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    <recommendedItem id="20090101_19_3538"
                     title="CHEST: No Sex Difference Found in COPD Treatment (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/MeetingCoverage/CHEST/tb/16795?impressionId=1265818746803"
                     
      &lt;p&gt;SAN DIEGO  --  Men and women with chronic obstructive pulmonary disorder (COPD) derive comparable benefits from treatment with tiotropium (Spiriva), researchers found.&lt;/p&gt;
&lt;p&gt;A secondary analysis of a large clinical trial found improvements of similar magnitude in lung function, exacerbations, and health-related quality of life in both genders, according to Donald Tashkin, MD, of the University of California Los Angeles.&lt;/p&gt;
&lt;p&gt;The proportion of women with COPD is steadily increasing, although the disease still strikes more women, Tashkin said at the American College of Chest Physicians meeting here.&lt;/p&gt;
&lt;p&gt;Some studies have suggested that women may be more susceptible to developing COPD from smoking, may have a harder time quitting smoking, and may respond differently to COPD therapy than men, he said.&lt;/p&gt;
&lt;p&gt;To find out whether women reacted differently to tiotropium, Tashkin and his colleagues took a second look at data from the UPLIFT (Understanding Potential Long-Term Impacts on Function with Tiotropium) trial.&lt;/p&gt;
&lt;p&gt;This four-year, randomized, double-blind, placebo-controlled trial found that 18 mcg of tiotropium delivered via HandiHaler had significant benefits over placebo for patients with COPD. (See &lt;a href=&quot;http://www.medpagetoday.com/Pulmonary/SmokingCOPD/11180&quot; mce_href=&quot;http://www.medpagetoday.com/Pulmonary/SmokingCOPD/11180&quot; target=&quot;_blank&quot;&gt;Tiotropium Has Benefits in COPD&lt;/a&gt;)&lt;/p&gt;
&lt;p&gt;All 5,993 patients had a post-bronchodilator FEV&lt;sub&gt;1&lt;/sub&gt; of no more than 70% the predicted value, were 40 and older, and had at least 10 pack-years of smoking with no history of asthma.&lt;/p&gt;
&lt;p&gt;A quarter of the patients were women, who were slightly younger than the men (mean age 63 versus 65).&lt;/p&gt;
&lt;p&gt;A higher proportion of women were current smokers, but, on average, they had fewer pack-years than men.&lt;/p&gt;
&lt;p&gt;Baseline post-bronchodilator FEV&lt;sub&gt;1&lt;/sub&gt; values were 1.41 L (47% predicted) in men and 1.07 L (49% predicted) in women.&lt;/p&gt;
&lt;p&gt;The female patients had worse health-related quality of life at baseline, according to scores on St. George&apos;s Respiratory Questionnaire.&lt;/p&gt;
&lt;p&gt;At four years, both pre- and post-bronchodilator FEV&lt;sub&gt;1&lt;/sub&gt; values were significantly better than placebo for both men and women (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01 for all comparisons). There were similar findings for forced vital capacity (FVC).&lt;/p&gt;
&lt;p&gt;Pre- and post-bronchodilator FEV&lt;sub&gt;1&lt;/sub&gt; and FVC values declined at &quot;fairly comparable&quot; rates in the two genders in terms of percent declines, if not absolute values, Tashkin said.&lt;/p&gt;
&lt;p&gt;Even though women started out with worse health-related quality of life, both improved to a similar degree throughout the study.&lt;/p&gt;
&lt;p&gt;The risk of exacerbation was reduced for both men (HR 0.87, 95% CI 0.81 to 0.93) and women (0.83, 95% CI 0.74 to 0.94).&lt;/p&gt;
&lt;p&gt;Reductions in exacerbations per patient-year compared to placebo were similar in men (0.82 to 0.71) and women (0.92 with placebo to 0.77) (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.05 for both).&lt;/p&gt;
&lt;p&gt;The risk of exacerbation requiring hospitalization was reduced in both genders, but to a greater extent in women (HR 0.77, 95% CI 0.62 to 0.94) than men (HR 0.89, 95% CI 0.79 to 0.99).&lt;/p&gt;
&lt;p&gt;The improvement in survival was of similar magnitude for patients of both sexes, but the reduced risk of dying during treatment was significant only for men (HR for men 0.85, 95% CI 0.72 to 0.99; HR for women 0.85, 95% CI 0.62 to 1.18).&lt;/p&gt;
&lt;p&gt;Tashkin said this wasn&apos;t surprising because women are less likely to die overall, reducing the statistical power of the analysis.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;UPLIFT was supported by Boehringer-Ingelheim and Pfizer.&lt;/p&gt;&lt;p&gt;Tashkin has received grants from the National Heart, Lung, and Blood Institute, Boehringer-Ingelheim, Schering-Plough, Dey Labs, GlaxoSmithKline, Novartis, and AstraZeneca and has served as a speaker for Boehringer-Ingelheim, Pfizer, AstraZeneca, Dey Labs, and GlaxoSmithKline and an advisory board member for Boehringer-Ingelheim and AstraZeneca.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_3582"
                     title="CHEST: Uncertainty Surrounds Opioids in Advanced COPD (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/MeetingCoverage/CHEST/tb/16853?impressionId=1265818746803"
                     
      &lt;p&gt;SAN DIEGO  --  Patients with advanced chronic obstructive pulmonary disease (COPD) may not be getting effective treatment for dyspnea toward the end of life, researchers reported here.&lt;/p&gt;
&lt;p&gt;A retrospective review of administrative claims data showed that patients with advanced COPD were significantly less likely to receive morphine in the last three months of life than those with terminal lung cancer (OR 2.36, 95% CI 1.52 to 3.67), according to Donna Goodridge, PhD, of the University of Saskatchewan in Saskatoon.&lt;/p&gt;
&lt;p&gt;They were also less likely to receive palliative care at home (2.8% versus 37.4%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.005), and palliative care itself was associated with an increased likelihood of receiving morphine in the months before death (OR 2.64, 95% CI 1.72 to 4.06), Goodridge said at the American College of Chest Physicians meeting.&lt;/p&gt;
&lt;p&gt;She said the findings underscore the need for further research.&lt;/p&gt;
&lt;p&gt;&quot;We need to explore the efficacy and safety of opioid use for relief of dyspnea at the end of life in persons with COPD,&quot; she said. &quot;And we also need to assess patient, family, and clinician experiences with opioid use for dyspnea at the end of life for those people dying of COPD.&quot;&lt;/p&gt;
&lt;p&gt;Dyspnea is the most burdensome symptom and a source of disability in end-stage COPD, Goodridge said, and it doesn&apos;t respond to conventional therapies in 56% to 98% of patients.&lt;/p&gt;
&lt;p&gt;Opioids are commonly used to treat dyspnea in patients with terminal cancer, but Goodridge said she was surprised to see that there wasn&apos;t a very good management strategy in COPD.&lt;/p&gt;
&lt;p&gt;Low doses of opioids could relieve dyspnea in COPD patients by reducing total ventilation, increasing ventilatory efficiency with exercise, reducing responses to hypoxia/hypercapnia, and reducing the drive to breathe, Joanne Young, a registered respiratory therapist at Dalhousie University in Halifax, Nova Scotia, and colleagues noted in a separate presentation at the meeting.&lt;/p&gt;
&lt;p&gt;The drugs might also affect bronchoconstriction, they said in a poster session.&lt;/p&gt;
&lt;p&gt;A 2002 meta-analysis in &lt;em&gt;Thorax&lt;/em&gt; found that both oral and parenteral opioids had a positive effect on breathlessness (&lt;em&gt;P&lt;/em&gt;=0.0008) in all patient groups, including those with COPD. But how often patients with COPD are treated with opioids has not been well studied.&lt;/p&gt;
&lt;p&gt;So Goodridge and her colleagues examined administrative data from the Saskatchewan Health Ministry on all patients who died during 2004 of lung cancer (433 patients) or COPD (602 patients).&lt;/p&gt;
&lt;p&gt;Patients with COPD were less likely to die in the hospital and more likely to die in a long-term care facility (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.05).&lt;/p&gt;
&lt;p&gt;In the last three months of life, more patients with lung cancer received a prescription for morphine (31% versus 9%).&lt;/p&gt;
&lt;p&gt;The strongest predictor of receiving morphine was palliative care at home, which, though more frequent in patients with lung cancer, was surprisingly underused in both groups, Goodridge said.&lt;/p&gt;
&lt;p&gt;&quot;This is something that I think we may need to explore further,&quot; she said.&lt;/p&gt;
&lt;p&gt;The study by Young and colleagues explored possible reasons at the clinical level for the infrequent use of opioids in patients with advanced COPD.&lt;/p&gt;
&lt;p&gt;The researchers interviewed 10 family physicians and eight respiratory therapists in the province of New Brunswick about their attitudes toward prescribing the medications for the relief of dyspnea.&lt;/p&gt;
&lt;p&gt;Although the clinicians all agreed that the control of dyspnea was the biggest challenge in treating patients with end-stage COPD, there was reluctance in using opioids unless death was imminent.&lt;/p&gt;
&lt;p&gt;They cited concerns about respiratory depression, as well as about a lack of education and guidance from professional societies.&lt;/p&gt;
&lt;p&gt;Two younger family physicians who received training in palliative care during their residencies expressed more comfort in using opioids for these patients.&lt;/p&gt;
&lt;p&gt;Like Goodridge, Young and colleagues called for further research regarding the use of opioids for relieving dyspnea at the end of life in patients with COPD.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study by Young and colleagues received funding from the Atlantic Health Sciences Corporation Health Promotion and Research Fund.&lt;/p&gt;&lt;p&gt;None of the authors of either of the studies reported any conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_1_578"
                     title="CHEST: Americans Treated Suboptimally for Obstructive Lung Disease"
                     score="-0.005"
                     href="