The step-up protocol increases clinical pregnancy rates compared with the step-down in patients with unexplained infertility. A randomized controlled trial

Unexplained infertility is a relevant indication for controlled ovarian stimulation associated to intrauterine insemination. The "step-up" and "step-down" gonadotropin-based protocols were designed to reduce multiple pregnancy and ovarian hyperstimulation syndrome in polycystic ovary syndrome patients, but there is no related evidence in normoovulatory women undergoing intrauterine insemination. Our aim was to compare the efficacy and safety of both protocols with intrauterine insemination in unexplained infertility patients. Randomized clinical trial including 145 women with unexplained infertility randomly following the step-up (n=73) or step-down (n=72) protocol. In the step-up group, patients started on day 3 of a spontaneous cycle administrating recombinant FSH 75IU sc/day, increasing it to 150IU if no response after 7 days. In the step-down, patients started administrating 150IU sc/day, constantly decreasing it to 75IU after 5 days. Recombinant hCG was administered when a follicle reached ≥18mm diameter. Clinical pregnancy rate was higher in the step-up group than in the step-down (20.5% vs . 8.3%; p =0.037). Significant differences between step-up and step-down protocols were found regarding days of rFSH administration (8.83±4.01% vs . 7.42±2.18%; p =0.001) and cancellation rate due to hyper response (8.21% vs . 25%; p =0.05). No differences were detected in miscarriage rates, multiple pregnancy rates/cycle and hyper stimulation syndrome incidence. The step-up protocol is longer-lasting but more effective obtaining pregnancies than the step-down in patients with unexplained infertility undergoing intrauterine insemination. This effect could be explained by lower cancellation rates due to ovarian hyper response than the step-down protocol, with no differences in ovarian hyper stimulation syndrome incidence

Mass of intercostal muscles associates with risk of multiple exacerbations in COPD

BACKGROUND: The potential role of decreased respiratory muscle mass, if any, in mediating the susceptibility to exacerbation in COPD patients has not been determined. We hypothesized that a decrease in respiratory muscle mass is associated with increased risk of multiple hospital admissions due to acute exacerbations of the disease. METHODS: Eligible cases and controls (n=20) were identified from records of our department's pulmonary clinic. Ten subjects diagnosed with COPD (males, 66+/-7yr, Body Mass Index (BMI)=26+/-4kg/m(2)) were identified as fragile patients. Fragility was defined as four or more admissions in the previous year due to severe exacerbations of the disease. Fragile patients were matched with 10 non-fragile controls, defined as COPD patients who had required only one admission due to exacerbation of the disease. Criteria for 1:1 matching included ethnicity, gender, age, BMI, degree of airflow obstruction (i.e., FEV(1)), comorbidity and chronic treatment. Multiple computed tomography (CT) scan slices were obtained to assess area and attenuation coefficients of multiple upper limb, thorax, abdomen and lower limb muscles. RESULTS: CSA of intercostal and abdominal muscles was significantly decreased in fragile COPD patients (right side intercostals, mean relative difference (MRD)=-14%, p=0.010; OR (95% CI)=2.2 (1.1-4.8), p=0.021; left side, MRD=-13%, p=0.007; OR=2.2 (1.1-4.5), p=0.027). CSA and attenuation coefficients of all other muscle compartments showed no statistical differences between the two study groups but showed the same trend. Strength of the inspiratory and expiratory muscles did not differ between the two study groups. CONCLUSIONS: This study shows that the risk for multiple admissions due to a COPD exacerbation associates with a marked decrease in the CSA of the intercostal muscle compartment.Grants from CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Spain; ARMAR, SEPAR and SOCAP fellowships; and Judith Garcia-Aymerich has a research contract from the Instituto de Salud Carlos III (CP05/00118), Ministry of Health, Spain

Lifetime occupational exposure to dusts, gases and fumes is associated with bronchitis symptoms and higher diffusion capacity in COPD patients

Background: Occupational exposure to dusts, gases and fumes has been associated with reduced FEV1 and sputum production in COPD patients. The effect of occupational exposure on other characteristics of COPD, especially those reflecting emphysema, has not been studied in these patients. Methods: We studied 338 patients hospitalized for a first exacerbation of COPD in 9 Spanish hospitals, obtaining full occupational history in a face-to-face interview; job codes were linked to a job exposure matrix for semi-quantitative estimation of exposure to mineral/biological dust, and gases/fumes for each job held. Patients underwent spirometry, diffusing capacity testing and analysis of gases in stable conditions. Quality of life, dyspnea and chronic bronchitis symptoms were determined with a questionnaire interview. A high- resolution CT scan was available in 133 patients. Results: 94% of the patients included were men, with a mean age of 68(8.5) years and a mean FEV1% predicted 52 (16). High exposure to gases or fumes was associated with chronic bronchitis, and exposure to mineral dust and gases/fumes was associated with higher scores for symptom perception in the St. George’s questionnaire. No occupational agent was associated with a lower FEV1. High exposure to all occupational agents was associated with better lung diffusion capacity, in long-term quitters. In the subgroup with CT data, patients with emphysema had 18% lower DLCO compared to those without emphysema. Conclusions: In our cohort of COPD patients, high exposure to gases or fumes was associated with chronic bronchitis, and high exposure to all occupational agents was consistently associated with better diffusion capacity in long-term quitters.The PAC-COPD Study is funded by grants from the Fondo de Investigación Sanitaria (FIS PI020541), Ministry of Health, Spain; Agència d’Avaluació de Tecnologia i Recerca Mèdiques (AATRM 035/20/02), Catalan Government; Spanish Society of Pulmonology and Thoracic Surgery (SEPAR 2002/137); Catalan Pulmonology Foundation (FUCAP 2003 Beca Maria Ravà); Red RESPIRA (RTIC C03/11); Red RCESP (RTIC C03/09); Fondo de Investigación Sanitaria (PI052486); Fondo de Investigación Sanitaria (PI052302); Fondo de Investigación Sanitaria (PI060684); Fundació La Marató de TV3 (num. 041110); and Novartis Farmacèutica, Spain. CIBERESP and CIBERES are funded by Instituto de Salud Carlos III, Ministry of Health, Spain. Judith Garcia-Aymerich has a researcher contract from Instituto de Salud Carlos III (CP05/00118), Ministry of Health, Spai

Clinical and functional characteristics of COPD patients at first hospital admission (Spain, 2004–2006).

<p>Abbreviation<i>: mMRC</i>, Modified Medical Research Council; Number (%) is given, unless otherwise indicated.</p><p>*Chronic cough with phlegm;</p>†<p>Scores range from 0 (no health impairment) to 100 (maximum impairment).</p

Associations between cumulative lifetime occupational exposure and clinical and functional outcome.

<p>Abbreviations: GOLD, Global Initiative for Chronic Obstructive Lung Disease; MMRC, Modified Medical Research Council; SGRQ, St George’s Respiratory Questionnaire.</p><p>Multivariate logistic or linear regression models, adjusted for sex, age, age 2, weight, smoking status, and pack-years smoked. Referral category for all comparisons includes participants with no history of high exposure to biological dust, mineral dust, or gases/fumes (n = 110; see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0088426#pone-0088426-t002" target="_blank">Table 2</a>).</p><p>* As compared to MMRC dyspnea scale 0, 1 or 2.</p>†<p>As compared to GOLD Stage.</p

Associations between lifetime occupational exposures and DLCO, stratified according to smoking history.

<p>Linear regression models adjusted for sex, age, age2, weight and pack-years smoked. The reference category for all comparisons included participants with no history of high exposure to biological dust, mineral dust, or gases/fumes (n = 110; see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0088426#pone-0088426-t002" target="_blank">Table 2</a>).</p

Mass of intercostal muscles associates with risk of multiple exacerbations in COPD

BACKGROUND: The potential role of decreased respiratory muscle mass, if any, in mediating the susceptibility to exacerbation in COPD patients has not been determined. We hypothesized that a decrease in respiratory muscle mass is associated with increased risk of multiple hospital admissions due to acute exacerbations of the disease. METHODS: Eligible cases and controls (n=20) were identified from records of our department's pulmonary clinic. Ten subjects diagnosed with COPD (males, 66+/-7yr, Body Mass Index (BMI)=26+/-4kg/m(2)) were identified as fragile patients. Fragility was defined as four or more admissions in the previous year due to severe exacerbations of the disease. Fragile patients were matched with 10 non-fragile controls, defined as COPD patients who had required only one admission due to exacerbation of the disease. Criteria for 1:1 matching included ethnicity, gender, age, BMI, degree of airflow obstruction (i.e., FEV(1)), comorbidity and chronic treatment. Multiple computed tomography (CT) scan slices were obtained to assess area and attenuation coefficients of multiple upper limb, thorax, abdomen and lower limb muscles. RESULTS: CSA of intercostal and abdominal muscles was significantly decreased in fragile COPD patients (right side intercostals, mean relative difference (MRD)=-14%, p=0.010; OR (95% CI)=2.2 (1.1-4.8), p=0.021; left side, MRD=-13%, p=0.007; OR=2.2 (1.1-4.5), p=0.027). CSA and attenuation coefficients of all other muscle compartments showed no statistical differences between the two study groups but showed the same trend. Strength of the inspiratory and expiratory muscles did not differ between the two study groups. CONCLUSIONS: This study shows that the risk for multiple admissions due to a COPD exacerbation associates with a marked decrease in the CSA of the intercostal muscle compartment.Grants from CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Spain; ARMAR, SEPAR and SOCAP fellowships; and Judith Garcia-Aymerich has a research contract from the Instituto de Salud Carlos III (CP05/00118), Ministry of Health, Spain

Lifetime occupational exposure to dusts, gases and fumes is associated with bronchitis symptoms and higher diffusion capacity in COPD patients

Background: Occupational exposure to dusts, gases and fumes has been associated with reduced FEV1 and sputum production in COPD patients. The effect of occupational exposure on other characteristics of COPD, especially those reflecting emphysema, has not been studied in these patients. Methods: We studied 338 patients hospitalized for a first exacerbation of COPD in 9 Spanish hospitals, obtaining full occupational history in a face-to-face interview; job codes were linked to a job exposure matrix for semi-quantitative estimation of exposure to mineral/biological dust, and gases/fumes for each job held. Patients underwent spirometry, diffusing capacity testing and analysis of gases in stable conditions. Quality of life, dyspnea and chronic bronchitis symptoms were determined with a questionnaire interview. A high- resolution CT scan was available in 133 patients. Results: 94% of the patients included were men, with a mean age of 68(8.5) years and a mean FEV1% predicted 52 (16). High exposure to gases or fumes was associated with chronic bronchitis, and exposure to mineral dust and gases/fumes was associated with higher scores for symptom perception in the St. George’s questionnaire. No occupational agent was associated with a lower FEV1. High exposure to all occupational agents was associated with better lung diffusion capacity, in long-term quitters. In the subgroup with CT data, patients with emphysema had 18% lower DLCO compared to those without emphysema. Conclusions: In our cohort of COPD patients, high exposure to gases or fumes was associated with chronic bronchitis, and high exposure to all occupational agents was consistently associated with better diffusion capacity in long-term quitters.The PAC-COPD Study is funded by grants from the Fondo de Investigación Sanitaria (FIS PI020541), Ministry of Health, Spain; Agència d’Avaluació de Tecnologia i Recerca Mèdiques (AATRM 035/20/02), Catalan Government; Spanish Society of Pulmonology and Thoracic Surgery (SEPAR 2002/137); Catalan Pulmonology Foundation (FUCAP 2003 Beca Maria Ravà); Red RESPIRA (RTIC C03/11); Red RCESP (RTIC C03/09); Fondo de Investigación Sanitaria (PI052486); Fondo de Investigación Sanitaria (PI052302); Fondo de Investigación Sanitaria (PI060684); Fundació La Marató de TV3 (num. 041110); and Novartis Farmacèutica, Spain. CIBERESP and CIBERES are funded by Instituto de Salud Carlos III, Ministry of Health, Spain. Judith Garcia-Aymerich has a researcher contract from Instituto de Salud Carlos III (CP05/00118), Ministry of Health, Spai