Complexity of patients with chronic obstructive pulmonary disease hospitalized in internal medicine: a survey by FADOI

Chronic obstructive pulmonary disease (COPD) is one of the most frequent pathologies among patients hospitalized in Internal Medicine (IM) Departments. COPD is frequently associated with concomitant diseases, which represent major causes of death, and affect disease management. Objectives of our study are to assess the prevalence of COPD patients in IM, to evaluate their comorbidity status, and to describe their complexity, by means of the validated multidimensional prognostic index (MPI) score. COMPLEXICO is an observational, prospective, multicenter study, enrolling consecutive patients hospitalized for any cause in IM, with diagnosis of COPD documented by spirometry. A total of 1002 patients in 43 IM Units in Italy were enrolled. The prevalence of COPD in IM was found to be 18.1%, and 72.8% of patients had at least three chronic diseases other than COPD. The mean MPI was 0.43±0.15, and according to a stratification algorithm 31.8% of patients were classified as having low-risk, 58.9% moderate-risk and 9.3% severe-risk of adverse outcome. More than two-thirds of COPD patients in our study present moderate to severe risk of poor outcome according to the MPI stratification

Long term therapy and outcome of chronic obstructive pulmonary disease with or without co-morbidity: the TORCH study

BACKGROUND COPD affects over 5% of the adult population, and it is the only major cause of mortality that is increasing worldwide. Patients with COPD don’t die usually of respiratory failure: indeed lung cancer and cardiovascular diseases are the leading causes of mortality in patients with mild to moderate COPD. Pulmonary and systemic inflammations are prominent. Inhaled corticosteroids have little effect on the rate of decline of lung function, but they reduce the frequency of exacerbations, especially when combined with an inhaled long-acting beta-agonist. AIM OF THE STUDY The combination of the long-acting beta-agonist salmeterol (SM) and the inhaled corticosteroid fluticasone propionate (FP) would reduce mortality among patients with COPD, as compared with usual care. The primary end-point was the time to death from any cause by 3 years. Secondary end-points were the frequency of exacerbations and health status. PATIENTS AND METHODS Of 8,554 patients recruited, 6,184 underwent randomization; the mean age was 65 years, and the mean value of postbronchodilator FEV1 was 44% of the predicted value. This double-blind study was conducted in 444 centers of 42 countries. After a 2-week run-in period, eligible patients were randomly assigned to treatment with the combination of SM at a dose of 50 μg and FP at a dose of 500 μg or SM alone at a dose of 50 μg, FP alone at a dose of 500 μg, or placebo, all taken as a dry powder with the use of an inhaler bid for 3 years. RESULTS There were 875 deaths within 3 years after randomization. The proportions of deaths from any cause at 3 years were 12.6% in the combination therapy group, 15.2% in the placebo group, 13.5% in the SM group, and 16.0% in the FP group. The absolute risk reduction for death in the combination-therapy group as compared with the placebo group was 2.6%, and the hazard ratio was 0.825 (95% confidence interval [CI], 0.681 to 1.002; p = 0.052), corresponding to a reduction in the risk of death at any time in the 3 years of 17.5% (95% CI, –0.2 to 31.9). DISCUSSION In this trial, the reduction in mortality from any cause did not meet the level of statistical significance (p = 0.052), but the treatment with the combination regimen resulted in significantly fewer exacerbations and improved health status and lung function, as compared with placebo. Mortality could be influenced mainly by factors unresponsive to the study drugs, or it is possible that this study was underpowered to detect this effect. There was also a high withdrawal rate, which was highest among patients in the placebo group. CONCLUSIONS Even though p = 0.052 is not statistically significant, 126 deaths for every 1,000 treated in the combination-therapy group, after 3 years, instead of 152 in the placebo group, is anyway an important result? Further investigation is needed in future large, prospective trials

When to use and not to use spirometry in patients admitted to the internal medicine wards for the diagnosis of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is one of the main causes for admission to an internal medicine ward, due to exacerbations of the disease itself or to comorbidities leading to dyspnea as an intriguing symptom. In many cases, a diagnosis of COPD is made only on clinical grounds, but well-accepted guidelines strongly suggest measuring the lung function to diagnose and stage such a common disease. Problems with the equipment, its use and data interpretation lead to underuse spirometry in general and in patients in internal medicine in particular

From Internal Wards to Intensive Care Units and backwards: the paths of the difficult patient

Sepsis-induced organ dysfunction may be occult; therefore, its presence should be considered in any patient presenting with infection. Conversely, unrecognized infection may be the cause of new-onset organ dysfunction. Any unexplained organ dysfunction should thus raise the possibility of underlying infection. Severe sepsis is a heterogeneous clinical entity with a wide spectrum of manifestations and severity, and over half of patients never receive care in an Intensive Care Unit (ICU). Due to ageing of the population, patients with severe sepsis are frequently admitted to general wards and, given the standard diagnostic approach, treatment must be tailored to the single patient, taking into account the burden of comorbidities. From Internal Medicine Wards the single patient could be transferred to ICU, but again admitted to our Units, due to his/her frailty, to complete the path of cure. First of all, we have to be aware of the illness and more, according to the recent literature, that, generally speaking, limits invasiveness, to be able to take care of this kind of patients