Executive Summary of the Recommendations on the Management of Asthma In Primary Care (2022) – New Updates

Background : Asthma is a heterogenous disease defined by the history of respiratory symptoms (shortness of breath, wheezing, cough, and chest tightness) that vary over time and in intensity, along with variable expiratory airflow limitation. Despite an ever-increasing prevalence of asthma across all age groups, this condition remains poorly managed in India. Majority of the Indian patients remain undiagnosed or wrongly diagnosed in general clinical practice and even those who get diagnosed, remain poorly or inadequately treated1,2. Since the last published 2020 Indian Medical Association (IMA) recommendations on the management of asthma in primary care, noteworthy critical changes have been recommended in relation to the diagnosis/management of asthma in international guidelines. Hence, there was a need to update the existing IMA recommendations. For the same, an expert group meeting was organized with family physicians having clinical experience in managing patients with asthma along with chest physicians and pediatricians. Important updates related to asthma diagnosis and its management were discussed and the final recommendation decisions were derived from the joint group discussion. Some of the key points derived from the discussion are mentioned below in the executive summary. For a detailed version of the new recommendations please click on the url.

EPOC reagudizada hospitalizada: Estudio de costos directos en un hospital público de la Ciudad de Buenos Aires / Exacerbations of COPD hospitalized: Direct cost study in a public hospital of Buenos Aires City

RESUMEN No existe información sobre la estructura y costos anuales de una hospitalización por agudización de la EPOC en nuestro país actualmente Objetivos: Determinar la estructura de costos de los pacientes hospitalizados por EPOC reagudizada en un hospital público de la Ciudad Autónoma de Buenos Aires (CABA) en el año 2018. Materiales y métodos: Se evaluaron pacientes con EPOC reagudizada (GOLD), in ternados durante 2018 en nuestro hospital. Se determinaron costos directos (perspec tiva del financiador), según costos de medicamentos y la modulación de internación clínica y Unidad de Terapia Intensiva (UTI) del Gobierno de CABA a junio de 2021, valor dólar Banco Nación al 30 de Junio 2021 de $101,17. Resultados: Se internaron 26 pacientes, edad 64 ± 9,56 años, masculino 73%, 61% tabaquistas actuales y 39% extabaquistas (101,8 ± 47,1 paq.-año), seguro social 31%, FEV1% 31 mediana (23-42) y FEV1/FVC 0,46 ± 0,12. La duración de internación fue: guardia 1 d (1-1,75); piso, 9 d (4-12); y UTI, 13 d (11-29,5), con mortalidad 23% (n = 6). El costo final fue 1462,62 dólares/paciente, mediana (RIQ 25%-75%,763,85-2915,95), 162,44 dólares/d/paciente, y el costo total (n = 26) fue USD 117 480. El costo de UTI fue 9898,28 dólares/paciente, mediana (RIQ 25%-75%, 6700,94-35 780,25). El costo total (n = 3) fue USD 75 064,11. Conclusión: Los pacientes con EPOC reagudizada que se hospitalizan son en su mayoría hombres, más de 60 años, alta carga tabáquica y obstrucción grave. El costo directo desde la perspectiva del financiador fue de USD 1462 por paciente; el costo del paciente que se hospitaliza en UTI fue casi siete veces superior. Se deben instru mentar programas sistematizados de manejo de la EPOC para identificar pacientes con factores de riesgo, educar y permitir acceso a la medicación.

ABSTRACT There is not information about the annual and structure of costs of a hospitalization of COPD exacerbation in our country actually. Objective: To determine the structure of direct costs in hospitalized patients due to COPD exacerbations in a public hospital of Buenos Aires in 2018. Methods: Patients hospitalized of COPD exacerbation (GOLD) in 2018 were analyzed in our hospital. Direct costs were determined (financier perspective), due to modulation of the Health Ministry of Buenos Aires City Government, stratified by Intensive Care Unit hospitalization and in room at June 2021, in dollars (dol.), parity at June 30th 2021 was 1 dollar = 101,17$ (price Banco Nación). Results: 26 patients were hospitalized: age 64 ± 9.56 years, male gender 73%, 61% actual smokers and 39% ex-smokers (101.8 ± 47.1 pack-y, social health assurance 31% (n = 8); FEV1% 31 median (23-42) and FEV1/FVC 0,46 ± 0,12. Ward length of hospitalization (median) was 1 day (1-1,75), 9 days in room (4-12), 13 days in UCI (11- 29,5) with mortality rate 23% (n = 6). Final direct cost by patient was 1462,62 dol, median (IQR 25%-75%,763,85-2915,95),at 162,44 dol./day/patient. Total cost (n = 26) was 117 480 dol. UCI cost was median 9898,28 dol./patient (IQR 25%-75%, 6700,94-35 780,25). Final UCI total cost (n = 3) 75 942,3 dol. Conclusion: Patients with COPD exacerbation hospitalized were mainly males, sixty years old, heavy smokers and severe airway obstruction. With financier perspective, direct cost of hospitalization was 1462 dol./patient, almost seven times higher in UCI. Disease management program must be implemented to manage COPD, to identify patients at risk, to educate and to assure access to drugs.

Níveis de eosinófilos circulantes e declínio da função pulmonar em doença pulmonar obstrutiva crônica estável: um estudo longitudinal retrospectivo / Circulating eosinophil levels and lung function decline in stable chronic obstructive pulmonary disease: a retrospective longitudinal study

RESUMO Objetivo Discute-se se eosinófilos no sangue (EOS) na doença pulmonar obstrutiva crônica (DPOC) são associados à evolução da doença. O objetivo deste estudo foi avaliar se a contagem diferencial de células brancas do sangue (CBS), os sintomas e o tratamento podem prever o declínio da função pulmonar e as exacerbações em pacientes com DPOC. Métodos Foram retrospectivamente examinados pacientes com DPOC estável submetidos a um monitoramento mínimo de três anos em nossas clínicas ambulatoriais. Coletaram-se informações sobre volumes pulmonares (VEF1 e CVF), contagens total e diferencial de CBS, exacerbações agudas de DPOC (número nos 12 meses anteriores ao início do estudo = EA-DPOC-B; e durante o monitoramento = EA-DPOC-F), status tabagístico e tratamento. Os declínios de VEF1 e EA-DPOC-F foram descritos empregando modelo linear generalizado e regressão binomial negativa com interceptação aleatória de nível 2, respectivamente. Os modelos incluíram contagens de eosinófilo e neutrófilo como potenciais preditores e foram ajustados de acordo com sexo, idade, status tabagístico, EA-DPOC-B, tratamento com broncodilatadores e corticosteroides inalados (CSI). Resultados 68 pacientes foram considerados, dos quais 36 para EOS- (< 170 células/μL, valor da mediana) e 32 para EOS+ (≥ 170 células/μL). ∆VEF1 foi maior em EOS+ do que em EOS- (34,86 mL/ano vs 4,49 mL/ano, p = 0,029). Após o ajuste em relação aos potenciais confundidores, as contagens de eosinófilos (β = 19,4; CI 95% 2,8,36,1; p = 0,022) e CSI (β = -57,7; CI 95% -91,5,-23,9; p = 0,001) foram positivamente e negativamente associadas ao declínio da função pulmonar, respectivamente. Os EOS não foram associados ao número de EA-DPOC-F. Conclusão Em pacientes com DPOC estável, o maior nível de EOS (embora em um intervalo regular) prevê um maior declínio de VEF1, enquanto os CSIs são associados a uma evolução mais lenta da obstrução do fluxo aéreo.

ABSTRACT Objective Whether blood eosinophils (bEOS) in chronic obstructive pulmonary disease (COPD) are associated with disease progression is a topic of debate. We aimed to evaluate whether the differential white blood cell (WBC) count, symptoms and treatment may predict lung function decline and exacerbations in COPD patients. Methods We retrospectively examined stable COPD patients with a minimum follow-up of 3 years at our outpatients' clinic. We collected information about lung volumes (FEV1, FVC), the total and differential WBC count, acute exacerbations of COPD (number in the 12 months before the beginning of the study=AE-COPD-B, and during the follow-up=AE-COPD-F), smoking status and treatment. FEV1 decline and AE-COPD-F were described by using a generalized linear model and a 2-level random intercept negative binomial regression, respectively. The models included eosinophil and neutrophil counts as potential predictors and were adjusted by sex, age, smoking status, AE-COPD-B, treatment with bronchodilators and inhaled corticosteroids (ICS). Results Sixty-eight patients were considered, 36 bEOS- (<170 cells/μL, the median value) and 32 bEOS+ (≥170 cells/μL). ∆FEV1 was higher in bEOS+ than bEOS- (34.86 mL/yr vs 4.49 mL/yr, p=0.029). After adjusting for potential confounders, the eosinophil count was positively (β=19.4; CI 95% 2.8, 36.1; p=0.022) and ICS negatively (β=-57.7; CI 95% -91.5,-23.9; p=0.001) associated with lung function decline. bEOS were not found to be associated with the number of AE-COPD-F. Conclusion In stable COPD patients, a higher level of blood eosinophils (albeit in the normal range) predicts a greater FEV1 decline, while ICS are associated with a slower progression of airflow obstruction.

Efectos de la suplementación con vitamina D en el control del asma en pacientes adultos: una revisión sistemática / Effects of vitamin D supplementation on asthma control in adult patients: a systematic review

INTRODUCCIÓN: El asma es una enfermedad crónica inflamatoria de la vía aérea e inmunomediada en su patogénesis. La vitamina D es un inmunomodulador que regula el perfil secretor de citoquinas, entre otras funciones celulares. Una asociación entre la suficiencia de vitamina D y mejoría en la función pulmonar, control de asma y número de exacerbaciones se ha propuesto en adultos, importante dada la elevada prevalencia de insuficiencia de vitamina D globalmente. OBJETIVO: Conocer los efectos de la suplementación con vitamina D en el control del asma en adultos. MÉTODOS: Se realizó una revisión sistemática de la literatura a través de una búsqueda en la base de datos PubMed y EMBASE. Los desenlaces primarios fueron cambios en VEF1, control sintomático, frecuencia de exacerbaciones, además de eventos adversos y FEM como desenlaces secundarios. La calidad de evidencia de los desenlaces fue evaluada a través del modelo GRADE. RESULTADOS: Siete estudios fueron seleccionados después de remover duplicados y aplicar los criterios de inclusión y exclusión, con calidad de evidencia muy baja aplicando sistema GRADE. DISCUSIÓN: No se encontraron diferencias estadísticamente significativas tras la suplementación con vitamina D en los desenlaces evaluados en general, pero dada la calidad de evidencia muy baja y que no se reportaron efectos adversos serios, es necesario tomar cautelosamente estos resultados. Asímismo no se puede descartar la utilidad de esta terapia como tratamiento auxiliar a los pacientes asmáticos con este déficit vitamínico.

BACKGROUND: Asthma is an airway chronic disease, with an important inflammatory component within its pathogenesis, driven by a dysregulated immune response. Vitamin D is an immunomodulator that regulates cell proliferation, differentiation and cytokine secretion profile. An association between vitamin D sufficiency and improvement in pulmonary function, asthma control and a decrease in exacerbations have been proposed in the adult population, which falls into importance given the high prevalence of vitamin D insufficiency globally. OBJECTIVE: To know vitamin D supplementation effects in asthma control in adults. METHODS: Through a PubMed and EMBASE database search, a systematic review of the literature was conducted. Primary outcomes were: changes in FEV1, symptomatic control, exacerbation frequency and PEF and adverse events as secondary outcomes. Outcome evidence quality assessment was made using the GRADE model. Results: Seven studies were selected after taking out duplicates, applying inclusion and exclusion criteria. In all cases, evidence quality assessed by the GRADE system yielded very low quality. CONCLUSIONS: No statistically significant differences were found after vitamin D supplementation in the overall evaluated outcomes. Nonetheless, a cautious interpretation of studies is mandatory, because evidence quality was very low and no serious adverse events were reported. Hence this treatment usefulness as an ancillary therapy for vitamin D deficient asthmatic patients cannot be dismissed.

Bronchiectasis in patients with chronic obstructive pulmonary disease in a tertiary care center in North-East India

Background: Bronchiectasis is common in patients with Chronic Obstructive Pulmonary Disease (COPD). COPD with bronchiectasis has been considered a phenotype with worse lung function and more severe exacerbations. There is scarce literature on the characteristics and optimal management of such patients.Methods:Patients with COPD reporting within the one-year study period were subjected to High Resolution Computed Tomography (HRCT) scan of the thorax. Sputum was sent for Gram-stain and culture/sensitivity for patients found to have bronchiectasis. Bronchiectasis Severity Index (BSI) was calculated using the online BSI calculator. Association between presence of bronchiectasis and gender, lung function and frequency of exacerbations was statistically analysed.Results: Total 62 patients with COPD were enrolled. Bronchiectasis was present in 11 (17.7%) patients. The most common bacterial isolate from sputum of patients with bronchiectasis was Haemophilus influenza (54.54%). The prevalence of bronchiectasis was more in females (19.45% compared to 15.4% in males), but this association was not found to be statistically significant(p=0.748). Forced Expiratory volume in 1st second (FEV1) was found to be significantly lower in patients with bronchiectasis (p<0.05). There was increased frequency of exacerbations among patients with bronchiectasis. This association was however not found to be statistically significant (p=0.765), 1 (9.1%) patient had low BSI score (0-4), 3 (27.3%) patients had intermediate BSI score (5-8) and 7 (63.3%) patients had high BSI score (?9).Conclusions:The presence of bronchiectasis in COPD is a phenotype associated with a poor clinical course. The characteristics of this co-existence are largely unknown. More studies are required to properly characterize and manage patients with this coexistence.

Oxigenoterapia por cánula nasal de alto flujo en pacientes con crisis asmática en un departamento de emergencia pediátrica / High flow nasal cannula oxygen therapy in patients with asthmatic crisis in the pediatric emergency department

INTRODUCCIÓN: Pocos estudios son concluyentes sobre la utilidad de la Oxigenoterapia por Cánula Nasal de Alto Flujo (CNAF) en pacientes con crisis asmática. OBJETIVO: Determinar la eficacia de la CNAF en niños mayores de 2 años con crisis asmática severa y moderada que no responde al tratamiento inicial. PACIENTES Y MÉTODO: Ensayo clínico randomizado controlado abierto de pacientes con exacerbación asmática en un Departamento de Emergencia Pediátrica. Se excluyó crisis mediadas por infecciones y comorbilidad. Los pacientes fueron aleatorizados: Grupo 1 CNAF (n: 32) y Grupo 2 Oxigenoterapia Convencional (n: 33). Ambos grupos recibieron el tratamiento farmacológico habitual. El primer punto de corte fue el descenso del PIS en más de 2 puntos a las 2 horas del tratamiento; los puntos secundarios: descenso del PIS a las 6 horas, tiempo de permanencia en la emergencia e ingreso a UCIP. RESULTADOS: Las características basales fueron similares en ambos grupos. La proporción de sujetos con disminución de más de dos puntos en el PIS a las 2 horas de tratamiento Grupo 1: 43,7% IC 95% (28-60) vs Grupo 2: 48,4%; IC 95% (32-64) p 0,447. La estadía media fue 24,8 ± 12,3 horas en el Grupo1 vs 24 ± 14,8 horas en el Grupo2; IC 95% (7,56-5,96) p 0,37. No encontramos diferencias del score y puntaje del esfuerzo respiratorio en mediciones cada 2 horas. Ningún paciente ingresó a cuidados intensivos. CONCLUSIONES: La incorporación de la CNAF al tratamiento de pacientes con crisis asmática no presentó beneficios clínicos ni disminuyó el tiempo de estadía en el DEP.

INTRODUCTION: There are few conclusive studies on the usefulness of High-Flow Nasal Cannula (HFNC) Oxygen Therapy in patients with asthmatic crises. OBJECTIVE: To determine the effectiveness of HFNC in chil dren older than 2 years of age that present severe and moderate asthmatic crises that do not respond to initial treatment. PATIENTS AND METHOD: Open controlled randomized clinical trial of patients with asthma exacerbation in the Pediatric Emergency Department. Infection- and comorbidity-media ted crises were excluded. Subjects were randomized as follows: Group 1 HFNC (n:32) and Group 2 Conventional Oxygen Therapy (n:33). Both groups received the usual pharmacological treatment. The first cut-off point was the decrease of more than 2 points of the PIS after 2 hours of treatment; secondary points were PIS decrease at 6 hours, stay time in the Emergency Room, and PICU admis sion. RESULTS: The patient's baseline characteristics were similar in both groups. The proportion of subjects with more than two points decrease in the PIS after two hours of treatment in Group 1 was 43.7% CI 95% (28-60) vs. Group 2 48.4%; CI 95% (32-64) p 0.447. The mean stay time was 24.8 ± 12.3 hours in Group 1 vs. 24 ± 14.8 hours in Group 2; CI 95% (7.56-5.96) p 0.37. We did not find differences in the respiratory effort score measurements every 2 hours. No patients were admitted to intensive care. CONCLUSIONS: The incorporation of HFNC oxygen therapy in the treatment of patients with asthmatic crises in the Pediatric Emergency Department did not show clinical benefits nor did it diminish the stay time.

Factores de riesgo asociados a exacerbaciones respiratorias en pacientes pediátricos con fibrosis quística / Risk factors associated with pulmonary exacerbations in pediatric patients with cystic fibrosis

Introducción. Los pacientes con fibrosis quística presentan exacerbaciones respiratorias (ER) que requieren tratamiento endovenoso. El objetivo fue determinar los factores de riesgo asociados a ER y obtener porcentaje de pacientes que no recuperaban su función pulmonar previa. Población y métodos. Observacional, de cohorte, retrospectivo. Se revisaron las historias clínicas de los pacientes con fibrosis quística atendidos en el Hospital de Niños Ricardo Gutiérrez durante 2013. Se dividieron en: grupo 1, con ER (criterios de Fuchs), y grupo 2, sin ER. Se registró edad, género, mutación p.F508del, porcentaje del volumen espiratorio forzado en el primer segundo basal, puntaje Z de índice de masa corporal basal, colonización crónica (criterios de Leeds) por Pseudomonas aeruginosa, Staphylococcus aureus meticilino resistente y complejo Burkholderia cepacia, porcentaje de diabetes relacionada con fibrosis quística y recuperación del volumen espiratorio forzado en el primer segundo basal. Resultados. Se incluyeron 117 pacientes. Grupo 1: 50; y grupo 2: 67 pacientes. Se asociaron a las ER: el menor puntaje Z de IMC (RR: 1,45; p=0,002), p.F508del (RR: 3,23; p=0,05) y colonización crónica por el complejo Burkholderia cepacia (RR: 3,69; p = 0,002), Pseudomonas aeruginosa (RR: 1,89; p = 0,01) y Staphylococcus aureus meticilino resistente (RR: 2,32; p = 0,002). El 24 % no recuperó su función pulmonar. Conclusiones. p.F508del, el bajo estado nutricional y la colonización crónica fueron factores de riesgo para exacerbación. Una cuarta parte de los pacientes no recuperó su función pulmonar previa.

Introduction. Cystic fibrosis patients develop pulmonary exacerbations (PEs) that require intravenous treatment. The objective of this study was to determine the risk factors associated with PEs and establish the percentage of patients who failed to recover their lung function. Population and methods. Observational, retrospective, cohort study. The medical records of cystic fibrosis patients seen at Hospital de Niños Ricardo Gutiérrez in 2013 were reviewed. Patients were divided into group 1, with PE (Fuchs criteria), and group 2, without PE. Age, sex, p.F508del mutation, percentage of baseline forced expiratory volume in the first second, baseline body mass index Z-score, chronic Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus and Burkholderia cepacia complex colonization (Leeds criteria), percentage of cystic fibrosis-related diabetes, and recovery of baseline forced expiratory volume in the first second were recorded. Results. A total of 117 patients were included. Group 1: 50, group 2: 67 patients. PEs were associated with a lower body mass index Z-score (RR: 1.45; p = 0.002), p.F508del mutation (RR: 3.23; p = 0.05), and chronic Burkholderia cepacia complex (RR: 3.69; p = 0.002), Pseudomonas aeruginosa (RR: 1.89; p = 0.01) and methicillin-resistant Staphylococcus aureus colonization (RR: 2.32; p = 0.002). Twenty-four percent of patients failed to recover their lung function. Conclusions. The presence of the p.F508del mutation, a poor nutritional status, and chronic colonization were the risk factors for exacerbation. A fourth of patients failed to recover their lung function.

Bronquiectasias no fibrosis quística: desde la infancia a la adultez: enfoque diagnostico y terapéutico / Bronchiectasis no cystic fibrosis: from childhood to adult: diagnostic and therapeutic approach

Bronchiectasis is a suppurative lung disease with heterogeneous phenotypic characteristics. It is defined as abnormal dilation of the bronchi, losing the existing relationship between bronchial sizes and accompanying artery. According to their form, they can be cylindrical, varicose, saccular or cystic. According to its location, they could be diffuse or localized. The diagnosis of bronchiectasis is usually suspected in patients with chronic cough, mucopurulent bronchorrea, and recurrent respiratory infections. The etiology can be varied, being able to classify in cystic fibrosis bronchiectasis, when there is cystic fibrosis transmembrane regulator (CFTR) gene mutation and not cystic fibrosis, being post infectious the most frequent. Its relationship with childhood is unknown. Severe respiratory infections can predispose in a susceptible subject the so-called theory of the "vicious circle" and the development of these. Persistent bacterial bronchitis in children has been described as a probable cause of not cystic fibrosis bronchiectasis in adults. The treatment is based on the management of symptoms and the prevention of exacerbations. The evidence is poor and many treatments are extrapolated from cystic fibrosis bronchiectasis. We are going to describe the diagnostic and therapeutic approach of non-cystic fibrosis bronchiectasis in adults.

La bronquiectasia es una enfermedad pulmonar supurativa con características fenotípicas heterogéneas. Se define como la dilatación anormal de los bronquios, perdiendo la relación existente entre tamaño bronquial y arteria que acompaña. Según su forma, pueden ser clasificadas en cilíndricas, varicosas, saculares o quísticas y según su etiología presentarse de forma difusa o localizada. El diagnóstico de bronquiectasias se sospecha generalmente en pacientes con tos crónica, broncorrea mucosa, mucupurulenta e infecciones respiratorias recurrentes. La etiología es variada, pudiendo clasificarse en bronquiectasias fibrosis quística, aquellas que se encuentran en el contexto de la mutación del gen regulador transmembrana de fibrosis quística (CFTR) y no fibrosis quística, de etiologías diversas, siendo post infecciosas la gran mayoría. No se conoce con certeza su relación con la infancia, es sabido que infecciones respiratorias severas pueden predisponer en un sujeto susceptible, a la llamada teoría del "circulo vicioso" y el desarrollo de estas. La bronquitis bacteriana persistente en niños se ha descrito como una causa probable del desarrollo de bronquiectasias no fibrosis quística en adultos. El tratamiento se basa en el manejo de los síntomas y la prevención de las exacerbaciones. La evidencia es escasa y la mayoría de las terapias se han investigado en las bronquiectasias tipo fibrosis quística. En este trabajo se explicará el enfrentamiento diagnóstico y terapéutico de los adultos portadores de bronquiectasias no fibrosis quística.

Body mass index, obstruction of the airflow, dyspnea, and exercise capacity index as predictor of the severity of exacerbations and systemic involvement in patients with COPD

Background: Allocation of the limited resources to the needed patients and decision making regarding timely interventions demand development of a reliable, cost effective, simple assessment tool. Several studies propose body-mass index, airflow obstruction, dyspnea, and exercise (BODE) index for this purpose in patients with Chronic obstructive pulmonary disease (COPD). The objective of this study was to assess the utility of BODE index to predict the severity of exacerbations and systemic involvement in COPD.Methods: A Present hospital based cross sectional study was carried out among 100 COPD patients. BODE index was used to assess the patients and its association was studied with various variables. The data was analyzed using one-way analysis of variance (ANOVA) test.Results: As the body index class of severity increases, the number of hospitalizations required in the past also increases and this association is statistically significant. As the severity of the disease increased as indicated by the class the mean number of exacerbations in the past increased and this association was found out to be statistically significant. As the severity of the disease increased as indicated by the class level, the mean number of days of hospitalization increased. But this increase was of small difference and hence on one-way ANOVA test was not found out to be statistically significant. As the pack years increases, the BODE index increases significantly (p value <0.001). As the severity of the disease increased, the mean body mass index decreased. Haemoglobin level was found to decrease with increase in BODE index class of severity. This association was statistically significant.Conclusions: The BODE index has been found to be a very good tool to assess the prognosis of COPD as well as severity of acute exacerbations.

Role of genetic susceptibility in nicotine addiction and chronic obstructive pulmonary disease

Abstract Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in developed countries. Although cigarette smoking is the major risk factor, only 10-20% of smokers develop COPD. The extent of cigarette smoking (pack-years and smoking duration) accounts for only 15% of the variation in lung function, indicating that differences in susceptibility to COPD must exist. We provide an overview of the complexity of nicotine addiction and COPD, with special attention to the involvement of genetic factors. The following aspects are discussed in the present article: (1) epidemiology in Mexico and (2) a review of the published literature on genetic association studies using the National Center for Biotechnology Information database of the United States as a search tool. COPD is unique among complex genetic diseases where an environmental risk factor is known and the level of exposure can be documented with some precision. The high morbidity and mortality associated with COPD and its chronic and progressive nature has prompted the use of molecular genetic studies to identify susceptibility factors for the disease. Biomedical research has a remarkable set of tools to aid in the discovery of genes and polymorphisms. We present a review of the most relevant genetic associations in nicotine addiction and COPD.

Examining the Impact of Refractory Myasthenia Gravis on Healthcare Resource Utilization in the United States: Analysis of a Myasthenia Gravis Foundation of America Patient Registry Sample

BACKGROUND AND PURPOSE: Patients with refractory myasthenia gravis (MG) experience ongoing disease burden that might be reflected in their healthcare utilization. Here we examine the impact of refractory MG on healthcare utilization. METHODS: The 825 included participants were aged 18–64 years, enrolled in the Myasthenia Gravis Foundation of America Patient Registry between July 2013 and February 2018, and had been diagnosed with MG ≥2 years previously. RESULTS: Participants comprised 76 (9.2%) with refractory MG and 749 (90.8%) with nonrefractory MG. During the 6 months before enrollment, participants with refractory MG were significantly more likely than those with nonrefractory MG to have experienced at least one exacerbation [67.1% vs. 52.0%, respectively, p=0.01; odds ratio (OR)=1.882, 95% confidence interval (CI)=1.141–3.104], visited an emergency room at least once [43.4% vs. 27.1%, p<0.01; OR=2.065, 95% CI=1.276–3.343], been hospitalized overnight at least once (32.9% vs. 20.5%, p=0.01; OR=1.900, 95% CI=1.140–3.165), ever been admitted to an intensive care unit (ICU) (61.8% vs. 33.4%, p<0.01; OR=3.233, 95% CI=1.985–5.266), or ever required a feeding tube (21.1% vs. 9.1%, p<0.01; OR=2.671, 95% CI=1.457–4.896). A total of 75.8% younger females with refractory disease (<51 years, n=33) experienced at least one exacerbation, 69.7% had been admitted to an ICU, and 30.3% had required a feeding tube. For older females with refractory disease (≥51 years, n=33), 60.6%, 54.6%, and 6.1% experienced these outcomes, respectively (between-group differences were not significant). CONCLUSIONS: Refractory MG is associated with higher disease burden and healthcare utilization than nonrefractory MG.

Estudio descriptivo de una población de pacientes EPOC asistidos en el Hospital Pasteur: severidad e impacto en la vida diaria / Descriptive study of a population of COPD patients assisted at the Pasteur Hospital: severity and impact on daily life / Estudo descritivo de uma população de pacientes com DPOC atendidos no Hospital Pasteur: gravidade e impacto na vida diária

resumen está disponible en el texto completo

Abstract: Introduction: COPD is an important sanitary problem. It is the fourth cause of death worldwide, with a prevalence of 19.7% in Uruguay. It is a preventable and treatable disease, characterized by persistent airflow limitation associated to chronic inflammatory airway response and pulmonary parenchima destruction as a consecuence of exposure to noxious particles. Objectives: Describe clinical and demographic features of a group of COPD patients. Determine the disease´s severity and its impact over the quality of life. Materials and methods: This is an observational, descriptive and transversal study which included 61 inpatients of Hospital Pasteur´s Internal Medicine service who were summoned for their follow-up at the COPD outpatient clinic between October 1st 2015 and December 31st 2016. The inclusion criteria were: both genders, over 40 years of age, presence of risk factors, congruent symptoms and signs or previous COPD diagnosis. The exclusion criteria were: moderate to severe cognitive impairment, bedridden patients, pregnancy, active pulmonary tuberculosis, neuromuscular diseases. The sampling was done by convenience. Data was obtained from ambulatory follow-up and processed with the programme EPI-DATA version 3.1 and PSPP. Results: The diagnosis of COPD was confirmed by spirometry in 42 of the 61 summoned patients. The mean age of COPD patients was 63 years (± 11), prevailing among males (24, 57.1%). The majority had a low education level (incomplete primary schooling in 15 patients, 35.7%). Smoking constituted a risk factor in 100%, with mean pack-year index (PYI) of 81.9 (± 59.8). More than half associated at least two risk factors. 21 patients (50%) had grade 3 mMRC (Modified British Medical Research Council) dyspnea, while 26 (61.9%) had frequent exacerbations. The mean value obtained in the COPD Assessment Test (CAT) was 19.58 (SD 10.56). Therefore, most patients belonged to groups D (17, 40.4%) and C (9, 21.4%) defined by the GOLD Report 2017. Where airflow limitation is concerned, the majority corresponded to group GOLD 2 or moderate limitation. Conclusions: He existence of selection biases determined a small number of COPD patients. The average age and sex agreed with international data. The low level of instruction may have implications for adherence to controls and treatment. The average API was higher than in international studies. The association of risk factors was linked to worse results. The COPD patients analyzed were highly symptomatic, presented frequent exacerbations and had an important impact on quality of life, unlike that observed in large European studies that show better symptomatic control of included COPD. The foregoing did not correlate with a severe limitation to air flow, as indicated in the international literature.

Resumo: Introdução: A DPOC representa um grande problema de saúde. No Uruguai, a prevalência é de 19,7%. É caracterizada por limitação persistente do fluxo aéreo associada à resposta inflamatória crônica das vias aéreas e destruição do parênquima pulmonar contra partículas nocivas. Objetivos: Conhecer as características clínico-demográficas de uma população de pacientes com DPOC. Determinar a gravidade da doença e seu impacto na vida diária. Materiais e métodos: Estudo observacional, descritivo e transversal de 61 pacientes recrutados na admissão ao serviço de Medicina Interna do Hospital Pasteur e acompanhamento na policlínica do EPOC entre 01 de outubro de 2015 e 31 de dezembro de 2016. Os critérios de inclusão foram: ambos os sexos, acima de 40 anos de idade, fatores de risco clínicos e compatíveis ou diagnóstico prévio de DPOC. Os critérios de exclusão foram: comprometimento cognitivo moderado-grave, pacientes prostrados, gestantes, tuberculose pulmonar ativa, doenças neuromusculares. A amostragem foi feita por conveniência. Os dados foram obtidos do acompanhamento ambulatorial. O processamento dos dados foi feito no programa EPI-DATA versão 3.1 e PSPP. Resultados: Dos 61 pacientes recrutados, o diagnóstico de DPOC por espirometria em 42. A idade média da DPOC foi de 63 anos (± 11), predominando no sexo masculino (24, 57,1%) foi confirmada. A maioria tinha um baixo nível de escolaridade (primário incompleto em 15 pacientes, 35,7%). O tabagismo esteve presente como fator de risco em 100%, com uma API média de 81,9 (± 59,8). Mais da metade associava pelo menos dois fatores de risco. 21 pacientes (50%) apresentaram dispneia grau 3 do mMRC, enquanto 26 (61,9%) foram exacerbações freqüentes. O valor médio obtido no questionário CAT foi de 19,58 (DP 10,56). Assim, a maioria pertencia a grupos D (17, 40,4%) e C (9, 21,4%) definidos pelas guias de ouro 2017. Em relação limitação do fluxo de ar, em grande parte correspondeu ao ouro ou dois grupo limitação moderada . Conclusões: A existência de vieses de seleção determinou um pequeno número de pacientes com DPOC. A idade média e sexo concordaram com dados internacionais. O baixo nível de instrução pode ter implicações na adesão aos controles e tratamento. A API média foi maior do que em estudos internacionais. A associação de fatores de risco esteve ligada a piores resultados. Os pacientes com DPOC analisados ​​foram altamente sintomáticos, apresentaram exacerbações freqüentes e tiveram impacto importante na qualidade de vida, diferentemente do observado em grandes estudos europeus que mostram melhor controle sintomático da DPOC. O precedente não se correlacionou com uma limitação severa ao fluxo de ar, como indicado na literatura internacional.

Pulmonary Embolism in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease / 中华医学杂志(英文版)

Objective@#In most countries, nearly 6% of the adults are suffering from chronic obstructive pulmonary disease (COPD), which puts a huge economic burden on the society. Moreover, COPD has been considered as an independent risk factor for pulmonary embolism (PE). In this review, we summarized the existing evidence that demonstrates the associations between COPD exacerbation and PE from various aspects, including epidemiology, pathophysiological changes, risk factors, clinical features, management, and prognosis.@*Data Sources@#We searched the terms "chronic obstructive pulmonary disease," "pulmonary embolism," "exacerbations," and "thromboembolic" in PubMed database and collected the results up to April 2018. The language was limited to English.@*Study Selection@#We thoroughly examined the titles and abstracts of all studies that met our search strategy. The data from prospective studies, meta-analyses, retrospective studies, and recent reviews were selected for preparing this review.@*Results@#The prevalence of PE in patients with COPD exacerbation varied a lot among different studies, mainly due to the variations in race, sample size, study design, research setting, and enrollment criteria. Overall, whites and African Americans showed significantly higher prevalence of PE than Asian people, and the hospitalized patients showed higher prevalence of PE compared to those who were evaluated in emergency department. PE is easily overlooked in patients with COPD exacerbation due to the similar clinical symptoms. However, several factors have been identified to contribute to the increased risk of PE during COPD exacerbation. Obesity and lower limb asymmetry were described as independent predictors for PE. Moreover, due to the high risk of PE, thromboprophylaxis has been used as an important treatment for hospitalized patients with COPD exacerbation.@*Conclusions@#According to the previous studies, COPD patients with PE experienced an increased risk of death and prolonged length of hospital stay. Therefore, the thromboembolic risk in patients with acute exacerbation of COPD, especially in the hospitalized patients, should carefully be evaluated.

Pranlukast reduces asthma exacerbations during autumn especially in 1- to 5-year-old boys

BACKGROUND: Leukotriene receptor antagonists have been used to prevent virus-induced asthma exacerbations in autumn. Its efficacy, however, might differ with age and sex. OBJECTIVE: This study aimed to investigate whether pranlukast added to usual asthma therapy in Japanese children during autumn, season associated with the peak of asthma, reduces asthma exacerbations. It was also evaluated the effect of age and sex on pranlukast's efficacy. METHODS: A total of 121 asthmatic children aged 1 to 14 years were randomly assigned to receive regular pranlukast or not according to sex, and were divided in 2 age groups, 1–5 years and 6–14 years. The primary outcome was total asthma score calculated during 8 weeks by using a sticker calendar related to the days in which a child experienced a worsening of asthma symptoms. This open study lasted 60 days from September 15 to November 14, 2007. RESULTS: Significant differences in pranlukast efficacy were observed between sex and age groups. Boys aged 1 to 5 years had the lower total asthma score at 8 weeks (p = 0.002), and experienced fewer cold episodes (p = 0.007). There were no significant differences between pranlukast and control group in total asthma score at 8 weeks (p = 0.35), and in the days in which a child experienced a worsening of asthma symptoms (p = 0.67). CONCLUSION: There was a substantial benefit of adding pranlukast to usual therapy in asthmatic children, especially in boys aged 1 to 5 years, during autumn season.

Pharmaceutical Care for a AECOPD Patient with Benign Prostatic Hyperplasia and Bronchodilators-in-duced Acute Urinary Retention / 中国药房

OBJECTIVE:To investigate the role of clinical pharmacists on drug therapy for acute exacerbations of chronic ob-structive pulmonary disease(AECOPD)patients with benign prostatic hyperplasia(BPH). METHODS:Clinical pharmacists partici-pated in drug therapy for a AECOPD patient with BPH. According to clinical guideline and relevant literatures,based on the history of disease,the characteristics of bronchodilators and the symptoms of acute urinary retention,it was suggested to stop taking Ip-ratropium bromide solution for inhalation but receive Finasteride capsules 5 mg,po,qd,to reduce prostate volume and improve ob-struction+Terazosin hydrochloride tablets 2 mg,po,qd,to relax urethral smooth muscle;the occurrence of ADR was monitored closely. Salmeterol xinafoate and fluticasone propionate powder for inhalation was suggested and medication guidance for patients af-ter discharge was given by clinical pharmacists. RESULTS:Physicians adopted some suggestions of clinical pharmacists. The pa-tient was stable and had no dysuria. The patient was allowed to leave the hospital with drugs. CONCLUSIONS:Rational use of bronchodilators is directly related to the remission of clinical symptoms and prognosis in AECOPD patients. In view of patient's dis-ease history,drug characteristics and clinical symptoms,clinical pharmacists point to possible risks of anticholinergics use,and as-sist physicians to formulate and adjust therapy plan so as to guarantee the safety and effectiveness of drug use.

Progress in the treatment of childhood bronchial asthma exacerbations——comparison of guidelines for bronchical asthma in different countries / 中华实用儿科临床杂志

Bronchial asthma (also called asthma) is the most common chronic respiratory inflammatory disease in childhood.With the increased incidence of asthma in recent years,the guidelines for diagnosis and treatment of asthma have been also updated quickly at both domestic and overseas.Acute exacerbations of asthma will result in unscheduled medical attendances in emergency department or hospitalizations,and the severe one may be life-threatening,which brings a heavy burden to the families and society.Several guidelines,Meta analysis,and studies in treatment of childhood asthma exacerbations are reviewed in this article,so as to provide recommendations in the treatment of childhood asthma exacerbations for physicians.

Acute exacerbations of chronic obstructive pulmonary disease causes and impacts.

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are recognised clinically as episodes of increased breathlessness and productive cough requiring a more intensive treatment. A subset of patients with this disease is especially prone to such exacerbations. These patients are labelled as ‘frequent exacerbators’. Though yet poorly characterised in terms of host characteristics, including any genetic basis, these patients are believed to represent a distinct phenotype as they have a different natural history with a more progressive disease and a poorer prognosis than those who get exacerbations infrequently. Most exacerbations appear to be associated with infective triggers, either bacterial or viral, although ‘non-infective’ agents, such as air pollution and other irritants may also be important. Susceptibility to exacerbations is determined by multiple factors. Several risk factors have been identified, some of which are modifiable. Chronic obstructive pulmonary disease (COPD) exacerbations are major drivers of health status and patient-centered outcomes, and are a major reason for health care utilisation including hospitalisations and intensive care admissions. These are associated with considerable morbidity and mortality, both immediate and long-term. These episodes have a negative impact on the patient and the disease including high economic burden, increased mortality, worsening of health status, limitation of activity, and aggravation of comorbidities including cardiovascular disease, osteoporosis and neuro-psychiatric complications. Exacerbations also increase the rate of progression of disease, increasing the annual decline in lung function and leading to a poorer prognosis. Evaluation of risk of exacerbations is now included as a major component of the initial assessment of a patient with COPD in addition to the traditionally used lung function parameter, forced expiratory volume in one second (FEV1). Decreasing the risk of exacerbations and their prevention is a major therapeutic goal of management in COPD.

Safety of modified sputum induction in moderate-to-very severe COPD during exacerbation / 实用医学杂志

Objective To evaluate the safety of modified sputum induction in moderate to very severe COPD during exacerbation. Methods Ninety patients with moderate, severe or very severe COPD during exacerbation (27 with type Ⅰ and Ⅱ respiratory failure,18 with coronary heart disease, 38 with tachycardia) were chosen as research subjects. All the patients underwent induced sputum. During induction , all patients were given electrocardiographic monitoring and pulmonary function check every 5 minutes and FEV1, HR, SpO2 in the process of testing were recorded. Results Ninety patients underwent 224 sputum inductions progress, 222 were safety. Qualified sputum samples were collected for 216 times, sputum induction was successful in 96.43% of occasions. Heart rate rising and SpO2 reducing during sputum induction mainly occurred in the beginning 5 minutes, FEV1 did not change in the whole process. Conclusion Modified sputum induction can be safe through closely monitoring in patients with moderate-to-very severe COPD with exacerbation, even with type Ⅰ or typeⅡ respiratory failure. But the risk of sputum induction will increase if patients with coronary heart disease and tachyarrhythmia, especially within beginning 5 minutes of sputum induction.

A clinical study on treatment of acute exacerbations of chronic bronchitis with Sangpa Zhike decoction / 中国中西医结合急救杂志

Objective To observe the clinical effect of Sangpa Zhike decoction in the treatment of acute exacerbations of chronic bronchitis. Methods 180 patients with acute exacerbation of chronic bronchitis admitted to Autonomous Prefecture Hospital of traditional Chinese medicine(TCM)in Changji,Xinjiang,from August 2012 to August 2013 were enrolled. They were divided into Sangpa Zhike decoction treatment group and western medicine treatment control group by random number table,90 cases in each group. General treatments were given to the two groups. In the Sangpa Zhike decoction treatment group,additionally only oral Sangpa Zhike decoction was given(composition:Morus alba 10 g,loquat leaf 10 g,Houttuynia 10 g,honey aster 15 g,honey coltsfoot flower 6 g,Zhejiang Fritillaria 12 g,perilla 10 g,white mustard seed 6 g,Platycodon grandiflorum 10 g,Rhizoma Cynanchi Stauntonii 12 g,tangerine peel 6 g,Stemona 6 g). The ingredients were mixed in water and boiled to form a decoction,one dose daily,divided into two parts to be taken twice a day. In the western medicine treatment group,the infection was controlled by western medicine and the drugs to eliminate cough and phlegm,etc were used. The therapeutic course in both groups was 7 days. The therapeutic effect for treatment of TCM syndromes and the cough quantized integration score in the two groups were observed after treatment. Results The cure rate of Sangpa Zhike decoction treatment group was significantly higher than that of western medicine treatment control group〔70.00%(63/90)vs. 33.33%(30/90),P<0.01〕. Before treatment,the cough symptom quantization integral scores in the two groups had no statistically significance, but after treatment,the scores in the two groups were significantly lower than those before treatment. And the score in Sangpa Zhike decoction treatment group was decreased more significantly (1.66±1.12 vs. 4.36±2.32, P<0.01). Conclusion Sangpa Zhike Decoction has obvious curative effect in the treatment of acute attack of chronic bronchitis.