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in these patients would be 9&#8211;10&#44; and that after implementation of the RDH this rate could be reduced by 25&#37;&#46; To achieve a power of 85&#37;&#44; 125 patients would be needed to detect significant differences &#40;<span class="elsevierStyleItalic">p</span>&#60;0&#46;05&#41; between the number of events before and after RDH&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">During the study period&#44; 1053 visits to the RDH for exacerbations were recorded in 129 patients &#40;COPD &#91;87&#93;&#44; bronchiectasis &#91;12&#93;&#44; asthma &#91;7&#93;&#44; and others &#91;23&#93;&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the level of physical activity &#40;low&#47;moderate in 112&#47;129&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#44; dyspnea grade &#40;mMRC 34 in 71&#47;129&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#44; 6-minute walk test &#40;42&#47;129 walked<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>250<span class="elsevierStyleHsp" style=""></span>m&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#44; and FEV1 &#40;84&#47;129<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50&#37;&#41; of the overall study population &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46; Among COPD patients&#44; 57&#47;87 had a BODE index<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>4 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>E&#41;&#44; 82&#47;87 were GOLD stage D &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>F&#41;&#44; 76&#47;87 had a GesEPOC exacerbator phenotype &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>G&#41;&#44; 76&#47;87 had CAT<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>10&#44; 5&#47;87 had a body mass index<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>21&#44; 5&#47;87 had alpha-1 antitrypsin deficiency&#44; and 16&#47;87 were receiving BiPAP home oxygen therapy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>H&#41;&#46; In total&#44; 8&#46;6&#37; of visits &#40;91&#47;1053&#41; required hospital admission&#44; mainly due to the need for intravenous antibiotics &#40;25&#59; 27&#46;5&#37;&#41;&#44; acute respiratory failure &#40;21&#59; 23&#46;1&#37;&#41;&#44; and failure of previous outpatient therapy &#40;12&#59; 13&#46;2&#37;&#41;&#46; When the year prior to and the year after the first visit to the RDH were compared&#44; a reduction in both the number of visits to the emergency room &#40;110 vs 57&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;001&#41;&#44; and in the number of hospital admissions &#40;236 vs 183&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;006&#41; was observed&#46; Results were similar when data from patients who died during the follow-up year &#40;19&#59; 14&#46;7&#37;&#41; were excluded&#58; 90 vs 43 visits to the emergency room &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;002&#41;&#59; and 190 vs 141 hospital admissions &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;003&#41;&#46; Moreover&#44; 81&#46;8&#37; &#40;45&#47;55&#41; of patients receiving continuous home oxygen therapy had COPD&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">A multivariate analysis of COPD patients found that factors associated with a greater risk of admission were respiratory acidosis &#40;OR 9&#46;67&#44; 95&#37; CI&#58; 1&#46;48&#8211;62&#46;9&#41;&#44; diabetes mellitus &#40;OR 2&#46;01&#59; 95&#37; CI&#58; 1&#46;08&#8211;3&#46;77&#41;&#44; low blood pressure &#40;OR 0&#46;99&#59; 95&#37; CI&#58; 0&#46;97&#8211;1&#46;00&#41;&#44; tachycardia &#40;OR 1&#46;02&#59; 95&#37; CI&#58; 1&#46;00&#8211;1&#46;04&#41;&#44; diuretic failure &#40;OR 19&#46;7&#59; 95&#37; CI&#58; 4&#46;32&#8211;89&#46;8&#41;&#44; isolation of a multiresistant microorganism in sputum &#40;OR 4&#46;41&#59; 95&#37; CI&#58; 2&#46;06&#8211;9&#46;42&#41;&#44; sepsis &#40;OR 4&#46;01&#59; 95&#37; CI&#58; 1&#46;16&#8211;13&#46;8&#41;&#44; and use of accessory muscles &#40;OR 4&#46;94&#59; 95&#37; CI&#58; 2&#46;60&#8211;9&#46;40&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">This study confirms that even in the first year of functioning&#44; the RDH can reduce pressure on the emergency department and the number of admissions&#44; despite the advanced respiratory disease status and high comorbidity burden of the patients seen&#46; Moreover&#44; it shows that certain factors are associated with a higher risk of admission among COPD patients&#46; Our results coincide with those of other studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1&#44;13&#44;14</span></a> although our series differs in that that most of our patients had very severe disease and presented higher exacerbation rates&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The significant reduction&#44; in both the number of visits to the emergency room &#40;110 vs 57&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;001&#41;&#44; and the number of hospital admissions &#40;236 vs 183&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;006&#41; compared to the previous year appears to confirm the efficacy of the RDH&#46; These results may be directly associated with the more specialized care provided the RDH doctors and nurses in the management of the respiratory patient&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The opening hours of the RDH are limited and a patient&#39;s destination must be decided within a few hours&#44; so we examined which factors in COPD patients might predict hospitalization&#44; to be able to anticipate their final destination&#46; Some of the factors we identified are indicative of very severe COPD exacerbations<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a>&#58; patients who may need ventilation &#40;acidosis&#41; or who have hemodynamic instability &#40;tachycardia and hypotension&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The limitations of this study are&#58; &#40;1&#41; no strict protocol for reevaluation of each exacerbation &#40;all patients were seen 72 hours after an exacerbation&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a> but some had to be seen several times&#41;&#59; &#40;2&#41; use of an mMRC scale for evaluating dyspnea in all patients although it is only validated for COPD&#46; We decided to use this tool because it is easy to apply and because it is usually collected in the emergency department&#59; and &#40;3&#41; lack of a cost-effectiveness study&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In short&#44; a RDH can constitute an alternative to conventional hospitalization&#44; and is suitable for the outpatient management of a large number of respiratory exacerbations&#44; even in severe patients&#46; COPD patients present a series of factors that predict a greater risk of hospital admission&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Lourido-Cebreiro T&#44; Rodr&#237;guez-Garc&#237;a C&#44; Gude F&#44; Vald&#233;s L&#46; &#191;Es &#250;til un hospital de d&#237;a de enfermedades respiratorias en pacientes graves&#63; Arch Bronconeumol&#46; 2017&#59;53&#58;400&#8211;402&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Level of physical activity&#44; &#40;B&#41; dyspnea grade&#44; &#40;C&#41; 6-minute walk test&#44; and &#40;D&#41; FEV<span class="elsevierStyleInf">1</span> in the overall study population&#46; &#40;E&#41; BODE index&#44; &#40;F&#41; GOLD stage&#44; &#40;G&#41; GesEPOC phenotype&#44; &#40;H&#41; CTA&#44; body mass index&#44; alpha-1 antitrypsin deficiency&#44; and BiPAP home therapy in COPD patients&#46; A1ATD&#58; alpha-1 antitrypsin deficiency&#59; BiPAP&#58; bilevel positive airway pressure&#59; BMI&#58; body mass index&#59; CAT&#58; chronic obstructive pulmonary disease assessment test&#59; CB&#58; chronic bronchitis&#59; Em&#58; emphysema&#59; Ex&#58; exacerbator&#59; mMRC&#58; modified Medical Research Council&#46;</p>"
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Scientific Letter
Is a Respiratory Day Hospital Useful in Patients with Severe Disease?
¿Es útil un hospital de día de enfermedades respiratorias en pacientes graves?
Tamara Lourido-Cebreiroa,
Corresponding author
, Carlota Rodríguez-Garcíaa, Francisco Gudeb,c, Luis Valdésa,d
a Servicio de Neumología, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
b Unidad de Epidemiología Clínica, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
c Grupo Epidemiología de Enfermedades Frecuentes, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
d Servicio de Neumología, Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Level of physical activity&#44; &#40;B&#41; dyspnea grade&#44; &#40;C&#41; 6-minute walk test&#44; and &#40;D&#41; FEV<span class="elsevierStyleInf">1</span> in the overall study population&#46; &#40;E&#41; BODE index&#44; &#40;F&#41; GOLD stage&#44; &#40;G&#41; GesEPOC phenotype&#44; &#40;H&#41; CTA&#44; body mass index&#44; alpha-1 antitrypsin deficiency&#44; and BiPAP home therapy in COPD patients&#46; A1ATD&#58; alpha-1 antitrypsin deficiency&#59; BiPAP&#58; bilevel positive airway pressure&#59; BMI&#58; body mass index&#59; CAT&#58; chronic obstructive pulmonary disease assessment test&#59; CB&#58; chronic bronchitis&#59; Em&#58; emphysema&#59; Ex&#58; exacerbator&#59; mMRC&#58; modified Medical Research Council&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Respiratory day hospitals &#40;RDH&#41; are a useful alternative form of hospitalization&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> However&#44; no studies are available that demonstrate their suitability for managing exacerbations in patients with severe respiratory disease&#46; In this communication&#44; we report our experience in this area&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Between December 2013 and November 2014&#44; we performed an observational&#44; longitudinal&#44; quasi-experimental study &#40;patients were their own controls&#41; of all patients who attended the RDH &#40;2 or more admissions&#47;emergency visits due to decompensation of an underlying respiratory disease in the previous year&#41;&#46; All patients were followed for 1 year&#44; and data from the previous year were obtained from their clinical records&#46; The study was approved by the Ethics Committee &#40;no&#46; 2016&#47;424&#41;&#46; Widely accepted criteria were used to establish the diagnosis of COPD&#44; asthma&#44; and bronchiectasis&#44; and to determine levels of physical activity&#44; dyspnea grade&#44; deterioration of state of health&#44; BODE index&#44; 6-minute walk test&#44; classification of COPD patients&#44; and definition of sepsis&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">2&#8211;12</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A descriptive analysis was conducted of patient characteristics&#44; and visits to the emergency department&#47;hospitalizations between the year prior to and the year after the patient&#39;s first visit to the RDH were compared using the Wilcoxon non-parametric test for paired data&#44; and variables associated with hospitalization were studied&#46; It was estimated that the mean annual number of events &#40;emergency visits and admissions&#41; in these patients would be 9&#8211;10&#44; and that after implementation of the RDH this rate could be reduced by 25&#37;&#46; To achieve a power of 85&#37;&#44; 125 patients would be needed to detect significant differences &#40;<span class="elsevierStyleItalic">p</span>&#60;0&#46;05&#41; between the number of events before and after RDH&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">During the study period&#44; 1053 visits to the RDH for exacerbations were recorded in 129 patients &#40;COPD &#91;87&#93;&#44; bronchiectasis &#91;12&#93;&#44; asthma &#91;7&#93;&#44; and others &#91;23&#93;&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the level of physical activity &#40;low&#47;moderate in 112&#47;129&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#44; dyspnea grade &#40;mMRC 34 in 71&#47;129&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#44; 6-minute walk test &#40;42&#47;129 walked<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>250<span class="elsevierStyleHsp" style=""></span>m&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#44; and FEV1 &#40;84&#47;129<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50&#37;&#41; of the overall study population &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46; Among COPD patients&#44; 57&#47;87 had a BODE index<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>4 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>E&#41;&#44; 82&#47;87 were GOLD stage D &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>F&#41;&#44; 76&#47;87 had a GesEPOC exacerbator phenotype &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>G&#41;&#44; 76&#47;87 had CAT<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>10&#44; 5&#47;87 had a body mass index<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>21&#44; 5&#47;87 had alpha-1 antitrypsin deficiency&#44; and 16&#47;87 were receiving BiPAP home oxygen therapy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>H&#41;&#46; In total&#44; 8&#46;6&#37; of visits &#40;91&#47;1053&#41; required hospital admission&#44; mainly due to the need for intravenous antibiotics &#40;25&#59; 27&#46;5&#37;&#41;&#44; acute respiratory failure &#40;21&#59; 23&#46;1&#37;&#41;&#44; and failure of previous outpatient therapy &#40;12&#59; 13&#46;2&#37;&#41;&#46; When the year prior to and the year after the first visit to the RDH were compared&#44; a reduction in both the number of visits to the emergency room &#40;110 vs 57&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;001&#41;&#44; and in the number of hospital admissions &#40;236 vs 183&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;006&#41; was observed&#46; Results were similar when data from patients who died during the follow-up year &#40;19&#59; 14&#46;7&#37;&#41; were excluded&#58; 90 vs 43 visits to the emergency room &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;002&#41;&#59; and 190 vs 141 hospital admissions &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;003&#41;&#46; Moreover&#44; 81&#46;8&#37; &#40;45&#47;55&#41; of patients receiving continuous home oxygen therapy had COPD&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">A multivariate analysis of COPD patients found that factors associated with a greater risk of admission were respiratory acidosis &#40;OR 9&#46;67&#44; 95&#37; CI&#58; 1&#46;48&#8211;62&#46;9&#41;&#44; diabetes mellitus &#40;OR 2&#46;01&#59; 95&#37; CI&#58; 1&#46;08&#8211;3&#46;77&#41;&#44; low blood pressure &#40;OR 0&#46;99&#59; 95&#37; CI&#58; 0&#46;97&#8211;1&#46;00&#41;&#44; tachycardia &#40;OR 1&#46;02&#59; 95&#37; CI&#58; 1&#46;00&#8211;1&#46;04&#41;&#44; diuretic failure &#40;OR 19&#46;7&#59; 95&#37; CI&#58; 4&#46;32&#8211;89&#46;8&#41;&#44; isolation of a multiresistant microorganism in sputum &#40;OR 4&#46;41&#59; 95&#37; CI&#58; 2&#46;06&#8211;9&#46;42&#41;&#44; sepsis &#40;OR 4&#46;01&#59; 95&#37; CI&#58; 1&#46;16&#8211;13&#46;8&#41;&#44; and use of accessory muscles &#40;OR 4&#46;94&#59; 95&#37; CI&#58; 2&#46;60&#8211;9&#46;40&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">This study confirms that even in the first year of functioning&#44; the RDH can reduce pressure on the emergency department and the number of admissions&#44; despite the advanced respiratory disease status and high comorbidity burden of the patients seen&#46; Moreover&#44; it shows that certain factors are associated with a higher risk of admission among COPD patients&#46; Our results coincide with those of other studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1&#44;13&#44;14</span></a> although our series differs in that that most of our patients had very severe disease and presented higher exacerbation rates&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The significant reduction&#44; in both the number of visits to the emergency room &#40;110 vs 57&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;001&#41;&#44; and the number of hospital admissions &#40;236 vs 183&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;006&#41; compared to the previous year appears to confirm the efficacy of the RDH&#46; These results may be directly associated with the more specialized care provided the RDH doctors and nurses in the management of the respiratory patient&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The opening hours of the RDH are limited and a patient&#39;s destination must be decided within a few hours&#44; so we examined which factors in COPD patients might predict hospitalization&#44; to be able to anticipate their final destination&#46; Some of the factors we identified are indicative of very severe COPD exacerbations<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a>&#58; patients who may need ventilation &#40;acidosis&#41; or who have hemodynamic instability &#40;tachycardia and hypotension&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The limitations of this study are&#58; &#40;1&#41; no strict protocol for reevaluation of each exacerbation &#40;all patients were seen 72 hours after an exacerbation&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a> but some had to be seen several times&#41;&#59; &#40;2&#41; use of an mMRC scale for evaluating dyspnea in all patients although it is only validated for COPD&#46; We decided to use this tool because it is easy to apply and because it is usually collected in the emergency department&#59; and &#40;3&#41; lack of a cost-effectiveness study&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In short&#44; a RDH can constitute an alternative to conventional hospitalization&#44; and is suitable for the outpatient management of a large number of respiratory exacerbations&#44; even in severe patients&#46; COPD patients present a series of factors that predict a greater risk of hospital admission&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Lourido-Cebreiro T&#44; Rodr&#237;guez-Garc&#237;a C&#44; Gude F&#44; Vald&#233;s L&#46; &#191;Es &#250;til un hospital de d&#237;a de enfermedades respiratorias en pacientes graves&#63; Arch Bronconeumol&#46; 2017&#59;53&#58;400&#8211;402&#46;</p>"
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Article information
ISSN: 15792129
Original language: English
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