***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: BACKGROUND S In China , the prevalence of chronic obstructive pulmonary disease ( COPD ) in persons 40 years of age or older is estimated at 8.2 % , but this is likely a substantial underestimate . METHODS Eight secondary hospitals which did n't have spirometries were chosen r and omly in Hunan province of central south China . Physician subjects at these hospitals underwent a one-hour training course on the Chinese COPD guidelines . Physicians answered question naires assessing their knowledge of the guidelines before and after the training session . The mean correct scores of question naires were compared before and after training . Four out of the eight hospitals were given access to spirometry .  Eligible patient subjects underwent spirometry testing prior to the physician visit . After seeing the patient , physicians were asked to answer a question naire relating to the diagnosis and severity of COPD . Physicians were then given the results of the spirometry , and asked to answer the same question naire . Physicians ' responses before and after receiving the spirometry results were compared . RESULTS 225 physicians participated in the training session . 207 question naires were completed . Mean scores ( out of 100 ) before and after the training were 53.1 ± 21.7 and 93.3 ± 9.8 , respectively . 18 physicians and 307 patient subjects participated in the spirometry intervention  . Based on spirometric results , the prevalence of COPD was 38.8 % . Physicians correctly identified the presence of COPD without spirometric data in 85 cases ( 76.6 % ) ; this increased to 117 cases ( 97.4 % ) once spirometric data were available . Without spirometric data , physicians incorrectly diagnosed COPD in 38 patients ; this decreased to 6 patients once spirometric data were available . Spirometric data also improved the ability of physicians to correctly grade COPD severity . CONCLUSIONS Simple educational training can substantially improve  physicians ' knowledge relating to COPD . Spirometry combined with education improves the ability of physicians to diagnose COPD and to assess its severity The aim of this study was to test the hypothesis that use of tiotropium , a new long-acting anticholinergic bronchodilator , would be associated with sustained reduction in lung hyperinflation and , thereby , would improve exertional dyspnoea and exercise performance in patients with chronic obstructive pulmonary disease . A r and omised , double-blind , placebo-controlled , parallel-group study was conducted in 187 patients ( forced expiratory volume in one second 44±13 % pred ) : 96 patients received 18 µg tiotropium and 91 patients received placebo once daily for 42 days . Spirometry , plethysmographic lung volumes , cycle exercise endurance and exertional dyspnoea intensity at 75 % of each patient 's maximal work capacity were compared . On day 42 , the use of tiotropium was associated with the following effects at pre-dose and post-dose measurements as compared to  placebo : vital capacity and inspiratory capacity ( IC ) increased , with inverse decreases in residual volume and functional residual capacity  . Tiotropium  increased post-dose exercise endurance time by 105±40 s ( 21 % ) as compared to placebo on day 42 . At a st and ardised time near end-exercise ( isotime ) , IC , tidal volume and minute ventilation all increased , whilst dyspnoea decreased by 0.9±0.3 Borg scale units . In conclusion , the use of tiotropium was associated with sustained reductions of lung hyperinflation at rest and during exercise . Result ant increases in inspiratory capacity permitted greater expansion of tidal volume and contributed to improvements in both exertional dyspnoea and exercise endurance BACKGROUND COPD ranks within the top three causes of mortality in the global burden of disease , yet it remains largely underdiagnosed . We assessed the underdiagnosis of COPD and its determinants in national and international surveys of general population s. METHODS We analyzed representative sample s of adults aged ≥ 40 years r and omly selected from well-defined administrative areas worldwide ( 44 sites from 27 countries ) .  Postbronchodilator FEV1/FVC < lower limit of normal ( LLN ) was used to define chronic airflow limitation consistent with COPD . Undiagnosed COPD was considered when participants had postbronchodilator FEV1/FVC < LLN but were not given a diagnosis of COPD . RESULTS Among 30,874 participants with a mean age of 56 years , 55.8 % were women , and 22.9 % were current smokers . Population prevalence of ( spirometrically defined ) COPD ranged from 3.6 % in Barranquilla , Colombia , to 19.0 % in Cape Town , South Africa . Only 26.4 % reported a previous lung function test , and only 5.0 % reported a previous diagnosis of COPD , whereas 9.7 % had a postbronchodilator FEV1/FVC < LLN . Overall , 81.4 % of ( spirometrically defined ) COPD cases were undiagnosed , with the highest rate in Ile-Ife , Nigeria ( 98.3 % ) and the lowest rate in Lexington , Kentucky ( 50.0 % ) . In multivariate analysis , a greater probability of underdiagnosis of COPD was associated with male sex , younger age , never and current smoking , lower education , no previous spirometry , and less severe airflow limitation . CONCLUSIONS Even with substantial heterogeneity in COPD prevalence , COPD underdiagnosis is universally high . Because effective management strategies are available for COPD , spirometry can help in the diagnosis of COPD at a stage when treatment will lead to better outcomes and improved quality of life OBJECTIVE To determine the quality of  spirometry performed in primary care practice and to assess the impact of formal training . DESIGN R and omized , controlled prospect i ve interventional study . SETTING Primary care practice , Auckl and City , New Zeal and . PARTICIPANTS Thirty r and omly selected primary care practice s r and omized to " trained " or " usual " groups . One doctor and one practice nurse were nominated to participate from each practice . INTERVENTIONS " Trained " was defined as participation in an " initial " spirometry workshop at week 0 and a " maintenance of st and ards " workshop at week 12 . " Usual " was defined as no formal training until week 12 , when participants they attended the same " initial " workshop provided for the trained group . The study duration was 16 weeks . Each practice was provided with a spirometer to be used at their clinical discretion . MEASUREMENTS AND RESULTS Spirometry data were uploaded weekly and analyzed using American Thoracic Society ( ATS ) criteria for acceptability and reproducibility . The workshops were assessed objective ly with practical and written assessment s , confirming a significant training effect . However , analysis of spirometry performed in clinical practice by the trained practitioners revealed three acceptable blows in only 18.9 % of patient tests . In comparison , 5.1 % of patient tests performed by the usual practitioners had three acceptable blows ( p<0.0001 ) . Only 13.5 % of patient tests in the trained group and 3.4 % in the usual group ( p<0.0001 ) satisfied full acceptability and reproducibility criteria . However , 33.1 % and 12.5 % of patient tests in the trained and usual groups , respectively ( p<0.0001 ) , achieved at least two acceptable blows , the minimum requirement . Nonacceptability was largely ascribable to failure to satisfy end-of-test criteria ; a blow of at least 6 s. Visual inspection of the results of these blows as registered on the spirometer for the presence of a plateau on the volume-time curve suggests that < 15 % were acceptable . CONCLUSIONS Although a significant training effect was demonstrated , the quality of the spirometry performed in clinical practice did not generally satisfy full ATS criteria for acceptability and reproducibility . Further study would be required to determine the clinical impact . However , the ATS guidelines allow for the use of data from unacceptable or nonreproducible maneuvers at the discretion of the interpreter . Since most of the failures were end-of-test related , the FEV1 levels are likely to be valid . Our results serve to emphasize the importance of effective training and quality assurance programs to the provision of successful spirometry in primary care practice Unreported chronic obstructive pulmonary disease ( COPD ) exacerbations are common , but their intermediate-to-long-term impacts on health-related quality of life ( HRQoL ) are unknown . The aim of the present study was to examine the impact of unreported exacerbations on HRQoL at 1 yr . A multicentric prospect i ve cohort study in 491 COPD patients was conducted in China . HRQoL was measured using the St George 's Respiratory Question naire ( SGRQ ) . Other measurements included sociodemographic , clinical , psychosocial and treatment profiles . Patients were monitored monthly for 12 months to document exacerbations ( at least one symptom worsening for ≥48 h ) . Patients were categorised into six groups : no exacerbation , one unreported exacerbation only , more than one unreported exacerbation only , one reported exacerbation only , more than one reported exacerbation only , and both unreported and reported exacerbations . Generalised estimating equations were used to estimate the adjusted associations between exacerbations and HRQoL change . A total of 466 unreported and 410 reported exacerbations were recorded . Compared with patients with no exacerbations , the change in SGRQ total score was similar amongst patients with one unreported exacerbation ( adjusted mean change 1.22 points ( 95 % CI -4.05–6.48 ) ) , but significantly worse among patients with more than one unreported exacerbation ( 4.61 ( 95 % CI 0.09–9.13 ) ) . Development and evaluation of self-management programmes emphasising early recognition of exacerbations and consequent action appear to be warranted BACKGROUND Patients with chronic obstructive pulmonary disease ( COPD ) and asthma depend on inhalers for management , but critical errors committed during inhaler use can limit drug effectiveness . Outpatient education in inhaler technique remains inconsistent due to limited re sources and inadequate provider knowledge . OBJECTIVE To determine whether a simple , two-session inhaler education program can improve physician attitudes toward inhaler teaching in primary care practice . METHODS An inhaler education program with small-group h and s-on device training was instituted for family physicians ( FP ) in British Columbia and Alberta . Sessions were spaced one to three months apart . All critical errors were corrected in the first session . Question naires surveying current inhaler teaching practice s and attitudes toward inhaler teaching were distributed to physicians before and after the program . RESULTS Forty-one ( 60 % ) of a total 68 participating FPs completed both before and after program question naires . Before the program , only 20 ( 49 % ) reported providing some form of inhaler teaching  in their practice s , and only four ( 10 % ) felt fully competent to teach patients inhaler technique . After the program , 40 ( 98 % ) rated their inhaler teaching as good to excellent . Thirty-four ( 83 % ) reported providing  inhaler teaching  in their practice s , either by themselves or by an allied health care professional they had personally trained . All stated they could teach inhaler technique within 5 min . Observation of FPs during the second session by certified respiratory educators found that none made critical errors and all had excellent technique . CONCLUSION A physician inhaler education program can improve attitudes toward inhaler teaching and facilitate implementation in clinical practice BACKGROUND Chronic obstructive pulmonary disease ( COPD ) is characterized by an incompletely reversible limitation in airflow . A physiological variable -- the forced expiratory volume in one second (FEV1)--is often used to grade the severity of COPD . However , patients with COPD have systemic manifestations that are not reflected by the FEV1 . We hypothesized that a multidimensional grading system that assessed the respiratory and systemic expressions of COPD would better categorize and predict outcome in these patients . METHODS We first evaluated 207 patients and found that four factors predicted the risk of death in this cohort : the  body-mass index ( B  ) , the degree of airflow obstruction ( O ) and dyspnea ( D ) , and exercise capacity ( E ) , measured by the six-minute-walk test . We used these variables to construct the BODE index , a multidimensional 10-point scale in which higher scores indicate a higher risk of death . We then prospect ively vali date d the index in a cohort of 625 patients , with death from any cause and from respiratory causes as the outcome variables . RESULTS There were 25 deaths among the first 207 patients and 162 deaths ( 26 percent ) in the validation cohort . Sixty-one percent of the deaths in the validation cohort were due to respiratory insufficiency , 14 percent to myocardial infa rct ion , 12 percent to lung cancer , and 13 percent to other causes . Patients with higher BODE scores were at higher risk for death ; the hazard ratio for death from any cause per one-point increase in the BODE score was 1.34 ( 95 percent confidence interval , 1.26 to 1.42 ; P<0.001 ) , and the hazard ratio for death from respiratory causes was 1.62 ( 95 percent confidence interval , 1.48 to 1.77 ; P<0.001 ) . The C statistic for the ability of the BODE index to predict the risk of death was larger than that for the FEV1 ( 0.74 vs. 0.65 ) . CONCLUSIONS The BODE index , a simple multidimensional grading system , is better than the FEV1 at predicting the 
    Output:
    
Simple educational training can substantially improve physicians ' knowledge relating to COPD diagnosis .
Similarly , a physician inhaler education program can improve attitudes toward inhaler teaching and facilitate its implementation in routine clinical practice s. Spirometry combined with inhaled technique education improves the ability of predominantly nonrespiratory physicians to correctly diagnose COPD , to adequately assess its severity , and to increase the percentage of correct COPD treatment used in a real-life setting