COPD World News

COPD World News - Week of September 12, 2021

Increasing temperatures linked to worsening COPD symptoms

Barcelona, Spain - Warmer weather was associated with worsening COPD symptoms, as early as 2 days after a rise in ambient temperature, in adults with COPD, according to new data presented at the virtual European Respiratory Society International Congress. “With increasing temperatures worldwide due to the ongoing climate crisis, the risks of increased morbidity are not equally distributed among all patient groups,” Supaksh Gupta, MD, pulmonary and critical care fellow at the University of Washington, Seattle, told Healio. “Individuals living with COPD may be one such subset of patients at increased risk due to the warming climate.” Data were derived from Gupta S, et al. Abstract OA103. Presented at: European Respiratory Society International Congress; Sept. 5-8, 2021 (virtual meeting). Gupta and colleagues conducted a time-stratified case-crossover analysis that evaluated 1,177 current and former smokers (mean age, 63.7 years; mean time to first exacerbation, 603 days) from the SPIROMICS cohort from 2010 to 2015. All participants had at least one COPD exacerbation. Researchers assessed COPD exacerbation risk based on local ambient temperatures that were measured on the day of exacerbation and in the preceding 7 days. Risk for COPD exacerbations increased with rising temperatures in the preceding 6 days. According to the researchers, the observed risk for exacerbation peaked at 2 days after temperatures rose. When researchers controlled for relative humidity during the study period, every 1°C increase in ambient temperature was associated with a 2% increase in odds of COPD exacerbation 2 days following increased temperatures (P = .002) “Existing data suggested that extremes of temperature, both hot and cold, as well as heat waves, were associated with an increased risk of exacerbations in individuals with COPD. It was surprising to us to see smaller increases in temperature, that were not necessarily outside of normally expected values, also appear to be associated with an increased risk of morbidity in COPD patients,” Gupta told Healio. The mechanisms underlying the link between temperature and COPD exacerbations are not fully understood, but may include hyperventilation, which can lead to increased pressure in the chest cavity and a subsequent decrease in blood flow back to the heart, according to an ERS press release. “Further research is warranted to better characterize the degree of risk in individuals with COPD based on various climate change-related exposures, along with an evaluation of potential protective factors that may mitigate those risks,” Gupta told Healio. “With the increasing frequency of wildfires due to the ongoing climate crisis, it will also be important to better understand the impact these fires and their smoke have upon respiratory health in individuals with preexisting lung diseases.”

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COPD World News - Week of September 5, 2021

Israel planning to administer forth Covid vaccine shot

Tel Aviv, Israel - The country's national coronavirus czar says people should expect to receive a new vaccination against the virus more frequently - 'every five to six months'. Israel expected to give out vaccines that have been specially adapted to cope with different variants of the coronavirus by late 2021 or early 2022, he says. Israel is set to begin preparations to administer fourth doses of the coronavirus vaccines as the country deals with soaring cases despite its trail-blazing roll-out of jabs. The country's national coronavirus czar Salman Zarka said the country needs to prepare for a fourth injection, which could be modified to better protect against new variants of the virus.      'Given that that the virus is here and will continue to be here, we also need to prepare for a fourth injection,' he told Kan public radio.  'This is our life from now on, in waves.' Last month, he told The Times of Israel that people should expect to receive more vaccines to deal with new variants.     'It seems that if we learn the lessons from the fourth wave, we must consider the [possibility of subsequent] waves with the new variants, such as the new one from South America,' he said at the time.  'Thinking about this and the waning of the vaccines and the antibodies, it seems every few months — it could be once a year or five or six months — we'll need another shot.' He added that he expects Israel to be given out vaccines that had been specially adapted to cope with different variants of the virus by late 2021 or early 2022.  While Israel is seeing record case numbers in its fourth wave, the jabs are still protecting against severe illness with Covid deaths running at about half of the level of its second wave. Stats compiled by Oxford University-backed research team Our World in Data shows there were a record 1,892 Covid cases per million people in Israel on Wednesday — nearly 0.2 per cent of the entire population in a single day. That was significantly higher than second worst-hit Mongolia, where the rate was 1,119 per million, and double the figures for Kosovo (980), Georgia (976) and Montenegro (909), which rounded out the top five.  Israel has become the Covid capital of the world just months after leading the charge on vaccines, according to data that shows jab protection is waning.

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COPD World News - Week of August 29, 2021

Surge in smoking among young adults during lockdown

London, UK - The number of 18 – 34 year-olds who smoke increased by 25% in England during the first lockdown, according to a new study led by UCL researchers. This means that over 652,000 more young adults smoke, compared to before the pandemic. The study, published today in the journal Addiction and funded by Cancer Research UK, found that over 4.5 million more adults would be classed as high-risk drinkers during the same period as the number rose by 40%. But this trend was particularly worrying in women (up 55%) as well as people from lower socioeconomic groups (up 64%). Though existing heavy drinkers did make attempts to cut down, this was only observed in adults from higher socioeconomic groups, suggesting that if trends continue, health inequalities linked to alcohol could worsen. There were increases in the number of existing smokers quitting successfully, and overall levels of smoking in adults remains stable. However, the increased number of young adults who smoke means that, for the Government to deliver its goal for England to become smoke-free by 2030, smokers would need to quit at a rate of around 40% faster than predicted. While the study doesn't explain why these changes occurred, the researchers noted that people from lower income backgrounds, younger adults, and women are among those who have been disproportionately affected by the pandemic. Given that many people mistakenly believe that smoking and drinking help relieve stress, they suggest it's possible that some may have taken up these up for the first time or relapsed to help them cope. Smoking is the biggest preventable cause of cancer—it is known to cause at least 15 different cancer types—while drinking even small amounts of alcohol increases the risk of seven different types of cancer. Lead author Dr. Sarah Jackson (UCL Institute of Epidemiology & Health) said: "The first lockdown was unprecedented in the way it changed people's day-to-day lives. We found that many smokers took this opportunity to stop smoking, which is fantastic. However, the first lockdown was also a period of great stress for many people, and we saw rates of smoking and risky drinking increase among groups hardest hit by the pandemic. "It will be important to keep a close eye on how these increases in smoking and drinking develop over time to ensure appropriate support is made accessible for anyone who needs it." Michelle Mitchell, Cancer Research UK's chief executive, said: "There's no 'safe' level of smoking or drinking, and stopping smoking or cutting down drinking will help to reduce your risk of cancer. "Public health campaigns and prevention services have a vital role to play in helping people to quit and also maintaining the motivation of those who have already made positive changes. The upcoming tobacco control plan for England is a key opportunity for the Government to reduce smoking rates, but this can only be achieved with sufficient investment. "A Smokefree Fund—using tobacco industry funds, but without industry interference—could pay for the comprehensive measures needed to prevent people from starting to smoke and helping those who do, to quit." The Addiction study also involved researchers from the University of Sheffield. Cancer Research UK extrapolations comparing smoking prevalence of in 18–34 year olds in England 21.5% before lockdown (August 2019–February 2020) to 26.8% during the first lockdown (April 2020–July 2020) and using ONS mid-year population estimates for 2020 to estimate the number of people this represents. This includes those taking up smoking for the first time and those who have relapsed after not smoking for at least a year. Cancer Research UK estimates that around 3,300,000 18–34 year olds in England were classed as smokers during the first lockdown in April 2020–July 2020. Comparing high-risk drinking prevalence of all adults in England of 25.8% August 2019–February 2020 to 36% in April 2020–July 2020 and using ONS mid-year population estimates for 2020 to estimate the number of people this represents.

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COPD World News - Week of August 22, 2021

UHN considers leave of absence and terminations for unvaccinated staff

Toronto, ON - Unvaccinated employees at the University Health Network could be forced to take a leave of absence during the fourth wave of COVID-19, as the health system considers new measures to convince vaccine-resistant workers to take the shot. The change in strategy comes after Ontario Premier Doug Ford authorized a new health directive impacting thousands of employees in health care and education, requiring proof of vaccination, a medical reason for remaining unvaccinated, or mandatory COVID-19 testing to weed out the virus. Ontario's Chief Medical Officer of Health Dr. Kieran Moore indicated the new rules – set to take effect on Sept. 7 – were a baseline and gave hospitals and other public sector employers the power the go further in order to drive up vaccine uptake.  Kevin Smith, the health network's CEO, says roughly 950 employees – eight per cent of the workforce –remains unvaccinated and could be offered a stark choice in the coming weeks. "We have to insist that people actually participate in a vaccine program, or think about taking a leave of absence," Smith told CTV News Toronto. UHN was among the first employers in Ontario to require unvaccinated individuals to submit to regular COVID-19 testing before arriving for work, a policy that quickly boosted vaccination rates since it took effect in early august. Smith said the vaccine uptake rose from 85 per cent in late July to the current rate of 92 per cent of employees vaccinated against COVID-19. The remaining 950 employees entered into a "swabbing program" with regular testing up to 48 hours before their shift. While Smith said the first phase of the jab or swab program has been a "remarkable success" they encountered a small group of unvaccinated employees who refused to be regularly tested – leading to tough talk from hospital officials. "There was a very small number of people who said I don't want to test. And we said that that's really not an option," Smith said. The hospital went further and gave employees who resisted the hospital's rules a cooling off period from work. “We had very frank dialogues with [them] and said ... here's a couple of weeks off for you to consider whether that's really your position that you don't wish to comply with the hospital's policies. Happy to say we now have 100 per cent compliance," Smith said. The success of that hard lined approach, combined with new provincial guidelines, convinced UHN to take a second look at their minimum standards for employment, including asking unvaccinated employees to work from home or take a leave of absence. While Smith said UHN would "love to avoid termination wherever possible" it could be a last resort option if all other efforts fail the convince employees of the benefits of the vaccine. "The needs of the patient comes first. That at times will require us to make very difficult decisions by always in the best interests of patients," Smith said. "These need to be the safest possible environments for patients, families and our at-risk staff."

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COPD World News - Week of August 15, 2021

American Lung Association requires COVID-19 vaccine for all employees

Chicago, IL - In response to the growing need to increase vaccination rates, American Lung Association National President and CEO Harold P. Wimmer issued the following statement: “The American Lung Association is requiring all employees to be fully vaccinated against COVID-19 before reconvening in the workplace. And we are encouraging other for profit and nonprofit organizations to make this a requirement as well. We are aligned with the President’s statement earlier today urging a vaccine requirement for businesses in an effort to protect public health. “Vaccines in the United States are highly effective, including against the Delta variant, which is nearly twice as contagious as previous variants. Unvaccinated people are much more likely to contract the virus and are at the greatest risk for hospitalization and death. “As the leading non-profit organization advocating for lung health, the American Lung Association has been on the frontlines of the COVID pandemic. The availability of safe and effective COVID-19 vaccines offers an opportunity to end the pandemic and save lives. “To date, more than 61% of adults in the United States have been fully vaccinated. While this number is encouraging, our work is not finished yet. With more employers and organizations requiring vaccinations, we will continue to see vaccination rates increase, which will protect public health and help everyone get back to what they love."

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COPD World News - Week of August 8, 2021

Perioperative LAMA/LABA inhaled therapy optimal for patients with lung cancer, COPD

Tokyo, Japan - Perioperative combination therapy using a long-acting muscarinic antagonist and long-acting beta agonist may be an optimal treatment for patients with lung cancer and COPD undergoing cancer for lung surgery, researchers reported. “Because the prognosis of patients with lung cancer complicated by COPD is reportedly poor, it is important to provide respiratory care for an extended duration, not just during the perioperative period,” Yoko Azuma, MD, assistant professor in the division of chest surgery at Toho University School of Medicine, Tokyo, Japan, and colleagues wrote in BMC Pulmonary Medicine. “The aim of this study [was] to determine the effects of perioperative LAMA/LABA therapy on perioperative lung function, postoperative morbidity and mortality, and long-term prognosis for patients with COPD and lung cancer.” Researchers conducted a retrospective review of medical records of 130 consecutive patients who were newly diagnosed with COPD and underwent lung cancer surgery from January 2005 to October 2019. All patients received perioperative rehabilitation before being categorized into groups according to the type of perioperative inhaled therapy and management used: 64 patients received combination LAMA/LABA, 23 patients received LAMA only and 43 received rehabilitation only. The researchers reported that values for FEV1 and FEV1 percent predicted were significantly improved among patients who received preoperative LAMA/LABA therapy before lung cancer surgery (P < .001 for both). Lung function was significantly improved with LAMA/LABA therapy compared with patients receiving preoperative LAMA therapy (FEV1, 223.1 mL vs. 130 mL; FEV1 percent predicted, 10.8% vs. 6.8%).Patients who received LAMA/LABA had a lower frequency of postoperative complications compared with patients who received LAMA only (P = .007). Those who received LAMA/LABA had lower rates of any complications (21.9% vs. 52.2%), pneumonia (10.9% vs. 26.1%), acute respiratory failure (1.6% vs. 8.7%), prolonged air leakage (9.4% vs. 21.7%) and atrial fibrillation (6.3% vs. 8.7%). Compared with patients who received LAMA only or rehabilitation only, of the 61 patients with moderate-to-severe air flow limitation, those who received LAMA/LABA therapy had significantly longer overall survival (P = .049 and P = .001) and disease-free (P = .026 and P < .001) survival. Researchers also observed an association between lower recurrence rates and perioperative LAMA/LABA therapy compared with LAMA only (P = .006) and rehabilitation only (P = .008). “Our data demonstrate that LAMA/LABA therapy improves not only short-term outcomes such as respiratory function and postoperative complications, but also long-term prognosis in patients with lung cancer and COPD,” the Azuma and colleagues wrote. “Perioperative combined LAMA/LABA therapy is the optimal bronchodilator for patients with COPD who require surgery for lung cancer.”

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COPD World News - Week of August 1, 2021

Researchers to study COVID-19 vaccine efficacy and safety in transplant patients

Montreal, PQ - A national research study has just launched to investigate the effectiveness and safety of COVID-19 vaccines in transplant recipients. The Government of Canada, through its COVID-19 Immunity Task Force (CITF) and Vaccine Surveillance Reference Group (VSRG), is investing over $2.84 million in this research study, based at University Health Network and called PREVenT COVID, short for Prospective Evaluation of COVID-19 Vaccine in Transplant Recipients: A National Strategy. “Because people who have received a solid organ transplant and other immunosuppressed individuals, are generally excluded from clinical trials of vaccines, little data exists to guide clinical best practices for these populations,” says Dr. Deepali Kumar, project lead, Clinician Investigator at the Toronto General Hospital Research Institute and Director of Transplant Infectious Diseases at the Ajmera Transplant Centre. “Our research will address this knowledge gap by revealing how transplant recipients—who are on immune-suppressing medications to prevent organ rejection—respond to COVID-19 vaccines. We will compare their immune responses to non-transplanted individuals as well as those who have contracted COVID-19.” With this funding, Dr. Kumar’s team will launch this study across multiple transplant centres to examine short- and long-term antibody responses in transplant recipients following first and second doses of COVID-19 vaccines. The team will compare these responses to those of healthy individuals who have not undergone transplant and those of transplant recipients who naturally contracted COVID-19. The team will also assess the short- and long-term safety profile of vaccines in transplant recipients, tracking the rates of local and systemic reactions, organ rejection and other transplant complications. “People who have received an organ or stem cell transplant may have unique immunization needs. For example, we do not know whether the effectiveness of vaccines differs depending on the timing of immunization relative to transplant,” explains Dr. Kumar. The researchers will then develop a national COVID-19 vaccination safety surveillance system for transplant recipients. This system will build upon the Canadian National Vaccine Safety Network, an ongoing Canada-wide vaccine safety surveillance initiative. “Our goal is to help coordinate the efforts of provincial and national organizations that are involved in public health and vaccination research and facilitate information sharing among public health agencies and patient partners,” says Dr. Kumar. “This research will build on Canada’s leadership in transplant medicine and inform health policy to best protect transplant recipients from COVID-19.” COVID-19 vaccination remains one of the most effective ways to protect ourselves and others from COVID-19. This is why vaccination is important for the general population around immunosuppressed individuals who may have a reduced immune response to any authorized COVID-19 vaccine series. “It is imperative that we study the immune response and safety of vaccines not only in the general population, but in populations with specific health issues, such as persons having received organ transplants,” says Scott Halperin, Co-Chair of the Vaccine Surveillance Reference Group. “We need to ensure that vaccines are working in vulnerable Canadians: studies like this will help to inform us whether a booster dose is needed in this specific population.”

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COPD World News - Week of July 25, 2021

UHN to implement mandatory COVID-19 home testing for unvaccinated staff

Toronto, ON - Ontario’s largest hospital network will require mandatory and frequent testing for any staff who choose not to be vaccinated against COVID-19 according to a recent article in The Toronto Star. The University Health Network, which includes Toronto General Hospital and Toronto Western Hospital among others, will be the first major hospital and research organization in Ontario to create requirements around immunization for health-care workers. The move comes as multiple countries have already made vaccination mandatory for health-care staff amid the rise of the fast-spreading Delta variant. And with fears of a fourth wave, Ontario’s lack of mandatory immunization policy has led some businesses and institutions to make their own policies. The UHN is aiming to implement new rules that will create testing requirements for unvaccinated staff in their network by Aug. 9. In an email to the Star, the UHN said it started communicating its new policy to staff at the end of June, so all employees, full-time, part-time or casual, would be well aware by the time it is enforced. “We are implementing this to keep patients and staff as safe as we possibly can. The best protection for anyone is double vaccination, which has been made available to all employees of UHN,” said Gillian Howard, a spokesperson for UHN. Once the policy is in place, staff must report whether they are vaccinated, whether they can’t be vaccinated due to a valid medical reason and provide documentation, whether they do not wish to report vaccination status, or whether they are choosing not to be vaccinated. All who are unvaccinated must complete rapid home COVID-19 tests 48 hours prior to their shifts, which amounts to about three times a week, said Howard. Those who are not reporting their vaccination status or choosing not to be vaccinated must complete an education module about the vaccine. About 18,000 UHN staff had already reported their vaccination status, as of July 12, and 750 home test kits were distributed, according to the UHN. The vaccination rate for full-time staff is now at 85 and 90 per cent, Howard said. “We are now working on ensuring that part-time and casual staff are aware of the reporting requirement,” she added. Last week, Ontario Premier Doug Ford said he did not support proof of immunization in any context. Ford said no one should be “forced” to get their shot. His comments came as multiple countries, including France and Italy, have implemented mandatory vaccination policies for those working in health care. France also introduced a COVID-19 health pass Wednesday as infections have surged as the country contends with a fourth wave of the virus. The pass requires a recent negative COVID-19 test or proof of vaccination in order to visit cultural centres, museums, sports venues and movie theatres. The Delta variant has continued to spread across Europe. There are concerns the same could happen in Canada if hundreds of thousands of people remain unvaccinated, despite the availability of an abundance of the vaccine.

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COPD World News - Week of July 18, 2021

Study identifies strategies for rapid access rehab program success post-COPD hospitalization

Toronto, ON - A new study published in Respiratory Medicine identified approaches for success in establishing a rapid access rehabilitation program following hospitalization for acute exacerbations of COPD. “Considering the demonstrated benefits of early post-acute exacerbation of COPD rehabilitation and the limited access to conventional programs, there is increasing interest in the provision of a rapid access rehabilitation program,” Ana Oliveira, PhD, researcher at the School of Rehabilitation Science at McMaster University, Hamilton, and West Park Healthcare Centre, Toronto, and the Respiratory Research and Rehabilitation Laboratory in the School of Health Sciences and the Institute of Biomedicine at the University of Aveiro in Portugal, and colleagues wrote. “The rapid access rehabilitation program accepts patients within 48 hours of their discharge from hospital to provide a bridge from the peri-exacerbation period to enrollment in a conventional pulmonary rehabilitation program.” Researchers conducted semi-structured interviews using phone calls with three patients recently hospitalized for acute exacerbations of COPD, 10 health care professionals and three policymakers who provided care for these patients from September to December 2020. All of those interviewed shared similar visions for the essential elements and approaches of a rapid access rehabilitation program, according to the researchers. The interviews led to the following themes for the development of a rapid access rehabilitation program: pre-rapid access rehabilitation aspects (management properties, eligibility); rapid access rehabilitation program (outcomes, structure, components); rapid access rehabilitation optimization (referral, uptake); partnership (collaboration, dedicated coordinator); and COVID-19 adaptations. In addition, patients, health care professionals and policymakers identified the following as essential elements for developing a program for this population: clear eligibility criteria, addressing patients’ needs at discharge, having structured education and self-management programs and modifying to respond to unexpected events. “There is ongoing interest in better understanding the role of post-acute exacerbation of COPD pulmonary rehabilitation and there does appear to be a consistent need for programs that are flexible to patient needs and that emphasize self-management,” the researchers wrote. For rapid access rehabilitation referral optimization, participants suggested a clear referral pathway, improving program awareness, assigning dedicated care coordinators to provide patient support, and establishing strong partnerships with different care settings and providers. One way to accomplish these tasks would be to make rapid access rehabilitation part of standard care and follow similar models from other rehabilitation areas, according to the researchers. “A structured program based on education and self-management customized to patients needs and adaptable to unexpected events such as COVID were considered essential components of rapid access rehabilitation development,” the researchers wrote. “Suggestions for optimizing referral, uptake and effectiveness include raising program awareness, having a clear referral pathway, a dedicated care coordinator and established partnership among different care settings and providers.” Currently, a Delphi study based on these results is being created to include a broader and international participant range to define final characteristics of a rapid access rehabilitation programs after hospital discharge, according to the researchers.

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COPD World News - Week of July 11, 2021

Canadians would support use of vaccine passports, Angus Reid survey finds

Arnprior, ON - The idea of providing proof of vaccination is one Canadians would be on board with if it meant a return to the things they enjoy during the pandemic. In a recent survey by the Angus Reid Institute, 79 per cent of Canadians polled said they would carry a vaccine passport to travel internationally, while 76 per cent said they would carry one to cross the border to the United States. At home, 55 per cent of people said they would provide proof at public places such as restaurants, malls, movie theatres, and even workplaces. "If it meant I didn’t have to wear a mask anymore and we could open everything up and put everything back to normal, I’ll carry whatever they ask me to carry," said Shawn Lewis, who was out picking up groceries at the Metro location in Arnprior. "It would definitely make a lot of sense because you know everybody around you is vaccinated." In Renfrew County, more than 50 per cent of the population has received at least one dose of the COVID-19 vaccine. Medical Officer of Health Dr. Robert Cushman is anticipating that number to reach 70 per cent before vaccine hesitancy becomes prominent. "Renfrew County tends to be very pro-vaccine, which is great," says Dr. Cushman. "I think most people want their own private vaccine passport because they realize that it will help them in certain places." But there are some who say they don’t like the idea of a digital passport being scanned on their phone. "Personally, myself no," says Bob Lachance, who was also out running errands in Arnprior. "If we need a passport, maybe present it if you want to go somewhere. But personally I don’t think it’s necessary."

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COPD World News - Week of July 4, 2021

A 3-Year study of Tele-Pulmonary rehab program for COPD

Montreal, PQ – A new study published in the Annals of the American Thoracic Society looked at access to pulmonary rehab for people with chronic obstructive pulmonary disease. The researchers surmised that few individuals with COPD are able to access pulmonary rehabilitation (PR) despite its importance. Barriers include increased travel time and lack of resources. Tele-PR has been proposed as a novel solution to overcome such barriers and improve access. Their study aimed to provide information on implementing a novel province-wide standardized community-based tele-PR program and determine its accessibility, feasibility and safety. Secondary objectives examined the effectiveness of tele-PR compared to standard-PR and if clinical improvements were sustained over time. The researchers conducted a concurrent prospective study of people with COPD enrolled in either standard-PR or community-based tele-PR at satellite centers between January 2017 and January 2020. To determine accessibility and feasibility, they recorded the number of participating centers meeting eligibility criteria, centers remaining in the program over 3 years, number of delivered programs and major adverse events. Participants had a 6MWT and CAT at baseline, immediately post-PR and at 1,3,6 and 12 months. Descriptive analysis was carried out for accessibility, feasibility and safety. Mixed-effects random models were used to estimate change in 6MWT and CAT. Seven tele-sites were recruited into the tele-PR program with 6 continuing to participate at 3 years, delivering a total of 58 programs for 177 individuals with COPD. During that same period, the standard-PR site delivered 15 programs for 89 individuals with COPD. Over 70% of participants completed each program and no major adverse events were reported. There were significant improvements in the 6MWT and CAT scores in both groups immediately post-PR with no between-group differences. Participants in both programs had persistent 6MWT improvement at 1,3,6 and 12 months post-PR. Participants in tele-PR had persistent improvement of CAT scores but not in standard-PR beyond 1 month post-PR. The researchers concluded that this study provides real-world evidence demonstrating successful implementation of tele-PR. The Canadian standardized tele-PR program is an accessible, feasible, safe and effective model for delivering pulmonary rehabilitation for people with chronic obstructive pulmonary disease. The researchers who participated in the study are: Amr J Alwakeel, Albert Sicondolfo, Chantal Robitaille, Jean Bourbeau and Nathalie Saad.

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