Documento de consenso de expertos para el control del asma en personas mayores / Expert consensus recommendations for the management of asthma in older adults

El asma constituye un problema de salud pública presente en pacientes de cualquier edad, aunque continúa existiendo cierta tendencia a asumir de forma errónea que dicha entidad resulta casi siempre exclusiva de la infancia y de gente joven. Los estudios epidemiológicos señalan que, a partir de la sexta década de la vida, la prevalencia de esta enfermedad en países como España alcanza el 6-10%, con mayor predominio entre las mujeres de 64 a 75 años. Asimismo, dos tercios de las muertes debidas al asma acontecen en esta etapa de la vida, llegando a ocasionar un número de ingresos sustancial, estancias hospitalarias más prolongadas y, desde el punto de vista del financiador, unos costes económicos directos notables. En la actualidad el asma en las personas mayores (65 años o más) constituye un tema de enorme preocupación, cuya realidad se encuentra infravalorada e infratratada, por lo que resulta del todo necesario establecer unas recomendaciones adecuadas para el diagnóstico y tratamiento de la enfermedad en esta población de edad. Con este objetivo nació este consenso que recoge la evidencia disponible más actualizada. Las recomendaciones/conclusiones que se proponen son el resultado de un consenso de tipo nominal desarrollado a lo largo del año 2019 y que han sido validadas por los panelistas en sucesivas rondas de votación. (AU)

Asthma is a public health problem in patients of any age, although there is still a tendency to erroneously assume that it is almost always confined to children and young people. Epidemiological studies indicate that, from the sixth decade of life, the prevalence of this disease in countries such as Spain reaches 6-10%, with a higher prevalence among women aged 64 to 75 years. In addition, two-thirds of asthma deaths occur at this stage of life, resulting in a substantial number of hospital admissions, longer hospital stays and, from a finance point of view, significant direct economic costs. Asthma in older adults (65 years or older) is now a matter of great concern, the reality of which is underestimated and undertreated. It is therefore essential to establish appropriate recommendations for the diagnosis and treatment of asthma in the aging population. This consensus, which brings together the latest evidence available, was conceived with this objective. The proposed recommendations/conclusions are the result of a nominal consensus developed throughout 2019 and validated by panellists in successive rounds of voting. (AU)

Expert consensus recommendations for the management of asthma in older adults. / Documento de consenso de expertos para el control del asma en personas mayores.

Asthma is a public health problem in patients of any age, although there is still a tendency to erroneously assume that it is almost always confined to children and young people. Epidemiological studies indicate that, from the sixth decade of life, the prevalence of this disease in countries such as Spain reaches 6-10%, with a higher prevalence among women aged 64 to 75 years. In addition, two-thirds of asthma deaths occur at this stage of life, resulting in a substantial number of hospital admissions, longer hospital stays and, from a finance point of view, significant direct economic costs. Asthma in older adults (65 years or older) is now a matter of great concern, the reality of which is underestimated and undertreated. It is therefore essential to establish appropriate recommendations for the diagnosis and treatment of asthma in the aging population. This consensus, which brings together the latest evidence available, was conceived with this objective. The proposed recommendations/conclusions are the result of a nominal consensus developed throughout 2019 and validated by panellists in successive rounds of voting.

Effects of Obesity and Asthma on Lung Function and Airway Dysanapsis in Adults and Children.

Obesity increases the risk of developing asthma in children and adults. Obesity is associated with different effects on lung function in children and adults. In adults, obesity has been associated with reduced lung function resulting from a relatively small effect on forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC), with the FEV1/FVC ratio remaining unchanged or mildly increased (restrictive pattern). In contrast, in children, obesity is associated with normal or higher FEV1 and FVC but a lower FEV1/FVC ratio (obstructive pattern). This anomaly has recently been associated with a phenomenon known as dysanapsis which results from a disproportionate growth between lung parenchyma size and airway calibre. The mechanisms that promote disproportionate lung parenchyma growth compared with airways in obese children remain to be elucidated. Obesity and dysanapsis in asthma patients might contribute to asthma morbidity by increasing airway obstruction, airway hyper-reactivity and airway inflammation. Obesity and dysanapsis in asthma patients are associated with increased medication use, more emergency department visits, hospitalizations and systemic corticosteroid burst than patients with normal weight. Dysanapsis may explain the reduced response to asthma medications in obese children. Weight loss results in a significant improvement in lung function, airway reactivity and asthma control. Whether these improvements are associated with the changes in the dysanaptic alteration is as yet unclear.

Excesiva variabilidad en la realización e interpretación de la prueba de provocación bronquial con metacolina / Excessive variability in the performance and interpretation of the metacholine bronchial challenge test

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What pulmonologists think about the asthma-COPD overlap syndrome.

BACKGROUND: Some patients with COPD may share characteristics of asthma; this is the so-called asthma-COPD overlap syndrome (ACOS). There are no universally accepted criteria for ACOS, and most treatments for asthma and COPD have not been adequately tested in this population. MATERIALS AND METHODS: We performed a survey among pulmonology specialists in asthma and COPD aimed at collecting their opinions about ACOS and their attitudes in regard to some case scenarios of ACOS patients. The participants answered a structured questionnaire and attended a face-to-face meeting with the Metaplan methodology to discuss different aspects of ACOS. RESULTS: A total of 26 pulmonologists with a mean age of 49.7 years participated in the survey (13 specialists in asthma and 13 in COPD). Among these, 84.6% recognized the existence of ACOS and stated that a mean of 12.6% of their patients might have this syndrome. In addition, 80.8% agreed that the diagnostic criteria for ACOS are not yet well defined. The most frequently mentioned characteristics of ACOS were a history of asthma (88.5%), significant smoking exposure (73.1%), and postbronchodilator forced expiratory volume in 1 second/forced vital capacity <0.7 (69.2%). The most accepted diagnostic criteria were eosinophilia in sputum (80.8%), a very positive bronchodilator test (69.2%), and a history of asthma before 40 years of age (65.4%). Up to 96.2% agreed that first-line treatment for ACOS was the combination of a long-acting ß2-agonist and inhaled steroid, with a long-acting antimuscarinic agent (triple therapy) for severe ACOS. CONCLUSION: Most Spanish specialists in asthma and COPD agree that ACOS exists, but the diagnostic criteria are not yet well defined. A previous history of asthma, smoking, and not fully reversible airflow limitation are considered the main characteristics of ACOS, with the most accepted first-line treatment being long-acting ß2-agonist/inhaled corticosteroids.

Stepping-across controlled asthmatic patients to extrafine beclometasone/formoterol combination.

BACKGROUND: Asthma management focuses on achieving and maintaining asthma control. Few studies have assessed whether complete and sustained asthma control is maintained in clinical practice after stepping-across ICS/LABA fixed combinations. Aim of this double-blind, double-dummy, randomized, parallel group, controlled study was to demonstrate clinical equivalence between equipotent doses of extrafine beclometasone/formoterol (BDP/F) pMDI and fluticasone/salmeterol (FP/S) Diskus® in maintaining lung function and asthma control. METHODS: A total of 416 asthmatic patients already controlled with FP/S 500/100 µg/day (Diskus®, pMDI or separate inhalers) were randomized to a 12-week treatment with extrafine BDP/F 400/24 µg/day pMDI or FP/S 500/100 µg/day Diskus®. Pre-dose 1-s forced expiratory volume (FEV(1)) was the primary efficacy variable; secondary variables included asthma control questionnaire (ACQ-7) and FEV(1)0-1 h area under the curve (FEV(1)AUC(0-1h)). Safety was assessed through adverse events monitoring and vital signs. RESULTS: After 12 weeks of treatment, pre-dose FEV(1) did not differ between treatments (difference between means 0.01 L; 95% CI -0.03-0.06 L) with no significant changes from baseline in both groups (p = 0.726 and p = 0.783 in BDF/F arm and FP/S, respectively). ACQ-7 score showed that control was maintained after stepping-across to extrafine BDP/F. FEV(1)AUC(0-1h) was significantly higher in BDP/F arm at the beginning (p = 0.004) and at the end of the 12-week treatment period (p = 0.019). No safety issues were reported in both groups. CONCLUSIONS: Patients previously controlled with FP/S in any device formulation can effectively step-across to extrafine BDP/F pMDI, maintaining lung function and asthma control with a 5-min onset of action.

Respuesta inflamatoria de la exacerbación asmática de instauración rápida / Inflammatory Response of Rapid Onset Asthma Exacerbation

No se ha estudiado suficientemente la asociación entre la rapidez de instauración de la crisis de asma y la respuesta inflamatoria desencadenada.ObjetivoDeterminar los mecanismos inflamatorios que caracterizan la exacerbación asmática de instauración rápida.MétodoSe diseñó un estudio prospectivo y multicéntrico en los servicios de urgencias hospitalarias, que evaluó a 34 pacientes que se distribuyeron en tres grupos en función de las horas de instauración de la exacerbación asmática: (menos de 24h), instauración intermedia (25–144h), e instauración lenta (145 o más horas). Se recogieron datos clínicos, de esputo, sangre y orina en el momento de la primera atención y pasadas 24h, determinándose celularidad inflamatoria y marcadores solubles.ResultadosLos pacientes con exacerbación rápida presentaron una significativa mayor concentración de elastasa (1.028±1.140; 310±364; 401±390ng/ml) y albúmina (46,2± 4,3; 42±3,4; 39,9±4,8g/l) en sangre. El número de neutrófilos, eosinófilos, (tanto en sangre como en esputo), los niveles de proteína catiónica del eosinófilo (PCE) (sangre), interleuquina 8 (IL8) (sangre) y leucotrieno E4 (LTE4) (orina) estaban elevadas en los tres grupos (p>0,05). Se constataron asociaciones lineales entre el tiempo de instauración de la exacerbación y la intensidad de la obstrucción (FEV1) (r=−0,360; p=0,037), los eosinófilos en esputo (r=−0,399; p=0,029), la albúmina (r=−0,442; p=0,013); y con la IL8 (r=0,357; p=0,038).ConclusionesLos resultados sugieren una activación precoz de la respuesta neutrofílica y eosinofílica en la exacerbación asmática. No obstante, es posible que el edema bronquial juegue un papel importante en la respuesta inicial inflamatoria de las exacerbaciones dependiendo del tiempo de instauración(AU)

The association between onset of asthma exacerbation and the inflammatory response has not been sufficiently studied.ObjectiveTo determine the differential mechanisms of the rapid onset (RO) asthma exacerbation.MethodsWe designed a prospective, multicentre study that included 34 patients who suffered from asthma exacerbation. They were distributed into three groups of asthmatics, depending of the time of onset: from 0 to 24h, from 25 to 144h and more than 145h. We collected clinical data, sputum, blood and urine samples when first seen at the clinic and the next 24h later, and differential cell counts and biomarkers were determinedResultsThe asthmatics who suffered a RO exacerbation showed a higher elastase concentration, (1.028±1.140; 310±364; 401±390ng/ml) (P<0.05) and albumin (46.2±4.3; 42±3.4; 39.9±4.8g/l) (P<0.05) in the blood sample. Neutrophils, eosinophils (blood or sputum), eosinophil cationic protein (ECP) (blood), interleukin 8 (IL8) (blood) and leukotriene E4 (LTE4) (urine) were high in the three groups (P>0.05). We demonstrated an association between the onset of exacerbation and the severity of obstruction (FEV1) (r=−0.360; P=0.037), eosinophils in sputum (r=−0.399; P=0.029), albumin (r=−0.442; P=0.013), and IL8 in sputum (r=0.357; P=0.038).ConclusionsThe results suggest a rapid inflammatory response, both neutrophilic and eosinophilic, in the asthmatic exacerbation. However, the swelling in the bronchi may play an important role in the initial inflammatory response in the exacerbations depending of time of onset(AU)

[Inflammatory response of rapid onset asthma exacerbation]. / Respuesta inflamatoria de la exacerbación asmática de instauración rápida.

UNLABELLED: The association between onset of asthma exacerbation and the inflammatory response has not been sufficiently studied. OBJECTIVE: To determine the differential mechanisms of the rapid onset (RO) asthma exacerbation. METHODS: We designed a prospective, multicentre study that included 34 patients who suffered from asthma exacerbation. They were distributed into three groups of asthmatics, depending of the time of onset: from 0 to 24h, from 25 to 144h and more than 145h. We collected clinical data, sputum, blood and urine samples when first seen at the clinic and the next 24h later, and differential cell counts and biomarkers were determined RESULTS: The asthmatics who suffered a RO exacerbation showed a higher elastase concentration, (1.028±1.140; 310±364; 401±390ng/ml) (P<0.05) and albumin (46.2±4.3; 42±3.4; 39.9±4.8g/l) (P<0.05) in the blood sample. Neutrophils, eosinophils (blood or sputum), eosinophil cationic protein (ECP) (blood), interleukin 8 (IL(8)) (blood) and leukotriene E4 (LTE(4)) (urine) were high in the three groups (P>0.05). We demonstrated an association between the onset of exacerbation and the severity of obstruction (FEV(1)) (r=-0.360; P=0.037), eosinophils in sputum (r=-0.399; P=0.029), albumin (r=-0.442; P=0.013), and IL(8) in sputum (r=0.357; P=0.038). CONCLUSIONS: The results suggest a rapid inflammatory response, both neutrophilic and eosinophilic, in the asthmatic exacerbation. However, the swelling in the bronchi may play an important role in the initial inflammatory response in the exacerbations depending of time of onset.

[Impact of preventive treatment with long-acting beta(2)-adrenergic agonists and inhaled corticosteroids on the morbidity and mortality of severe asthma exacerbations in 1543 patients]. / Impacto del tratamiento preventivo con agonistas adrenérgicos beta(2) de acción larga y glucocorticoides inhalados en la morbimortalidad de 1.543 episodios de exacerbación grave de asma.

BACKGROUND AND OBJECTIVES: Recent systematic reviews and meta-analyses examining long-acting #b(2)-adrenergic agonists (LABA) as maintenance treatment for asthma have shown surprisingly conflicting results. The aim of the present study was to determine the impact, in terms of efficacy and safety, of previous maintenance treatment on severe asthma exacerbations. PATIENTS AND METHODS: We retrospectively evaluated the clinical characteristics of exacerbations experienced by 1543 patients with moderate persistent and severe persistent asthma. Drug therapy was as follows: a combination of inhaled LABAs and corticosteroids (493 patients), an inhaled corticosteroid only (456 patients), and no maintenance treatment (594 patients). RESULTS: Asthmatic patients taking LABAs did not show higher mortality, longer stay in the intensive care unit, longer hospital stay, lower pH, or worse airflow obstruction than the other 2 groups. On the contrary, they had a higher mean (SD) forced expiratory volume in 1 second at discharge (54% [16%]) than patients taking inhaled corticosteroids (48% [19%]) and patients taking no maintenance treatment (48% [20%]) (P=.009). Patients taking no maintenance treatment also had lower mean (SD) pH values (7.37 [0.11]) than patients taking LABAs (7.39 [0.09]) and patients taking inhaled corticosteroids (7.39 [0.08]) (P=.002), and more admissions to the intensive care unit (11.1% vs 6.5% and 7.7%; P=.002 and P=.018, respectively). CONCLUSIONS: This study did not reveal higher morbidity or mortality in severe asthma exacerbations in patients with moderate persistent or severe persistent asthma who had received inhaled LABAs combined with inhaled corticosteroids. On the contrary, asthma patients who did not use maintenance treatment experienced more severe asthma exacerbations.

[Perception of dyspnea and treatment adherence in asthmatic patients]. / Percepción de la disnea y cumplimiento terapéutico en pacientes con asma.

OBJECTIVE: The majority of studies show that treatment adherence in chronic diseases such as asthma does not exceed 50%. Although the reasons may vary, it is clear that lack of treatment adherence is a determining factor in poor disease control. An association has also been observed between lack of perception of dyspnea and difficult-to-control asthma and with the occurrence of fatal or near-fatal asthma attacks. In this study we therefore attempted to demonstrate that one of the reasons that asthmatic patients do not adhere to treatment is a failure to perceive dyspnea associated with bronchial obstruction. PATIENTS AND METHODS: We analyzed 2 groups of patients with moderate persistent asthma who had all been prescribed the same chronic treatment (a dose of inhaled drug administered with a dry powder inhaler every 12 hours). The first group comprised 24 patients (16 women and 8 men; mean [SD] age, 44 [15] years) who took the medication almost every day. The second group contained 24 patients (16 women and 8 men; mean [SD] age, 48 [14] years) who did not use the medication or only took it occasionally. There were no significant differences between the groups in terms of age, sex, percentage of smokers, socioeconomic and educational level, anxiety, depression, or spirometry variables. A histamine challenge test was carried out in all patients and the dyspnea perceived after each dose of the drug was measured on a modified Borg scale. The dose of histamine leading to a 20% reduction in forced expiratory volume in 1 second (FEV(1)), perception of dyspnea associated with a 20% reduction in FEV(1) (PS(20)), and the change in dyspnea measured on the Borg scale between baseline and 20% reduction in FEV(1) were analyzed. Patients were also classified as poor perceivers of dyspnea if the change in perception of dyspnea on the modified Borg scale was less than or equal to zero. RESULTS: The group of patients with poor treatment compliance had a lower PS(20) (2.27 [1.9] vs 3.51 [1.8], P=.03) and change in Borg score (1.64 [1.9] vs 2.7 [1.84], P=.057), and they were more often poor perceivers of dyspnea (50% vs 21%, P=.034). CONCLUSIONS: There is a relationship between treatment adherence and dyspnea perception, such that poor perception is among the reasons for poor treatment adherence in patients with asthma.

Percepción de la disnea y cumplimiento terapéutico en pacientes con asma / Perception of dyspnea and treatment adherence in asthmatic patients

OBJETIVO: El cumplimiento terapéutico en una enfermedad crónica como el asma no supera el 50% en la mayoría de las series. Aunque las razones sean de muy diversa índole, es evidente que el incumplimiento es un factor determinante en el mal control de la enfermedad. Por otra parte, la falta de percepción de la disnea se ha asociado con el asma de control difícil y con la aparición de crisis de asma fatal o casi fatal. Así pues, el objetivo del presente estudio ha sido intentar demostrar que una de las razones por las cuales los asmáticos no toman su medicación es que no tienen percepción de disnea cuando sus bronquios se obstruyen. PACIENTES Y MÉTODOS: Hemos estudiado a 2 grupos de pacientes con asma persistente y moderada, a quienes se había prescrito el mismo tratamiento de forma continuada (una dosis de medicación inhalada en polvo seco cada 12 h). El primero estaba formado por 24 pacientes (16 mujeres y 8 varones; edad media ± desviación estándar: 44 ± 15 años) que tomaban casi todos los días la medicación, y el segundo, por otros 24 pacientes (16 mujeres y 8 varones; edad media: 48 ± 14 años) que no tomaban la medicación o lo hacían sólo de vez en cuando. No había diferencias significativas entre los grupos en cuanto a edad, sexo, porcentaje de fumadores, niveles económico y educativo, ansiedad, depresión y parámetros espirométricos. A todos ellos se les realizó una prueba de broncoprovocación con histamina, y se midió la disnea experimentada tras cada dosis del fármaco en una escala modificada de Borg. Se determinaron la dosis de histamina con la que se alcanzó una caída del 20% en el volumen espiratorio forzado en el primer segundo (FEV1), la percepción de disnea con una caída del FEV1 del 20% (PS20) y el cambio de disnea en la escala de Borg desde la situación inicial hasta la caída del 20% de FEV1 (cambio en Borg). Además, se clasificó a los pacientes como hipoperceptores de disnea cuando su cambio en Borg fue igual o inferior a 0. RESULTADOS: El grupo de incumplidores tenía menor PS20 (2,27 ± 1,9 frente a 3,51 ± 1,8 en el grupo de cumplidores; p = 0,030) y cambio en Borg (1,64 ± 1,9 frente a 2,7 ± 1,84; p = 0,057), y eran con mayor frecuencia hipoperceptores de disnea (el 50% frente al 21%; p = 0,034). CONCLUSIONES: Existe relación entre el cumplimiento del tratamiento y la percepción de disnea, de forma que uno de los motivos del incumplimiento terapéutico en los pacientes con asma es la hipopercepción de disnea

OBJECTIVE: The majority of studies show that treatment adherence in chronic diseases such as asthma does not exceed 50%. Although the reasons may vary, it is clear that lack of treatment adherence is a determining factor in poor disease control. An association has also been observed between lack of perception of dyspnea and difficult-to-control asthma and with the occurrence of fatal or near-fatal asthma attacks. In this study we therefore attempted to demonstrate that one of the reasons that asthmatic patients do not adhere to treatment is a failure to perceive dyspnea associated with bronchial obstruction. PATIENTS AND METHODS: We analyzed 2 groups of patients with moderate persistent asthma who had all been prescribed the same chronic treatment (a dose of inhaled drug administered with a dry powder inhaler every 12 hours). The first group comprised 24 patients (16 women and 8 men; mean [SD] age, 44 [15] years) who took the medication almost every day. The second group contained 24 patients (16 women and 8 men; mean [SD] age, 48 [14] years) who did not use the medication or only took it occasionally. There were no significant differences between the groups in terms of age, sex, percentage of smokers, socioeconomic and educational level, anxiety, depression, or spirometry variables. A histamine challenge test was carried out in all patients and the dyspnea perceived after each dose of the drug was measured on a modified Borg scale. The dose of histamine leading to a 20% reduction in forced expiratory volume in 1 second (FEV1), perception of dyspnea associated with a 20% reduction in FEV1 (PS20), and the change in dyspnea measured on the Borg scale between baseline and 20% reduction in FEV1 were analyzed. Patients were also classified as poor perceivers of dyspnea if the change in perception of dyspnea on the modified Borg scale was less than or equal to zero. RESULTS: The group of patients with poor treatment compliance had a lower PS20 (2.27 [1.9] vs 3.51 [1.8], P=.03) and change in Borg score (1.64 [1.9] vs 2.7 [1.84], P=.057), and they were more often poor perceivers of dyspnea (50% vs 21%, P=.034). CONCLUSIONS: There is a relationship between treatment adherence and dyspnea perception, such that poor perception is among the reasons for poor treatment adherence in patients with asthma

Risk factors of emergency care and admissions in COPD patients with high consumption of health resources.

This study is a case-control study looking to identify factors associated with frequent use of hospital services (emergency care and admissions) in COPD patients. Data from 64 patients with moderate-severe COPD (FEV1/FVC < or = 70, FEV1 < or = 50%) were prospectively collected, 32 cases with high consumption of health resources (COPD-HC) and 32 controls. COPD-HC was defined as a patient diagnosed of COPD requiring during one year: (1) two or more hospitalizations; (2) three or more emergency visits; or (3) one admission and two emergency visits. Patients with COPD and a similar age, FEV1 and PaO2 who required no hospital care during the study year (1998) were randomly selected as controls. Demographic, clinical and socioeconomic data were collected from each subject, and evaluations were made of anxiety, health-related quality of life [measured with the St. George's Respiratory Questionnaire (SGRQ)], nutritional parameters, and different therapeutic aspects. Forced spirometry, resting arterial blood gases, maximal respiratory muscle pressures and a 6-min walking test were measured in all cases. After applying a logistic regression model, the variables that finally proved to be independent predictors of frequent use of hospital services were: treatment with salmeterol, the presence of cardiac arrhythmias, and increased SGRQ scores. The administration of inhaled salmeterol multiplied the risk of having COPD-HC criteria by 27.4 (95%CI: 2.4-308.1), while the presence of arrhythmias multiplied the probability of meeting high consumption criteria by 24.3 (95%CI: 1.7-340.1). For each point of worsened quality of life, the risk of hospital care increased 1.06-fold (95%CI: 1.01-1.10). Although a severity bias related to the presence of long-acting beta2-agonists in the final regression equation cannot be ruled out, the variables associated in our sample to an increased utilization of hospital services are the regular use of inhaled salmeterol, the presence of cardiac arrhythmias, and an impaired health-related quality of life. The use of specific strategies aimed at modulating these aspects could, at least in theory, reduce the number of exacerbations requiring hospital care, with the resultant individual and collective benefits derived.

Determinants of dyspnea in patients with different grades of stable asthma.

Dyspnea is a main feature of symptomatology in asthma, and its perception does not necessarily correlates well with airway obstruction. The aim of this study was twofold: (1) to identify factors determining the subjective degree of dyspnea in patients with different grades of stable bronchial asthma and (2) to compare various clinical methods existing for grading dyspnea. The investigation comprised 153 outpatients with stable asthma. The parameters studied were the following: demographic characteristic of subjects, baseline dyspnea score by means of three clinical instruments (baseline dyspnea index [BDI], Medical Research Council [MRC] scale, and modified Borg scale), asthma severity, standard measures of physiologic lung function, anxiety, depression, subconscious illness attention, and asthma-related quality of life (HRQOL). The dyspnea scores were all significantly interrelated (r=0.77-0.85, p<0.001). The three clinical scales for grading dyspnea were significantly correlated with the same parameters: airflow obstruction, lung hyperinflation, emotional factors, HRQOL, age, age at asthma onset, asthma duration, female gender, clinical severity, and lower economical, and educational levels. Multiple regression analysis showed that independent factors determining clinical dyspnea scores were: age, airway obstruction, and emotional status. Moreover, in patients with severe asthma, lung hyperinflation helped to explain the individual dyspnea score. These data suggest that clinical methods are appropriate for evaluating the impact of dyspnea on daily activities of asthmatic patients. BDI, MRC, and Borg clinical dyspnea scales showed similarly information in subjects with asthma. Independently of asthma severity, older age, airway obstruction, and psychological disturbance were associated with higher degree of dyspnea. However, if subjects had severe airway obstruction, lung hyperinflation was a major determinant of baseline dyspnea score.

Evaluation of nonresolving and progressive pneumonia.

The concepts of nonresolving and progressive pneumonia are difficult to define: both refer to a failure in the therapeutic response, which in the case of progressive pneumonia may cause a medical emergency even in the first 72 hours after empiric treatment. The incidence of nonresolving pneumonia in community-acquired pneumonia is approximately 10%, and greater than 30% in nosocomial pneumonia. Mortality in nonresponding pneumonia increases 3-fold in community-acquired and 5-fold in nosocomial pneumonia compared with global mortality in hospitalized patients. Factors associated with the resolution of pneumonia are related to the host, the microorganisms, and the cytokine response that modulates the relationship between them. Causes of nonresolving or progressive pneumonia may be infectious or noninfectious. Management of nonresponding patients requires a reevaluation of epidemiologic data, a complete microbiologic investigation, with conventional and invasive respiratory samples, and performance of a new radiographic study. Empiric therapeutic changes are aimed at broadening bacteriologic coverage to treat resistant or unusual microorganisms.

Gender differences in health-related quality of life among patients with asthma.

This study has a twofold objective: 1) to explore to what extent suffering from asthma affects the HRQL of men and women differently at several stages of disease severity and 2) to analyze whether the informed poorer HRQL of asthmatic women is related to their higher scores on instruments measuring emotionally disordered symptoms. One hundred fifty-one outpatient asthmatics (84 women and 67 men) completed the Spanish versions of the Asthma Quality of Life questionnaire (AQL), as well as anxiety and depression inventories. A full history, physical examination, and pulmonary function test were performed on all subjects. Patients were classified into one of four asthma severity categories following the criteria of the Global Initiative on Asthma (GINA). There were no gender differences in sociodemographic variables, asthma duration, GINA, FEV1 or dyspnea. However, women showed a poorer HRQL than men, as well as high degrees of anxiety and depression. When these data were reanalyzed taking into account the four groups of asthma severity, women only reported a poorer HRQL than men at the intermittent asthma level. The gender differences on depression and anxiety scores were maintained at the three lower severity levels, but not at the most severe asthma degree. When depression and anxiety scores were partialed out, the AQL scores maintained significant relationships with asthma severity, dyspnea, and FEV1, both in women and men. Therefore, only in men were there also relationships among AQL and sociodemographic data. The best predictor of the women's HRQL was the dyspnea score, whereas in men it was the asthma severity (GINA).

Características clínicas y prevalencia de los estados de hipercoagulabilidad en pacientes con enfermedad tromboembólica venosa / Clinical manifestations and prevalence of hypercoagulable states in patients with venous thromboembolic disease

FUNDAMENTO: La enfermedad tromboembólica venosa (ETV) puede deberse a tres mecanismos fundamentales: la estasis venosa, una alteración en el proceso de la coagulación o una lesión del endotelio. Uno o más de estos elementos constituyen los denominados estados de hipercoagulabilidad (EH), que se clasifican en primarios (EHP) y secundarios (EHS), algunos de los cuales son medibles. El objetivo fue conocer la prevalencia de EH en pacientes ingresados por ETV que cumplían criterios para realizar el estudio y las características clínicas de la embolia de pulmón en los pacientes en que se halló un EH. PACIENTES Y MÉTODO: Se practicó el estudio de trombofilia a 60 de los 175 pacientes diagnosticados de trombosis venosa profunda y embolia de pulmón que cumplían los criterios de inclusión. El análisis se realizó un mes después de terminar el tratamiento anticoagulante. RESULTADOS: Se encontró un EH en 17 de los 60 pacientes (28,3 por ciento), de los cuales 14 eran EHP y tres EHS. El EHP más frecuente fue el aumento del inhibidor del activador tisular del plasminógeno tipo 1 (PAI-1). La embolia de pulmón fue masiva en 2 pacientes con un EH, hubo recidivas en cinco y se halló afección de varios miembros de una misma familia en cinco. CONCLUSIONES: La prevalencia de EH en pacientes ingresados por ETV es alta. Las características clínicas fueron parcialmente comparables a los pacientes de otras series, y el aumento del PAI-1 fue el marcador de hipercoagulabilidad más frecuente (AU)