Factores predictores de mortalidad en pacientes con enfermedad pulmonar obstructiva crónica y exacerbaciones frecuentes / Precipitating factors of mortality in chronic obstructive pulmonary disease patients with frequent exacerbations

Objetivo. Identificar las características de pacientes con una agudización de la enfermedad pulmonar obstructiva crónica (AEPOC) capaces de predecir en un plazo corto de tiempo la mortalidad por EPOC. Material y método. Estudio retrospectivo caso-control de pacientes ingresados por AEPOC para la identificación de factores predictores de mortalidad. El grupo control estaba formado por pacientes vivos a los 6 meses. Las variables recogidas incluían antecedentes, comorbilidad, estado de salud y nutricional, disnea basal, dependencia, agudizaciones, exploración física, función pulmonar, radiología, electrocardiograma, microbiología y tratamiento. Las diferencias entre grupos se compararon con los test de la χ2 y de la T-Student. La capacidad predictiva se analizó con regresión logística, estableciendo como variable dependiente la mortalidad. Resultados. Se incluyeron 125 pacientes (44 éxitus/81 vivos) (10 mujeres/115 varones) de 74±10 años. Ambos grupos eran similares en edad, sexo y gravedad de la enfermedad. De todas las variables, encontramos diferencias significativas en la disnea basal (p<0,01), los niveles de proteína C reactiva (p<0,007), la hemoglobina (p<0,037) y las plaquetas (p<0,041), en la actividad física (p<0,036), el uso de musculatura accesoria (p<0,007), el aislamiento microbiológico positivo (p<0,013) y el tratamiento con anticolinérgicos (p<0,029) y con digoxina (p<0,039). Ninguna de estas variables, sin embargo, era capaz de predecir la mortalidad en el análisis de regresión logística. Conclusiones. Con los datos que se manejan para el seguimiento habitual de los pacientes con EPOC no parece posible identificar predictores de mortalidad a corto plazo (6 meses) en un ingreso hospitalario, diferentes a la propia gravedad de la agudización. Únicamente algún parámetro que expresaría mayor inflamación crónica y la menor tolerancia al ejercicio parecen ser diferentes en el grupo de pacientes fallecidos en la AECOP(AU)

Objective. To identify the main characteristics in patients with COPD exacerbation, capables to predict the short-term COPD mortality. Matherials and methods. This is a case-control retrospective study of admitted patients with COPD to identify risk factors of mortality. The control group was constituted by alive patients after 6 months. The variables studied were clinical antecedents, comorbility, health and nutritional status, basal dyspnea, dependency, exacerbations, physical examination, pulmonary function, radiology, ECG, microbiology and treatment. Both groups were compared with the Chi-square and the T tests. The predictive capacity was analyzed with logistic regression for which the dependent variable was mortality. Results. 125 patients were enrolled (44 exitus and 81 alive) (10 females and 115 males) with mean age of 74+10 years. No significant differences were found between groups in age, sex and disease severity. On the other hand, we found statistically significant differences in basal dyspnea (p<0,01), RCP levels (p<0,007), Hb (p<0,037) and platelets (p<0,041), physic activity (p<0,036), accessory muscles use (p<0,007), positive microbiological culture (p<0,013) and treatment with anticholinergic agents (p<0,029) and digoxin (p<0,039). However, none of these variables was able to predict mortality in the logistic regression analysis. Conclusions. The usual data managed in the follow-up of COPD patients are not useful to identify short-term mortality predictors (6 months) during a hospital admittance. Only some variables that would represent a higher chronic inflammation and a lower exercise tolerance showed a statistical tendence in the dead patients group in a exacerbation of COPD(AU)

[Identification of new diagnostic categories within bronchial asthma and COPD. A review of traditional classifications]. / Identificación de nuevas categorías diagnósticas dentro del asma bronquial y la EPOC. Una revisión de las clasificaciones tradicionales.

The overlapping of function test results and clinical symptoms of airway diseases makes it difficult to differentiate sub-categories of diagnoses. Our aim was to identify "occult" categories within the traditional diagnostic labels for bronchial asthma and chronic bronchitis. We studied 211 patients with those diagnoses by lung function testing (spirometry), variability of obstruction (bronchodilator test, peak expiratory flow, and bronchial challenge testing), atopy (prick test, total serum IgE), biological parameters (eosinophil count), frequency of smoking and symptoms. Multivariant analysis was used to group the data (Quick Cluster) and reclassify the subjects based on the selected parametric clusters with factorial analysis of the principal components. This analysis allowed us to identify four types of patients by diagnosis (atopic asthma, asthmatic bronchitis, simple chronic bronchitis and hyperresponsive chronic bronchitis) which we consider to represent the diagnostic categories with clinical relevance and which would overlap and be partially overshadowed by the diagnoses of bronchial asthma and chronic bronchitis.

Identificación de nuevas categorías diagnósticas dentro del asma bronquial y la EPOC. una revisión de las clasificaciones tradicionales / Identification of new diagnostic categories within bronchial asthma and COPD. A review of traditional classifications

El solapamiento en la expresión clínica y funcional de las enfermedades de la vía aérea hace difícil separar las diferentes entidades nosológicas incluidas dentro de ellas. Nuestro objetivo ha sido identificar categorías "ocultas" dentro de las etiquetas diagnósticas tradicionales de asma bronquial y de bronquitis crónica. Para ello, estudiamos a 211 pacientes diagnosticados de alguna de estas enfermedades mediante la valoración de su función pulmonar (espirometría), variabilidad de la obstrucción (test broncodilatador, flujo espiratorio máximo, test de provocación bronquial), atopia (prick-test, IgE sérica total), parámetros biológicos (eosinófilos), grado de tabaquismo y sintomatología. Se utilizó una técnica multivariante de clasificación automática de datos (quick cluster) para reclasificar a los sujetos en base a los parámetros de agrupación seleccionados con un análisis factorial de componentes principales. Este análisis nos permitió identificar 4 tipos diferentes de pacientes (asma tópico, bronquitis asmática, bronquitis crónica simple y bronquitis con hiperrespuesta bronquial) que consideramos representativos de categorías diagnósticas con significado clínico relevante y que estarían solapadas y parcialmente ocultas dentro de los diagnósticos de asma bronquial y bronquitis crónica (AU)

[Usefulness of the IUATLD respiratory symptoms questionnaire for the differential diagnosis of bronchial asthma and chronic bronchitis]. / Utilidad del cuestionario de síntomas respiratorios IUATLD para el diagnóstico diferencial del asma bronquial y la bronquitis crónica.

Our objective was to determine the diagnostic value of the questionnaire devised by the International Union against Tuberculosis and Lung Disease (IUATLD) for distinguishing between bronchial asthma and chronic bronchitis. We therefore compared clinical diagnoses established independently by two pneumologists for 211 patients to the patients' responses to the IUATLD questionnaire. The questions were analyzed for their ability to discriminate using the responses as independent variables and the diagnosis as the dependent variable. The individual predictive capacity of each question and the discriminating functions that identified the best clusters of questions were calculated using bayesian analysis. Finally, we compared IUATLD results to tests that assessed lung function (spirometry), obstruction variability (bronchodilator test, peak flow, bronchial challenge test), atopy (prick test, serum IgE), and clinical and biological markers (eosinophilia). The questionnaire correctly diagnosed 91% of the patients and a cluster of five questions registered a sensitivity of 85.6%, specificity of 91.4%, a positive predictive value of 93.1% and a negative predictive value of 82.2%, thus proving superior to the other tests. These results, along with the ease of administering the questionnaire allows us to consider the IUATLD instrument to be a good tool for the differential diagnosis of bronchial asthma and chronic bronchitis.

Utilidad del cuestionario de síntomas respiratorios IUATLD para el diagnóstico diferencial del asma bronquial y la bronquitis crónica / Usefulness of the IUATLD respiratory symptoms questionnaire for the differential diagnosis of bronchial asthma and chronic bronchitis

Nuestro objetivo fue conocer el valor diagnóstico del cuestionario de la IUATLD para diferenciar pacientes con asma bronquial y bronquitis crónica. Para ello las respuestas de 211 pacientes fueron validadas frente al diagnóstico clínico establecido de forma independiente por 2 neumólogos. Las preguntas se incluyeron en un análisis discriminante utilizando como variables independientes las respuestas y como variable dependiente el diagnóstico. La capacidad predictiva individual de cada pregunta y de las funciones discriminantes que agrupaban los mejores módulos de preguntas se calcularon con un análisis bayesiano. Finalmente se compararon con pruebas que valoraban: función pulmonar (espirometría); variabilidad de la obstrucción (test broncodilatador, peak flow, test de provocación bronquial); atopia (prick test, IgE sérica), y parámetros clínicos y biológicos (eosinofilia). Este cuestionario conseguía diagnosticar correctamente al 91 por ciento de los pacientes, y utilizando únicamente 5 preguntas la sensibilidad (85,6 por ciento), especificidad (91,4 por ciento), valor predictivo positivo (93,1 por ciento) y valor predictivo negativo (82,2 por ciento) superaban a los del resto de pruebas. Estos resultados, junto a la sencillez de su manejo, nos permiten considerar a este cuestionario como una buena herramienta para el diagnóstico de asma bronquial frente a bronquitis crónica (AU)

Effects of air pollution and weather conditions on asthma exacerbation.

BACKGROUND: Meteorological conditions and a high concentration of air pollutants have been associated with increased respiratory morbidity. However, few studies have examined the association between asthma exacerbation and air pollution. OBJECTIVES: In the present study, the possible relationship of the concentration of black smoke and SO2 in the air, the local weather conditions and emergency room visits for asthma is investigated. METHODS: The weekly total of emergency room admissions for asthmatic adults during a 1-year period was recorded together with daily metereological conditions (average temperature, humidity, rainfall, wind speed and barometric pressure) and average weekly levels of daily pollutant concentrations (black smoke and SO2). The relationship was assessed by stepwise regression linear models and analysis of variance. The analysis took into account season and metereological variables. RESULTS: Both air pollutants correlated significantly with emergency room admissions for asthma (SO2 [r = 0. 32], black smoke [r = 0.35]); however, multiple regression analysis showed that black smoke was the only significant predictor of weekly visits. There were approximately 3.5 admissions a week per SD of change (34.6 microg.m-3). There were no significant correlations between weekly emergency room visits and the weather variables. Analysis of the data stratified by season and weather conditions demonstrated that the association of black smoke with asthma exacerbation was more pronounced in autumn (r = 0.67) or when temperatures were higher than average. CONCLUSION: In our city, a high concentration of certain air pollutants is indeed associated with an increase in the number of hospital emergency room admissions for asthma.

[Coexistence of bronchogenic carcinoma and active pulmonary tuberculosis]. / Coexistencia de carcinoma broncogénico y tuberculosis pulmonar activa.

We describe 9 patients with coincident active tuberculosis of the lung and bronchogenic carcinoma who were all diagnosed within a 5-year period. All were men, with a mean age of 55 +/- 10 years. The principal symptom was toxic syndrome lasting 1-3 months and the most common X-ray sign was alveolar consolidation. Analysis of tissue samples revealed squamous carcinoma (4 cases), adenocarcinoma (4 cases, one of which was bronchioloalveolar) and non-small cell carcinoma (1 case). Tumoral stage was often advanced: IV (44%) and III (33%). The tuberculosis bacillus was isolated in sputum (100%) and in bronchial aspirate (50%); no in vitro resistance was observed. Three patients were treated with radical surgery and three with radiotherapy. Average survival was 3 months in this series.

Pleural cholesterol in differentiating transudates and exudates. A prospective study of 232 cases.

Two hundred and four patients with pleural effusion were studied to investigate the utility of Light's criteria and pleural fluid cholesterol level (pCHOL) in the identification of exudative pleural effusion (EPE) and transudative pleural effusion (TPE). There were 48 TPE, 56 tumor, 47 tuberculous, 30 metapneumonic and 23 miscellaneous patients. A value > or = 54 mg/dl for pCHOL and > or = 0.32 for the pleura/serum cholesterol ratio (p/sCHOL) showed sensitivity (S) and specificity (Sp) of 95.5% and 91.6% for pCHOL, and 97.4% and 91.6% for p/sCHOL, respectively. Combined pCHOL and/or p/sCHOL showed a S of 98.7% and Sp of 89.5%. Light's criteria achieved a S of 100% and Sp of 64.5%. Combined pCHOL and p/sCHOL revealed a similar accuracy to Light's criteria in EPE diagnosis but was found to be more exact in TPE diagnosis.