Hospital admissions due to chronic obstructive pulmonary disease (COPD) exacerbations have a major impact on the disease evolution and costs. The current authors postulated that a simple and well-standardised, low-intensity integrated care intervention can be effective to prevent such hospitalisations. Therefore, 155 exacerbated COPD patients (17% females) were recruited after hospital discharge from centres in Barcelona (Spain) and Leuven (Belgium). They were randomly assigned to either integrated care (IC; n565; age mean¡SD 70¡9 yrs; forced expiratory volume in one second (FEV1) 1.1¡0.5 L, 43% predicted) or usual care (UC; n590; age 72¡9 yrs; FEV1 1.1¡0.05 L, 41% pred). The IC intervention consisted of an individually tailored care plan upon discharge shared with the primary care team, as well as accessibility to a specialised nurse case manager through a web-based call centre.After 12 months' follow-up, IC showed a lower hospitalisation rate (1.5¡2.6 versus 2.1¡3.1) and a higher percentage of patients without re-admissions (49 versus 31%) than UC without differences in mortality (19 versus 16%, respectively).In conclusion, this trial demonstrates that a standardised integrated care intervention, based on shared care arrangements among different levels of the system with support of information technologies, effectively prevents hospitalisations for exacerbations in chronic obstructive pulmonary disease patients.

The 6-min walk distance (6MWD) predicted values have been derived from small cohorts mostly from single countries. The aim of the present study was to investigate differences between countries and identify new reference values to improve 6MWD interpretation.We studied 444 subjects (238 males) from seven countries (10 centres) ranging 40-80 yrs of age. We measured 6MWD, height, weight, spirometry, heart rate (HR), maximum HR (HRmax) during the 6-min walk test/the predicted maximum HR (HRmax % pred), Borg dyspnoea score and oxygen saturation.The mean¡SD 6MWD was 571¡90 m (range 380-782 m). Males walked 30 m more than females (p,0.001). A multiple regression model for the 6MWD included age, sex, height, weight and HRmax % pred (adjusted r 2 50.38; p,0.001), but there was variability across centres (adjusted r 2 50.09-0.73) and its routine use is not recommended. Age had a great impact in 6MWD independent of the centres, declining significantly in the older population (p,0.001). Age-specific reference standards of 6MWD were constructed for male and female adults. In healthy subjects, there were geographic variations in 6MWD and caution must be taken when using existing predictive equations. The present study provides new 6MWD standard curves that could be useful in the care of adult patients with chronic diseases.

It was postulated that home hospitalisation (HH) of selected chronic obstructive pulmonary disease (COPD) exacerbations admitted at the emergency room (ER) could facilitate a better outcome than conventional hospitalisation.To this end, 222 COPD patients (3.2% female; 71¡10 yrs (mean¡SD)) were randomly assigned to HH (n=121) or conventional care (n=101). During HH, integrated care was delivered by a specialised nurse with the patient9s free-phone access to the nurse ensured for an 8-week follow-up period.Mortality (HH: 4.1%; controls: 6.9%) and hospital readmissions (HH: 0.24¡0.57; controls: 0.38¡0.70) were similar in both groups. However, at the end of the follow-up period, HH patients showed: 1) a lower rate of ER visits (0.13¡0.43 versus 0.31¡0.62); and 2) a noticeable improvement of quality of life (D St George9s Respiratory Questionnaire (SGRQ), -6.9 versus -2.4). Furthermore, a higher percentage of patients had a better knowledge of the disease (58% versus 27%), a better self-management of their condition (81% versus 48%), and the patient9s satisfaction was greater. The average overall direct cost per HH patient was 62% of the costs of conventional care, essentially due to fewer days of inpatient hospitalisation (1.7 ¡ 2.3 versus 4.2 ¡ 4.1 days).A comprehensive home care intervention in selected chronic obstructive pulmonary disease exacerbations appears as cost effective. The home hospitalisation intervention generates better outcomes at lower costs than conventional care.

This IC trial improved disease knowledge, and treatment adherence, after 1 year of intervention, suggesting that these factors may play a role in the prevention of severe COPD exacerbations triggering hospital admissions.

The 6-min walking test (6MWT) is frequently used to assess functional capacity in chronic cardiopulmonary disorders because of its simplicity. The study examines the physiological responses during encouraged 6MWT in patients with chronic obstructive pulmonary disease.Pulmonary oxygen (O 2 ) uptake (V9O 2 ) was measured in 20 male patients (age 66¡6 yrs, forced expiratory volume in one second 45¡14% predicted) during 6MWT and incremental cycling, in random order. O 2 tension in arterial blood, carbon dioxide tension in arterial blood and arterial lactate concentration ([La]art) were obtained in the last 10 patients. During the 6MWT, V9O 2 showed a plateau after the 3rd min (1.39 ¡ 0.28, 1.42 ¡ 0. The study demonstrates that an encouraged 6-min walking test generates a high but sustainable oxygen uptake. Since the oxygen uptake plateau reflects the integrated response of the system, it may explain the high prognostic value of the 6-min walking test. Eur Respir J 2002; 20: 564-569.

Study objectives:In patients with moderate-to-severe COPD, an encouraged 6-min walking test (6MWT) is a high-intensity submaximal exercise protocol that shows an oxygen uptake (V O 2 ) plateau after the third minute of the test. This last feature prompted the hypothesis that self-paced walking speed is set to achieve "maximal" sustainable V O 2 , namely "critical power" or "critical speed. Key words: COPD; critical power; exercise testing; exercise tolerance; 6-min walking test; sustainable submaximal exerciseAbbreviations: ANOVA ϭ analysis of variance; 6MWT ϭ 6-min walking test; 6MWT-10 ϭ 6-min walking test carried out in a 10-m course; 6MWT-90 ϭ 6-min walking test carried out in a 90-m course; CWS ϭ critical walking speed; GOLD ϭ Global Initiative for Chronic Obstructive Lung Disease; HR ϭ heart rate; L 1 ϭ 90% of the peak walking speed; L 2 ϭ 95% of the peak walking speed; L 3 ϭ 100% of the peak walking speed; L 4 ϭ 105% of the peak walking speed; RER ϭ respiratory exchange ratio; V co 2 ϭ carbon dioxide output; V e ϭ minute ventilation; V o 2 ϭ oxygen uptake; V o 2 peak ϭ peak oxygen uptake

BackgroundInadequate glucose control may be simultaneously associated with inflammation and decreased lung function in type 2 diabetes. We evaluated if lung function is worse in patients with inadequate glucose control, and if inflammatory markers are simultaneously increased in these subjects.MethodsSubjects were selected at the Colombian Diabetes Association Center in Bogotá. Pulmonary function tests were performed and mean residual values were obtained for forced expiratory volume (FEV1), forced vital capacity (FVC) and FEV1/FVC, with predicted values based on those derived by Hankinson et al. for Mexican-Americans. Multiple least-squares regression was used to adjust for differences in known determinants of lung function. We measured blood levels of glycosylated hemoglobin (HBA1c), interleukin 6 (IL-6), tumor necrosis factor (TNF-α), fibrinogen, ferritin, and C-reactive protein (C-RP).Results495 diabetic patients were studied, out of which 352 had inadequate control (HBA1c > 7%). After adjusting for known determinants of lung function, those with inadequate control had lower FEV1 (-75.4 mL, IC95%: -92, -59; P < 0.0001) and FVC (-121 mL, IC95%: -134, -108; P < 0,0001) mean residuals, and higher FEV1/FVC (0.013%, IC95%: 0.009, 0.018, P < 0.0001) residuals than those with adequate control, as well as increased levels of all inflammatory markers (P < 0.05), with the exception of IL-6.ConclusionsSubjects with type 2 diabetes and inadequate control had lower FVC and FEV1 than predicted and than those of subjects with adequate control. It is postulated that poorer pulmonary function may be associated with increased levels of inflammatory mediators.

BackgroundThis study assessed the adherence profiles to inhaled therapies and the agreement between two patient self-report adherence methods in stable COPD lpatients from seven Latin American countries.MethodsThis observational, cross-sectional, multinational, multicenter study involved 795 COPD patients (post-bronchodilator forced expiratory volume in 1 second/forced vital capacity [FEV1/FVC] <0.70). Adherence to inhaled therapy was assessed using the specific Test of Adherence to Inhalers (10-item TAI) and the generic 8-item Morisky Medication Adherence Scale (MMAS-8) questionnaires. The percentage agreement and the kappa index were used to compare findings.Results59.6% of patients were male (69.5±8.7 years); post-bronchodilator FEV1 percent predicted was 50.0±18.6%. Mean values for 10-item TAI and MMAS-8 questionnaires were 47.4±4.9 and 6.8±1.6, respectively. Based on the TAI questionnaire, 54.1% of patients had good, 26.5% intermediate, and 19.4% poor adherence. Using the MMAS-8 questionnaire, 51% had high, 29.1% medium, and 19.9% low adherence. According to both questionnaires, patients with poor adherence had lower smoking history, schooling but higher COPD Assessment Test score, exacerbations in the past-year and post-bronchodilator FEV1. The agreement between 10-item TAI and MMAS-8 questionnaires was moderate (Kappa index: 0.42; agreement: 64.7%).ConclusionSuboptimal adherence to medication was frequent in COPD patients from Latin America. Low adherence was associated with worse health status impairment and more exacerbations. There was inadequate agreement between the two questionnaires. Greater effort should be made to improve COPD patients’ adherence to treatment, and assessment of adherence with more specific instruments, such as the TAI questionnaire, would be more convenient in these patients.Clinical Trial RegistrationNCT02789540