Stanislav Suskovic

Self-Rated Health Predicts Acute Exacerbations and Hospitalizations in Patients With COPD

BACKGROUND Self-rated health predicts outcome in chronic disease, but such information is scarce in COPD. We aimed to assess self-rated health as an outcome predictor in carefully characterized patients with this condition. METHODS This was a prospective study in 127 clinically stable patients with COPD (64 +/- 8 years, 79% men, 82% Global Initiative for Chronic Obstructive Lung Disease stage II or III). Self-rated health was assessed using a 5-grade Likert scale ranging from very poor to very good. RESULTS During 26.0 +/- 4.9 months of follow-up, 78 patients experienced acute exacerbation, 39 were hospitalized, and 10 died. Poor or very poor self-rated health was reported by 19 patients (15%) and was more common in patients experiencing acute exacerbations (20% vs 6%, P = .027) and hospitalizations (19% vs 5%, P = .039). Kaplan-Meier curves demonstrated more acute exacerbations (P = .003) and hospitalizations (P = .008) in patients with poor or very poor self-rated health. In a fully adjusted Cox model of proportional hazard, poor or very poor self-rated health remained predictive of acute exacerbations (hazard ratio [HR], 1.80; 95% CI, 1.03-3.11) and hospitalizations (HR, 1.93; 95% CI, 1.12-3.68) but not of death. CONCLUSIONS This study suggests that self-rated health is predictive of acute exacerbations and hospitalizations. Although prediction of mortality was limited, the study is supportive of self-rated health testing in COPD.

The need for medication reconciliation: a cross-sectional observational study in adult patients

BACKGROUND Poor communication of drug therapy at care interface often results in medication errors and adverse drug events. Medication reconciliation has been introduced as a measure to improve continuity of patient care. The aim of this cross-sectional observational study was to evaluate the need for medication reconciliation. METHODS Comprehensive information on pre-admission therapy was obtained by a research pharmacist for adult medical patients, admitted to a teaching hospital, specialised in pulmonary and allergic diseases, in Slovenia. This information was compared with the in-patient and discharge therapies to identify unintentional discrepancies (medication errors) whose clinical significance was determined by an expert panel reaching consensus. RESULTS Most of the included 101 patients were elderly (median age: 73 years) who had multiple medications. Among their in-patient drugs (880), few discrepancies were a medication error (54/654), half of which were judged to be clinically important. A higher rate was observed in the discharge drug therapy (747): 369 of the identified discrepancies (566) were a medication error, over half of which were judged as clinically important. A greater number of pre-admission drugs, poorly taken medication histories and a greater number of medication errors in in-patient therapy predisposed patients to clinically important medication errors in discharge therapy. CONCLUSIONS This study provided evidence in a small sample of patients on the discontinuity of drug therapy at patient discharge in a hospital in Slovenia and its implications for patient care. To ensure continuity and safety of patient care, medication reconciliation should be implemented throughout a patients hospital stay.

Adherence to treatment guidelines and long‐term survival in hospitalized patients with chronic obstructive pulmonary disease

RATIONALE AND AIMS Adherence to treatment guidelines in chronic obstructive pulmonary disease (COPD) has been shown to be less than optimal over the COPD continuum. This retrospective study aimed to assess the implementation of COPD guidelines and potential association with long-term mortality in patients with COPD. METHODS All consecutive patient discharges in the period of February 2002-June 2007 from the University Clinic of Pulmonary and Allergic Diseases Golnik, Slovenia, were screened for a primary discharge diagnosis of COPD. RESULTS Data on 1185 patients (mean age 70 ± 9 years, 72% men, 64% GOLD stage III/IV) were analysed. In the discharge letters 62% of patients had three or more drugs prescribed; 3% had no regular prescription. Most patients were discharged with short-acting (91%) and long-acting β2-agonists (LABAs, 65%) and inhaled corticosteroids (61%), and 23% received long-term oxygen therapy. Prescription rates of LABAs, tiotropium and inhaled corticosteroids increased over the disease continuum (P < 0.001). In total, 48% of patients died during a median follow-up of 1149 days. Deceased patients had been less often treated with LABAs, inhaled corticosteroids and tiotropium. In multivariate Cox proportional-hazards analysis, advanced age, current smoking status, lower body mass index, longer hospital stay and cancer were associated with higher mortality (P < 0.05 for all), and inhaled corticosteroids predicted lower mortality (hazard ratio 0.72, 95% confidence interval 0.55-0.94). CONCLUSION Implementation of guideline-recommended therapy was not optimal, particularly in patients who died during follow-up. The high long-term mortality calls for careful risk assessment and appropriate adherence to treatment guidelines.

Distribution of self-rated health and association with clinical parameters in patients with chronic obstructive pulmonary disease

SummaryBACKGROUND: Data on self-rated health (SRH) in patients with chronic obstructive pulmonary disease (COPD) are very limited; we therefore initiated this study to investigate the distribution of SRH and association with established parameters of disease severity. PATIENTS AND METHODS: We included 135 clinically stable patients with COPD (64 ± 8 years, 71% men, GOLD stage: II –59; III –55; IV –21) and 25 healthy control persons. SRH was evaluated using the 5-grade Likert scale (1-very poor to 5-very good). RESULTS: Patients with COPD had poorer SRH when compared with controls (3.0 ± 0.7 vs. 3.8 ± 0.6, P < 0.001). SRH decreased over GOLD stage (P = 0.016) and 27 (20%) patients reported poor or very poor SRH. In univariate analysis, GOLD stage (P = 0.022), Center for Epidemiologic Studies Depression (CES-D) score (P = 0.001), BODE index score (P < 0.001), score on the modified Medical Research Council (MMRC) dyspnea scale (P < 0.001) and 6-minute walk test (6MWT) distance (P < 0.001) determined poor or very poor SRH. In a multivariate model which included BODE index score, a CES-D score ≥ 16 (P = 0.013) and BODE index score (P = 0.012) determined poor or very poor SRH. In the model with individual components of the BODE index, a CES-D score ≥ 16 (P = 0.012), MMRC score of 3 or 4 (P = 0.019) and 6MWT distance ≤ 249 m (P = 0.019) determined poor or very poor SRH. CONCLUSION: In patients with COPD, SRH is worse than in healthy control persons and deteriorates over GOLD stage. Perception of health as poor or very poor is associated with psychological components (CES-D score) and disease severity (BODE index score, 6MWT distance and MMRC dyspnea score).

Asthma Treatment Outcome in Children Is Associated with Vascular Endothelial Growth Factor A (VEGFA) Polymorphisms

BackgroundAsthma is a common chronic disease characterized by airway inflammation and structural remodeling. Vascular endothelial growth factor (VEGF), a major regulator of angiogenesis, is elevated in asthma patients. VEGF contributes to airway responsiveness and remodeling. It has been shown that treatment of asthma patients decreases VEGF levels, and inhibition of VEGF diminishes asthma symptoms in mice. Therefore, polymorphisms in the vascular endothelial growth factor A (VEGFA) gene might be associated with asthma treatment response.MethodsThis study enrolled 131 children with asthma treated with different therapies — specifically, the inhaled corticosteroid (ICS) fluticasone propionate or the leukotriene receptor antagonist (LTRA) montelukast. We performed an association analysis between improvement of lung function — assessed by measurement of the percentage of the predicted forced expiratory volume in 1 second (%predicted FEV1), the ratio between the FEV1 and the forced vital capacity (FEV1/FVC) after 6 and 12 months of treatment, and asthma control after 12 months of treatment — and two polymorphisms, rs2146323 and rs833058, in the VEGFA gene.ResultsPolymorphism rs2146323 A>C in VEGFA was associated with response to ICS therapy. Asthma patients with the AA genotype had a greater improvement in the %predicted FEV1 than those with the AC or CC genotype (p = 0.018). Conversely, the AA genotype in rs2146323 was associated with uncontrolled asthma in patients regularly receiving LTRA therapy (p = 0.020) and a worse FEV1/FVC ratio in patients who episodically used LTRA therapy (p = 0.044). Furthermore, polymorphism rs833058 C>T was associated with treatment response to episodically used LTRA therapy. A subgroup of patients with the TT genotype had an improvement in the %predicted FEV1, compared with no improvement in patients with the CT or CC genotype (p = 0.029).ConclusionsOur results showed that treatment response to commonly used asthma therapies (ICS or LTRA) is associated with polymorphisms rs2146323 and rs833058 in VEGFA. With additional replication of this preliminary study, our findings could contribute to the development of individualized asthma therapy.

Clinical-pharmacist intervention reduces clinically relevant drug–drug interactions in patients with heart failure: A randomized, double-blind, controlled trial

BACKGROUND Incidence of drug-drug interactions (DDIs) increases with complexity of treatment and comorbidities, as in heart failure (HF). This randomized, double-blind study evaluated the intervention of the pharmacist on prevalence of clinically relevant DDIs (NCT01855165). METHODS Patients admitted with HF were screened for clinically relevant DDIs, and randomized to control or intervention. All attending physicians received standard advice about pharmacological therapy; those in the intervention group also received alerts about clinically relevant DDIs. Primary endpoint was DDI at discharge and secondary were re-hospitalization or death during follow-up. RESULTS Of 213 patients, 51 (mean age, 79 ± 6 years; male, 47%) showed 66 clinically relevant DDIs and were randomized. For intervention (n=26) versus control (n=25), the number of patients with and the number of DDIs were significantly lower at discharge: 8 vs. 18 and 10 vs. 31; p=0.003 and 0.0049, respectively. Over a 6 month follow-up period, 11 control and 9 intervention patients were re-hospitalized or died (p>0.2 for all). No significant differences were seen between control and intervention for patients with eGFR <60 mL/min/1.73 m(2) (78%) for re-hospitalization or death (10 vs. 7; p=0.74). CONCLUSIONS Pharmacist intervention significantly reduces the number of patients with clinically relevant DDIs, but not clinical endpoints 6 months from discharge.

Heart failure and chronic obstructive pulmonary disease: Two for tea or tea for two?

A combination of chronic obstructive pulmonary disease (COPD) and heart failure (HF) is common yet it is inadequately and rarely recognized. Because of the similar clinical manifestations, comorbidity is frequently not considered and appropriate diagnostic tests are not performed. It is very important that a combination of COPD and HF is recognized as these patients have a worse prognosis than patients with an individual disease. When present, COPD should not prevent the use of life-saving therapy in patients with HF, particularly β-blockers. Despite clear evidence of the safety and tolerability of cardioselective β-blockers in COPD patients, these drugs remain grossly underprescribed and underdosed. Routine spirometry and echocardiography in HF and COPD patients, respectively, is therefore warranted to improve current clinical practice.

Comprehensive medication history: the need for the implementation of medication reconciliation processes.

Comprehensive medication history: the need for the implementation of medication reconciliation processes Introduction: Providing comprehensive medication history (CMH) upon hospital admission is of outmost importance for proper patient evaluation and prescription of drug treatment. The aim of this study was to evaluate the implementation of medication reconciliation in clinical practice. Methods: Patients admitted to a teaching hospital in Slovenia were randomly selected and included in the study. For each patient a CMH was obtained by a research pharmacist using various sources of information. Next, the medication history in the hospital medical record was reviewed. The prescribed drugs were assessed for completeness of information, and possible discrepancies between both medication histories were recorded and classified. Results: Overall, 108 patients with a median age of 73 years were included in the study. The research pharmacist recorded the use of 651 medicaments, with all relevant details being available for 94.9% of these drugs. Of the 464 medicines listed in the hospital medical record, only 42.0% were considered complete. A comparison of the medication history and the medical record with the CMH revealed at least one discrepancy in 72.4% of the drugs listed. The majority of the identified discrepancies were often present both in the medication order on the drug chart (76.2%) and in the discharge letter (69.9%). Most medication discrepancies were due to drug omissions (20.9%) and commissions (6.5%). Conclusion: The high rate of discrepancies between the recorded drug history and CMH reported in our study stresses the need for the implementation of medication reconciliation. The participation of pharmacists in the reconciliation process, described in this study, resulted in more complete and accurate drug histories acquired. Popolnost Informacij o Zdravljenju z Zdravili Pred Sprejemom v Bolnišnico in Potreba po Implementaciji Principov Usklajevanja Zdravljenja z Zdravili Uvod: Popolnost informacij o zdravljenju z zdravili pred sprejemom v bolnišnico je pomembna pri nadaljnji obravnavi bolnika. Opisana raziskava preučuje smiselnost implementacije principov usklajevanja v proces zdravljenja z zdravili. Metode: V raziskavo so bili naključno vključeni bolniki sprejeti v Bolnišnico Golnik KOPA. Informacije o zdravljenju z zdravili je poleg tistih pridobljenih ob sprejemu, z uporabo različnih virov informacij samostojno pridobil tudi farmacevt. Ocenili smo popolnost informacij, zapisanih v anamnezi in pridobljenih s strani farmacevta, ter ugotovljene razlike kategorizirali. Rezultati: Raziskava je zajela 108 bolnikov z mediano starosti 73 let. Farmacevt je ugotovil uporabo 651 zdravil, za 94,9% katerih je dobil vse potrebne informacije o imenu, odmerku, režimu odmerjanja in načinu administracije. Pri istih bolnikih je bila v anamnezi zapisana uporaba 464 zdravil, 42,0% zapis katerih je bil popoln. Pri primerjavi informacije zapisane v anamnezi in pridobljene s strani farmacevta je bila vsaj ena razlika ugotovljena pri 72,4% zdravil, ista razlika je bila pogosto prisotna tudi na terapevtski listi (76,2%) in v odpustnici (69,9%). Izpust zdravila (20,9%) in predpis zdravila, ki ga bolnik doma ni prejemal (6,5%), sta bila najpogostejša razloga za ugotovljene razlike. Zaključek: Veliko število razlik v zabeleženih in pridobljenih informacijah o zdravilih, ki jih je bolnik jemal pred sprejemom v bolnišnico, kaže na potrebo po implementaciji principov usklajevanja zdravljenja z zdravili v sedanjo klinično prakso. Vključitev farmacevta v ta proces, kot je opisano v tem prispevku, je izboljšalo popolnost in pravilnost informacij o zdravilih.

Chronic obstructive pulmonary disease status 2011: long walk home

Chronic obstructive pulmonary disease (COPD) is characterized by chronic and progressive airflow limitation that is practically irreversible. COPD typically progresses over time, with ever increasing symptom burden. Typically, patients will experience breathlessness during normal daily activities or even at rest, increased production and purulence of sputum, overall health decline, and episodes of prognostically grim exacerbations that require medical intervention and sometimes hospitalizations.1–3 Worldwide, COPD is one of the leading causes of morbidity and mortality.1 Prevalence and incidence of COPD is, at least in some countries, exceptionally high, which makes proper and comprehensive management of disease even more important.3 It is projected that COPD will become the third leading cause of death worldwide by 2020 so studies of prevalence, pathophysiology, and management of this disease are needed and in fact fully justified. But are they properly valued? And even more important, are physicians interpreting the obtained information in a proper manner? Pathogenesis of COPD is far from being completely elucidated, with many still poorly recognized pathophysiological mechanisms and pathways.4–9 It is a multifaceted syndrome with much clinical, cellular, and molecular diversity.5,6,8,9 Paradoxically, its diagnosis, assessment of severity, and currently available therapeutic options are based primarily on the degree of airflow obstruction.1 COPD also is a disease with chronic airway inflammation, which is resistant to all known anti-inflammatory drugs with possible exception of anti-inflammatory action of new PD4 antagonist roflumilast.10 Inflammatory cells produce diverse mediators, which can be occasionally detected in exhaled air of patients with COPD. In last years many such biomarkers were identified and their utility partially tested. Assessing the value of specific biomarker is not an easy task.11 Among other prerequisites there should be reproducible association between the biomarker and the outcome of COPD management (diagnosis, risk stratification; selection

TREATMENT OF STEROID DEPENDENT ASTHMATICS WITH LOW DOSES OF CYCLOSPORINE

Background. Asthmatics with glucocorticoid dependent asthma should be treated with systemic steroids. Cyclosporine is in many ways a potent anti-inflammatory drug. Cyclosporine is sometimes very effective in treating asthmatics and could allow us to lower the dose of oral steroid. In some randomized, double blind studies steroid dependent asthmatics were treated 12–36 weeks with cyclosporine in dose 5 mg/kg/day. We tried cyclosporine in steroid dependent asthmatics in shorter course and in lower dose. Methods. 13 steroid dependent asthmatics were in the first four weeks of the study treated by their own drugs (phase 1). Then they were for the next four weeks (phase 2) randomly and in double blind fashion treated with either cyclosporine (mean 1.7 mg/kg/day, SD 0.5, 6 patients – group 1) or by identical placebo (7 patients – group 2). To the patients in the group 2 serum concentration of cyclosporine was measured on the eight day of the study. Results. Morning peak expiratory flow (PEF) raised significantly in group 1 (200 L/sec to 247 L/sec or for 23%). Patients in group1 had significantly less episodes of nocturnal asthma (2.2 episodes/night to 1.5 episodes/night or for 32%). In group 2 were not found any changes between first phase and second phase of the study. Steroid consumption did not change in any group. Mean serum concentration of cyclosporine in patients of group1 was 35.7 µg/L. We did not find any adverse effects of cyclosporine or placebo. Conclusions. Cyclosporine could have dangerous side effects, which are dependent on its serum concentration. So it should be administered in the lowest possible dose and for the most possible short period. In our study it was found that it is possible to successfully treat steroid dependent asthmatics with lower daily dose and for shorter time, than was found in other similar studies.