Quality indicators in the rational management of severe asthma: A Spanish multidisciplinary consensus.

AIM: Severe asthma is a complex, heterogeneous condition that can be difficult to control despite currently available treatments. Multidisciplinary severe asthma units (SAU) improve control in these patients and are cost-effective in our setting; however, their implementation and development can represent an organizational challenge. The aim of this study was to validate a set of quality care indicators in severe asthma for SAU in Spain. METHODS: The Carabela initiative, sponsored by SEPAR, SEAIC, SECA and SEDISA and implemented by leading specialists, analyzed the care processes followed in 6 pilot centers in Spain to describe the ideal care pathway for severe asthma. This analysis, together with clinical guidelines and SEPAR and SEAIC accreditation criteria for asthma units, were used to draw up a set of 11 quality of care indicators, which were validated by a panel of 60 experts (pulmonologists, allergologists, and health-policy decision-makers) using a modified Delphi method. RESULTS: All 11 indicators achieved a high level of consensus after just one Delphi round. CONCLUSIONS: Experts in severe asthma agree on a series of minimum requirements for the future optimization, standardization, and excellence of current SAUs in Spain. This proposal is well grounded on evidence and professional experience, but the validity of these consensus indicators must be evaluated in clinical practice.

Response to Monoclonal Antibodies in Asthma: Definitions, Potential Reasons for Failure, and Therapeutic Options for Suboptimal Response.

Real-life data reveal that more than half of severe asthma patients treated with monoclonal antibodies (mAbs) do not achieve a complete response. Response to mAbs must be assessed holistically, considering all the clinically meaningful therapeutic goals, not only reduction of exacerbations and oral corticosteroids. There are 2 different ways of measuring the response to mAbs. One, qualitative, classifies patients according to the degree of disease control they have achieved, without explaining how much a given patient improves relative to the baseline (pre-mAb) clinical situation; the other, quantitative, scores the changes occurring after treatment. Both methods are complementary and essential to making clinical decisions on whether to continue treatment. The various potential causes of suboptimal response to mAbs include incorrect identification of the specific T2 pathways, comorbidities that reduce the room for improvement, insufficient dose, autoimmune phenomena, infections, change in the initial inflammatory endotype, and adverse events. Once a suboptimal response has been confirmed, a well-structured and multifaceted assessment of the potential causes of failure should be performed, with emphasis on the resulting inflammatory process of the airway after mAb therapy and the presence of chronic or recurrent infection. This investigation should guide the decision on the best therapeutic approach. The present review aims to help clinicians gain insights into how to measure response to mAbs and proceed in cases of suboptimal response.

Response to Monoclonal Antibodies in Asthma: Definitions, Potential Reasons for Failure, and Therapeutic Options for Suboptimal Response

Real-life data reveal that more than half of severe asthma patients treated with monoclonal antibodies (mAbs) do not achieve a complete response. Response to mAbs must be assessed holistically, considering all the clinically meaningful therapeutic goals, not only reduction of exacerbations and oral corticosteroids. There are 2 different ways of measuring the response to mAbs. One, qualitative, classifies patients according to the degree of disease control they have achieved, without explaining how much a given patient improves relative to the baseline (pre-mAb) clinical situation; the other, quantitative, scores the changes occurring after treatment. Both methods are complementary and essential to making clinical decisions on whether to continue treatment. The various potential causes of suboptimal response to mAbs include incorrect identification of the specific T2 pathways, comorbidities that reduce the room for improvement, insufficient dose, autoimmune phenomena, infections, change in the initial inflammatory endotype, and adverse events. Once a suboptimal response has been confirmed, a well-structured and multifaceted assessment of the potential causes of failure should be performed, with emphasis on the resulting inflammatory process of the airway after mAb therapy and the presence of chronic or recurrent infection. This investigation should guide the decision on the best therapeutic approach. The present review aims to help clinicians gain insights into how to measure response to mAbs and proceed in cases of suboptimal response (AU)

Los estudios clínicos en vida real revelan que más de la mitad de los pacientes con asma grave, tratados con anticuerpos monoclonales (mAb), no logran una respuesta completa. La respuesta a los mAbs debe evaluarse de manera integral, considerando todos los objetivos terapéuticos clínicamente significativos y no solo las exacerbaciones o la reducción de corticosteroides orales. Existen dos formas diferentes de medir la respuesta a los mAbs: una, cualitativa, que clasifica a los pacientes según el grado de control de la enfermedad que han logrado, sin explicar cuánto mejora un determinado paciente con respecto a su situación clínica basal (pre-mAb); y la otra, cuantitativa, la cual puntúa los cambios ocurridos después del tratamiento. Ambos métodos son complementarios y claramente esenciales a la hora de tomar decisiones clínicas sobre la continuación del tratamiento con estos fármacos biológicos. Se han descrito varias causas posibles de respuesta subóptima a los mAbs que son: la identificación incorrecta de las vías T2 específicas, las comorbilidades que reducen el margen de mejora, una dosis insuficiente, fenómenos autoinmunes, infecciones, cambio del endotipo inflamatorio inicial y la aparición de efectos adversos. na vez que se ha confirmado una respuesta subóptima, se debe realizar una evaluación bien estructurada y polifacética de estas posibles causas del fracaso, considerando, en particular, el proceso inflamatorio residual de las vías respiratorias tras la terapia con mAb y la presencia de infecciones crónicas o recurrentes. Esta evaluación es la que debe guiar las decisiones sobre el mejor enfoque terapéutico. Esta revisión tiene como objetivo ayudar a los clínicos a obtener un conocimiento más profundo sobre cómo medir la respuesta a los mAbs y cómo proceder con los pacientes que presenten una respuesta subóptima (AU)

Fractura intraarticular de calcáneo asociada a lesión de ligamentos colaterales laterales del tobillo / Intra-articular fracture of the calcaneus associated with injury to lateral collateral ligaments of the ankle

Resumen: Las fracturas de calcáneo son las más frecuentes del tarso (3.5% de todas las fracturas). Afectan a adultos jóvenes, siendo más frecuentes en hombres (5.9:1). Por otro lado, las lesiones ligamentarias asociadas a fractura de calcáneo no son muy frecuentes. Presentamos un caso de un paciente de 39 años que sufrió entorsis de tobillo. Mostraba inestabilidad en flexión plantar e inversión. Radiografías mostraron una fractura de calcáneo. Durante la cirugía se evidenció una lesión completa del complejo ligamentario lateral. Se realizó la reducción y osteosíntesis asociada a la reconstrucción ligamentaria. Ante fracturas de calcáneo es importante corroborar la estabilidad del tobillo. La falta de diagnóstico en este tipo de lesiones puede generar inestabilidades crónicas.

Abstract: Calcaneal fractures are the most frequent of the tarsus (3.5% of all fractures). Young adults are mainly affected, being more frequent in men (5.9:1). On the other hand, ligament injuries associated with fracture of the calcaneus are very infrequent. We describe a case of a 39 year old patient who suffered ankle trauma. He presented instability in plantar flexion and inversion. A fracture of the calcaneus was diagnosed. During surgery, a complete lesion of the lateral ligament complex was found. The reduction and osteosynthesis associated with ligament reconstruction was performed. We consider important to confirm the stability of the ankle after a calcaneus fracture. Lack of diagnosis in this type of injuries can evolve into chronic instability.

[Intra-articular fracture of the calcaneus associated with injury to lateral collateral ligaments of the ankle]. / Fractura intraarticular de calcáneo asociada a lesión de ligamentos colaterales laterales del tobillo.

Calcaneal fractures are the most frequent of the tarsus (3.5% of all fractures). Young adults are mainly affected, being more frequent in men (5.9:1). On the other hand, ligament injuries associated with fracture of the calcaneus are very infrequent. We describe a case of a 39 year old patient who suffered ankle trauma. He presented instability in plantar flexion and inversion. A fracture of the calcaneus was diagnosed. During surgery, a complete lesion of the lateral ligament complex was found. The reduction and osteosynthesis associated with ligament reconstruction was performed. We consider important to confirm the stability of the ankle after a calcaneus fracture. Lack of diagnosis in this type of injuries can evolve into chronic instability.

Las fracturas de calcáneo son las más frecuentes del tarso (3.5% de todas las fracturas). Afectan a adultos jóvenes, siendo más frecuentes en hombres (5.9:1). Por otro lado, las lesiones ligamentarias asociadas a fractura de calcáneo no son muy frecuentes. Presentamos un caso de un paciente de 39 años que sufrió entorsis de tobillo. Mostraba inestabilidad en flexión plantar e inversión. Radiografías mostraron una fractura de calcáneo. Durante la cirugía se evidenció una lesión completa del complejo ligamentario lateral. Se realizó la reducción y osteosíntesis asociada a la reconstrucción ligamentaria. Ante fracturas de calcáneo es importante corroborar la estabilidad del tobillo. La falta de diagnóstico en este tipo de lesiones puede generar inestabilidades crónicas.

Exacerbations of Severe Asthma While on Anti-IL-5 Biologics.

Anti-interleukin 5 (IL-5) and anti-IL-5 receptor α monoclonal antibodies markedly decrease airway and peripheral blood eosinophil numbers and are thus highly effective in reducing asthma exacerbations. Nonetheless, these biologics do not completely resolve exacerbations. There is very little information on the cellular nature of exacerbations during treatment with biologics. Using illustrative clinical case scenarios, we highlight the importance of carefully characterizing asthmatics at the time of exacerbation and recognizing neutrophilic causes of exacerbations to ensure optimal management. While an eosinophilic exacerbation may improve with more corticosteroids or by switching to another anti-IL-5 monoclonal antibody, a noneosinophilic exacerbation will likely not. An infective exacerbation needs to be recognized, and the pathogen must be identified and treated with the appropriate antimicrobial agent.

Exacerbations of severe asthma while on anti-IL-5 biologics

Anti-interleukin 5 (IL-5) and anti-IL-5 receptor alfa monoclonal antibodies markedly decrease airway and peripheral blood eosinophil numbers and are thus highly effective in reducing asthma exacerbations. Nonetheless, these biologics do not completely resolve exacerbations. There is very little information on the cellular nature of exacerbations during treatment with biologics. Using illustrative clinical case scenarios, we highlight the importance of carefully characterizing asthmatics at the time of exacerbation and recognizing neutrophilic causes of exacerbations to ensure optimal management. While an eosinophilic exacerbation may improve with more corticosteroids or by switching to another anti-IL-5 monoclonal antibody, a noneosinophilic exacerbation will likely not. An infective exacerbation needs to be recognized, and the pathogen must be identified and treated with the appropriate antimicrobial agent

Los anticuerpos monoclonales anti-interleucina 5 (IL5) y anti-receptor de IL5 son altamente efectivos en reducir las exacerbaciones del asma al disminuir notablemente el número de eosinófilos en las vías respiratorias y en sangre periférica. Sin embargo, aun estando bajo el tratamiento con estos biológicos, las descompensaciones asmáticas no desaparecen por completo. Disponemos de una modesta evidencia que señala la naturaleza de estas exacerbaciones, y los pacientes afectos de asma grave en estas terapias podrían tener exacerbaciones graves no eosinofílicas. Utilizando como escenarios ilustrativos varios casos clínicos, destacamos la importancia de caracterizar cuidadosamente al paciente asmático en el momento de la exacerbación y reconocer las causas neutrofílicas de las exacerbaciones, lo cual es de importancia a la hora de manejar estas exacerbaciones. Si bien una exacerbación eosinofílica puede beneficiarse con más glucocorticosteroides o al cambiar a otro mAb anti-IL5, una exacerbación no eosinofílica probablemente no lo hará. Es necesario reconocer una exacerbación infecciosa, identificar el patógeno y tratarlo con el agente antimicrobiano más apropiado

Multidisciplinary expert discussion. Uncontrolled asthma: causes, consequences and possible solutions / Debate multidisciplinar de expertos. Asma no controlada: causas, consecuencias y posibles soluciones.

Background. Numerous studies conclude that about half of the asthmatic population is not well controlled. The aim of this study was to discuss causes, consequences and possible solutions of uncontrolled asthma (UCA). Methods. Discussion amongst asthma experts from the fields of Pneumology, Allergy and Primary Care, structured in three phases: 1) survey to get the opinion of participants involved in different areas of UCA; 2) expert meeting, in which the results of the survey were discussed, and the diagnosis, treatment and monitoring of UCA were presented and discussed; and, 3) with the main findings, 83 items were formulated and subjected to consensus among all participants through the Delphi method. Results. There was consensus on 86.7% of the items in the Delphi questionnaire, mostly in terms of agreement. Conclusions. The UCA analysis results show the need for future improvement in the following areas: to incorporate clinical performance protocols into asthma CPG to identify aggravating factors and comorbidities; to develop an inexpensive and easy-to-use tool to identify adherence; to establish patient phenotype; to analyse treatment side effects and to provide personalized treatment, especially assessing its efficacy and safety (symptom control and future risks). It is necessary to generate new evidence to determine additional tests to be used to monitor these patients.

Debate multidisciplinar de expertos. Asma no controlada: causas, consecuencias y posibles soluciones / Multidisciplinary expert discussion. Uncontrolled asthma: causes, consequences and possible solutions

Fundamento: Numerosos estudios constatan que aproximadamente la mitad de la población asmática no está bien controlada. El objetivo de este trabajo fue analizar entre expertos las causas, consecuencias y las posibles soluciones del asma no controlada (ANC). Material y métodos: Debate entre expertos en asma de las especialidades de Neumología, Alergología y Atención Primaria, estructurado en tres fases 1) Cuestionario para pulsar la opinión de los participantes en los diferentes elementos implicados del ANC; 2) Reunión presencial de los expertos, en la que se discutieron los resultados de la encuesta y se presentaron y debatieron ponencias sobre el diagnóstico, tratamiento y seguimiento del ANC; 3) Formulación de 83 ítems que fueron sometidos a consenso entre todos los participantes mediante el método Delphi. Resultados: El 86,7% de los ítems del cuestionario Delphi fue consensuado, mayoritariamente en términos de acuerdo. Conclusiones: El análisis de los resultados sobre el ANC señala la necesidad de mejora futura en: incorporar en las Guías de Práctica Clínica de asma un protocolo de actuación clínico para identificar agravantes y comorbilidades; desarrollar una herramienta barata y de fácil utilización que permita identificar la adherencia al tratamiento; establecer el fenotipo del paciente; analizar los efectos secundarios del tratamiento y ofrecer un tratamiento personalizado, valorando especialmente la eficacia y seguridad (control de síntomas y riesgo futuro). Se precisa generar nuevas evidencias (estudios) que determinen exploraciones complementarias a emplear en el seguimiento de estos pacientes (AU)

Background: Numerous studies conclude that about half of the asthmatic population is not well controlled. The aim of this study was to discuss causes, consequences and possible solutions of uncontrolled asthma (UCA). Methods: Discussion amongst asthma experts from the fields of Pneumology, Allergy and Primary Care, structured in three phases: 1) survey to get the opinion of participants involved in different areas of UCA; 2) expert meeting, in which the results of the survey were discussed, and the diagnosis, treatment and monitoring of UCA were presented and discussed; and, 3) with the main findings, 83 items were formulated and subjected to consensus among all participants through the Delphi method. Results: There was consensus on 86.7% of the items in the Delphi questionnaire, mostly in terms of agreement. Conclusions: The UCA analysis results show the need for future improvement in the following areas: to incorporate clinical performance protocols into asthma CPG to identify aggravating factors and comorbidities; to develop an inexpensive and easyto- use tool to identify adherence; to establish patient phenotype; to analyse treatment side effects and to provide personalized treatment, especially assessing its efficacy and safety (symptom control and future risks). It is necessary to generate new evidence to determine additional tests to be used to monitor these patients (AU)

The role of surgery in the management of "body packers".

INTRODUCTION: The concealment of packets of illegal substances within body cavities is a common technique for drug smuggling worldwide. The goal of our study was to analyze the results of conservative treatment of "body packers", indications for surgical intervention, and postoperative morbidity. METHODS: This is a retrospective study of patients admitted to our hospital and diagnosed as body packers. The diagnostic protocol included an abdominal X-ray and urinalysis for toxic substances. Only patients with gastrointestinal symptoms, signs of intoxication, or a positive urinalysis were admitted for observation. Conservative management included bowel rest and serial abdominal radiographs to confirm the passage per rectum of all foreign bodies. Asymptomatic patients were given laxatives in the emergency department (ED) to promote bowel movements and were not admitted to the hospital. RESULTS: A total of 763 body packers were admitted to the hospital, all of whom were initially treated conservatively. Of these patients, 47 (6 %) developed complications: 28 with bowel obstruction, three with bowel perforation, and 16 with substance intoxication. In patients developing complications, urinalysis for toxic substances was negative in 19 (40 %). Sixteen (34 %) patients who developed complications were successfully managed nonoperatively. Three (6 %) other patients died before surgery: two deaths resulted from acute toxicity (one of them with an acute onset and a negative urinalysis) and the third patient died of bowel perforation. Laparotomy was required in 28 (3.5 %) body packers admitted for observation. Enterotomy and/or gastrotomy to remove the packets were the most frequently performed procedures. Postoperative morbidity occurred in 57 % of patients, with wound infection being the most frequent complication. CONCLUSIONS: Conservative management was effective in 94 % of symptomatic patients. A laparotomy was required in only 3.5 % of cases. The mortality rate in this series was low, resulting from either severe cocaine poisoning from ruptured packets or bowel perforation.