With the looming expansion of the elderly population of the US, a thorough understanding of “normal” aging-related changes on the respiratory system is paramount. The respiratory system undergoes various anatomical, physiological and immunological changes with age. The structural changes include chest wall and thoracic spine deformities which impairs the total respiratory system compliance leading to increase work of breathing. The lung parenchyma loses its supporting structure causing dilation of air spaces: “senile emphysema”. Respiratory muscle strength decreases with age and can impair effective cough, which is important for airway clearance. The lung matures by age 20–25 years, and thereafter aging is associated with progressive decline in lung function. The alveolar dead space increases with age, affecting arterial oxygen without impairing the carbon dioxide elimination. The airways receptors undergo functional changes with age and are less likely to respond to drugs used in younger counterparts to treat the same disorders. Older adults have decreased sensation of dyspnea and diminished ventilatory response to hypoxia and hypercapnia, making them more vulnerable to ventilatory failure during high demand states (ie, heart failure, pneumonia, etc) and possible poor outcomes.

BACKGROUND National and population-based information on the increase in patient care by hospitalists in the United States is lacking. METHODS Using a 5% sample of Medicare beneficiaries in 1995, 1997, 1999, and the period from 2001 through 2006, we identified 120,226 physicians in general internal medicine who were providing care to older patients in 5800 U.S. hospitals. We defined hospitalists as general internists who derived 90% or more of their Medicare claims for evaluation-and-management services from the care of hospitalized patients. We then calculated the percentage of all inpatient Medicare services provided by hospitalists and identified patient and hospital characteristics associated with the receipt of hospitalist services. RESULTS The percentage of physicians in general internal medicine who were identified as hospitalists increased from 5.9% in 1995 to 19.0% in 2006, and the percentage of all claims for inpatient evaluation-and-management services by general internists that were attributed to hospitalists increased from 9.1% to 37.1% during this same period. Accompanying the increase in care by hospitalists was an increase in the percentage of all hospitalized Medicare patients who were treated by general internists (both hospitalists and traditional, non–hospital-based general internists), from 46.4% in 1995 to 61.0% in 2006. In a multilevel, multivariable analysis controlling for patient and hospital characteristics, the odds of receiving care from a hospitalist increased by 29.2% per year from 1997 through 2006. In 2006, there was marked geographic variation in the rates of care provided by hospitalists, with rates of more than 70% in some hospital-referral regions. CONCLUSIONS These analyses of data from Medicare claims showed a substantial increase in the care of hospitalized patients by hospitalist physicians from 1995 to 2006.

Background Readmissions in patients with chronic obstructive pulmonary disease (COPD) are common and costly. We examined the effect of early follow-up visit with patient’s primary care physician (PCP) or pulmonologist following acute hospitalization on the 30-day risk of an emergency department (ER) visit and readmission. Methods We conducted a retrospective cohort study of fee-for-service Medicare beneficiaries with an identifiable PCP who were hospitalized for COPD between 1996 and 2006. Three or more visits to a PCP in the year prior to the hospitalization established a PCP for a patient. We performed a Cox proportional hazard regression with time-dependent covariates to determine the risk of 30-day ER visit and readmission in patients with or without a follow-up visit to their PCP or pulmonologist. Results Of the 62 746 patients admitted for COPD, 66.9% had a follow-up visit with their PCP or pulmonologist within 30 days of discharge. Factors associated with lower likelihood of outpatient follow-up visit were longer length of hospital stay, prior hospitalization for COPD, older age, black race, lower socioeconomic status, and emergency admission. Those receiving care at nonteaching, for-profit, and smaller-sized hospitals were more likely to have a follow-up visit. In a multivariate, time-dependent analysis, patients who had a follow-up visit had a significantly reduced risk of an ER visit (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.83–0.90) and readmission (HR, 0.91; 95% CI, 0.87–0.96). Conclusion Continuity with patient’s PCP or pulmonologist after an acute hospitalization may lower rates of ER visits and readmission in patients with COPD.

Obesity is a worldwide epidemic and is known to increase the risk of cardiovascular disease, type 2 diabetes, and certain forms of cancer. In addition, obesity is now recognized as an important risk factor in the development of several respiratory diseases. Of these respiratory diseases, it has already been well established that obesity can lead to obstructive sleep apnea (OSA) and obesity-hypoventilation syndrome (OHS). More recent data suggest that the prevalence of wheezing and bronchial hyper-responsiveness, two symptoms often associated with asthma, are increased in overweight and obese individual. Indeed, epidemiological studies have reported that obesity is a risk factor for the development of asthma. Furthermore, a number of studies indicate that obesity is also associated with a higher risk of developing deep vein thrombi, pulmonary emboli, pulmonary hypertension, and pneumonia. Finally, weight reduction has been shown to be effective in improving the symptoms and severity of several respiratory diseases, including OSA and asthma. Thus, overweight and obese patients should be encouraged to lose weight to reduce their risk of developing respiratory diseases or improve the course of pre-existing conditions.

One of 11 patients hospitalized with COPD is readmitted within 30 days of discharge. Provider and system factors are important modifiable risk factors of early readmission.

Background: Low peak inspiratory flow rate (PIFR) (<60 L/min) among patients with chronic obstructive pulmonary disease (COPD) may result in ineffective medication inhalation, leading to poor bronchodilation. Objective: The objectives of this analysis were to evaluate the prevalence of low PIFR at the time of discharge from a COPD-related hospitalization and to examine the real-world treatment patterns and rehospitalizations by PIFR. Methods: Patients at 7 sites in the United States were screened for enrollment at hospital discharge. PIFR was measured using the InCheck TM DIAL to simulate resistance of the DISKUS® dry powder inhaler (DPI). An equal number of patients were enrolled into low PIFR (<60 L/min) or normal PIFR (≥60 L/min) cohorts. Demographics, COPD-related clinical characteristics, health status, treatment and rehospitalization data were collected. Results: Mean PIFR was 71±22.12 L/min among 268 screened patients; 31.7% (n=85) of patients had low PIFR. Among all enrolled patients (n=170), the low PIFR cohort was older (66.2±10.04 years versus 62.1±9.41 years, p=0.006) and more likely to be female (61.2% versus 42.4%, p=0.014). There was an increase in DPI use at discharge, compared with admission, in the low PIFR cohort (62.4% versus 70.6%, p=0.020). The incidences of allcause rehospitalization up to 180 days were similar between the low and normal PIFR cohorts. Conclusions: At discharge following hospitalization for an exacerbation of COPD, approximately one-third of patients had a PIFR <60 L/min. More patients with a low PIFR were discharged with a DPI medication compared with use at admission. There was no difference in the rehospitalization rates by PIFR. AbstractAbbreviations: peak inspiratory flow rate, PIFR; chronic obstructive pulmonary disease, COPD; dry powder inhaler, DPI; metered dose inhalers, MDI; soft mist inhalers, SMI; modified Medical Research Council, mMRC; COPD Assessment Test, CAT; Morisky Medication Adherence Scale, MMAS; forced expiratory volume in 1 second, FEV 1 ; forced vital capacity, FVC; body mass index, BMI; length of stay, LOS; short-acting beta-agonist, SABA; short-acting muscarinic antagonist, SAMA; long-acting muscarinic antagonist, LAMA; long-acting beta2-agonist, LABA; inhaled corticosteroids, ICS

Background: NEIL2 (Nei-like 2) is a mammalian oxidized base-specific DNA glycosylase. Results: Neil2-null mice accumulate oxidative damage in transcribed genes and are susceptible to inflammatory agents. Conclusion:In long-lived species, NEIL2 plays a critical role in maintaining genomic integrity and tissue homeostasis. Significance: We provide in vivo evidence for NEIL2's role in preferential repair of oxidized bases in active genes in mammals.

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