of COPD subjects.

Prevalence of sleep related symptoms in four Latin American cities.

STUDY OBJECTIVES: to estimate the prevalence of the most common sleep related symptoms (SRS) in the metropolitan areas of Mexico City, Montevideo (Uruguay), Santiago (Chile), and Caracas (Venezuela). METHODS: The study consisted of a multistage cluster sampling of adults aged > or = 40 years living in metropolitan areas. All participants completed a questionnaire on sleep related symptoms. Simplified respiratory polygraphy during sleep was conducted on 188 subjects from Mexico City. Obstructive sleep apnea syndrome was defined as Epworth Sleepiness Scale score > or = 11 and respiratory disturbance index (RDI) > or = 15 events/h; a cut-off of 15 was chosen because of its high sensitivity and specificity in association with the portable monitor used in the study. RESULTS: The study included 4,533 subjects (1,062 in Mexico City, 941 in Montevideo, 1,173 in Santiago, and 1,357 in Caracas). Snoring was reported by 60.2% (95% CI 58.8% to 61.6%), excessive daytime sleepiness by 16.4% (15.3% to 17.5%), observed apneas by 12.3% (11.4% to 13.3%), insomnia by 34.7% (33.3% to 36%), sedative use by 15.1% (14.1% to 16.2%), daytime napping by 29.2% (27.7% to 30.6%), and a combination of snoring, sleepiness, and observed apneas by 3.4% (2.9% to 4%). Men had a higher frequency of snoring and daytime napping, whereas women reported more insomnia and sedative use. Prevalence of OSAS varied from 2.9% among subjects who denied snoring, excessive daytime sleepiness, and observed apneas, to 23.5% among those reporting these 3 symptoms. CONCLUSIONS: A high prevalence of sleep related symptoms and undiagnosed obstructive sleep apnea in Latin America was observed.

Use of respiratory medication in five Latin American cities: The PLATINO study.

BACKGROUND: There is scanty information regarding respiratory medication prescription pattern in Latin America. We examined the use of bronchodilators and corticosteroids in a population-based study conducted in five Latin American cities. METHODS: Medication use was derived from questions regarding the use of medication "to help breathing" within the previous 12 months, type of medicine, and frequency of use. To minimize the possibility of overdiagnosis, we used postbronchodilator FEV(1)/FVC<0.70 plus FEV(1)<80% as the definition of obstruction. RESULTS: Interviews were completed in 5571 subjects from 6711 eligible individuals, and spirometry was performed in 5314 subjects. There were 360 (6.5%) treated subjects and 5211 not treated. Treated subjects were more likely to be older, women, unemployed, have higher tobacco consumption, higher body mass index, higher FEV(1) reversibility and airway obstruction. They were also more likely to report prior spirometry, prior diagnosis of COPD, asthma or tuberculosis, and more respiratory symptoms. Over half of treated subjects had neither obstruction nor FEV(1) reversibility, and approximately 30% reported no prior diagnosis of asthma or COPD. Prior respiratory diagnoses and wheezing were more strongly associated with treatment than objective measures of airway obstruction. CONCLUSIONS: The use of bronchodilators and/or corticosteroids is common in the general population aged 40 years or older, with over one-half of treated subjects using them without being obstructed.

[Treatment of chronic obstructive pulmonary disease in 5 Latin American cities: the PLATINO study]. / Tratamiento de la EPOC en 5 ciudades de América Latina: estudio PLATINO.

OBJECTIVE: PLATINO project is a population-based study designed to determine the prevalence of chronic obstructive pulmonary disease (COPD) in São Paulo, Brazil; Mexico City, Mexico; Montevideo, Uruguay; Santiago de Chile, Chile; and Caracas, Venezuela. The objective of this portion of PLATINO was to describe preventive and pharmacological treatment of COPD patients and factors associated with such treatment. PATIENTS AND METHODS: Eligible subjects completed a questionnaire and underwent postbronchodilator spirometry. RESULTS: Of the total of 5529 individuals who answered items referring to treatment, 758 had COPD (ratio of postbronchodilator forced expiratory volume in 1 second to forced vital capacity of <0.7), and 86 of them had been previously diagnosed by a physician. Among all COPD patients, only half of smokers or former smokers had been advised to quit and 24.7% had received some type of respiratory medication. Only 13.5% had used inhaled corticosteroids, and those were the patients with the most severe disease. In the group of patients who had a previous medical diagnosis of COPD, 69% of the smokers or former smokers had been advised to quit by a physician and 75.6% had received respiratory medication in the preceding year: 43% reported having used inhaled medication and 36% had used bronchodilators. Rates of vaccination against influenza and the use of mucolytic drugs and inhalers varied from one health care facility to another. All drug prescriptions were based on previous spirometry. CONCLUSIONS: Spirometry emerged not only as a diagnostic tool, but also as a factor associated with treatment, against a background of uneven use of available health care resources in these 5 Latin American cities.

Chronic obstructive pulmonary disease and body mass index in five Latin America cities: the PLATINO study.

BACKGROUND: The body mass index (BMI) is a prognostic factor for chronic obstructive pulmonary disease (COPD). Despite its importance, little information is available regarding BMI alteration in COPD from a population-based study. We examined characteristics by BMI categories in the total and COPD populations in five Latin-American cities, and explored the factors influencing BMI in COPD. METHODS: COPD was defined as a postbronchodilator forced expiratory volume in the first second/forced vital capacity (FEV(1)/FVC) <0.70. BMI was categorized as underweight (< 20 kg/m(2)), normal weight (20-24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)), and obese (> or = 30.0 kg/m(2)). RESULTS: Interviews were completed in 5571 subjects from 6711 eligible individuals, and spirometry was performed in 5314 subjects. There were 759 subjects with COPD and 4555 without COPD. Compared with the non-COPD group, there was a higher proportion of COPD subjects in the underweight and normal weight categories, and a lower proportion in the obese category. Over one-half COPD subjects had BMI over 25 kg/m(2). No differences in BMI strata among countries were found in COPD subjects. Factors associated with lower BMI in males with COPD were aging, current smoking, and global initiative for chronic obstructive lung disease (GOLD) stages III-IV, whereas wheeze and residing in Santiago and Montevideo were associated with higher BMI. In females with COPD, current smoking, lower education, and GOLD stages II-IV were associated with lower BMI, while dyspnea and wheeze were associated with higher BMI. CONCLUSIONS: BMI alterations are common in COPD with no significant differences among countries. Current smoking, age, GOLD stages, education level, residing in Santiago and Montevideo, dyspnea and wheeze were independently associated with BMI in COPD.

Tratamiento de la EPOC en 5 ciudades de América Latina: estudio PLATINO / Treatment of chronic obstructive pulmonary disease in 5 Latin American Cities: the PLATINO study

Objetivo: PLATINO es un estudio de base poblacional para medir la prevalencia de la enfermedad pulmonar obstructiva crónica (EPOC) en São Paulo (Brasil), Ciudad de México (México), Montevideo (Uruguay), Santiago de Chile (Chile) y Caracas (Venezuela). El objetivo ha sido describir el tratamiento preventivo y farmacológico en individuos con EPOC y los factores asociados al mismo. Pacientes y métodos: Los sujetos elegibles completaron un cuestionario y realizaron una espirometría posbroncodilatador. Resultados: De un total de 5.529 individuos con datos autorreferidos sobre tratamiento, se identificó como afectados de EPOC (relación volumen espiratorio forzado en el primer segundo/capacidad vital forzada < 0,7 posbroncodilatador) a 758, de los que 86 tenían diagnóstico médico previo. Considerando la totalidad de los pacientes con EPOC, sólo la mitad de los fumadores o exfumadores había recibido consejo antitabáquico y el 24,7% recibió algún tipo de medicación respiratoria. El uso de esteroides inhalados alcanzó un 13,5% de los individuos más graves. En el grupo de EPOC con diagnóstico médico previo, el 69% de los fumadores o exfumadores había recibido consejo médico para dejar de fumar y el 75,6% medicación respiratoria en el último año, un 43% de ellos por vía inhalada y un 36% broncodilatadores. La cobertura de vacunación antigripal y el uso de mucolíticos e inhaladores fueron variables en los distintos centros. Todas las prescripciones terapéuticas se asociaron a espirometría previa. Conclusiones: La espirometría surge no sólo como una herramienta diagnóstica, sino como factor asociado al tratamiento, en un contexto dispar de utilización de los recursos disponibles en estas 5 ciudades de Latinoamérica

Objective: PLATINO project is a population-based study designed to determine the prevalence of chronic obstructive pulmonary disease (COPD) in São Paulo, Brazil; Mexico City, Mexico; Montevideo, Uruguay; Santiago de Chile, Chile; and Caracas, Venezuela. The objective of this portion of PLATINO was to describe preventive and pharmacological treatment of COPD patients and factors associated with such treatment. Patients and methods: Eligible subjects completed a questionnaire and underwent postbronchodilator spirometry. Results: Of the total of 5529 individuals who answered items referring to treatment, 758 had COPD (ratio of postbronchodilator forced expiratory volume in 1 second to forced vital capacity of <0.7), and 86 of them had been previously diagnosed by a physician. Among all COPD patients, only half of smokers or former smokers had been advised to quit and 24.7% had received some type of respiratory medication. Only 13.5% had used inhaled corticosteroids, and those were the patients with the most severe disease. In the group of patients who had a previous medical diagnosis of COPD, 69% of the smokers or former smokers had been advised to quit by a physician and 75.6% had received respiratory medication in the preceding year: 43% reported having used inhaled medication and 36% had used bronchodilators. Rates of vaccination against influenza and the use of mucolytic drugs and inhalers varied from one health care facility to another. All drug prescriptions were based on previous spirometry. Conclusions: Spirometry emerged not only as a diagnostic tool, but also as a factor associated with treatment, against a background of uneven use of available health care resources in these 5 Latin American cities

[Spirometry reference values after inhalation of 200 microg of salbutamol]. / Valores de referencia para la espirometría después de la inhalación de 200 microg de salbutamol.

OBJECTIVE: The criteria for disease severity established by the Global Initiative for Chronic Obstructive Lung Disease are based on forced expiratory volume in 1 second (FEV1) expressed as a percentage of the predicted value after application of a bronchodilator. This study aims to determine postbronchodilator spirometry reference values. SUBJECTS AND METHODS: A cluster sample of subjects aged 40 years or over was chosen to be representative of the metropolitan areas of 5 Latin American cities (São Paulo, Mexico City, Montevideo, Santiago, and Caracas). Spirometry was performed on 5183 subjects following the recommendations of the American Thoracic Society before and after inhalation of 200 microg of salbutamol. Multiple linear regression equations were fitted for the postbronchodilator spirometric values-FEV1, forced expiratory volume in 6 seconds (FEV6), peak expiratory flow rate, forced vital capacity (FVC), FEV1/FEV6, FEV1/FVC and forced expiratory flow between 25% and 75% of vital capacity (FEF25-75). These were adjusted for sex, age, and height in 887 asymptomatic subjects with no history of lung disease. RESULTS: The postbronchodilator reference values for FEV1, FEV1/FVC, and FEV1/FEV6 were on average 3% higher than those obtained before bronchodilation. This apparently small difference caused an upward shift in the 5th percentile (lower limit of normal) of the predicted values. When prebronchodilation instead of postbronchodilation reference values were used, 3.2% of the results for airflow obstruction in our population of over-40-year-olds were false negatives. CONCLUSIONS: The reported reference values are more appropriate for postbronchodilator spirometry and make it possible to reduce the number of misclassifications.

Valores de referencia para la espirometría después de la inhalación de 200 mg de salbutamol / Spirometry reference values after inhalation of 200 mg of salbutamol

Objetivo: La clasificación de la gravedad de la enfermedad pulmonar obstructiva crónica (EPOC) se basa, de acuerdo con la iniciativa GOLD, en el volumen espiratorio forzado en el primer segundo (FEV1) después de usar broncodilatador, expresado como porcentaje del esperado. El propósito de este trabajo ha sido determinar los valores de referencia para la espirometría después de la administración de broncodilatador. Sujetos y métodos: Se realizó un muestreo por conglomerados de sujetos de 40 años o más, representativos de las zonas metropolitanas de São Paulo, Ciudad de México, Montevideo, Santiago y Caracas. Se realizó una espirometría a 5.183 sujetos de acuerdo con las recomendaciones de la American Thoracic Society, antes y después de la inhalación de 200 μg de salbutamol. Se efectuaron regresiones lineales múltiples para los valores espirométricos ­FEV1, volumen espiratorio forzado en 6 s (FEV6), índice de flujo espiratorio máximo, capacidad vital forzada (FVC), FEV1/FEV6, FEV1/FVC y flujo mesoespiratorio forzado­ después del uso del broncodilatador, ajustando por sexo, edad y altura, en 887 sujetos sin evidencia de enfermedad pulmonar previa. Resultados: Los valores de referencia tras broncodilatador para FEV1, FEV1/FVC y FEV1/FEV6 fueron en promedio un 3% mayores que los obtenidos con la espirometría realizada antes de la inhalación del broncodilatador. Esta diferencia, que parece pequeña, causa un desplazamiento hacia arriba en el percentil 5 (límite inferior de la normalidad) de los valores esperados. Si se utiliza el valor de referencia prebroncodilatador, en lugar del posbroncodilatador, se genera un 3,2% de falsos negativos para obstrucción al flujo aéreo en el total de la población de 40 o más años de edad. Conclusiones: Los valores de referencia indicados son más apropiados para espirometrías realizadas después de la inhalación del broncodilatador y permiten minimizar los errores de clasificación

Objective: The criteria for disease severity established by the Global Initiative for Chronic Obstructive Lung Disease are based on forced expiratory volume in 1 second (FEV1) expressed as a percentage of the predicted value after application of a bronchodilator. This study aims to determine postbronchodilator spirometry reference values. Subjects and methods: A cluster sample of subjects aged 40 years or over was chosen to be representative of the metropolitan areas of 5 Latin American cities (São Paulo, Mexico City, Montevideo, Santiago, and Caracas). Spirometry was performed on 5183 subjects following the recommendations of the American Thoracic Society before and after inhalation of 200 μg of salbutamol. Multiple linear regression equations were fitted for the postbronchodilator spirometric values­FEV1, forced expiratory volume in 6 seconds (FEV6), peak expiratory flow rate, forced vital capacity (FVC), FEV1/FEV6, FEV1/FVC and forced expiratory flow between 25% and 75% of vital capacity (FEF25-75). These were adjusted for sex, age, and height in 887 asymptomatic subjects with no history of lung disease. Results: The postbronchodilator reference values for FEV1, FEV1/FVC, and FEV1/FEV6 were on average 3% higher than those obtained before bronchodilation. This apparently small difference caused an upward shift in the 5th percentile (lower limit of normal) of the predicted values. When prebronchodilation instead of postbronchodilation reference values were used, 3.2% of the results for airflow obstruction in our population of over-40-year-olds were false negatives. Conclusions: The reported reference values are more appropriate for postbronchodilator spirometry and make it possible to reduce the number of misclassifications

Impact of bronchodilator use on the prevalence of COPD in population-based samples.

The aim of this study was to describe the impact of using bronchodilators on the prevalence of Chronic Obstructive Pulmonary Disease in a population-based survey (Platino study). A cluster sampling of subjects 40 years of age or older, representative of the metropolitan areas of 5 Latin American cities (Sao Paulo, Mexico, Montevideo, Santiago and Caracas) was chosen. Spirometry according to ATS standards was done before and after inhalation of 200 micrograms of salbutamol in 5183 subjects. Prevalences of airflow obstruction were estimated using different criteria, in tests done before and after bronchodilator use, and with reference values for pre- or post-bronchodilator use. Bronchodilator testing reduced the overall prevalence of FEV(1)/FVC% < 0.70 from 21.7% to 14% (35%). In the group with FEV(1)/FVC < 0.70 after bronchodilator use, 21% were asymptomatic from the respiratory point of view, and lacked significant adverse exposures. Subjects below the 5th percentile for FEV(1)/FVC and FEV(1)/FEV(6) were fewer than those with FEV(1)/FVC < 0.70, especially among the elderly. More subjects are below the 5th percentile of FEV(1)/FVC and FEV(1)/FEV(6) using reference values for tests after bronchodilator use than using the reference values determined without bronchodilator testing. Testing after bronchodilator use reduces the prevalence of airflow obstruction from 32 to 39% depending on the definition used. In addition, the subjects who were still obstructed after bronchodilator use were the ones who showed more respiratory symptoms and exposure to tobacco and other smokes and dusts, than subjects with reversible obstruction, suggesting an increased specificity for COPD.

Diagnostic labeling of COPD in five Latin American cities.

BACKGROUND: COPD is a major worldwide problem with a rising prevalence. Despite its importance, there is a lack of information regarding underdiagnosis and misdiagnosis of COPD in different countries. As part of the Proyecto Latinoamericano de Investigación en Obstrucción Pulmonar study, we examined the relationship between prior diagnostic label and airway obstruction in the metropolitan areas of five Latin American cities (São Paulo, Santiago, Mexico City, Montevideo, and Caracas). METHODS: A two-stage sampling strategy was used in each of the five areas to obtain probability samples of adults aged >or= 40 years. Participants completed a questionnaire that included questions on prior diagnoses, and prebronchodilator and postbronchodilator spirometry. A study diagnosis of COPD was based on airway obstruction, defined as a postbronchodilator FEV(1)/FVC < 0.70. RESULTS: Valid spirometry and prior diagnosis information was obtained for 5,303 participants; 758 subjects had a study diagnosis of COPD, of which 672 cases (88.7%) had not been previously diagnosed. The prevalence of undiagnosed COPD was 12.7%, ranging from 6.9% in Mexico City to 18.2% in Montevideo. Among 237 subjects with a prior COPD diagnosis, only 86 subjects (36.3%) had postbronchodilator FEV(1)/FVC < 0.7, while 151 subjects (63.7%) had normal spirometric values. In the same group of 237 subjects, only 34% reported ever undergoing spirometry prior to our study. CONCLUSIONS: Inaccurate diagnostic labeling of COPD represents an important health problem in Latin America. One possible explanation is the low rate of spirometry for COPD diagnosis.

The long-term stability of portable spirometers used in a multinational study of the prevalence of chronic obstructive pulmonary disease.

BACKGROUND: We report the performance of an ultrasound-based portable spirometer (EasyOne) used in a population-based survey of the prevalence of chronic obstructive pulmonary disease, conducted in 5 Latin American cities: São Paulo, Brazil; México City, México; Montevideo, Uruguay; Santiago, Chile; and Caracas, Venezuela (the Latin American COPD Prevalence Study [PLATINO]). METHODS: During the survey period (which ranged from 3 months to 6 months in the various locations) we collected daily calibration data from the 70 EasyOne spirometers used in the 5 survey cities. The calibrations were conducted with a 3-L syringe, and the calibration data were stored in the spirometer's database. RESULTS: Ninety-seven percent of the calibration volumes were within +/- 64 mL (2.1%) of the 3-L calibration signal. Excluding data from the first city studied (São Paulo), where one calibration syringe had to be replaced, 98% of the calibration checks were within +/- 50 mL (1.7%). The measured volume was affected only minimally by the syringe's peak flow or emptying time. CONCLUSION: In these 70 EasyOne spirometers neither calibration nor linearity changed during the study. Such calibration stability is a valuable feature in spirometry surveys and in the clinical setting.

[Spirometric reference values in 5 large Latin American cities for subjects aged 40 years or over]. / Valores de referencia espirométrica en 5 grandes ciudades de Latinoamérica para sujetos de 40 o más años de edad.

OBJECTIVE: In clinical practice, spirometry is a extremely useful test that requires strict quality control, an appropriate strategy for interpretation, and reliable reference values. The aim of this study was to report spirometric reference values for 5 cities in Latin America. PATIENTS AND METHODS: From data for 5315 subjects who had undergone spirometry in the PLATINO study in Caracas, Mexico City, Santiago, São Paulo, and Montevideo, we selected information for 906 (17%) individuals aged between 40 years and 90 years to provide reference values. The chosen subjects had never smoked, were asymptomatic, had not been diagnosed with lung disease, and were not obese. Multiple regression models were constructed with the following spirometric parameters: forced expiratory volume in 1 second (FEV1) and in 6 seconds (FEV6), peak expiratory flow, forced vital capacity (FVC), FEV1/FEV6, FEV1/FVC, and forced midexpiratory flow rate. Height, sex, and age were also included in the model. RESULTS: Average values for the subjects studied were similar to those for the white North American population and the Mexican-American population of the third National Health and Nutrition Examination Survey, but exceeded those of the black population of the same survey by 20%. CONCLUSIONS: The proposed reference values are an improvement on those currently available for Latin America because the participants were chosen by population sampling methods and standardized up-to-date methodology was used.