Pedro Almagro

Risk Factors for Hospital Readmission in Patients with Chronic Obstructive Pulmonary Disease

Background: Hospital readmissions for acute exacerbation of chronic obstructive pulmonary disease (COPD) are one of the leading causes of healthcare expenditures worldwide. Objectives: To identify risk factors for hospital readmission in COPD patients. Methods:We prospectively evaluated 129 consecutive patients hospitalized for acute exacerbation of COPD. Clinical, spirometric and arterial blood gas variables were measured during hospitalization. Socioeconomic characteristics, comorbidity, dyspnea, functional dependence, depression, social support and quality of life were also analyzed. Readmission was defined as one or more hospitalizations in the following year. Results:During the follow-up period, 75 (58.5%) patients were readmitted. In bivariate analysis, readmission was associated with previous hospitalization for COPD in the past year, dyspnea scale, PaCO2 at discharge, depression, cor pulmonale, chronic domiciliary oxygen and quality of life measured by the St. George’s Respiratory Questionnaire. In multivariate analysis, the best predictor of readmission was the combination of hospitalization for COPD in the previous year (odds ratio, OR: 4.27; 95% confidence interval, CI: 1.5–12), the total score of the St. George’s Respiratory Questionnaire ≧50 points (OR: 2.36; 95% CI: 1.03–5.04) and PaCO2 at discharge ≧45 mm Hg (OR: 2.18; 95% CI: 0.84–5.06). With this model, the probability of readmission for patients without any of these variables was 7%, while it was 70% for the patients with all three variables present. Conclusion: The combination of quality of life, hospitalization for COPD in the previous year and hypercapnia at discharge are useful predictors of readmission at 1 year.

Comorbidities and Short-term Prognosis in Patients Hospitalized for Acute Exacerbation of COPD: The EPOC en Servicios de Medicina Interna (ESMI) Study

BACKGROUND Comorbidities are frequent in patients hospitalized for COPD exacerbation, but little is known about their relation with short-term mortality and hospital readmissions. Our hypothesis is that the frequency and type of comorbidities impair the prognosis within 12 weeks after discharge. METHODS A longitudinal, observational, multicenter study of patients hospitalized for a COPD exacerbation with spirometric confirmation was performed. Comorbidity information was collected using the Charlson index and a questionnaire that included other common conditions not included in this index. Dyspnea, functional status, and previous hospitalization for COPD or other reasons among other variables were investigated. Information on mortality and readmissions for COPD or other causes was collected up to 3 months after discharge. RESULTS We studied 606 patients, 594 men (89.9%), with a mean (SD) age of 72.6 (9.9) years and a postbronchodilator FEV1 of 43.2% (21.2). The mean Charlson index score was 3.1 (2.0). On admission, 63.4% of patients had arterial hypertension, 35.8% diabetes mellitus, 32.8% chronic heart failure, 20.8% ischemic heart disease, 19.3% anemia, and 34% dyslipemia. Twenty-seven patients (4.5%) died within 3 months. The Charlson index was an independent predictor of mortality (P < .003; OR,1.23; 95% CI, 1.07-1.40), even after adjustment for age, FEV1, and functional status measured with the Katz index. Comorbidity was also related with the need for hospitalization from the ED, length of stay, and hospital readmissions for COPD or other causes. CONCLUSIONS Comorbidities are common in patients hospitalized for a COPD exacerbation, and they are related to short-term prognosis.

Pulmonary capillary hemangiomatosis associated with primary pulmonary hypertension: report of 2 new cases and review of 35 cases from the literature.

Pulmonary capillary hemangiomatosis (PCH) is a rare cause of primary pulmonary hypertension characterized by thin-walled microvessels infiltrating the peribronchial and perivascular interstitium, the lung parenchyma, and the pleura. These proliferating microvessels are prone to bleeding, resulting in accumulation of hemosiderin-laden macrophages in alveolar spaces. Here we report 2 cases of PCH with pulmonary hypertension, 1 of them associated with mechanical intravascular hemolysis, a feature previously reported in other hemangiomatous diseases, but not in PCH. Case 2 was diagnosed by pulmonary biopsy; to our knowledge the patient is the second adult to be treated with interferon α-2a.Review of the literature identified 35 patients with PCH and pulmonary hypertension. The prognosis is poor and median survival was 3 years from the first clinical manifestation. Dyspnea and right heart failure are the most common findings of the disease. Hemoptysis, pleural effusion, acropachy, and signs of pulmonary capillary hypertension are less common. Chest X-ray or computed tomography scan usually shows evidence of interstitial infiltrates, pulmonary nodules, or pleural effusion. Hemodynamic features include normal wedge pressures. Radiologic and hemodynamic findings are undifferentiated from those of pulmonary veno-occlusive disease but differ from other causes of primary pulmonary hypertension.Epoprostenol therapy, considered the treatment of choice in patients with primary pulmonary hypertension, may produce pulmonary edema and is contraindicated in patients with PCH. Regression of lesions was reported in 1 patient treated with interferon therapy and 2 other patients stabilized, including our second patient. PCH was treated successfully by lung transplantation in 5 cases. Early recognition of PCH in patients with suspected primary pulmonary hypertension is possible based on clinical and radiologic characteristics. Diagnosis by pulmonary biopsy is essential for allowing appropriate treatment.

Comorbidity and gender-related differences in patients hospitalized for COPD. The ECCO study

RATIONALE Patients hospitalized for a COPD exacerbation are usually of advanced age, with functional deterioration, and suffering an increased number of associated conditions, but little is known about gender differences. Our hypothesis is that the frequency and type of comorbidities differ in male and female COPD patients. MATERIAL AND METHODS A cross-sectional, multicentre study of patients hospitalized for a COPD exacerbation. All of them had COPD confirmed by baseline forced spirometry with a bronchodilator test. Comorbidity information was collected using the Charlson index, and an ad hoc questionnaire that included other common conditions not included in the Charlson index. RESULTS We studied 398 patients, 353 men (89%) and 45 women (11%), with a mean (S.D.) age of 73.7 (8.9) years and a percent predicted FEV(1) of 43.2 (12.5). The mean score of the Charlson index was 2.7 (2.0), with no differences by gender; in contrast, the mean number of all comorbid conditions assessed was 3.7 (1.7) in men and 1.8 (1.8) in women (p < 0.05). Overall, 55% of the patients had arterial hypertension, 26% diabetes mellitus, 27% chronic heart failure, and 17% ischemic heart disease. Female COPD patients had a lower prevalence of ischemic heart disease (p = 0.008) and alcoholism (p = 0.03), but presented more frequently with chronic heart failure (p = 0.03), osteoporosis (p = 0.007) and diabetes mellitus without complications (p = 0.02). CONCLUSIONS Comorbidities are common in patients hospitalized for a COPD exacerbation, but their relative distribution varies by gender. The exclusive use of the Charlson index underestimates comorbidities in COPD patients.

Short- and Medium-term Prognosis in Patients Hospitalized for COPD Exacerbation : The CODEX Index

BACKGROUND No valid tools exist for evaluating the prognosis in the short and medium term after hospital discharge of patients with COPD. Our hypothesis was that a new index based on the CODEX (comorbidity, obstruction, dyspnea, and previous severe exacerbations) index can accurately predict mortality, hospital readmission, and their combination for the period from 3 months to 1 year after discharge in patients hospitalized for COPD. METHODS A multicenter study of patients hospitalized for COPD exacerbations was used to develop the CODEX index, and a different patient cohort was used for validation. Comorbidity was measured using the age-adjusted Charlson index, whereas dyspnea, obstruction, and severe exacerbations were calculated according to BODEX (BMI, airfl ow obstruction, dyspnea, and previous severe exacerbations) thresholds. Information about mortality and readmissions for COPD or other causes was collected at 3 and 12 months after hospital discharge. RESULTS Two sets of 606 and 377 patients were included in the development and validation cohorts, respectively. The CODEX index was associated with mortality at 3 months ( P < .0001; hazard ratio [HR], 1.5; 95% CI, 1.2-1.8) and 1 year ( P < .0001; HR, 1.3; 95% CI, 1.2-1.5 ), hospital readmissions in the same periods, and their combination (all P < .0001). All CODEX C statistics were superior to those of the BODEX, DOSE (dyspnea, airfl ow obstruction, smoking status, and exacerbation frequency), and updated ADO (age, dyspnea, and airfl ow obstruction) indexes. CONCLUSIONS The CODEX index was a useful predictor of survival and readmission at both 3 months and 1 year after hospital discharge for a COPD exacerbation, with a prognostic capacity superior to other previously published indexes.

Pseudomonas aeruginosa and Mortality after Hospital Admission for Chronic Obstructive Pulmonary Disease

Background:Pseudomonas aeruginosa (PA) is isolated in advanced stages of chronic obstructive pulmonary disease (COPD). Objectives: The aim of our study was to determine whether PA isolation during hospitalization for COPD exacerbation was associated with a poorer prognosis after discharge. Methods: We prospectively studied all patients with COPD exacerbation admitted between June 2003 and September 2004. A sputum culture was obtained at admission. Comorbidity, functional dependence, hospitalizations during the previous year, dyspnea, quality of life and other variables previously associated with mortality in COPD were studied. Spirometry and a 6-min walking test were performed 1 month after discharge. Mortality was evaluated 3 years after discharge. Results: A total of 181 patients were included in the study. Of these, 29 (16%) had PA in the sputum. The mean age was 72 years, and mean basal postbronchodilator forced expiratory volume in 1 s was 45.2% predicted (SD 14.4). The mean point value on the BODE index was 5.1 (SD 2.5). At 3 years, 17 of 29 patients (58.6%) in the PA group had died, compared to 53 of the 152 non-PA patients [34.9%; p < 0.004; hazard ratio (HR) 2.23, 95% confidence interval (CI) 1.29–3.86]. In the multivariate analysis, PA remained statistically related to posthospital mortality (p = 0.02; HR 2.2, 95% CI 1.2–4.2) after adjustment for age (p < 0.02; HR 1.04, 95% CI 1.007–1.07), BODE index (p < 0.02; HR 1.15, 95% CI 1.02–1.3) and comorbidity (p < 0.02; HR 1.24, 95% CI 1.03–1.5). Conclusions: PA isolation in sputum in patients hospitalized for acute exacerbation of COPD is a prognostic marker of 3-year mortality. Poor prognosis is independent of other significant predictors of mortality such as BODE index, age and comorbidity, as measured by the Charlson index.

Empiema pleural por Gemella morbillorum

Sr. Director. Gemella morbillorum es un coco grampositivo microaerofílico que forma parte de la flora normal del tubo digestivo y del tracto urogenital. Se ha descrito como causa de endocarditis, meningitis, artritis séptica y sepsis1. Presentamos un caso de empiema causado por G. morbillorum. Se trata de un paciente de 75 años que ingresó por fiebre y deterioro del estado general de dos semanas de evolución. Entre sus antecedentes destacaban una fibrilación auricular crónica y un ictus isquémico del territorio carotídeo izquierdo, quedando como secuelas una hemiplejía derecha, afasia mixta y disfagia. A la exploración física destacaba una semiología de derrame pleural derecho. La radiografía de tórax reveló la presencia de un infiltrado en la base derecha pulmonar con derrame pleural. Una toracocentesis dio salida a un líquido de aspecto turbio con los siguientes parámetros: pH 7,15; proteínas 62 mg/dl; glucosa 6 mg/dl; leucocitos 1.400/mm3 (87% polimorfonucleares); LDH 2.510 U/l; ADA 34 U/l. El cultivo del liquido pleural en agar-sangre para anaerobios fue positivo para un coco grampositivo, anaerobio, agrupado en cadenas, que formaba colonias alfahemolíticas, catalasa negativa y optoquina resistente. El microorganismo fue identificado por el sistema API 20 Strep (BioMérieux, Francia) como G. morbillorum. El microorganismo era sensible a penicilina, vancomicina, imipenem y gentamicina. Se procedió a la colocación de un tubo de drenaje pleural y se inició tratamiento antibiótico con imipenem, que posteriormente se sustituyó por amoxicilinaácido clavulánico (1g/8 horas iv). A pesar de que una ecografía torácica evidenció signos de tabicación pleural, se desestimó la intervención quirúrgica dado el estado basal del paciente. Se mantuvo tratamiento intravenoso con amoxicilina-ácido clavulánico durante 4 semanas, y por vía oral durante 6 semanas más. En un control a los 3 meses del ingreso el paciente estaba afebril y había recuperado su estado basal; en aquel momento una radiografía de tórax evidenció una mínima afección parenquimatosa en la base derecha, sin evidencia de derrame pleural. G. morbillorum, previamente conocido como Streptococcus morbillorum tiene un espectro de infecciones similar al de los estreptococos del grupo viridans, habiéndose implicado fundamentalmente en casos de endocarditis subaguda2. De hecho, no es infrecuente que se confunda con un estreptococo del grupo viridans debido a su lento crecimiento en agar sangre y a que puede producir alfahemólisis2. En la revisión de la literatura mediante MEDLINE sólo hemos encontrado descritos tres casos de empiema por G. morbillorum3-5. Habitualmente se reconoce un factor predisponente para el desarrollo de la infección, como cirugía colónica o dental, o una deficiente higiene bucal3,6,7. En nuestro paciente el empiema se originó probablemente a partir de la aspiración de las secreciones orofaríngeas. Aunque la broncoaspiración no ha sido reconocida anteriormente como un factor predisponente a infecciones por G. morbillorum, esta hipótesis parece la más plausible dados los antecedentes del paciente y el hábitat natural el microorganismo. El tratamiento óptimo de las infección por G. morbillorum no está bien definido. En casos de endocarditis se ha sugerido que el tratamiento debería consistir en la combinación de un agente β-lactámico con un aminoglucósido, reservando la vancomicina para las cepas resistentes a la penicilina8. Los empiemas asociados a neumonía aspirativa suelen ser polimicrobianos, y los microorganismos aislados con mayor frecuencia son anaerobios comensales de la orofaringe, bacilos gramnegativos y estreptococos del grupo viridans. Ante la sospecha de un empiema mixto nuestro paciente recibió tratamiento con amoxicilina-ácido clavulánico. Sin embargo, la conducta más racional, si se confirma la naturaleza monomicrobiana de la infección es el tratamiento con penicilina G sódica. En cualquier caso, el drenaje de cualquier foco supurativo debe considerarse prioritario. En nuestro paciente decidimos prolongar el tratamiento antibiótico a 10 semanas debido a que el drenaje del empiema fue incompleto.

Características clínicas y tratamiento de los pacientes ancianos hospitalizados por descompensación de enfermedad pulmonar obstructiva crónica en los servicios de Medicina Interna españoles. Estudio ECCO

BACKGROUND AND OBJECTIVE Hospitalizations for chronic obstructive pulmonary disease (COPD) occur mostly in elderly patients. We describe the characteristics and treatment of elderly patients hospitalized for COPD in Internal Medicine Services, compared with the younger age group. PATIENTS AND METHODS Observational, prospective, multicenter study. We compared the differences between patients older than 80 years and the rest regarding comorbidity, severity of COPD, previous admissions, length of stay and treatment prescribed. Comorbidity was assessed by the Charlson index and a questionnaire was designed for this purpose. RESULTS We included 398 subjects, 353 men (89%) with a mean age of 73.7 years (SD 8.8), of whom about 107 (26.9%) were older than 80 years. These patients had less severe COPD according to the GOLD classification (P<.02). Although the overall morbidity was similar in both groups, elderly patients had greater presence of arrhythmias (P<.01), left ventricular hypertrophy (P<.01) and received more diuretics (P<.05). Dyspnoea, length of stay and mortality were similar between both populations. Home oxygen therapy prior to and use of inhaled corticosteroids and oxygen therapy was lower in older patients, even when they were clinically indicated. CONCLUSIONS A quarter of patients hospitalized for COPD in Internal Medicine Services are over 80 years. Although they present less obstruction, they have a similar degree of dyspnea, increased cardiac morbidity and their treatment is less consistent with the recommendations of the guidelines.