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    "titulo" => "Need for Epidemiological Studies on Chronic Obstructive Pulmonary Disease in Rural Spain"
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            "entidad" => "Grupo C039 Biodiscovery HULA-USC&#44; Instituto de Investigaci&#243;n Sanitaria de Santiago de Compostela &#40;IDIS&#41;&#44; Santiago de Compostela&#44; Spain"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We have read with great interest the article on the prevalence and determinants of COPD in Spain &#40;EPISCAN II&#41;&#44; which offers the best information on the epidemiology of the disease in our country&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Two of the study&#39;s results stand out&#58; the spirometrically-defined prevalence of COPD in Spain is 11&#46;8&#37;&#44; and the underdiagnosis of the disease is 74&#46;7&#37;&#46; The authors acknowledge that one of the limitations of the study is that it was conducted essentially in an urban setting&#46; There is a significant lack of knowledge on the epidemiology of chronic respiratory diseases in general&#44; and COPD in particular&#44; in rural areas of our country&#46; Studies carried out in the USA have found rural-urban disparities in the prevalence of COPD&#44; which is higher in rural areas&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> The reason is likely to be multifactorial&#58; tobacco use is higher and access to smoking cessation programs is limited in rural populations&#46; Lower socioeconomic status could also be a risk factor for COPD in this population&#46; Finally&#44; environmental biomass smoke exposure is higher in this setting&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> This is a recognized risk factor for COPD&#44; even in developed countries&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Therefore&#44; the global prevalence of COPD found in EPISCAN II might underestimate the disease burden in rural population&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Furthermore&#44; it is plausible that underdiagnosis rates are higher in rural than in urban areas&#46; Clinical guidelines strongly emphasize the association between tobacco smoke and COPD&#44; and the diagnosis may be delayed in non-tobacco-related COPD&#46; Future analyses of EPISCAN II will likely explore whether there is a relationship between smoking history and underdiagnosis of the disease&#46; Access to spirometry may also be limited for rural residents&#44; and this is another credible source of underdiagnosis in this setting&#46; The On-Sint study&#44; carried out in our country&#44; revealed that being followed-up in a rural setting was associated with an inadequate diagnosis of COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Acquiring accurate information on the epidemiology of COPD in rural Spain becomes highly desirable in view of the results of a recently published study&#58; while mortality attributable to chronic lower respiratory disease in urban areas of the USA is declining&#44; it is increasing in rural areas&#44; widening the rural-urban gap in mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> This is in contrast to cardiovascular disease-related mortality&#44; which is decreasing both in rural and urban areas&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> It is currently speculative if a similar trend could be found in mortality from COPD in Spain&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">It is obvious that confirming possible differences in the prevalence&#44; impact or underdiagnosis of COPD in rural areas would have policy implications&#44; aimed at increasing support to improve prevention&#44; diagnosis and treatment of the disease in this setting&#46; Therefore&#44; epidemiological studies focused specifically on this population are urgently needed&#44; and should be promoted by the Spanish Society of Pulmonology and Thoracic Surgery &#40;SEPAR&#41;&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Sources of funding</span><p id="par0025" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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