Abel Pallarés Sanmartín

Enfermedad pulmonar obstructiva crónica con eosinofilia, ¿un fenotipo emergente?

La enfermedad pulmonar obstructiva crónica (EPOC) se define con base en una prueba, la espirometría, que de forma indirecta informa sobre el grado de resistencia que ofrecen las vías aéreas al paso de la mezcla de gas que hay en su interior. Carecemos por el momento de un patrón histológico, un biomarcador o incluso unos criterios clínicos que delimiten de forma más precisa lo que significa tener una EPOC. Ya desde sus primeras descripciones, hace más de 60 años, se intentó diferenciar a los pacientes según sus características clínicas. El notable aumento del conocimiento sobre esta enfermedad en los últimos años ha permitido describir lo que hemos venido a denominar fenotipos de la EPOC. Un fenotipo equivale a los rasgos que presenta un individuo debido a la interacción de su carga genética con el ambiente en el que vive. En toda enfermedad crónica el daño producido por un agente nocivo está modulado por la respuesta que el individuo es capaz de producir frente a ese agente. La guía GesEPOC1 ha descrito 4 fenotipos (agudizador, enfisema, bronquitis crónica y mixto), con unas características más o menos definidas, dentro de la EPOC. Es muy probable que esta clasificación cambie sustancialmente en la próxima actualización de la guía, dado que después de la primera entrega diversos estudios han puesto en entredicho algunos de los conceptos establecidos previamente. Hay 2 puntos que, en nuestra opinión, son claves y posiblemente deben ser revisados en profundidad: el concepto de exacerbador y el fenotipo mixto EPOC/asma. De acuerdo con los datos de ECLIPSE, un paciente con al menos 2 exacerbaciones el primer año (la definición del fenotipo exacerbador) tiene en torno a un 40% de posibilidades de tener una o ninguna el segundo año, e incluso el que ha pertenecido a dicho fenotipo los 2 primeros años, en el tercero alcanza un 30% de posibilidades de no serlo. A su vez, el que no ha tenido ninguna exacerbación el primer año tiene en torno a un 35% de posibilidades de tener 2 en el segundo2. Es decir, es un «fenotipo» bastante variable en el tiempo. La asociación de EPOC/asma presenta otros problemas. La propia definición es poco precisa, carece de biomarcadores definitivos y el diagnóstico se basa en una serie de criterios de consenso que

Cost-Effectiveness Study of the Diagnosis of Pleural Effusion in Chest Diseases Outpatient Clinic

Abstract Objective To evaluate the diagnostic efficacy of pleural procedures, safety, delay and cost of the diagnosis of pleural effusion (PE) by analysing the parameters that are dependent on the area of patient management (outpatient or inpatient). Patients and Methods Prospective non-randomized study. Two groups were established depending on whether they were managed in a specific outpatient unit or as a conventional hospital inpatient, with the rest of the criteria being the same for the study of the PE. Results We included 60 outpatients and 34 inpatients. The median number of visits as an outpatient was 2 (range 2-3), and the time an inpatient was hospitalized was 13 (range 7.7-25-2) days. The number of analytical and imaging studies was significantly higher in the inpatient group. There were no differences in the number of cytology and pleural biopsies, or complications between groups. There were no differences in time to performing computed tomography. The number of days until the pleural biopsy and the time until to obtain a diagnosis was lower in the outpatient group. Mean total cost for an outpatient was € 1.352 and € 9.793,2 for inpatients. Conclusions Management of ambulatory diagnosis of PE patients is highly cost-effective. The effectiveness and safety of forms of the study is at least similar. In this study, the mean cost for a hospitalised inpatient for a PE was 7.2 times higher than outpatient management.

Validation of the portable Air-Smart Spirometer

Background The Air-Smart Spirometer is the first portable device accepted by the European Community (EC) that performs spirometric measurements by a turbine mechanism and displays the results on a smartphone or a tablet. Methods In this multicenter, descriptive and cross-sectional prospective study carried out in 2 hospital centers, we compare FEV1, FVC, FEV1/FVC ratio measured with the Air Smart-Spirometer device and a conventional spirometer, and analyze the ability of this new portable device to detect obstructions. Patients were included for 2 consecutive months. We calculate sensitivity, specificity, positive and negative predictive value (PPV and NPV) and likelihood ratio (LR +, LR-) as well as the Kappa Index to evaluate the concordance between the two devices for the detection of obstruction. The agreement and relation between the values of FEV1 and FVC in absolute value and the FEV1/FVC ratio measured by both devices were analyzed by calculating the intraclass correlation coefficient (ICC) and the Pearson correlation coefficient (r) respectively. Results 200 patients (100 from each center) were included with a mean age of 57 (± 14) years, 110 were men (55%). Obstruction was detected by conventional spirometry in 73 patients (40.1%). Using a FEV1/FVC ratio smaller than 0.7 to detect obstruction with the Air Smart-Spirometer, the kappa index was 0.88, sensitivity (90.4%), specificity (97.2%), PPV (95.7%), NPV (93.7%), positive likelihood ratio (32.29), and negative likelihood ratio (0.10). The ICC and r between FEV1, FVC, and FEV1 / FVC ratio measured by the Air Smart Spirometer and the conventional spirometer were all higher than 0.94. Conclusion The Air-Smart Spirometer is a simple and very precise instrument for detecting obstructive airway diseases. It is easy to use, which could make it especially useful non-specialized care and in other areas.

Estudio de coste-efectividad del manejo diagnóstico del derrame pleural en una unidad de patología pleural ambulatoria

OBJECTIVE To evaluate the diagnostic efficacy of pleural procedures, safety, delay and cost of the diagnosis of pleural effusion (PE) by analysing the parameters that are dependent on the area of patient management (outpatient or inpatient). PATIENTS AND METHODS Prospective non-randomized study. Two groups were established depending on whether they were managed in a specific outpatient unit or as a conventional hospital inpatient, with the rest of the criteria being the same for the study of the PE. RESULTS We included 60 outpatients and 34 inpatients. The median number of visits as an outpatient was 2 (range 2-3), and the time an inpatient was hospitalized was 13 (range 7.7-25-2) days. The number of analytical and imaging studies was significantly higher in the inpatient group. There were no differences in the number of cytology and pleural biopsies, or complications between groups. There were no differences in time to performing computed tomography. The number of days until the pleural biopsy and the time until to obtain a diagnosis was lower in the outpatient group. Mean total cost for an outpatient was euro1.352 and euro9.793,2 for inpatients. CONCLUSIONS Management of ambulatory diagnosis of PE patients is highly cost-effective. The effectiveness and safety of forms of the study is at least similar. In this study, the mean cost for a hospitalised inpatient for a PE was 7.2 times higher than outpatient management.

Absceso de pared por Mycobacterium avium intracellulare (MAI) en un paciente con neumoconiosis

Only a minority of people exposed to Mycobacterium avium intracellulare (MAI), mainly immunosuppressed patients or those with underlying pulmonary pathology, develop lung disease caused by this germ. Although the relationship of silicosis with tuberculosis and even with other mycobacteria, such as Mycobacterium kasasii, are frequently reported, the association of this pneumoconiosis with MAI has been infrequently described. MAI affectation in immunocompetent patients varies depending on whether the presentation is in either a previously healthy or pathological pulmonary parenchyma. In subjects with previous parenchymatous affectation, the most frequent manifestation is more or less extensive fibrocavitary affectation, while in those with healthy lungs before the MAI infection, the most probable radiological alterations are bronchiectasis and reticularnodular affectation, with less lung affectation. Pleural adhesion and thickening are evident on computed tomography (CT) in half of the cases, and these are usually adjacent to the lung lesions; pleural effusion, however, is very infrequent. In an exhaustive review of the medical literature, we have not found any cases reporting an abscess due to MAI at the level of the chest wall produced by contiguity, either hematogenous or primary. We describe the exceptional case of a patient with complicated silicosis and MAI infection who developed an abscess due to this germ at the level of the chest wall due to a fistula from one of the present cavitated lung lesions. The patient was a 67-year-old male with a work history of various decades at a granite quarry, ex-smoker who had smoked more than 40 packs/year, who had been diagnosed some years earlier with stage C complicated silicosis with important functional repercussions and chronic respiratory insufficiency. Ten months before, he had been diagnosed with pulmonary mycobacteriosis caused by MAI and was receiving treatment with rifampicin, ethambutol and clarithromycin at standard dosages. The patient was transferred to our hospital from another center in order to study a mass on the anterior chest wall. He referred a lump that had been evolving over the previous six months, located in the left anterior chest wall, which had fluctuated in size. Given the persistence of the lesion and the appearance of pain and signs of inflammation, the patient had consulted with his physician. During our examination, we observed a tumor that was 10 cm in diameter, soft in consistency and painful to the touch on the upper anterior wall of the left hemothorax (fig. 1A). Lab work-up on peripheral blood, including HIV serology, revealed no noteworthy data. Sputum smear for acid-fast bacilli was slightly positive, with mycobacterial culture positive for MAI. Computed tomography (CT) revealed: micronodular pattern predominantly in both upper lobes, with irregularly-edged large masses also in the upper lobes (one of which was cavitated); panlobular emphysema; bullas and multiple calcified hilar and mediastinal lymphadenopathies; and a fistula towards the soft area, where a collection with air-fluid level had formed (fig. 1B). Fine-needle aspiration was performed, obtaining abundant purulentlooking material, whose immediate examination showed BAAR, while MAI was later cultured. Due to the comorbidity of the patient and the growth of the chest wall lesion with spontaneous cutaneous fistulization in the following weeks, a percutaneous drain was inserted. The aforementioned antibiotic treatment was maintained for a total of 18 months, obtaining favorable clinical, radiological and microbiological responses. This case is the first report describing a fistula from a cavitated lung lesion to the chest wall cause by MAI. In