Reducing COPD Readmissions: A Causal Bayesian Network Model

To investigate the correlations between lipid ratio/oxidative stress status in chronic obstructive pulmonary disease (COPD) patients and pulmonary hypertension as well as the prognosis. Methods: A total of 120 patients with COPD were randomly selected and served as the COPD group and 30 healthy persons were selected as the control group. The ratios of low density lipoprotein (LDL)/high-density lipoprotein (HDL), triglyceride (TG)/HDL and total cholesterol (TC)/HDL were measured. The superoxide dismutase (SOD) activity, malondialdehyde (MDA) content and total antioxidant capacity (T-AOC) level in the control group and COPD patients were detected. Pulmonary hypertension incidence and 3-year survival rate for COPD patients were statistically analyzed. Spearman rank correlation method was used to analyze relationship between lipid ratio /oxidative stress status and pulmonary hypertension. Results: Compared with control group, the ratios of LDL/HDL, TG/HDL and TC/HDL, and the serum MDA level in the COPD group were increased, while the serum SOD and T-AOC level in the COPD group were decreased; compared with stable period, lipid ratios and MDA levels in the acute period were elevated, while serum SOD and T-AOC levels were reduced (P<0.05). Pulmonary hypertension incidence and 3-year survival rates in the COPD group were 56.67% and 81.67% respectively; the lipid ratios and serum MDA levels in COPD patients with pulmonary hypertension were elevated compared with that in COPD patients without pulmonary hypertension; the serum SOD and T-AOC levels in COPD patients with pulmonary hypertension were reduced compared with that in patients without pulmonary hypertension (P<0.05). Spearman rank correlation analysis showed that ratios of LDL/HDL, TG/HDL and TC/HDL, and the serum MDA levels in COPD patients were positively correlated with 3-years pulmonary hypertension incidence (r=0.752, 0.748, 0.752, 0.748; P<0.05), and negatively correlated with 3-years survival rate (r=-0.722, -0.751, -0.736, -0.748; P<0.05); serum SOD and T-AOC levels in COPD patients were negatively correlated with 3-years pulmonary hypertension (r=-0.711, -0.734; P<0.05), and positively correlated with 3-year survival rate (r=0.726, 0.733; P<0.05). Conclusion: Blood lipid ratio and oxidative stress levels in COPD patients are elevated while antioxidant abilities were attenuated. The lipid ratio and oxidative stress status in COPD patients is closely related to the prognosis of pulmonary hypertension. Therefore, blood lipid ratio and oxidative stress status may be used in evaluation of pulmonary hypertension and prognosis for COPD patients.

Introduction: Little is known about protease, anti-protease markers in chronic obstructive pulmonary disease (COPD) patients. Objectives: The objective of present study was to identify and try to correlate serum markers of protease and anti-protease with pulmonary functions in different stages of patients with COPD and to determine the ratio of neutrophil elastase/alpha-1-antitrypsin in different stages of COPD patients. Methods: This prospective observational study was carried out in patients with stable COPD. Activities of serum alpha-1-antitrypsin and neutrophil elastase were measured in 220 stable COPD patients and in 60 healthy controls by ELISA method. 220 COPD patients were divided into 4 stages according to severity: stage I, II, III and IV. Results: An increase in serum neutrophil elastase and neutrophil elastase/alpha-1-antitrypsin ratio was observed in COPD patients with the advancement of the stage. In contrast to that, decreased activity of alpha-1-antitrypsin in serum was observed in different stages of COPD and is correlated positively with lung function parameters. Conclusion: From these findings we conclude that as the severity increases there is decrease in alpha-1-antitrypsin resulting in concomitant increase in neutrophil elastase activity causing imbalance between protease-antiprotease in COPD patients and this imbalance is associated with impairment of lung function. The neutrophil elastase/ α-1-antitrypsin ratio can tell us the severity of the chronic obstructive pulmonary disease it may be in terms of increased fibrosis of the lung. Though the magnitude of neutrophil elatase/alpha-1-antitrypsin ratio is minute, still it can be a good marker of pulmonary function in term of severity of the COPD.

Chronic obstructive pulmonary disease (COPD) is common in patients with aortic aneurysms. Severe COPD is associated with an increased risk of aneurysm rupture and perioperative complications. This study assesses the outcomes of COPD and non-COPD patients after fenestrated-branched endovascular aortic aneurysm repair (FBEVAR). A single institution, retrospective study of FBEVAR patients between 2011 and 2020 compared outcomes between COPD and non-COPD patients. COPD patients were stratified by Global Initiative for Chronic Obstructive Lung Disease criteria and oxygen dependence. Outcome measures included 30-day mortality, pulmonary complications, major adverse events (MAE), and mid-term survival. 387 patients (71% male, age 72 years, interquartile range [68-79]) underwent FBEVAR. 181 patients (47%) had COPD. Smoking history was more frequent in COPD patients (P = .022). Among COPD patients, 20.4% were oxygen-dependent. Technical success, defined as successful delivery of the main aortic endograft and all intended side branches, was 98.4%. 30-day mortality (P = .83) and MAE rates (P = .87) were similar between groups. While not statistically significant, COPD patients had more frequent pulmonary complications (6.1% vs. 2.4%, P = .13) and were more frequently discharged on oxygen (P = .002). There were no differences in intensive care unit or hospital length of stay between groups (P = .29; P = .85, respectively). 5-year survival was similar between groups (P = .10). Oxygen-dependent COPD and severe-very severe COPD were associated with decreased mid-term survival (Hazard Ratio 2.39, P = .048). FBEVAR is safe and effective for treating complex aortic pathology in COPD patients, including oxygen-dependent patients. Patients with more severe COPD were more frequently discharged on oxygen. Mid-term survival was slightly reduced in patients with oxygen-dependent and severe-very severe COPD. Level 3, non-randomized controlled cohort/follow-up study.

The mechanism responsible for the reversibility of airflow limitation in stable chronic obstructive pulmonary disease (COPD) patients is unknown. The aim of this study is to assess the relationship between the reversibility of airflow limitation, the redox balance and the inflammatory cells in the sputum of patients with stable COPD. For this purpose we examined 15 normal healthy control subjects and 20 nonatopic COPD patients. The COPD patients were divided into two groups: reversible COPD (increase in FEV1> 200 ml and/or > or =12> or = after 200 microg of inhaled salbutamol) or non-reversible COPD. GSH, GSSG were measured in induced sputum and blood. Protein carbonyls were evaluated by WB in sputum and IL-4 and IL-6 and TNF-alpha in plasma and sputum. GSH oxidation and protein oxidation were lower in reversible COPD patients than in those with no reversibility. The sputum eosinophil count was significantly higher in the reversible group than in the non-reversible group, and IL-4 concentration was higher in the same patients both in sputum and in plasma. In contrast, IL-6 and TNF-alpha were increased in non-reversible COPD patients in both biological samples. We conclude that airflow reversibility in COPD patients is associated with airway oxidative stress and activation of eosinophil inflammatory pattern in sputum and blood, suggesting that these patients could respond to specific pharmacological treatment.

Rheumatoid arthritis (RA) is a systemic autoimmune disease that is associated with high degrees of disability and mortality. Patients with RA are generally more prone to a multitude of comorbidities, with hyperlipidemia (HL) one of the most frequently observed. Therefore, the present study investigated the possible association between Chinese herbal medicine (CHM) treatment and the risk of readmission in patients with RA combined with HL (RA-HL). The aim of the present study was to potentially provide an evidence-based strategy for decreasing the risk of readmission in patients with RA-HL. The present study enrolled 839 patients with RA admitted to the First Affiliated Hospital of the Anhui University of Chinese Medicine from June 2014 to June 2015. Subsequently, 425 patients with RA were included into the present study after those with incomplete follow-up and laboratory parameter data were excluded. These 425 patients were then classified into the RA-HL and RA-non-HL groups, before incidences of sex distribution, age group, medication and readmission with propensity score matching were all compared. In total 263 patients with RA-HL were then included and arranged into the CHM and non-CHM groups. In particular, the variables of age, sex and diagnosis year between one patient in the CHM group and one in the non-CHM group were adjusted with propensity score matching to decrease selection bias and interference from confounding factors. Finally, 127 patients with RA-HL were included into the CHM group and 127 patients with RA-HL were allocated into the non-CHM group. The proportion of readmitted patients (including RA-HL and RA-non-HL, RA-CHM and RA-non-CHM) was analyzed and compared using the χ2 test and Kaplan-Meier curves. Bivariate logistics regression analysis was used to evaluate the possible factors that can influence the readmission of patients with RA-HL, whereas the potential association between CHM and improvements in the clinical indicators of the patients with RA-HL was assessed using association rules based on Apriori algorithm. It was found through the follow-up data that patients with RA-HL were at higher risk of readmission compared with that in those with RA-non-HL (P<0.05). The CHM treatments included both oral CHM decoction and Chinese patent medicine, including Xinfeng capsule and Huangqin chubi capsule, which may reduce the risk of readmission and improve the recovery of immune-inflammatory indicators in patients with RA-HL (P<0.05). Overall, CHM, as a protective factor, is associated with a reduced risk of readmission in RA-HL.

Efforts to reduce 30-day readmission have mostly concentrated on addressing deficiencies in care transitions and outpatient management after discharge. There is growing evidence to suggest that physical inactivity is associated with increased hospitalizations. We examined whether or not a potentially modifiable factor such as regular physical activity at baseline was associated with lower risk of 30-day readmission in patients with chronic obstructive pulmonary disease (COPD). Patients from a large integrated health system were included in this retrospective cohort study if they were hospitalized for COPD (following the Centers for Medicare and Medicaid Services and National Quality Forum proposed criteria) and discharged between January 1, 2011 and December 31, 2012, aged 40 years or older, on a bronchodilator or steroid inhaler, alive at discharge, and continuously enrolled in the health plan 12 months before the index admission and at least 30 days post discharge. Our main outcome was 30-day all-cause readmission. Regular physical activity was routinely assessed at the time of all outpatient visits and expressed as the total minutes of moderate or vigorous physical activity (MVPA) per week. The sample included a total of 4,596 patients (5,862 index admissions) with a mean age of 72.3 ± 11 years. The 30-day readmission rate was 18%, with 59% of readmissions occurring in the first 15 days. Multivariate adjusted analyses showed that patients reporting any level of MPVA had a significantly lower risk of 30-day readmission compared with inactive patients (1-149 min/wk of MVPA: relative risk, 0.67; 95% confidence interval, 0.55-0.81; ≥150 min/wk of MVPA: relative risk, 0.66; 95% confidence interval, 0.51-0.87). Other significant independent predictors of increased readmission included anemia, prior hospitalizations, longer lengths of stay, more comorbidities, receipt of a new oxygen prescription at discharge, use of the emergency department or observational stay before the readmission (all, P < 0.05), and being unpartnered (P = 0.08). Our findings further support the importance of physical activity in the management of COPD across the care continuum. Although it is possible that lower physical activity is a reflection of worse disease, promoting and supporting physical activity is a promising strategy to reduce the risk of readmission.

Background: Identifying comorbidities in chronic obstructive pulmonary disease (COPD) may lead to improved disease management, survival and costs. Objective: To compare comorbidities and associated healthcare use between COPD and non-COPD patients. Methods: COPD patients9 medical records data from primary care in Sweden were linked to primary and secondary care national registries information. Data included prescriptions, mortality, income/social characteristics, and pre- and post-COPD diagnosis comorbidities. Comorbidity prevalence was compared between COPD patients and an age-, gender- and calendar year-matched reference population. Healthcare costs were categorized as COPD- and non-COPD related, and comprised drug costs and primary and secondary care visits. Results: There were 17,545 COPD and 84,514 reference group patients. A higher pre-COPD diagnosis comorbidity of asthma (10.1% vs 5.6%), depression (5.0% vs 2.8%), type II diabetes (5.6% vs 3.8%), osteoporosis (1.3% vs 0.7%), fractures (7.5% vs 5.7%), cardiovascular disease (30.2% vs 21.6%), rheumatoid arthritis (1.5% vs 0.9%), and lung cancer (0.4% vs 0.1%) was observed in COPD patients compared with reference patients. Two years post-diagnosis, the comorbidity rate increased for both the COPD and the reference patients, but the proportion of COPD patients with each comorbidity was considerably higher than for the reference patients. Costs of treating COPD comorbidities were higher than COPD-related costs at all time points (e.g. €8,295 vs €620 for non-COPD vs COPD-related hospital nights, respectively, in 2013). Conclusion: Comorbidities are more prevalent in COPD than non-COPD patients and are the major contributor to healthcare costs.

Resistance training and exercise tolerance during high-intensity exercise: moving beyond just running economy and muscle strength.

Allele distribution at a highly polymorphic minisatellite adjacent to the c-Hras1 gene as well as deletions of microsatellite markers, D3S966, D3S1298, D9S171, and a microsatellite within p53 gene, were examined in bronchial epithelium specimens obtained from 53 chronic obstructive pulmonary disease (COPD) patients and healthy donors. A higher frequency of rare Hras1minisatellite alleles in COPD patients than in the individuals without pulmonary pathology (6.6% versus 2.2%; P < 0.05) was shown. This difference was most pronounced in the group of ten COPD patients with idiopathic pulmonary fibrosis. Three of these patients had rare Hras1 minisatellite allele (P < 0.02 in comparison with healthy controls). Alterations in at least one of the microsatellite markers (deletions or microsatellite instability) were detected in bronchial epithelium samples obtained from: 4 of 10 COPD patients with pneumofibrosis (40%); 15 of 43 COPD patients (34.9%) without pneumofibrosis; and 8 of 20 tobacco smokers (40%) without pulmonary pathology. These defects were not observed in the analogous samples obtained from healthy nonsmoking individuals. No statistically significant differences were revealed between COPD patients and healthy smokers upon comparison of both the total number of molecular defects and the number of defects in the individual chromosomal loci. The total number of molecular defects revealed in bronchial epithelium samples from the individuals of two groups examined correlated with the intensity of exposure to tobacco smoke carcinogens (r = 0.28; P < 0.05). These findings suggest that rare alleles at theHras1 locus may be associated with hereditary predisposition to COPD and the development of pneumofibrosis, while mutations in microsatellite markers result from exposure to tobacco smoke carcinogens and are not associated with the appearance of these pathologies.

Objective To explore the relationship between fat-free mass (FFM) and peak exercise performance in chronic obstructive pulmonary disease(COPD) patients. Methods 26 healthy subjects and 62 stable COPD patients performed incremental cardiopulmonary exercise testing with cycle ergometer. 62stable COPD patients were divided three groups(mild COPD,moderate COPD,severe COPD) according to FEV1%pred, peakVO2, peakLoad, peakO2 pulse, AT were measured during exercise. FFM and routine subjects, peakVO2 ,peakVO2 %pred,peakLoad,peakLoad%pred,peakO2 pulse,peakO2 pulse% pred and AT peakLoad%pred,AT and peakO2 pulse% pred ( r =0. 671,0. 478,0. 423,0. 618, P＜0. 05) in COPD patients.Conclusions FFM is significantly associated with muscle aerobic capacity and exercise tolerance in COPD patients. Key words: Fat-free mass; Chronic obstructive pulmonary disease; Cardiopulmonary exercise testing

Exhaled breath condensate levels of 8-isoprostane, growth related oncogene α and monocyte chemoattractant protein-1 in patients with chronic obstructive pulmonary disease

The aim of this study was to evaluate the effects of pneumoperitoneum and patient positioning on respiratory mechanics and blood gases in chronic obstructive pulmonary disease (COPD) patients during laparoscopic Nissen fundoplication. After the approval of the Ethical Committee, 32 patients were divided into 2 groups as COPD patients (n=16) and normal patients (n=16). Dynamic respiratory compliance (Cdyn), airway resistance, and peak inspiratory pressure were monitored. Measurements were made in 5 time points: after intubation (intubation), Trendelenburg position (Trendelenburg), during laparoscopic Nissen fundoplication surgery after pneumoperitoneum with the Fowler position (Fowler), right before the desufflation with Fowler position (Fowler-end), and after the desufflation in supine position (supine). Samples of arterial blood gases were collected at the same periods. At all periods, there was a significant decrease in Cdyn and arterial oxygen pressure in 2 groups. Although pneumoperitoneum did not exist during Trendelenburg position, the Cdyn (38+/-13 mL cm H2O(-1)) found to be significantly decreased in COPD patients. In 2 groups, the lowest Cdyn value detected during the Fowler-end period was 43+/-8 mL cm H2O(-1) in control group and 34+/-11 mL cm H2O(-1) in COPD group. Whereas the pH decreased at Fowler, Fowler-end, and supine period, arterial carbon dioxide pressure increased (P<0.05). There was no difference for the other parameters. In COPD patients, Trendelenburg position has negative effect on respiratory mechanics. Pneumoperitoneum and other positions have similar effect on respiratory mechanics in COPD and control patients.

To investigate how virtual admission during acute exacerbation influences self-efficacy in patients with chronic obstructive pulmonary disease, compared with conventional hospital admission. Telemedicine solutions have been highlighted as a possible way to increase self-efficacy in patients with chronic diseases, such as chronic obstructive pulmonary disease. However, little is known about how telemedicine-based virtual admission as a replacement of hospital admission during acute exacerbation affects chronic obstructive pulmonary disease patients' self-efficacy. This study was a nonblinded, randomised clinical multicentre trial. The study was a substudy to The Virtual Hospital, investigating the feasibility and safety of telemedicine-based treatment at home for patients with acute exacerbation of chronic obstructive pulmonary disease. Participants were consecutively randomised to virtual admission or conventional hospital admission. Data from 50 patients were analysed. Self-efficacy was assessed at baseline, three days after discharge, and also six weeks and three months after discharge, using the Danish version of 'The chronic obstructive pulmonary disease self-efficacy scale'. Intergroup comparison showed no significant differences between the two groups at baseline, three days after discharge, six weeks after discharge or three months after discharge. Furthermore, intragroup comparison did not reveal significant differences in the chronic obstructive pulmonary disease self-efficacy scale mean sum score within the two groups. The results of the study suggest that there is no difference between self-efficacy in chronic obstructive pulmonary disease patients undergoing virtual admission, compared with conventional hospital admission. However, the anticipated sample size could not be reached, which prompts caution regarding interpretation of the findings. This study provides new insight into how virtual admission affects chronic obstructive pulmonary disease patients' self-efficacy. Clinicians should consider the timing, duration and the content in the design of telemedical interventions directed at improving chronic obstructive pulmonary disease patients' self-efficacy, as telemedicine solutions alone may not be sufficient to enhance self-efficacy.

<b>Introduction:</b> Heart Failure (HF) and Chronic Obstructive Pulmonary Disease (COPD) patients have an endothelium function imbalance. Cachexia and phase angle are associated with a worse prognosis in this patients and there exists few body composition evidence. <b>Objectives:</b> To evaluate body composition in subjects with HF and COPD compared with COPD subjects. <b>Methods:</b> A Cross – sectional study, 77 subjects older than 18 years olds, with confirmed HF and / or COPD diagnosis, and those who attend to outpatient visits were included. Asthma subjects were excluded. Body composition were assessed by BIVA, endothelial function by photopletysmography. <b>Results:</b> Were randomized 77 patients, mean age 71.2 ± 11.57 years, 69.43% with COPD and 30.57% HF and COPD. Subjects with HF and COPD had higher prevalence of diabetes (21.6 vs 9.5, p= 0.07), pulmonary hypertension ( 29.7 vs 9.5, p= 0.005), obstructive sleep apnea syndrome (35.1 vs 10.7, p= 0.001) compared to subjects with COPD alone. There were not significative difference in other variables. In body composition the prevalence of cachexia were 57.1% in both groups, 20.8% obesity and normal composition 22.1%. Subjects with HF and COPD had a lower phase angle (4.15 ± 1.2 vs 4.73 ± 0.89, p= 0.05) and higher endothelial dysfunction (0.361± 0.086 vs 0.325 ± 0.064, p= 0.035) than COPD subjects. Respect to fluid body distribution subjects with HF and COPD reported low total body water (46 ± 8.23 vs 51.06 ± 8.64, p=0.019) and higher extracellular water (3.12 vs 3.03, p= 0.006) compared to COPD subjects. <b>Conclusions:</b> The body composition with subjects with HF and COPD showed a high deterioration that can lead to a worse condition.

Respiratory disorders in sulfur mustard (SM)-exposed and chronic obstructive pulmonary disease (COPD) patients are mostly associated with neutrophilic inflammation, severe airflow limitation, and oxidative stress. The objective of this study was to establish whether neutrophil (PMN) proteomes in these diseases were similar or differed. Blood neutrophil proteomes from healthy, SM-exposed, and COPD subjects were analyzed using two-dimensional gel electrophoresis followed by matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI TOF MS). Elastase activity was determined kinetically. The results showed that levels of S100 calcium-binding protein (CBP) A12, S100 CBP A8, glyceraldehyde-3-phosphate dehy-drogenase, superoxide dismutase, and protein disulfide isomerase proteins – as well as elastase activity – were significantly increased in PMN from ‘diseased’ hosts compared to in cells from healthy controls. In contrast, coactosin-like protein, RhoGDP dissociation inhibitor, and actin isoforms were significantly decreased in diseased subjects’ PMN compared to PMN of healthy controls. Moreover, serpin B1 and coronin-1A were expressed only in PMN of the healthy subjects. Lastly, S100 CBP A9, endoplasmic reticulum (ER)-60 protease, and glutathione-S-transferase isoforms were differentially expressed in the cells from the SM-exposed and COPD subjects. These results show that serpin B1, an efficient inhibitor of neutrophil serine proteases, was not detectable, and elastase activity significantly increased in PMN from both SM-exposed and COPD patients. It seems that, apart from inflammation and oxidative stress, a protease:anti-protease imbalance exists within PMN of both COPD and SM-exposed patients.