Missed diagnosis and overtreatment of COPD among smoking primary care population in Central Greece: old problems persist

Association of Lifestyle Behaviors with Quality of Life in Patients with COPD: A Cross-Sectional Study in Primary Care

Background/Objectives: The association between healthy lifestyle behaviors and their effect on quality of life among patients with COPD remains unclear. Therefore, the aim of this study was to explore the lifestyle behaviors and their association with the disease-specific quality of life among a primary care population with COPD in Greece. Methods: This cross-sectional study included 236 participants aged 40 years and older from the COCARE COPD study. The healthy lifestyle index (HLI) was created based on smoking, alcohol consumption, BMI, physical activity, and sleep duration, with each factor categorized as either healthy (1) or unhealthy (0). The HLI ranged from 0 (least healthy) to 5 (healthiest). COPD-specific quality of life was assessed using the COPD assessment test (CAT), where higher scores indicate poorer health status. Multiple logistic regression was used to analyze the association between HLI and CAT scores, adjusting for confounders. Results: Half of the participants were non-smokers or former smokers, while 92% reported consuming low levels of alcohol (less than 14 units per week). Additionally, 56% had a BMI below 30, indicating they were not obese. Surprisingly, only 32% engaged in regular exercise, with at least 150 min per week, and only 25% reported getting adequate sleep, ranging from 7 to 9 h per night. Importantly, poorer health status was inversely associated with non/former smoking (OR: 0.543, 95% CI: 0.282-1.049), physical activity (OR: 0.238, 95% CI: 0.122-0.463), and adequate sleep (OR: 0.337, 95% CI: 0.160-0.710). Patients with higher HLI scores were less likely to have poor health status. Conclusions: In conclusion, our findings indicate that a significant proportion of patients with COPD failed to adhere to a minimum of three out of five healthy behaviors. Additionally, a higher number of healthy lifestyle factors defined by a high HLI score were independently associated with a better disease-specific quality of life. This is particularly important for COPD where quality of life is in the epicenter of management. Therefore, healthcare providers could significantly improve the management of COPD and patient outcomes by targeting and improving these lifestyle behaviors with targeted and holistic intervention strategies.

Proportions and risk factors of chronic obstructive pulmonary disease and preserved ratio impaired spirometry, and association with small airway disease, in the positive screening older population from China: a cross-sectional study

BACKGROUND

Early diagnosing Chronic Obstructive Pulmonary Disease (COPD) is relatively difficult. Therefore, the concepts of preserved ratio impaired spirometry (PRISm) and small airway disease (SAD) were proposed to achieve early diagnosis for COPD. Besides, the occurrence of COPD is positively related to age. However, the relationship among COPD, PRISm, and SAD still requires clarification. Thus, we estimated the proportions and risk factors of COPD and PRISm in the positive screening participants, and searched the methods of early diagnosing COPD via the SAD indicators.

METHODS

A total of 53,641 residents aged more than 60 years old from Shaoxing City, Zhejiang Province, China, completed a series of screening projects. And 2327 of positive screening participants ultimately finished bronchodilator tests. The data were statistically analyzed to figure out the proportions and risk factors of COPD and PRISm, and the efficacy of early diagnosing COPD by the SAD indicators.

RESULTS

Totally 2229 positive screening participants were included, the proportion of PRISm was 6.3% (141/2229), and of COPD was 78.2% (1743/2229). Statistical analyses showed that COPD patients were more likely to be smokers, males, and older. And COPD patients had higher questionnaire scores, meaning that they were more prone to have family history of respiratory diseases and more severe respiratory symptoms. Additionally, COPD patients had lower maximal mid-expiratory flow (MMEF) pred, forced expiratory flow (FEF) 75pred, and FEF50pred. And we found that male sex and presence of respiratory symptoms might lead to COPD and PRISm. Also, the methods of early diagnosing COPD through the SAD indicators might be acceptable.

CONCLUSION

There is a close association between COPD and decreased small airway function (SAF) among the participants included. Age, smoking, male sex, worse SAF, and respiratory symptoms might cause the progressing from normal people to PRISm, then to COPD patients. Besides, the SAD indicators such as MMEFpred, FEF75pred, and FEF50pred were included in lung function tests and bronchodilator tests. Intriguingly, it was found that early diagnosing COPD via the SAD indicators might be feasible. In the future, early diagnosis for COPD requires further research.

Impact of Lung-Related Polygenic Risk Scores on Chronic Obstructive Pulmonary Disease Risk and Their Interaction with w-3 Fatty Acid Intake in Middle-Aged and Elderly Individuals

Chronic obstructive pulmonary disease (COPD) is a complex, progressive respiratory disorder with persistent airflow limitation and tissue destruction. We aimed to explore the genetic impact of COPD and its interaction with nutrient intake in 8840 middle-aged and elderly individuals from the Ansan/Ansung cohorts. Participants were diagnosed with COPD if the ratio of forced expiratory volume in 1 s (FEV1) to forced vital capacity (FVC) was less than 0.7 using spirometry, and if they were previously diagnosed with COPD by a physician. Genome-wide association studies (GWAS) were performed to screen for genetic variants associated with COPD risk. Among them, we selected the genetic variants that exhibited interactions using the generalized multifactor dimensionality reduction (GMDR) method. The polygenic risk score (PRS) was computed by summing the number of risk alleles in the SNP-SNP interaction models that adhered to specific rules. Subsequently, participants were categorized into low-PRS, medium-PRS, and high-PRS groups. The participants with COPD exhibited significantly lower FEV1/FVC ratios (0.64) than those without COPD (0.82). It was positively associated with inflammation markers (serum C-reactive protein and white blood cell levels). A higher proportion of COPD participants were smokers and engaged in regular exercise. The 5-SNP model consisted of FAM13A_rs1585258, CAV1_rs1997571, CPD_rs719601, PEPD_rs10405598, and ITGA1_rs889294, and showed a significant association with COPD risk (p < 0.001). Participants in the high-PRS group of this model had a 2.2-fold higher risk of COPD than those in the low-PRS group after adjusting for covariates. The PRS interacted with w-3 fatty acid intake and exercise, thus influencing the risk of COPD. There was an increase in COPD incidence among individuals with a higher PRS, particularly those with low consumption of w-3 fatty acid and engaged in high levels of exercise. In conclusion, adults with a high-PRS are susceptible to COPD risk, and w-3 fatty acid intake and exercise may impact the risk of developing COPD, potentially applying to formulate precision medicines to prevent COPD.

Undiagnosed and 'overdiagnosed' COPD using postbronchodilator spirometry in primary healthcare settings: a systematic review and meta-analysis

BACKGROUND

Despite chronic obstructive pulmonary disease (COPD) being a major global cause of mortality and hospitalisation, it is often undiagnosed or inaccurately diagnosed in clinical settings.

OBJECTIVE

To systematically synthesise all peer-reviewed papers from primary healthcare settings that have reported data on: (1) undiagnosed COPD, that is, patients with respiratory symptoms and postbronchodilator airflow obstruction consistent with COPD, without a formal clinician's diagnosis of COPD either documented in health records or reported by patients and (2) 'overdiagnosed COPD', that is, clinician's diagnosis without postbronchodilator airflow obstruction.

METHODS

Studies investigating these diagnostic metrics in patients from primary healthcare clinics (according to predefined inclusion/exclusion criteria) were sourced from Medline and Embase and assessed for bias (Johanna Briggs Institute tools for prevalence studies and case series). Meta-analyses of studies of adequate sample size used random effect modelling stratified by risk factor categories.

RESULTS

Of 26 eligible articles, 21 cross-sectional studies investigated 3959 cases of spirometry-defined COPD (with or without symptoms), and 5 peer-reviewed COPD case series investigated 7381 patients. The prevalence of spirometry-confirmed COPD without a diagnosis documented in their health records was 14%-26% in studies of symptomatic smokers (N=3). 1 in 4 patients taking inhaled therapies (25% (95% CI 22% to 28%), N=2) and 1 in 6 smokers irrespective of symptoms (16% (95% CI 14% to 18%), N=6) fulfilled diagnostic spirometry criteria but did not report receiving a COPD-related diagnosis. In an adequately powered series of COPD cases documented in primary healthcare records (N=4), only between 50% and 75% of subjects had any airflow obstruction on postbronchodilator spirometry performed by study researchers, therefore, COPD was clinically 'overdiagnosed' in 25%-50% of subjects.

DISCUSSION

Although data were heterogeneous and of modest quality, undiagnosed COPD was common in primary healthcare, especially for symptomatic smokers and patients treated with inhaled therapies. In contrast, frequent COPD 'overdiagnosis' may represent treatment of asthma/reversible component or another medical diagnosis.

PROSPERO REGISTRATION NUMBER

CRD42022295832.

How Accurate Is the Diagnosis of "Chronic Obstructive Pulmonary Disease" in Patients Hospitalized with an Acute Exacerbation?

Rationale: COPD diagnosis requires relevant symptoms and an FEV1/FVC ratio of <0.7 post-bronchodilator on spirometry. Patients are frequently labeled as COPD based on clinical presentation and admitted to the hospital with this diagnosis even though spirometry is either not available or has never been performed. The aim of this study was to evaluate the accuracy of COPD diagnosis based on post-bronchodilator spirometry, following hospital admission for COPD exacerbation. Methods: This is a retrospective study with a cross-sectional analysis of a subgroup of patients. Demographic and clinical data and pre-admission spirometry were collected from electronic records of patients hospitalized with a primary diagnosis of COPD. Patients without available spirometry were contacted for a pulmonary consultation and spirometry. Three groups were compared: patients with a confirmed COPD diagnosis (FEV1/FVC < 0.7), without COPD (FEV1/FVC > 0.7), and those who have never performed spirometry. Results: A total of 1138 patients with a recorded diagnosis of COPD were identified of which 233 patients were included in the analysis. Only 44.6% of patients had confirmed COPD according to GOLD criteria. In total, 32.6% of the patients had never undergone spirometry but were treated as COPD, and 22.7% had performed spirometry without evidence of COPD. Recurrent admission due to COPD was a strong predictor of a confirmed COPD diagnosis. Conclusions: Among the patients admitted to the hospital with a COPD diagnosis, a high proportion were not confirmed by the current GOLD report or had never performed spirometry. Stricter implementation of the diagnostic criteria of COPD in admitted patients is necessary to improve diagnosis and the treatment outcomes in these patients.

Comparison of newly diagnosed COPD patients and the non-COPD residents in Shanghai Minhang District

Background

To compare whether the general population, especially those without characteristic symptoms, need spirometry screening for chronic obstructive pulmonary disease (COPD).

Methods

Residents aged > 40 years old in Minhang, Shanghai, China, filled out screening questionnaires and underwent spirometry. The structured questionnaire integrating COPD population screening and COPD screening questionnaire was designed to obtain data on demographic characteristics, risk factors of COPD, respiratory symptoms, lifestyle habits, and comorbidities. We assessed the correlations between variables and COPD and the impact factors of FEV₁% predicted.

Results

A total of 1,147 residents were included with a newly diagnosed mild to moderate COPD prevalence of 9.4% (108/1,147); half of the patients (54/108) were asymptomatic. Multivariate analysis did not reveal any significant differences in symptoms or lifestyle factors between newly diagnosed COPD patients and non-COPD participants. However, according to the generalized linear model, older age (β = -0.062, p < 0.001), male sex (β = -0.031, p = 0.047), and respiratory symptoms (β = -0.025, p = 0.013) were associated with more severe airflow limitation.

Conclusion

Newly diagnosed COPD patients had few differences compared with the general population, which suggests that a targeted case finding strategy other than general screening was currently preferred. More attention should be paid to respiratory symptoms when making a diagnosis and exploring new therapies and interventions for COPD in the early stage.

Underdiagnosis, false diagnosis and treatment of COPD in a selected population in Northern Greece

BACKGROUND

In the primary care setting, diagnosis and treatment of COPD is not always consistent with GOLD guidelines.

OBJECTIVES

To calculate the prevalence of COPD underdiagnosis, false diagnosis and treatment in the general population of northern Greece.

METHODS

Observational study in the context of an early COPD detection and smoking cessation project. Inclusion criteria: >40-year-old, current and former smokers (>10 pack-years) in five primary care centres of northern Greece from 2012 to 2019. Participation was achieved via a campaign (posters and advertisements in the mass media).

RESULTS

We examined 5,226 subjects (mean age: 58.2 ± 12.7 years, 61.5% males, current smokers: 56.2%) of whom 564 (10.8%) had symptoms and spirometrically confirmed COPD. There were 5 groups of 'interest:' a) 117/264 (44.3%) with a previous correct diagnosis COPD and correct treatment; b) 139/264 (52.7%) previous correct diagnosis COPD but overtreatment; c) 8/264 (3%) previous correct diagnosis COPD but undertreatment; d) 461 subjects (63.6% of those with previous COPD diagnosis) had previous false diagnosis of COPD (= also overtreatment); e) 300/564 (53.2%) previously not diagnosed COPD (=underdiagnosis and also undertreatment). We found that 322/461 (69.8%) of those with a previous false diagnosis have been prescribed long-acting bronchodilators plus ICS.

CONCLUSION

Among the general population subjects in northern Greece, more than 50% of patients with COPD were underdiagnosed, more than 50% of correctly diagnosed COPD patients were overtreated and most patients taking inhaled drugs were those with a false diagnosis of COPD (possibly GOLD stage 0).

Effect of internet-based self-management on pulmonary function rehabilitation and living quality in patients with chronic obstructive pulmonary disease

OBJECTIVE

This study explored and analyzed the effect of Internet-based self-management on pulmonary function rehabilitation and living quality in patients with chronic obstructive pulmonary disease (COPD).

METHODS

Altogether, 106 stable-staged COPD patients admitted to our hospital from June 2018 to September 2019 were enrolled as the research subjects, and divided into the control group (n=51) and the observation group (n=55) according to the order of visit. The control group received conventional health education, and the observation group was treated with an educational model by Internet-based self-management. Afterwards, the changes of self-management ability, pulmonary function and living quality before and after intervention were compared between the two groups.

RESULTS

The scores of each dimension of self-management behavior in both groups of patients after intervention were critically higher than those prior to intervention (P<0.05), and the scores in observation-group patients were remarkably higher than thoes in control-group patients (P<0.05). Besides, the two groups of subjects were observed with elevated pulmonary function indexes FVC, FEV1 and 6MWD after intervention compared with that in prior-intervention (P<0.05), and the indexes in the observation-group after intervention were obviously higher than those in the control-group (P<0.05). In addition, the scores of each dimension of living quality in both groups after the intervention had a conspicuously rise compared with the prior-intervention period (P<0.05), and the scores in the observation group were remarkably lower than those in the control group (P<0.05). The satisfaction in observation group was obviously higher than that in control group (P<0.05).

CONCLUSION

Internet-based self-management can effectually improve the self-management ability of COPD patients. It is conducive to improve the patients' pulmonary function, and their living quality, thus it is worthy of clinical popularization and application.

Underestimation of respiratory symptoms by smokers: a thorn in chronic obstructive pulmonary disease diagnosis

Primary care centers are ideal positions to identify chronic obstructive pulmonary disease (COPD). We determined the COPD prevalence among ever-smokers aged 40-65 years attending a 2-year program conducted in 22 Greek primary healthcare centers and made comparisons between genders, patients less than or greater than 55 years, and newly or previously diagnosed COPD patients. A total of 117 persons, after studying 1100 people, were diagnosed with previously unknown or known COPD, providing a COPD prevalence of 10.6% among the study population. In all, 7.5% of the participants were newly diagnosed with COPD. Women with COPD reported smoking less but experienced worse respiratory and depressive symptoms than men. A total of 19% of the COPD population below 55 years experienced wheezing and exacerbations more frequently than older patients. Newly diagnosed COPD patients were significantly younger, reported a significant burden of symptoms without seeking medical help. Primary health care has a crucial role in the early detection of COPD among unsuspecting smokers.

Pulmonologists Adherence to the Chronic Obstructive Pulmonary Disease GOLD Guidelines: A Goal to Improve

Background and objectives: Data about pulmonologist adherence to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines showed a great variability and cannot be extrapolated. The present study investigates the current pharmacological prescribing practices in the treatment of chronic obstructive pulmonary disease (COPD) according to the 2017 GOLD guidelines, to determine the level of pulmonologist adherence and to identify possible factors that influence physician adherence. Materials and methods: This retrospective study took place between 1 February and 30 April 2018 in Pneumophtysiology Clinical Hospital Cluj-Napoca. We included 348 stable COPD outpatients classified according to the 2017 GOLD strategy in the ABCD risk groups. Pulmonologist adherence was defined as appropriate if the recommended pharmacological therapy was the first- or alternative-choice drug according to the guidelines, and inappropriate (overtreatment, undertreatment) if it was not in line with these recommendations. Results: The most prescribed treatment was the combination long-acting beta agonist (LABA) + long-acting antimuscarinic agent (LAMA) (34.77%), followed by LAMA + LABA + inhaled corticosteroid (ICS). Overall, pneumologist adherence was 79.02%. The most inappropriate therapies were in Group B (33.57%), followed by 33.33% in Group A. Compared to Groups C and D (analyzed together), Groups A and B had a 4.65 times higher chance (p = 0.0000001) of receiving an inappropriate therapy. Patients with cardiovascular comorbidities had a 1.89 times higher risk of receiving an inappropriate therapy (p = 0.021). ICS overprescription was the most common type of inappropriateness (17.81%). Groups C and D had a 3.12 times higher chance of being prescribed ICS compared to Groups A and B (p = 0.0000004). Conclusions: Pulmonologist adherence to the GOLD guidelines is not optimal and needs to be improved. Among the factors that influence the inappropriateness of COPD treatments, cardiovascular comorbidities and low-risk Groups A and B are important. ICS represent the most prescribed overtreatment. Further multicentric studies are needed to evaluate all factors that might influence the adherence rate.

Adherence of North-African Pulmonologists to the 2017-Global Initiative for Chronic Obstructive Lung Disease (GOLD) Pharmacological Treatment Guidelines (PTGs) of Stable Chronic Obstructive Pulmonary Disease (COPD)

Background

No previous study has investigated the adherence rate of North-African pulmonologists to the 2017-GOLD PTGs.

Aims

To investigate the adherence rate of Tunisian pulmonologists to the 2017-GOLD PTGs and to identify the barriers to their adherence.

Methods

This was a cohort study involving clinically stable COPD patients who presented to a pulmonology outpatient consultation. The patients were classified as having been appropriately and inappropriately (over- or undertreatment) treated for the GOLD group. Logistic regression was performed to determine the adherence barriers to the 2017-GOLD PTGs.

Results

A total of 296 patients were included (88.1% males, mean age: 68 ± 10 years; GOLD A (7.1%), B (36.1%), C (4.1%), and D (52.7%)). The pulmonologists' adherence rate to the 2017-GOLD PTGs was 29.7%. There was a significant statistical difference between the adherence rates among the four GOLD groups (A: 19.0%, B: 20.6%, C: 8.3%, and D: 39.1%; p = 0.001). Differences were statistically significant between the GOLD group D and groups B (p = 0.001). Differences were statistically significant between the GOLD group D and groups B (p = 0.001). Differences were statistically significant between the GOLD group D and groups B (.

Conclusion

The adherence rate of Tunisian pulmonologists to the 2017-GOLD PTGs is low. It seems that the patients' age, socioeconomic level, national health insurance coverage, and GOLD groups influenced their adherence.

Trends in prevalence and incidence of chronic respiratory diseases from 1990 to 2017

BACKGROUND

Chronic respiratory diseases (CRDs) are leading causes of morbidity worldwide. However, the spatial and temporal trends in prevalence and incidence of CRDs have not been estimated.

METHODS

Based on data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017, we analyzed the prevalence and incidence trends of CRDs from 1990 to 2017 according to age, sex, region and disease pattern. Furthermore, the correlations between the incidence and the World Bank income levels, sociodemographic index (SDI), and human development index (HDI) levels were analyzed to assess the factors affecting incidence.

RESULT

The total number of CRD cases increased by 39.5% from 1990 to 2017, nevertheless, the age-standardized prevalence rate (ASPR) and age-standardized incidence rate (ASIR) showed decreasing trends. The ASIRs of CRD, chronic obstructive pulmonary disease (COPD), pneumoconiosis, and asthma decreased, whereas the ASIR of interstitial lung disease and pulmonary sarcoidosis increased during the past 27 years. Significant differences between males and females in the incidence rates of pneumoconiosis, interstitial lung disease and pulmonary sarcoidosis were observed. Elderly people especially suffered from CRDs, except for asthma. For COPD, the ASIR decreased from low-SDI regions to high-SDI regions. The ASIR of interstitial lung disease and pulmonary sarcoidosis in the high-SDI region was highest and have increased mostly. The ASIRs for pneumoconiosis and asthma were inversely related to the HDI.

CONCLUSIONS

In 2017, CRDs were still the leading causes of morbidity worldwide. A large proportion of the disease burden was attributed to asthma and COPD. The incidence rates of all four types of CRDs varied greatly across the world. Statistically significant correlation was found between the ASIR and SDI/HDI.

Use of the terms "overdiagnosis" and "misdiagnosis" in the COPD literature: a rapid review

Challenges in the diagnostic process of chronic obstructive pulmonary disease (COPD) can result in diagnostic misclassifications, including overdiagnosis. The term "overdiagnosis" in general has been associated with variable definitions. In connection with efforts to reduce low-value care, "overdiagnosis" has been defined as a true positive diagnosis of a condition that is not associated with any harm in the diagnosed person. It is, however, unclear how the term "overdiagnosis" is used in the COPD literature. We conducted a rapid review of the literature to explore how the terms "overdiagnosis" and "misdiagnosis" are used in the context of COPD. Electronic searches of Medline were conducted from inception to October 2018, to identify primary studies that reported on over- and/or misdiagnosis of COPD using these terms. 28 articles were included in this review. Overdiagnosis and misdiagnosis in COPD were found to be used to describe five main concepts: 1) physician COPD diagnosis despite normal spirometry (14 studies); 2) discordant results for COPD diagnosis based on different spirometry-based definitions for airflow obstruction (10 studies); 3) COPD diagnosis based on pre-bronchodilator spirometry results (three studies); 4) comorbidities (e.g. heart failure or asthma) that affect spirometry and have clinical features which overlap with COPD (two studies); and 5) normalisation of abnormal (post-bronchodilator) spirometry at follow-up (one study). The terms "overdiagnosis" and "misdiagnosis" were often used interchangeably and almost always referred to a false positive diagnosis. Performing (technically correct) spirometry with correct interpretation of the results could probably reduce misdiagnosis in a large proportion of the misdiagnosed cases of COPD. In addition, guidelines need to provide a more acceptable consensus spirometric definition of airflow obstruction.

KEY POINTS

In the COPD literature, the terms "overdiagnosis" and "misdiagnosis" are often used interchangeably and almost always refer to a false positive diagnosis.Use of spirometry with correct interpretation of the results can avoid a substantial proportion of cases of misdiagnosis of COPD.

EDUCATIONAL AIMS

To explore the use of the terms "overdiagnosis" and "misdiagnosis" in the COPD literature.To identify the main sources of overdiagnosis and misdiagnosis in COPD.

Chronic Obstructive Pulmonary Disease as a Main Factor of Premature Aging

(1) Background: Chronic obstructive pulmonary disease (COPD) is defined as an inflammatory disorder that presents an increasingly prevalent health problem. Accelerated aging has been examined as a pathologic mechanism of many chronic diseases like COPD. We examined whether COPD is combined with accelerated aging, studying two hormones, dehydroepiandrosterone (DHEA) and growth hormone (GH), known to be characteristic biological markers of aging. (2) Methods: Data were collected from 119 participants, 70 (58.8%) COPD patients and 49 (41.2%) from a health control group over the period of 2014⁻2016 in a spirometry program. Information about their medical history, tobacco use, and blood tests was obtained. (3) Results: The average age of the health control patients was 73.5 years (SD = 5.5), and that of the COPD patients was 75.4 years (SD = 6.9). Both groups were similar in age and sex. A greater proportion of smokers were found in the COPD group (87.1%) versus the control group (36.7%). The majority of COPD patients were classified as STAGE II (51.4%) and STAGE III (37.1%) according to GOLD (Global Initiative for Chronic Obstructive Pulmonary Disease). Levels of DHEA (SD = 17.1) and GH (SD = 0.37) were significantly lower in the COPD group (p < 0.001) compared to those in the controls (SD = 26.3, SD = 0.79). DHEA and GH were more significant and negatively correlated with age. The regression equation of DHEA with age produced a coefficient equal to 1.26. In this study, the difference in DHEA between COPD patients and controls was, on average, 30.2 μg/dL, indicating that the biological age of a COPD patient is on average about 24 years older than that of a control subject of the same age. Similarly, the difference in GH between COPD patients and controls was, on average, 0.42 ng/mL, indicating that the biological age of a COPD patient is on average about 13.1 years older than that of a control subject of the same age. (4) Conclusions: The findings of our study strongly suggest the presence of premature biological aging in COPD patients. Their biological age could actually vary from 13 to 23 years older than non-COPD controls according to DHEA and GH variation.

The Emergency Medical System in Greece: Opening Aeolus' Bag of Winds

An Emergency Medical Service (EMS) system must encompass a spectrum of care, with dedicated pre-hospital and in-hospital medical facilities. It has to be organised in such a way as to include all necessary services&mdash;such as triage accurate initial assessment, prompt resuscitation, efficient management of emergency cases, and transport to definitive care. The global economic downturn has had a direct effect on the health sector and poses additional threats to the healthcare system. Greece is one of the hardest-hit countries. This manuscript aims to present the structure of the Greek EMS system and the impact of the current economic recession on it. Nowadays, primary care suffers major shortages in crucial equipment, unmet health needs, and ineffective central coordination. Patients are also facing economic limitations that lead to difficulties in using healthcare services. The multi-factorial problem of in-hospital EMS overcrowding is also evident and has been linked with potentially poorer clinical outcomes. Furthermore, the ongoing refugee crisis challenges the national EMS. Adoption of a triage scale, expansion of the primary care network, and an effective primary&ndash;hospital continuum of care are urgently needed in Greece to provide comprehensive, culturally competent, and high-quality health care.