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Interest in lifetime lung function trajectories has increased in the context of emerging evidence that chronic obstructive pulmonary disease (COPD) can arise from multiple disadvantaged lung function pathways, including those that stem from poor lung function in childhood. To our knowledge, no previous study has investigated both obstructive and restrictive lifetime patterns concurrently, while accounting for potential overlaps between them. We aimed to investigate lifetime trajectories of the FEVUsing z scores from spirometry measured at ages 7, 13, 18, 45, 50, and 53 years in the Tasmanian Longitudinal Health Study (n=2422), we identified six FEVThe prevalence of the four lifetime spirometry patterns was as follows: low FEVTo our knowledge, this is the first study to characterise lifetime phenotypes of obstruction and restriction simultaneously using objective data-driven techniques and unique life course spirometry measures of FEVNational Health and Medical Research Council of Australia, The University of Melbourne, Clifford Craig Medical Research Trust of Tasmania, The Victorian, QueenslandTasmanian Asthma Foundations, The Royal Hobart Hospital, Helen MacPherson Smith Trust, and GlaxoSmithKline.

Data de publicació electrònica: 02-05-2023 Objectives: To identify prognostic models which estimate the risk of critical COVID-19 in hospitalized patients and to assess their validation properties. Study design and setting: We conducted a systematic review in Medline (up to January 2021) of studies developing or updating a model that estimated the risk of critical COVID-19, defined as death, admission to intensive care unit, and/or use of mechanical ventilation during admission. Models were validated in two datasets with different backgrounds (HM [private Spanish hospital network], n = 1,753, and ICS [public Catalan health system], n = 1,104), by assessing discrimination (area under the curve [AUC]) and calibration (plots). Results: We validated 18 prognostic models. Discrimination was good in nine of them (AUCs ≥ 80%) and higher in those predicting mortality (AUCs 65%-87%) than those predicting intensive care unit admission or a composite outcome (AUCs 53%-78%). Calibration was poor in all models providing outcome's probabilities and good in four models providing a point-based score. These four models used mortality as outcome and included age, oxygen saturation, and C-reactive protein among their predictors. Conclusion: The validity of models predicting critical COVID-19 by using only routinely collected predictors is variable. Four models showed good discrimination and calibration when externally validated and are recommended for their use.

Rationale Consistent physical activity (PA) is key for health and well-being; however, various events (e.g., pandemic outbreaks, acute diseases) can act as stressors for PA, and thus may be followed by a decrease in PA levels. The process of recovering from such stressors and bouncing back to the previous state of PA can be referred to as resilience. Quantifying resilience is fundamental to assess the impact of stressors on daily PA and to identify factors and strategies to foster adaptive capacities. However, PA time series are typically characterized by evident daily fluctuations that mask the underlying trajectory and, therefore, prevent from detecting the point in time when the system consistently recovers from the stressor. Objective: In this paper, we present a methodological approach to identify the recovery point and ultimately quantify the resilience process from PA data using the area under the curve (AUC). Methods: As use case to illustrate the methodology, we quantified resilience in step count for eight participants following the stressor represented by the start of the first COVID-19 lockdown (March 15, 2020). Step count time series were collected in Barcelona, as part of the COVICAT study, in the period between October 1, 2019 and September 30, 2020. Steps were collected daily using wrist-worn devices. The methodology is implemented in R and a tutorial is available on Open Science Framework. Results: We applied the following analytical steps to each participant’s time series. 1) We calculated the pre-stressor baseline level for step count as the median step count before the first COVID-19 lockdown. 2) We fitted multiple growth models (i.e., linear, quadratic, generalized additive) to each participant’s post stressor time series and identified the best model using the Root Mean Squared Error (RMSE). 3) We used the fitted values from the selected model to identify the point in time when the participants recovered from the stressor (bouncing back to the baseline level). 4) We quantified the AUC and, ultimately, resilience as the cumulative difference between baseline level and each fitted value before the recovery point. Further resilience features were extracted to capture the different aspects of the process and will be presented. Conclusions: Our contribution offers a methodological guide to quantify resilience from PA data and proposes a ready-to-go toolbox that can be easily applied by interested researchers and foster further scientific investigation in different ways. For instance, it allows to i) explore the determinants of the resilience process for PA, ii) identify intervention strategies that improve individuals’ adaptive capacities and promote faster resilience, and iii) use the provided indicators of resilience as outcomes to test the effectiveness of interventions aiming at reducing the impact of stressors on PA.

Volcanic eruptions emit gases and particulate matter into the atmosphere which, if inhaled, can have an impact on health. The eruption of the volcano situated in the Cumbre Vieja Nature Reserve (La Palma, Canary Islands, Spain) affords a unique opportunity to study the effect of such a phenomenon on health. The aim of the proposed study is to assess the short-, medium- and long-term respiratory health effects of exposure to volcanic emissions from the eruption in three different population groups.We propose to undertake a multidesign study: an ambispective cohort study to analyze the effect of the eruption on the general population, the highly exposed population, and the childhood population; and a pre-post quasi-experimental study on subjects with previously diagnosed respiratory diseases. The information will be collected using a personal interview, biologic specimens, air pollution data, data from medical records, respiratory tests and imaging tests. The study has an envisaged follow-up of five years, to run from the date of initial recruitment, with annual data-collection. This study has been approved by the Santa Cruz de Tenerife Provincial Research Ethics Committee (Canary Island Health Service) on March 10, 2022.This study will make it possible to advance our knowledge of the effect a volcano eruption has on population health, both short- and long-term, and to assess the potential respiratory injury attributable to volcanic eruptions. It may serve as a model for future studies of new volcanic eruptions in the coming years.

Introduction and objectives: Determinants of chronic obstructive pulmonary disease (COPD) in the early stages of its natural history are not well known. Improving our knowledge of these factors will help to design interventions that can modify prognosis. Study objectives are: a) to characterize a COPD population of young adults aged 35-50 years from a multidimensional point of view; b) to compare these patients with smokers with normal lung function: and c) to create a cohort of young adults aged 35-50 years (smokers or former smokers), with and without COPD, who will be followed in the future to improve understanding of the natural history of the disease. Participants and method: This is a case-control multicenter study aimed at establishing a well characterized cohort of young adults, smokers or former-smokers, with and without COPD, for subsequent follow-up. A total of 311 participants (101 cases and 210 controls) were selected from approximately 30 primary care settings and 12 hospitals in 8 Spanish regions. Subjects were smokers or former smokers (> 10 pack-years) aged 35-50 years. Diagnosis of COPD was based on a post-bronchodilator result of FEV1/FVC < 70%. The main study variables were: questionnaires on health, symptoms, exacerbations and daily physical activity, lung function tests, blood and sputum samples, and low-dose computed tomography. In the statistical analysis, COPD patient characteristics will be described and compared with control subjects using a logistic regression analysis. (C) 2018 SEPAR. Published by Elsevier Espana, S.L.U. All rights reserved.

Resumen Introduccion y objetivos Los determinantes en fases iniciales de la historia natural de la enfermedad pulmonar obstructiva cronica (EPOC) son poco conocidos. Entenderlos mejor es de capital importancia para poder disenar intervenciones dirigidas a modificar su pronostico. Los principales objetivos del estudio son: a) caracterizar a una poblacion de adultos jovenes con EPOC de forma multidimensional; b) comparar estos pacientes con sujetos fumadores con funcion pulmonar normal; y c) establecer una cohorte de adultos jovenes con y sin EPOC, que pueda ser seguida a largo plazo para conocer mejor la historia natural de la enfermedad. Participantes y metodo EARLY COPD es un estudio multicentrico de casos y controles que permitira establecer una cohorte de sujetos para su seguimiento posterior. Se seleccionaron 311 (101 casos y 210 controles) participantes reclutados en una treintena de centros de atencion primaria y 12 hospitales de 8 comunidades autonomas espanolas. Los participantes eran fumadores o exfumadores (> 10 paquetes ano) de entre 35-50 anos de edad. Los casos presentaban una espirometria obstructiva con un FEV1/FVC

Variability in SARS-CoV-2 susceptibility and COVID-19 disease severity between individuals is partly due to genetic factors. Here, we identify 4 genomic loci with suggestive associations for SARS-CoV-2 susceptibility and 19 for COVID-19 disease severity. Four of these 23 loci likely have an ethnicity-specific component. Genome-wide association study (GWAS) signals in 11 loci colocalize with expression quantitative trait loci (eQTLs) associated with the expression of 20 genes in 62 tissues/cell types (range: 1:43 tissues/gene), including lung, brain, heart, muscle, and skin as well as the digestive system and immune system. We perform genetic fine mapping to compute 99% credible SNP sets, which identify 10 GWAS loci that have eight or fewer SNPs in the credible set, including three loci with one single likely causal SNP. Our study suggests that the diverse symptoms and disease severity of COVID-19 observed between individuals is associated with variants across the genome, affecting gene expression levels in a wide variety of tissue types., Graphical abstract, D’Antonio et al. characterize associations between GWAS signals for COVID-19 disease and eQTLs in 69 human tissues to identify causal variants and their underlying molecular mechanisms. They show that diverse symptoms and disease severity of COVID-19 are associated with variants affecting gene expression in a wide variety of tissues.

BACKGROUND The cardiac autonomic function in patients with chronic obstructive pulmonary disease (COPD) has been poorly studied. OBJECTIVES We aimed to 1) describe the cardiac autonomic function assessed by heart rate recovery (HRR) and chronotropic response (CR) during a 6-min walk test (6MWT) and afterward and 2) estimate the association of physical activity with HRR and CR in COPD patients. METHODS This cross-sectional analysis included 320 patients with mild to very severe COPD. Physical activity (steps, time in any/moderate-to-vigorous/vigorous physical activity, intensity and sedentary time) was measured during 1 week by accelerometer. CR and HRR were measured during a 6MWT and 5min after, respectively, and their association with physical activity parameters was estimated by multivariable linear regression models. RESULTS Patients were 82% male and had a mean (SD) age 68 (8) years, post-bronchodilator FEV1 57 (18) % predicted, and walked a mean of 7716 (4139) steps/day. HRR was slow until 5min after the 6MWT; the mean (SD) HRR was 15 (10), 22 (11), 25 (12), 25 (12) and 27 (12) bpm after 1, 2, 3, 4 and 5min, respectively. The mean (SD) CR was 35% (16). After adjusting for relevant confounders, time in vigorous physical activity was significantly associated with a fast decrease in HRR (p=0.044) and an increase in CR (p=0.021). We found no independent association for other physical activity parameters. CONCLUSION A cardiac autonomic dysfunction is present in patients with mild to very severe COPD and is inversely related to the practice of vigorous physical activity. Trial registration ClinicalTrials.gov NCT01897298.

Background: Mobility is defined as the ability to independently move around the environment and is a key contributor to quality of life. The aim of this study was to evaluate the use of mobility as a decisive outcome for the marketing authorisation of drugs by the European Medicines Agency (EMA). Methods: Fifteen therapeutic areas which commonly lead to mobility impairments and alter the quantity and/or the quality of walking were selected: two systemic neurological diseases, four conditions primarily affecting exercise capacity, seven musculoskeletal diseases, and two conditions representing sensory impairments. European Public Assessment Reports (EPARs) published by the EMA up to September 2020 were examined for mobility endpoints included in their ‘main studies’, defined as those which were decisive for EU approval. Clinical study registries and primary scientific publications for these studies were also reviewed. Findings: 484 EPARs yielded 186 relevant documents with 402 ‘main studies’. The EPARs reported 153 primary and 584 secondary endpoints which considered mobility; 70 different assessment tools (38 patient-reported outcomes, 13 clinician-reported outcomes, 8 performance outcomes, and 13 composite endpoints) were used. Importantly, only 15·7% of those tools distinctly informed on patients’ mobility status. 105/402 (26·1%) of the ‘main studies’ did not have any mobility assessment and none of these studies included a digital mobility outcome. The supplementary review of study registries and primary publications revealed only five uses of mobility assessments not reported by EPARs. Interpretation: For conditions with a high impact on mobility, distinct mobility assessment was given little consideration in the marketing authorisation of drugs by the EMA. Where mobility impairment was considered to be a relevant outcome, questionnaires or composite scores were predominantly used. Reporting biases for such outcomes presents challenges for the interpretation of study results. Funding: Mobilise-D (Innovative Medicines Initiative) and Robert Bosch Stiftung, Germany. Declaration of Interest: SJ is partly supported by the Robert Bosch Stiftung Stuttgart. MW reports grants from HORIZON2020 IMI No. 820820, during the conduct of the study. DS reports grants from HORIZON2020 IMI No. 820820, during the conduct of the study. MC reports personal fees from Takeda Pharmaceuticals, during the conduct of the study; personal fees from Takeda Pharmaceuticals, outside the submitted work. JK reports grants from HORIZON2020 IMI No. 820820, during the conduct of the study. JGA reports grants from HORIZON2020 IMI No. 820820, and from AstraZeneca, Chiesi, Esteve, outside the submitted work. WM receives or received funding from the European Union, the German Federal Ministry of Education of Research, Michael J. Fox Foundation, Robert Bosch Foundation, Neuroalliance, Lundbeck and Janssen. He received speaker honoraria from Abbvie, Bayer, GlaxoSmithKline, Licher MT, Rolke Pharma and UCB, was invited to Advisory Boards of Abbvie, Biogen, Lundbeck and Market Access & Pricing Strategy GmbH, and is an advisory board member of the Critical Path for Parkinson's Consortium. He serves as the co-chair of the MDS Technology Task Force. MP reports grants from HORIZON2020 IMI No. 820820, outside the submitted work. MS is supported by the Robert Bosch Stiftung Stuttgart and reports grants from HORIZON2020 IMI 2 Mobilise D, during the conduct of the study, and grants and non-financial support from Green Cross WellBeing Co. Ltd., Gilead Sciences Inc., Robert Bosch GmbH, and CORAT Therapeutics GmbH , as well as other from Agena Bioscience GmbH, outside the submitted work. CB disclosed consultation from E. Lilly and speaker fees from Amgen, Nutricia and Pfizer reports grants from HORIZON2020 IMI No. 820820, during the conduct of the study. RT, BS, LL, LR, SCR declare no competing interests.

Rationale Many clinical and psychological factors are known to influence the health-related quality of life (HRQL) in chronic obstructive pulmonary disease (COPD). However, research on whether environmental factors, such as air pollution, noise, temperature, and blue/green spaces also influence HRQL in COPD has not been systematically investigated. Objective To assess the relationship between air pollution, road traffic noise, temperature, and distance to blue/green spaces and respiratory-specific HRQL in COPD. Methods We used cross-sectional data from a multicenter study in 407 stable mild-to-very severe COPD patients from Barcelona (Catalonia). Patients answered the COPD Assessment Test (CAT) and Clinical COPD Questionnaire (CCQ). Individual residential exposure to air pollutants (nitrogen dioxide [NO2] and particulate matters of varying aerodynamic diameters [PM2.5, PM10, and PM2.5absorbance]), road traffic noise (Lden), and land surface temperature were estimated using long-term averages from land-use regression models, 24-h noise maps, and land surface temperature maps, respectively. We measured residential distances to blue/green spaces from the Urban Atlas. We used mixed-effect negative binomial (for CAT) and linear (for CCQ) regression models, adjusted for potential confounders, with a random effect by center. Results Of those patients, 85 % were male and had a mean (SD) age of 69 (9) years, CAT score of 12 (7), CCQ-total score of 1.4 (1.0), and post-bronchodilator forced expiratory volume in 1 s (FEV1) of 57 (18) %predicted. We found that NO2 and PM2.5absorbance were associated with worsened CAT and CCQ-mental scores, e.g., 0.15-unit change in CAT score [regression coefficient (β) = 0.15; 95 % confidence interval (CI) = 0.03, 0.26] per interquartile range in NO2 [13.7 μg/m3]. Greater distances to blue/green spaces were associated with worsened CCQ-mental scores [0.08; 0.002, 0.15]. Conclusions Our study showed that increased air pollution, particularly NO2 and PM2.5absorbance and greater distances to blue/green spaces negatively influence HRQL in COPD patients. These findings have important implications for the WHO promotion to develop healthy cities for our future.

Understanding the stakeholders' most relevant landscape values and preferences, and how they spatially interact, may contribute to identify potential conflicts and enabling integrated river landscape management and rehabilitation. With this purpose in mind, we aimed (i) to identify the most relevant positive and negative landscape values and improvement preferences (IPs) in the Caldes Stream Corridor (Catalonia, Spain), (ii) to explore the relationships among these landscape values to understand how they are spatially intermingled in factors, and (iii) to assess the spatial relationships between these landscape value factors and IPs. Based on a mixed qualitative-quantitative public participation GIS (PPGIS) approach, we interviewed 53 stakeholders. We found that most relevant positive values were recreational/tourism, cultural heritage and aesthetic/scenic, and most important negative values were uncleanliness, aesthetic unpleasantness and pollution. The three main categories of IPs were: paths and itineraries, environmental quality, and socio-cultural assets. Positive and negative landscape values were spatially bundled according to eight factors. We found significant and fairly spatially homogeneous associations between IP and five of the factors, except for amenity and attachment factor, which presented a significant and spatially heterogeneous relationship. The amenity and attachment factor was also strongly spatially associated with paths and itineraries IP, while the natural but unclean and social and educational correlated significantly with environmental quality. This spatially explicit information on values/preferences and their spatial relationships provides a valuable basis for the development of more effective and consensual landscape management and rehabilitation strategies.

Introduction The origin of systemic inflammation in chronic obstructive pulmonary disease (COPD) patients remains to be defined, but one of the most widely accepted hypothesis is the ‘spill over’ of inflammatory mediators from the lung to the circulation. Objective To evaluate the relationship between pulmonary and systemic inflammation in COPD quantifying several inflammatory markers in sputum and serum determined simultaneously. Methodology Correlations between various inflammatory variables (TNFα, IL6, IL8) in sputum and serum were evaluated in 133 patients from the PAC-COPD cohort study. A secondary objective was the evaluation of relationships between inflammatory variables and lung function. Results Inflammatory markers were clearly higher in sputum than in serum. No significant correlation was found (absolute value, r=0.03–0.24) between inflammatory markers in blood and in sputum. There were no significant associations identified between those markers and lung function variables, such as FEV1, DLCO and PaO2 neither. Conclusions We found no correlation between pulmonary and systemic inflammation in patients with stable COPD, suggesting different pathogenic mechanisms.

Background: Several studies have suggested an interaction between air pollution and pollen exposure with an impact on allergy symptoms. However, large studies with real-life data are not available. Objective: To investigate associations between major air pollutants (ozone and particulate matter with a diameter of

Background: Interactions between early life and adult insults on lung function decline are not well understood, with most studies investigating pre-bronchodilator (BD) FEV1 decline. We investigated relationships between adult risk factors and post-BD lung function decline and their potential effect modification by specific early life and genetic factors. Methods: Multivariable regression was used to examine associations between adult exposures (asthma, smoking, occupational exposure, traffic pollution, atopy and obesity) and decline in post-BD spirometry between ages 45 to 53 years in the Tasmanian Longitudinal Health Study (n=857). Effect modification of these relationships by childhood respiratory risk factors including low childhood lung function, and glutathione S-transferase (GST) gene polymorphisms was investigated. Findings: Accelerated FEV1 decline was associated with baseline asthma of early onset (excess rate: -7·0; -12·5, -1·6 mL/year) and smoking (-13·8; -18·7, -9·0 mL/year). In addition, it was associated with occupational exposure to vapours/gases/dusts/fumes (-11·8: -19·0, -4·2 mL/year) only in carriers of the GSTM1 null allele (p-interaction=0·04). Findings for changes in exposure status support those for baseline exposures. Accelerated FEV1/FVC decline was associated with these factors and living

Objective Bicycle use for commuting is being encouraged not only to address physical inactivity, but also vehicular congestion, air pollution and climate change. The current study aimed to ascertain the urban environmental correlates and determinants of bicycle use for commuting (bicycle commuting) among the working or studying population in Barcelona, Spain. Methods Adults ( n = 769; 52% females) recruited whilst commuting within Barcelona (Spain) responded to a comprehensive telephone survey concerning their travel behaviour. Based upon responses collected from June 2011 to May 2012, participants were categorised into four groups: frequent bicyclists, infrequent bicyclists, willing non-bicyclists, and unwilling non-bicyclists. The determinants of frequency and willingness (propensity) to commute by bicycle were assessed by multinomial logistic regression models adjusted for potential confounders and covariates. Results The number of public bicycle stations surrounding the home address and amount of greenness surrounding the work/study address were significant positive determinants of bicycle commuting propensity. On the other hand, the number of public transport stations surrounding the home address and elevation of the work/study address were significant negative determinants of bicycle commuting propensity. Individual age, education level, gender, nationality, physical activity level and commute distance significantly affected this propensity. Conclusion Greater availability of public bicycle stations and higher levels of urban greenness may increase bicycle use by adults commuting within a city such as Barcelona, Spain. Electrically-assisted public bicycles may address the challenge of elevation, making this system a more competitive mode against traditional motorised public transport.

Despite well established clinical guidelines, performance of long-term oxygen therapy (LTOT) programs shows marked variability among territories. The current study assessed the LTOT program and the health status of patients on LTOT prior to the deployment of community-based integrated care in an urban health district of Barcelona (Spain).To assess: i) the LTOT program and health status of the patients on LTOT in the health district; ii) their frailty profile; and, iii) the requirements for effective deployment of integrated care services for these patients.Cross-sectional observational study design including all patients (n = 406) on LTOT living in the health district. Health status, frailty, arterial blood gases, forced spirometry and hand-grip muscle strength were measured. Network analysis of frailty was carried out.Adequacy of LTOT prescription (n = 362): 47% and 31% of the patients had PaO2 ≤ 60 mmHg and ≤55 mmHg, respectively. Adherence to LTOT: 31% of all patients used LTOT ≥15 h/d; this figure increased to 67% in those with PaO2≤60 mmHg. Assessment of frailty: Overall, LTOT patients presented moderate to severe frailty. Care complexity was observed in 42% of the patients.Adequacy and adherence to LTOT was poor and many patients were frail and complex. The outcomes of the network analysis may contribute to enhance assessment of frailty in LTOT patients. These observations suggest that an integrated care strategy has the potential to improve the health outcomes of these patients.

Summary Background The effects of obesity in combination with chronic obstructive pulmonary disease (COPD) on exercise capacity are receiving increased attention. But, a comprehensive analysis of factors associated with aerobic capacity in obese COPD patients has not been performed. Methods Six-min walking test (6MWT) was performed in 251 COPD patients, and 159 of those also carried out an incremental cardiopulmonary exercise test (CPET) to evaluate exercise capacity. In all patients, anthropometrics, dyspnea and anxiety–depression scores, lung function, daily physical activity, co-morbidities and circulating inflammatory biomarkers were also assessed. Six-min walking distance (6MWD) and peak oxygen uptake (VO 2 peak) during CPET were two primary outcome variables. Results 57% of the patients showed body mass index (BMI) 2 (COPD N ) and the remaining 43% were obese with a BMI ≥ 30 kg/m 2 (COPD O ). In patients with COPD N , 6MWD showed independent negative associations with age, dyspnea score, sedentarism, depression scores and a positive relationship with arterial oxygenation; whereas in COPD O , 6MWD showed an inverse relationship with BMI. In COPD N , VO 2 peak showed a negative association with age and positive relationships with both FEV 1 and DL CO. However, in COPD O the dyspnea score was the strongest determinant of VO 2 peak. Conclusions Obese and non-obese COPD patients show different determinants of aerobic capacity, including pulmonary and non-pulmonary factors that are also dependent on the type of exercise protocol. These results could be considered in the evaluation of obese patients with COPD.

International audience; BACKGROUND: In the field of nutritional epidemiology, principal component analysis (PCA) has been used to derive patterns, but the robustness of interpretation might be an issue when the sample size is small. The authors proposed the alternative use of confirmatory factor analysis (CFA) to define such patterns. OBJECTIVE: The aim was to compare dietary patterns derived through PCA and CFA used as equivalent approaches in terms of stability and relevance. DESIGN: PCA and CFA were performed in 2 different studies: the Epidemiological Study on the Genetics and Environment of Asthma 2-France (EGEA2-France; n = 1236) and the Phenotype and Course of Chronic Obstructive Pulmonary Disease study-Spain (n = 274). To check for stability, PCA and CFA were also performed in 2 subsamples from the EGEA2 study (n = 618 and 309). Statistical proprieties were evaluated by 1000 bootstrapped random sets of observations for each of the 4 subsamples. For each random set of observations, the distribution of the factor loading for each pattern was obtained and represented by using box-plots. To check for relevance, partial correlations between different nutrients and the different patterns derived by either PCA or CFA were calculated. RESULTS: With the use of CFA, 2 consistent dietary patterns were derived in each subsample (the Prudent and the Western patterns), whereas dietary factors were less interpretable with the use of PCA (smaller median of factor loadings and higher dispersion), especially for the smallest subsample. Higher correlations were reported among total fiber, vitamins, minerals, and total lipids with patterns derived by using CFA than with patterns derived by using PCA. CONCLUSION: The current study shows that CFA may be a useful alternative to PCA in epidemiologic studies, especially when the sample size is small.

Dietary intake of polyunsaturated fatty acids, including omega-3 and omega-6, could modulate chronic obstructive pulmonary disease (COPD) persistent inflammation. We aimed to assess the relationship between dietary intake of omega-3 and omega-6 fatty acids and serum inflammatory markers in COPD. A total of 250 clinically stable COPD patients were included. Dietary data of the last 2 years were assessed using a validated food frequency questionnaire (122 items), which provided levels of three omega-3 fatty acids: docosahexaenoic acid, eicosapentaenoic acid and α-linolenic acid (ALA); and two omega-6 fatty acids: linoleic acid and arachidonic acid (AA). Inflammatory markers [C-reactive protein (CRP), interleukin (IL)-6, IL-8 and tumor necrosis factor alpha (TNFα)] were measured in serum. Fatty acids and inflammatory markers were dichotomised according to their median values, and their association was assessed using multivariate logistic regression. Higher intake of ALA (an anti-inflammatory omega-3 fatty acid) was associated with lower TNFα concentrations [adjusted odds ratio (OR)=0.46; P=.049]. Higher AA intake (a proinflammatory omega-6 fatty acid) was related to higher IL-6 (OR=1.96; P=.034) and CRP (OR=1.95; P=.039) concentrations. Therefore, this study provides the first evidence of an association between dietary intake of omega-3 and omega-6 fatty acids and serum inflammatory markers in COPD patients.

Introduccion Los pacientes con enfermedad pulmonar obstructiva cronica (EPOC) se caracterizan por una actividad fisica limitada. Sorprendentemente, apenas se dispone de investigacion sobre los cuestionarios para medir la actividad fisica en la EPOC. El objetivo del presente estudio fue validar el cuestionario Yale Physical Activity Survey en pacientes con EPOC. Metodos Un total de 172 pacientes de 8 hospitales universitarios espanoles usaron un acelerometro (SenseWear®PrO2Armband) durante 8 dias y contestaron el cuestionario. Los analisis estadisticos de comparacion de ambos instrumentos incluyeron: a) correlacion de Spearman; b) coeficiente de correlacion intraclase (CCI) y graficos de Bland-Altman; c) distribucion de las medidas del acelerometro segun los terciles del cuestionario, y d) la curva receiver operating characteristic (ROC) para detectar a los pacientes sedentarios. Resultados El 94% de los participantes eran hombres, el 28% eran fumadores y el 7% eran trabajadores activos; la edad media (±DE) fue de 70 (8) anos, el volumen espiratorio medio en el primer segundo (VEMS) posbroncodilatador fue de 52 (15) como porcentaje del valor de referencia, y la mediana (p25-p75) de pasos fue de 5.702 (3.273-9.253) pasos/dia. Las correlaciones de Spearman fueron debiles o moderadas (desde 0,29 hasta 0,52, todas las p

Chronic obstructive pulmonary disease (COPD) is a complex, multifaceted disease. The clinical presentation is highly heterogeneous and consequently, within what is known today as COPD, there may be some groups (phenotypes) of patients who share clinical and/or biological characteristics but who have distinct prognoses and/or who require different therapeutic approaches. In its broadest sense, phenotype is defined as any observable characteristic in the body, but "clinical phenotype" is defined as a characteristic or set of characteristics of a disease that can be used to distinguish individuals with COPD and are related to significant clinical outcomes, such as symptoms, exacerbations, treatment response, disease progression or death. The present article reviews current knowledge of this topic.

SummaryBackground & aimsWe described dietary habits in a Spanish sample of COPD patients and assessed its adequacy according to dietary recommendations, which so far have never been published.Methods275 patients hospitalized for the first time for a COPD exacerbation in Spain answered a 122-item food frequency questionnaire on their last 2 years dietary habits. A Spanish food composition table was used to estimate nutrient intake. Adequacy of dietary intakes was assessed using the Spanish Nutrition Society guidelines for the elderly.ResultsMean(SD) age was 68(8)years, 93% males, 32% current smokers, and post-bronchodilator FEV1 53(16)% predicted. Mean(SD) body mass index was 28(5)kg/m2, with only 2% of subjects under 20kg/m2. Mean intake of meat, poultry and eggs was slightly higher (mean 108g/d) than recommended. Fish and shellfish (86g/d) as well as fruit and vegetables (567g/d) were adequate. Mean energy intake was 2033kcal/d. The proportion of energy from carbohydrates was lower (39%) whereas that from proteins and lipids were higher than recommended (20% and 35%, respectively). Alcohol intake was

Resumen La definicion funcional de la enfermedad pulmonar obstructiva cronica (EPOC), basada en la limitacion al flujo aereo, ha predominado durante largo tiempo en el ambito de la neumologia. Sin embargo, ha surgido una nueva perspectiva que establece que en la EPOC tiene lugar una compleja variedad de manifestaciones celulares, organicas, funcionales y clinicas, y se ha incrementado el interes por desentranar la heterogeneidad fenotipica de dicha enfermedad. La presente revision se basa en la opinion de unos autores que tienen una amplia experiencia en la investigacion de los diversos aspectos de la EPOC. La revision parte de la base de que el conocimiento actual sobre la fisiopatologia y el cuadro clinico de la EPOC permite clasificar la informacion fenotipica en funcion de las siguientes dimensiones: sintomas respiratorios y estado de salud, exacerbaciones agudas, funcion pulmonar, cambios estructurales, inflamacion local y sistemica, y efectos sistemicos. Se han identificado 26 rasgos fenotipicos que se han asignado a alguna de las 6 dimensiones. Para cada dimension se proporciona un resumen de la mejor evidencia sobre la relacion existente entre los rasgos fenotipicos —en concreto, entre aquellos que corresponden a diferentes dimensiones— y sobre la relacion entre dichos rasgos y las manifestaciones relevantes en la evolucion natural de la EPOC. Toda la informacion se ha organizado graficamente en una matriz fenotipica donde cada celda que representa un par de rasgos fenotipicos esta vinculada a referencias bibliograficas relevantes. La informacion podria ayudar a comprender mejor la heterogeneidad de los fenotipos de la EPOC y a planificar estudios futuros sobre aspectos que todavia no se han investigado.

a b s t r a c t Background and Objectives: The Phenotype and Course of Chronic Obstructive Pulmonary Disease (PAC- COPD) study aims to improve our understanding of the phenotypic heterogeneity of this disease and the extent to which this heterogeneity is related to clinical course. The main objectives are a) to characterize the phenotypic variability in first-time hospitalizations for exacerbation of COPD and to propose a classification into subtypes, and b) to ascertain the association between the defined subtypes and the clinical and functional course of COPD. Patients and Methods: This is a cross-sectional and cohort study of 342 patients with COPD from 9 tertiary hospitals in 3 autonomous communities. The minimum follow-up period is 5 years. The main variables of interest are respiratory symptoms, smoking, alcohol use, physical activity, use of health care services, medical care, treatment received, activities of daily living, comorbid conditions, sleepiness, anxiety and depression, quality of life, forced spirometry and bronchodilator tests, lung volume and inspiratory capacity measured by body plethysmography, carbon monoxide diffusing capacity, baseline arterial blood gas values, respiratory and peripheral muscle function, electrocardiogram, body weight and composition measured by bioelectric impedance, chest radiograph, skin prick test, capacity for exercise measured in the 6-minute walk test and cardiopulmonary exercise test, induced sputum (for quantitative microbiological culture and determination of inflammatory markers), nighttime pulse oximetry, chest computed tomography scan, and echocardiography. Levels of markers of inflammation and oxidative stress are measured in serum and plasma; these samples are also used for genetic analysis and will be stored for other possible measurements that might be required in the future. The statistical analysis combines factor analysis and survival models such as Cox regression analysis. This project will enable us to reconsider the definition and classification of COPD and to better understand the factors associated with its natural history.

Objetivo El presente estudio examina la incidencia y las caracteristicas clinicas de los episodios de agudizacion asmatica (AA) atendidos en los servicios de urgencias (SU) de la ciudad de Barcelona (estudio ASMAB-I). Pacientes y metodos Se estudiaron los episodios de AA atendidos en los SU hospitalarios y en el SU domiciliario (061) durante 129 dias, correspondientes a una poblacion mayor de 14 anos de 1.203.598 habitantes. Resultados Se identificaron 831 episodios de AA, de los que 523 fueron atendidos en 3 hospitales universitarios, 113 en 2 hospitales de segundo nivel y otros 195 (de los que 20 se remitieron a hospitales) en los SU domiciliarios. La frecuentacion media fue de 6,4 episodios/dia, con una incidencia de AA de 0,53/105 habitantes/dia (intervalo de confianza del 95%, 0,46-0,56) y de 8,2/105 pacientes asmaticos (intervalo de confianza del 95%, 6,89-8,41). De los 276 episodios atendidos de lunes a jueves en los servicios de los hospitales universitarios, 66 pacientes (24%) reconocieron un inicio agudo y 14 (5%) un inicio subito. Unicamente 85 pacientes (31%) tomaban de modo regular corticoides inhalados y solo 33 (12%) anadieron corticoi-des orales en las 12 h previas a su llegada a urgencias. Un 16% de los episodios se calificaron de graves y un 3% de casi fatales. Un total de 82 pacientes (30%) fueron finalmente hospitalizados; ingresaron el 12% de las AA leves, el 39% de las AA moderadas, el 62% de las A A graves y el 100% de las casi fatales. El indice de comorbilidad de Charlson fue mayor en los pacientes hospitalizados (p Conclusiones La tasa de A A establecida puede ser un indicador util del grado de control del asma y servir para confirmar futuros aumentos de AA permanentes o puntuales. El inicio rapido (agudo o subito) es frecuente. Muchos pacientes no reciben un tratamiento adecuado antes de la hospitalizacion. La agudizacion grave es frecuente en nuestro medio. El ingreso esta relacionado con la gravedad y la comorbilidad. Los readmitidos han recibido al alta menos antibioticos y bromuro de ipratropio.

The aim of this study was to determine the incidence and clinical characteristics of asthma exacerbations seen by emergency services in Barcelona, Spain (the ASMAB-I study).The emergency services considered in the study served a population of 1 203 598 inhabitants aged over 14 years. Episodes treated in hospital emergency departments and by emergency services called to patients' homes over a period of 129 days were included in the study.In total, 831 episodes of exacerbation were identified; 523 were seen in 3 university hospitals, 113 in secondary hospitals, and 195 by emergency services at the patient's home. Twenty of the patients seen at home were subsequently taken to hospital. The mean frequency was 6.4 episodes per day, corresponding to a daily incidence of 0.53 exacerbations per 100 000 inhabitants (95% confidence interval, 0.46-0.56 exacerbations/100 000 inhabitants) and 8.2 per 100 000 asthmatic patients (95% confidence interval, 6.89-8.41 exacerbations/100 000 asthmatic patients). Of the 276 episodes treated between Monday and Thursday in university hospitals, 66 patients (24%) reported acute onset and 14 (5%) sudden onset. Only 85 patients (31%) regularly used inhaled corticosteroids and only 33 (12%) added oral corticosteroids in the 12 hours prior to consulting emergency services. In 16% of cases the episode was classified as severe and in 3% near fatal. Eighty-two patients (30%) were ultimately admitted to hospital: 12% of mild exacerbations, 39% of moderate exacerbations, 62% of severe episodes, and 100% of near-fatal episodes. The Charlson comorbidity index was higher in patients admitted to hospital (P.001). In the 28 patients readmitted to hospital (10%), antibiotics (P.001) and ipratropium bromide (P.0001) had been prescribed less often at the time of discharge after the first hospital admission.The rate of asthma exacerbation established in this study may be a useful indicator of the degree of control of the disease and may serve as a reference to confirm future short-term or lasting increases in asthma exacerbation. Rapid onset (acute or sudden) is common and many patients are not receiving appropriate treatment prior to hospital admission. Severe exacerbation is common in our practice setting. Hospital admission is related to severity and comorbidity. Patients who are readmitted to hospital had less often received antibiotic treatment and ipratropium bromide when discharged previously.

Summary Aim To assess the role of doctors who patients report as responsible of their disease, in moderate–severe chronic obstructive pulmonary disease (COPD), describing characteristics of patients and treatments use according to each type of doctor, and relating it to the way of access to hospital at the time of an exacerbation. Materials/patients and methods A systematic sample of 1:2 patients admitted for a COPD exacerbation during 1 year in four tertiary hospitals in the Barcelona area, Spain, was recruited. Information about health services was obtained by an administered questionnaire. Results A total of 346 patients were recruited: mean age 69 (±9) years, percent of predicted FEV 1 of 35 (±16)%, P O 2 of 64 (±13)mmHg. At the time of admission, 17% of patients reported being controlled by a general practitioner (GP) and 56% by a pneumologist whereas 21% reported its COPD not being under the regular control of any doctor. Patients not controlled by a pneumologist did not suffer from milder COPD than the remaining, but were less likely to receive pharmacological and non-pharmacological treatments and less likely to perform correctly the inhalation manoeuvres. During the course of the exacerbation 70% of patients reported a visit to a hospital emergency room department without a previous medical visit, this proportion being higher among those controlled by a pneumologist. Conclusions Lack of control and variability in the patterns of care among patients controlled by different types of physicians are common in moderate-to-severe COPD patients admitted for a COPD exacerbation, despite the lack of differences in COPD severity. Medical control of COPD patients needs more investigation and a wider inclusion in international guidelines.

We have previously reported an apparently paradoxical association between medical care related factors and an increased risk of chronic obstructive pulmonary disease (COPD) re-hospitalisation, in a cohort of 346 COPD subjects from Barcelona, Spain. Confounding by severity or by indication is a plausible explanation. We tested the confounding effect of severity-related variables on these paradoxical associations. Forced expiratory volume in one second (FEV 1 ), arterial oxygen pressure ( P O 2 ) and previous COPD admissions were associated with: (1) the presence of medical care related factors, and (2) re-admission during follow-up. Risks of re-admission associated with most of the medical care related factors were reduced after adjustment for the severity variables. The risk associated with long-term oxygen therapy use changed from a crude OR of 2.36 (95% CI: 1.79–3.11) to an adjusted OR of 1.38 (0.95–2.00), while that associated with anticholinergics use varied from 3.52 (2.37–5.21) to 2.10 (1.32–3.36)). We concluded that the excess risk of COPD re-admission associated with medical care related factors might be partially due to confounding by indication. Residual confounding may still account for part of the remaining excess risk. True adverse effects of some pharmacological treatments cannot be excluded.

Objective To evaluate the role of extracurricular physical activity and sedentary behavior at preschool and primary school age on working memory at primary school age and adolescence, respectively. Study design This prospective study was based on a birth cohort across 4 Spanish regions. In the 3 younger subcohorts (n = 1093), parents reported lifestyle habits of child at age 4 years of age on a questionnaire, and children performed a computerized working memory task at 7 years of age. In the older subcohort (n = 307), the questionnaire was completed at 6 years of age and working memory was tested at 14 years of age. Adjusted regression models were developed to investigate the associations between lifestyle habits and working memory. Results Low extracurricular physical activity levels at 4 years of age were associated with a nonsignificant 0.95% (95% CI −2.81 to 0.92) reduction of correct responses in the working memory task at age 7 years of age. Low extracurricular physical activity levels at 6 years of age were associated with a 4.22% (95% CI −8.05 to −0.39) reduction of correct responses at age 14 years. Television watching was not associated with working memory. Other sedentary behaviors at 6 year of age were associated with a 5.07% (95% CI −9.68 to −0.46) reduction of correct responses in boys at 14 years of age. Conclusion Low extracurricular physical activity levels at preschool and primary school ages were associated with poorer working memory performance at primary school age and adolescence, respectively. High sedentary behavior levels at primary school age were related negatively to working memory in adolescent boys.