Características clínicas de dos poblaciones diagnosticadas de enfermedad pulmonar obstructiva crónica por criterios espirométricos GOLD o por el límite inferior de la normalidad / Clinical characteristics of two populations diagnosed of chronic obstructive pulmonary disease with GOLD spirometric criteria or by lower limit of normality

Objetivo: Evaluar la relevancia clínica de modificar el criterio diagnóstico de enfermedad pulmonar obstructiva crónica (EPOC) utilizando el límite inferior de la normalidad (LIN) en una cohorte de pacientes diagnosticados de EPOC. Material y métodos: La población de estudio se reclutó entre pacientes previamente diagnosticados de EPOC por criterio GOLD y con un seguimiento previo por el médico responsable superior a un año. Resultados: Cuando la EPOC se definió por criterio LIN se identificaron pacientes con mayor repercusión clínica y funcional que cuando se utilizó el criterio GOLD. Los pacientes con EPOC por criterio LIN presentaban valores significativamente más bajos de volumen espiratorio forzado en el primer segundo (FEV1) sobre la capacidad vital forzada (FVC) FEV1/FVC: 0,52 (0,9) frente a 0,67 (0,2), p = 0,000; de FEV1: 49,5% (16,5) frente a 62% (14,2), p = 0,0000; de FVC 69,4 (18,7) frente a 73,3, p = 0,04; mayor grado de disnea valorada mediante la escala del Medical Research Council (MRC) 2,98 (1,1) frente a 2,67 (1,12), p = 0,003; un mayor número de exacerbaciones anuales 2,32 (1,5) frente a 1,84 (0,9), p = 0,001; más visitas a Urgencias 2,17 (1,6) frente a 1,45 (0,74), p = 0,001; y más ingresos hospitalarios 1,75 (1,2) frente a 1,1 (80,4), p = 0,005. Sin embargo, los pacientes no incluidos como EPOC por el criterio LIN presentaron grados clínicamente relevantes de disnea y un elevado consumo de recursos sanitarios. Utilizando el criterio del LIN para establecer el diagnóstico, la EPOC no se asoció con un incremento del riesgo cardiovascular, cerebrovascular ni del riesgo de enfermedad vascular periférica. Conclusiones: El uso del LIN como criterio para establecer el diagnóstico de EPOC, frente al criterio GOLD, excluye un elevado número de pacientes con repercusión clínica y con un elevado consumo de recursos sanitarios. El uso de este criterio no proporciona información adicional a la hora de establecer una posible relación entre EPOC y enfermedad vascular (AU)

Purpose: The purpose of this study has been to evaluate the clinical importance of modifying the COPD diagnostic criterion using the lower limit of normality (LLN) in a cohort of COPD diagnosed patients. Material and methods: The study population was recruited among patients previously diagnosed COPD with the GOLD criterion who had a previous follow-up by their attending position greater than one year. Results: When the COPD was defined by a LLN criterion, patients were identified with greater clinical and functional repercussion then when the GOLD criterion was used. The patients with COPD by the LLN criterion had significantly lower values of FEV1/FVC: 0.52 (0.9) vs 0.67 (0.2), p = 0.000; of FEV1: 49.5% (16.5) vs 62% (14.2), p = 0.0000; of FVC 69.4 (18.7) vs 73.3, p = 0,04; greater grade of dyspnea evaluated with the Medical Research Council (MRC) scale 2.98 (1.1) vs 2.67 (1.12), p = 0.003; a higher number of yearly exacerbations 2.32 (1.5) vs 1.84 (0.9), p = 0.001; more visits to the emergency service 2.17 (1.6) vs 1.45 (0.74), p = 0.001; and more hospital admissions 1.75 (1.2) vs 1.1 (80.4), p = 0.005. However, patients not included as COPD by the LLN criterion had clinically relevant grades of dyspnea and elevated use of health care resources. Using the LLN criterion to establish the diagnoses, COPD was not associated with an increased cardiovascular, cerebrovascular risk or risk of peripheral vascular disease. Conclusions: The use of the LLN as a criterion to establish the diagnosis of COPD versus the GOLD criterion excludes an elevated number of patients with clinical repercussions and with elevated use of health care resources. The use of this criterion does not provide additional information when establishing a possible relationship between COPD and vascular disease (AU)

Nutritional support and quality of life in stable chronic obstructive pulmonary disease (COPD) patients.

RATIONALE: Nutritional depletion is a common problem in chronic obstructive pulmonary disease (COPD) patients. It is caused, to a large extent, by an imbalance between low-energy intake and high-energy requirements. This problem adversely affects morbidity and mortality. However, the use of nutritional supplements to reach their energy necessities requires optimisation between positive and adverse effects on outcome before being used systematically as part of their comprehensive care. PURPOSE: The aim of our study was to investigate the effects of oral nutritional repletion on quality of life in stable COPD patients. METHODS: Prospective, randomised and multi-centre study. Stable COPD patients with a body mass index 22, a fat-free mass index 16, and/or a recent involuntary weight loss (5% during last month, or 10% during the last 3 months) were studied. Exclusion criteria were to present signs of an airway infection, to have a cardiovascular, neurological, or endocrine disease, to be treated with oral steroids, immunosuppressors or oxygen therapy at home, and to receive nutritional supplements. During 12 weeks, patients were encouraged to ingest a total daily defined energy intake. Randomly, in patients from group A the total daily energy load was Resting Energy Expenditure (REE)x1.7, and those from group B, REE x1.3. Total daily energy intake was achieved with regular food plus, if necessary, oral nutritional supplement rich in proteins (with 50% of whey protein), with predominance of carbohydrates over fat, and enriched in antioxidants. Primary end-point variable was quality of life. Secondary end-point outcomes included body weight, body composition, lung function, handgrip strength, and compliance with the energy intake previously planned. Data were treated with a SAS System. Student's test, Wilcoxon's rank sum test, and Mann-Whitney's test were used. RESULTS: At baseline both groups of patients were comparable. All patients needed oral nutritional supplements to achieve total daily defined energy intake. After 12 weeks of follow-up, patients in both groups significantly increased energy intake. Patients in group A increased body weight (P=0.001), triceps skin fold thickness (P=0.009) and body fat mass (P=0.02), and decreased body fat-free mass index (P=0.02). In this group a marked increase in airflow limitation was observed. A tendency to increase body weight and handgrip strength, and to decrease airflow limitation was observed in patients from group B. Furthermore, patients in the later group showed a significant improvement in the feeling of control over the disease (P=0.007) and a tendency to better the other criteria in a quality of life scale. CONCLUSIONS: According to our results, total daily energy intake of REE x 1.3 is preferable to REE x 1.7 in mild stable COPD patients. The administration of oral nutritional supplements, rich in proteins (with 50% of whey protein), with predominance of carbohydrates over fat, and enriched in antioxidants, to achieve total daily defined energy intake in patients in group B was followed by a significant improvement of one criteria (mastery) among many others in a quality of life scale.

Defective natural killer and phagocytic activities in chronic obstructive pulmonary disease are restored by glycophosphopeptical (inmunoferón).

We have investigated both modifications in natural (innate) immunity caused by chronic obstructive pulmonary disease (COPD) and the effects of a glycophosphopeptical immunomodulator (Inmunoferón) treatment on COPD-associated immunoalterations. In a double-blinded clinical trial, 60 patients with COPD received glycophosphopeptical or placebo during 90 consecutive days at oral doses of 3 g/d. Fifty-six sex- and age-matched healthy control subjects were included as a reference group for immunologic parameters. Peripheral blood natural killer (PBNK) cell cytotoxic activity and phagocytic activity of peripheral monocytes/macrophages (Mo/Ma) and polymorphonuclear (PMN) cells were assessed at baseline and then again at the end of treatments. We found both PBNK activity and phagocytic activity to be significantly decreased in patients with COPD compared with levels in healthy volunteers. The treatment with glycophosphopeptical provoked significant stimulatory effects on PBNK cytotoxic activity. This stimulation was not mediated by an increase in CD3(-)CD56(+) NK cells. Further, glycophosphopeptical significantly increased the percentage of monocytes and PMNs that phagocytize Escherichia coli in vitro, as well as increased phagocytic indices. We conclude that peripheral blood cells of patients with COPD show clear defects in natural immunity that are partially rescued by glycophosphopeptical.

The migraine: benign paroxysmal vertigo of childhood complex.

The migraine--a benign paroxysmal vertigo of childhood complex is the most frequent etiology of pediatric dizziness, with an incidence of 34.7%. We present a series of 34 children in whom this entity was diagnosed. We describe the most important characteristics and discuss the possible etiological factors. We review the theories about a common pathophysiological origin for migraine, benign paroxysmal vertigo of childhood, and paroxysmal torticollis. Evolution of these entities confirms the idea of a common origin and a different vestibular symptomatology, depending on the age of the child experiencing dizziness.

[Equilibrium disorders in childhood]. / Trastornos del equilibrio en la infancia.

Dizziness and imbalance are uncommon in children, but often alarming for their families. A detailed interview and otoneurological examination are important for reaching a specific diagnosis and treatment. The purpose of our study was to obtain our own etiological, clinical and diagnostic statistics, and to review the major related pathologies. We report a series of 76 children with imbalance or dizziness as the presenting symptom. Paroxysmal benign vertigo of childhood was the most common pathology in our study, followed by vestibular neuronitis. Our findings were compared to those of other authors. Early diagnosis is emphasized as the most important factor for achieving an effective vestibular rehabilitation in children.

[Comparative study of 2 diagnostic tests of aspecific bronchial hyperreactivity]. / Estudio comparativo de dos pruebas de diagnóstico de la hiperreactividad bronquial inespecífica.

Bronchial challenge test are useful in diagnosis of bronchial hyperresponsiveness (BH). To assess the sensitivity of histamine test (HT) and exercise test (ET), 45 asthmatic patients (31 men, 14 women, ages 9-34) with normal resting pulmonary function test were studied. HT and ET were performed in two different days. HT was positive in 40 (6 severe, 23 moderate and 11 mild) and ET was positive in 13 (88.8% vr 28.8%, p < 0.001). All patients with positive ET had positive HT. There is a relationship between the degree of BH severity and the response to ET (chi 2 = 5.995; p < 0.05). The HT has a high profitability the diagnosis of BH. The ET has a low sensitivity.

Nasal continuous positive airway pressure in patients with COPD in acute respiratory failure. A study of the immediate effects.

The aim of this study was to assess the effect of nasal continuous positive airway pressure (CPAP) breathing on patients with COPD when they are in respiratory failure during acute episodes of the disease. We studied 15 male patients with COPD who were in acute, unstable condition, without mechanical ventilatory support, before and during 4 h of nasal CPAP. The respiratory rate decreased (initial, 30 +/- 6; final, 25 +/- 6; p < 0.001), as did the subjective sensation of dyspnea (initial Borg index, 3 +/- 3; final, 2 +/- 2; p < 0.05). A significant decrease in the average PaCO2 (before, 73 +/- 10 mm Hg; after, 61 +/- 9 mm Hg; p < 0.001) and a significant increase in the PaO2 (before, 57 +/- 13 mm Hg; after 64 +/- 14 mm Hg; p < 0.05) were also observed. Nasal CPAP was generally well tolerated. According to these results, nasal CPAP should be considered as a possibility for treatment in patients with COPD who are in acute respiratory failure, in order to avoid mechanical ventilation.

Exertional dyspnea and ventilation in hyperthyroidism.

Dyspnea is recognized to be an important feature in patients with hyperthyroidism at rest and during exercise. However, its etiology is not well-understood. Since dyspnea is thought to be related to the perception of excessive ventilatory effort, we explored the possibility that dyspnea in these patients might be related to an inappropriate ventilatory response to the increased metabolic rate. We studied 11 hyperthyroid patients and 11 age- and sex-matched controls, performing spirometry, lung volumes, mouth pressure measurements, and incremental exercise test. Central drive was estimated by measuring P0.1 and sensation of dyspnea by the Borg scale. We found that hyperthyroid patients (1) have higher ventilation than normal subjects during exercise even when corrected for VCO2 levels; (2) this increased ventilation is secondary to increased central drive which is correlated to the T3ria level (r = 0.85, p less than 0.01); (3) hyperthyroid patients are more dyspneic than controls; and (4) the increased drive can be normalized by beta-blockade. We conclude that the main ventilatory abnormality in hyperthyroid patients is an inappropriate increase in respiratory drive, possibly secondary to increased adrenergic stimulation.