Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of osteoporosis. However, the prevalence, correlates and effectiveness of treatment of osteoporosis in COPD patients remain unclear.We performed a systematic review of the literature to answer three questions. 1) What is the prevalence of osteoporosis in COPD? 2) What are identified correlates of osteoporosis in COPD? 3) What are the effects of treatment of osteoporosis in COPD? A computerised literature search in MEDLINE/PubMed and the Cochrane database was carried out. In addition, reference lists were searched by hand and authors were contacted if necessary.The prevalence of osteoporosis and osteopenia varied 9-69% and 27-67%, respectively. Prevalence of osteoporosis was generally higher than in healthy subjects and some other chronic lung diseases. Correlates of osteoporosis in COPD are mainly measures of body composition, disease severity and the use of corticosteroids, although causality has not been proven. Effects of treatment of osteoporosis have not been investigated in samples consisting of COPD patients only.Longitudinal follow-up to assess determinants of osteoporosis in COPD and randomised placebo-controlled trials on the effects of treatment of osteoporosis in patients with COPD only are warranted.

The aim of the present study was to profile a multidimensional response to pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD).Dyspnoea, exercise performance, health status, mood status and problematic activities of daily life were assessed before and after a 40-session pulmonary rehabilitation programme in 2068 patients with COPD (mean forced expiratory volume in 1 s of 49% predicted). Patients were ordered by their overall similarity concerning their multidimensional response profile, which comprises the overall response on MRC dyspnoea grade, 6MWD, cycle endurance time, Canadian Occupational Performance Measure performance and satisfaction scores, Hospital Anxiety and Depression Scale anxiety and depression, and St George's Respiratory Questionnaire total score, using a novel non-parametric regression technique.Patients were clustered into four groups with distinct multidimensional response profiles: n=378 (18.3%; "very good responder"), n=742 (35.9%; "good responder"), n=731 (35.4%; "moderate responder"), and n=217 (10.5%; "poor responder"). Patients in the "very good responder" cluster had higher symptoms of dyspnoea, number of hospitalisations <12 months, worse exercise performance, worse performance and satisfaction scores for problematic activities of daily life, more symptoms of anxiety and depression, worse health status, and a higher proportion of patients following an inpatient PR programme compared to the other three clusters.A multidimensional response outcome needs to be considered to study the efficacy of pulmonary rehabilitation services in patients with COPD, as responses to regular outcomes are differential within patients with COPD. @ERSpublications Efficacy of pulmonary rehabilitation in patients with COPD needs to be assessed using a multidimensional response http://ow.ly/RsfYK

Background: With the rising mean age, more patients will be diagnosed with one or more other serious diseases at the time of lung cancer diagnosis. Little is known about the best way to treat elderly patients with comorbidity or the outcome of treatment. This study was undertaken to evaluate the independent effects of age and comorbidity on treatment and prognosis in patients with non-small cell lung cancer (NSCLC). Methods: All patients with NSCLC diagnosed between 1995 and 1999 in the southern part of the Netherlands (n = 4072) were included. Results: The proportion of patients with localised NSCLC who underwent surgery was 92% in patients younger than 60 years and 9% in those aged 80 years or older. In patients aged 60-79 years this proportion also decreased with comorbidity. In patients with non-localised NSCLC the proportion receiving chemotherapy was considerably higher for those aged less than 60 years (24%) than in those aged 80 or older (2%). The number of comorbid conditions had no significant influence on the treatment chosen for patients with non-localised disease. Multivariable survival analyses showed that age, tumour size, and treatment were independent prognostic factors for patients with localised disease, and stage of disease and treatment for those with non-localised disease. Comorbidity had no independent prognostic effect. Conclusions: It is questionable whether the less aggressive treatment of elderly patients with NSCLC is justified.

One of the extrapulmonary effects of chronic obstructive pulmonary disease (COPD) is osteoporosis. Osteoporosis is characterized by a low bone mineral density (BMD) and microarchitectural deterioration. Most studies in COPD patients use dual-energy X-ray absorptiometry (DXA) only to determine osteoporosis; therefore, microarchitectural changes without a low BMD are missed. The aim of this study was to determine the prevalence and correlates of osteoporosis in COPD patients based on DXA, spinal X-rays, and combinations thereof. DXA and spinal X-rays were obtained and pulmonary function tests, body composition, 6-minute walking distance, medical history, and medication use were assessed in 255 clinically stable COPD outpatients of a large teaching hospital in the Netherlands. Half of all patients had radiologic evidence of osteoporosis. Combining the results of DXA with spinal X-rays augmented the proportion of COPD patients with osteoporosis compared with both methods separately. The prevalence of osteoporosis was not significantly different after stratification for Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) stage. Most patients with osteoporosis did not receive pharmacologic treatment. Age, body mass index (BMI), and parathyroid hormone (PTH) level were significant independent correlates for osteoporosis. Chest physicians should be aware of the high prevalence of osteoporosis in patients with COPD, even in the presence of a low GOLD score, as well as especially in elder COPD patients with a low BMI and/or an increased PTH level. ß

Objective: To investigate whether for patients with incurable cancer comprehensive home care programmes are more effective than standard care in maintaining the patients' quality of life and reducing their "readmission time" (percentage of days spent in hospital from start of care till death). Design: Systematic review. Methods: A computer aided search was conducted using the databases of Medline, Embase, CancerLit, and PsychLit. The search for studies and the assessment of the methodological quality of the relevant studies were performed by two investigators, blinded from each other. Prospective, controlled studies investigating the effects of a home care intervention programme on patients' quality of life or on readmission time were included in the analyses.

The majority of COPD patients with osteoporosis entering pulmonary rehabilitation did not receive pharmacological treatment for osteoporosis. Cachectic COPD patients should be screened for osteoporosis, especially when over 55 years of age.

Lucas AEM, Smeenk FWJM, Smeele IJ and van Schayck CP. Overtreatment with inhaled corticosteroids and diagnostic problems in primary care patients, an exploratory study. Family Practice 2008; 25: 86-91.Background. Underdiagnosis and undertreatment of patients with asthma or chronic obstructive pulmonary disease are widely discussed in the literature. Not much is known about the possible overdiagnosis and consequently the overtreatment with inhaled corticosteroids (ICS). Aim. This study investigates how often ICS are prescribed without a proper indication and how big the diagnostic problem is caused by inappropriate prescription and use of ICS.Methods. All patients referred to a primary care diagnostic centre during 6 months who used ICS without a clear indication were included. Their GPs were questioned about the reasons for prescribing ICS. If still no diagnosis could be assessed, GPs were advised to stop ICS and renew spirometry after a steroid-free period of at least 3 months. After 1 year, the use of ICS was evaluated and the diagnoses were reassessed.Results. Of all referred patients (2271), 1171 used ICS, 505 (30%) without a clear indication. After 1 year, final results showed that 11% of all patients originally using ICS had no indication to use ICS and had successfully ceased using this mediation. For 15%, the reasons for using ICS remained unclear.Conclusions. Overtreatment with ICS in primary care seems to be considerable, which falsely labels patients as asthmatic and which generates unnecessary costs and possible side effects. The awareness of GPs of the need for proper diagnostic testing before prescribing ICS needs to be improved. Overtreatment with ICS in primary care patients can be diminished by systematically supporting the GP in the diagnostic procedures and decision making.

The majority of COPD patients had vitamin D deficiency. Plasma 25(OH)D concentration was positively associated with bone density and exercise capacity. Intervention studies are necessary to determine whether vitamin D supplementation is of benefit in the prevention or treatment of osteoporosis and poor exercise capacity in patients with COPD.