Rationale: Chronic obstructive pulmonary disease, (COPD) is a major cause of morbidity and mortality in the United States. Peak expiratory flow rate (PEFR) monitoring could provide a daily objective measurement of lung function in COPD patients at home. We hypothesized that individuals with greater variability in daily PEFR would signal an unstable patient population with worse outcomes. Methods: This was a retrospective analysis of prospectively collected data using an electronic diary to record daily PEFR and symptoms in severe and very severe COPD patients. Rates of PEFR change were used to characterize patients into stable and unstable groups determined by the distribution of slopes. Exacerbation-free days, time to first hospitalization, hospitalization rate, length of hospitalization, and all-cause mortality were assessed. Results: A total of 104 severe and very severe COPD patients met entry criteria, and were observed for 37,702 patient-days. There were no significant differences in baseline symptoms, demographics, forced expiratory volume in 1 second (FEV1) or comorbidities between stable versus unstable groups. The unstable group had 34.7 less exacerbation-free days and significantly shorter 6 minute walk distances (6MWD) (227.1 versus 270.7 meters, p=0.031), shorter time to first hospitalization (163 versus 286 days, p=0.017), more frequent hospitalizations (2.6 versus 1.7 per year, p=0.032) and higher all-cause mortality (10.8 versus 5.1%, p=0.04). Conclusion: Patients with severe to very severe COPD with greater changes in PEFR have shorter 6MWD, reduced time to first hospitalization, more frequent hospitalizations, and higher all-cause mortality despite similar demographic, spirometric and comorbid parameters at baseline. Daily peak flow monitoring can be a useful tool in identifying COPD patients predisposed to worse outcomes. AbstractAbbreviations: chronic obstructive pulmonary disease, COPD; peak expiratory flow rate, PEFR; forced expiratory volume in 1 second, FEV 1 ; 6 minute walk distance, 6MWD; Pennsylvania Study of COPD Exacerbations , PA-

Prevalence estimates of obstructive sleep apnea (OSA) continue to rise, partially due to better recognition of and screening for the disease, in part due to increase in obesity and in part due to changes in definitions of obstructive hypopneas. Despite increasing knowledge of the deleterious impact of OSA on health, underrecognition continues to be a major concern, especially in women. A middle-aged man that snores and is sleepy has been the accepted "textbook" picture of OSA; women may present with more atypical symptoms and excessive sleepiness that are not reflected on sleepiness scale questionnaires. Even when presenting with snoring and sleepiness, and in the presence of comorbidities, women are less likely to be evaluated for OSA. Symptom burden and poor health outcomes have been documented in women with OSA and treatment improves their health. In this article, we explore possible causes for this underrecognition of OSA in women, including gender bias and healthcare inequity, and propose solutions.

Background:The etiology and inflammatory profile of combined pulmonary fibrosis and emphysema (CPFE) remain uncertain currently. Objective:We aimed to examine the levels of inflammatory proteins in lung tissue in a cohort of patients with emphysema, interstitial pulmonary fibrosis (IPF), and CPFE.Materials and methods: Explanted lungs were obtained from subjects with emphysema, IPF, CPFE, (or normal subjects), and tissue extracts were prepared. Thirty-four inflammatory proteins were measured in each tissue section. Results:The levels of all 34 proteins were virtually indistinguishable in IPF compared with CPFE tissues, and collectively the inflammatory profile in the emphysematous tissues were distinct from IPF and CPFE. Moreover, inflammatory protein levels were independent of the severity of the level of diseased tissue.

Patients with CRS developed OSA at a lower BMI; patients CRS and OSA had similar sleep-related breathing patterns but higher risks for PLMs compared with patients with OSA and without CRS.

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