Ignasi Bolíbar

New evidence of risk factors for community-acquired pneumonia: a population-based study

The aim of the present study was to identify risk factors for community-acquired pneumonia (CAP), with special emphasis on modifiable risk factors and those applicable to the general population. A population-based, case–control study was conducted, with a target population of 859,033 inhabitants aged >14u2005yrs. A total of 1,336 patients with confirmed CAP were matched to control subjects by age, sex and primary centre over 1u2005yr. In the univariate analysis, outstanding risk factors were passive smoking in never-smokers aged >65u2005yrs, heavy alcohol intake, contact with pets, households with >10 people, contact with children, interventions on the upper airways and poor dental health. Risky treatments included amiodarone, N-acetylcysteine and oral steroids. Influenza and pneumococcal vaccine, and visiting the dentist were protective factors. Multivariable analysis confirmed cigarette smoking, usual contact with children, sudden changes of temperature at work, inhalation therapy (particularly containing steroids and using plastic pear-spacers), oxygen therapy, asthma and chronic bronchitis as independent risk factors. Interventions for reducing community-acquired pneumonia should integrate health habits and lifestyle factors related to household, work and community, together with individual clinical conditions, comorbidities and oral or inhaled regular treatments. Prevention would include vaccination, dental hygiene and avoidance of upper respiratory colonisation.

Inhaled drugs as risk factors for community-acquired pneumonia

The effect of inhaled drugs in community-acquired pneumonia (CAP) is unclear. This case–control study was designed to determine whether inhaled drugs were risk factors for CAP. All incident cases of confirmed CAP that occurred over 1 yr in patients with chronic bronchitis (CB), chronic obstructive pulmonary disease (COPD) or asthma were included, as well as CB, COPD and asthma controls. Risk factors for CAP and inhaled treatment were recorded during a personal interview. An effect of inhaled drugs on the risk of CAP was observed in COPD and asthma patients after adjusting for the effect of other respiratory diseases and their concomitant treatments. In COPD patients, inhaled steroids had a risk OR of 3.26 (95% CI 1.07–9.98) and in asthma patients inhaled anticholinergics had a risk OR of 8.80 (95% CI 1.02–75.7). In CB patients, no association with CAP was observed for any inhaler. These effects were independent of adjusting variables related to severity and other respiratory and non-respiratory risk factors for CAP, including vaccines. Inhaled &bgr;2-adrenergic agonists did not show a significant effect on the risk of CAP in any of the respiratory diseases. Inhaled steroids may favour CAP in COPD patients, whereas anticholinergics may favour CAP in asthma patients. It is difficult to differentiate the effect of inhaled therapy from the effect of COPD or asthma severity on the risk of CAP, and these relationships may not be causal, but could call attention to inhaled therapy in COPD and asthma patients.

Assessment of a primary and tertiary care integrated management model for chronic obstructive pulmonary disease

BackgroundThe diagnosis and treatment of patients with chronic obstructive pulmonary disease (COPD) in Spain continues to present challenges, and problems are exacerbated when there is a lack of coordinated follow-up between levels of care. This paper sets out the protocol for assessing the impact of an integrated management model for the care of patients with COPD. The new model will be evaluated in terms of 1) improvement in the rational utilization of health-care services and 2) benefits reflected in improved health status and quality of life for patients.Methods/DesignA quasi-experimental study of the effectiveness of a COPD management model called COPD PROCESS. The patients in the study cohorts will be residents of neighborhoods served by two referral hospitals in Barcelona, Spain. One area comprises the intervention group (n = 32,248 patients) and the other the control group (n = 32,114 patients). The study will include pre- and post-intervention assessment 18 months after the program goes into effect. Analyses will be on two datasets: clinical and administrative data available for all patients, and clinical assessment information for a cohort of 440 patients sampled randomly from the intervention and control areas. The main endpoints will be the hospitalization rates in the two health-care areas and quality-of-life measures in the two cohorts.DiscussionThe COPD PROCESS model foresees the integrated multidisciplinary management of interventions at different levels of the health-care system through coordinated routine clinical practice. It will put into practice diagnostic and treatment procedures that are based on current evidence, multidisciplinary consensus, and efficient use of available resources. Care pathways in this model are defined in terms of patient characteristics, level of disease severity and the presence or absence of exacerbation. The protocol covers the full range of care from primary prevention to treatment of complex cases.

Serum immunoglobulins in the infected and convalescent phases in community-acquired pneumonia

BACKGROUNDnA population-based case-control study was designed to assess changes of serum levels of immunoglobulins and IgG subclasses between infected and convalescent phase in community-acquired pneumonia (CAP).nnnMETHODSnOver a 2-year period, all subjects who were >14 years of age living in the Maresme region (Barcelona, Spain) diagnosed of CAP were registered. Controls were healthy subjects selected from the municipal census. Prognostic factors were assessed and serum levels of total IgG, IgA, IgM, and IgG subclasses were measured at diagnosis and 1 month later (cases).nnnRESULTSnWe studied 171 patients with CAP and 90 controls. All immunoglobulins were significantly lower in cases than in controls. At diagnosis, 42.7% of cases showed low levels of some immunologic parameter, mainly total IgG and IgG2. Low immunoglobulin levels at diagnosis were more frequent in patients requiring in-patient care and in those with pneumonia of other etiology than Streptococcus pneumoniae. In the convalescent phase, 26 (23.6%) patients normalized immunological levels. In 27 (24.5%) cases, some parameter with low levels persisted especially in patients with etiology of CAP other than S. pneumoniae.nnnCONCLUSIONSnLow serum levels of immunoglobulins particularly total IgG and IgG2 were a common finding in patients with CAP compared to healthy controls. Low immunoglobulin levels may be related to CAP prognosis and persisted in the convalescent phase in one-fourth of cases.

Relationship between the Use of Inhaled Steroids for Chronic Respiratory Diseases and Early Outcomes in Community-Acquired Pneumonia

Background The role of inhaled steroids in patients with chronic respiratory diseases is a matter of debate due to the potential effect on the development and prognosis of community-acquired pneumonia (CAP). We assessed whether treatment with inhaled steroids in patients with chronic bronchitis, COPD or asthma and CAP may affect early outcome of the acute pneumonic episode. Methods Over 1-year period, all population-based cases of CAP in patients with chronic bronchitis, COPD or asthma were registered. Use of inhaled steroids were registered and patients were followed up to 30 days after diagnosis to assess severity of CAP and clinical course (hospital admission, ICU admission and mortality). Results Of 473 patients who fulfilled the selection criteria, inhaled steroids were regularly used by 109 (23%). In the overall sample, inhaled steroids were associated with a higher risk of hospitalization (OR=1.96, p = 0.002) in the bivariate analysis, but this effect disappeared after adjusting by other severity-related factors (adjusted OR=1.08, p=0.787). This effect on hospitalization also disappeared when considering only patients with asthma (OR=1.38, p=0.542), with COPD alone (OR=4.68, p=0.194), but a protective effect was observed in CB patients (OR=0.15, p=0.027). Inhaled steroids showed no association with ICU admission, days to clinical recovery and mortality in the overall sample and in any disease subgroup. Conclusions Treatment with inhaled steroids is not a prognostic factor in COPD and asthmatic patients with CAP, but could prevent hospitalization for CAP in patients with clinical criteria of chronic bronchitis.

Spirometric Standards and Patient Characteristics: An Exploratory Study of Factors Affecting Fulfillment in Routine Clinical Practice

BACKGROUND: Spirometry is an apparently simple test, yet the recommended criteria for acceptability and reproducibility can be difficult to fulfill. This study aimed (1) to prospectively assess the number of tests that meet the American Thoracic Society/European Respiratory Society (ATS/ERS) 2005 acceptability and repeatability criteria in the routine practice of an experienced technician at a referral hospitals lung function laboratory, (2) to identify the most common errors, and (3) to explore patient characteristics possibly associated with failure to meet standards. METHODS: We prospectively evaluated 257 consecutive spirometries supervised by the same technician, who gave priority to achieving a minimum of 3 correct maneuvers within a maximum of 8 attempts. We recorded FVC, FEV1, expiratory time (TE), back-extrapolated volume (VE), end-of-test volume (VEOT), number of maneuvers with and without errors, and errors (VE > 0.15 L or 5% of FVC, TE < 6 s, and VEOT ≥ 0.025 L for ≥ 1 s). RESULTS: Two-hundred and fifteen spirometries (83.7%, 95% CI 78.6–87.7%) met the ATS/ERS 2005 criteria. Acceptability criteria were met in 73.9% (95% CI 71.2–76.3%) of the maneuvers and repeatability criteria in 90.7% (95% CI 86.5–93.6%). A mean ± SD of 3.3 ± 1.4 per subject was acceptable, and a mean ± SD of 4.5 ± 1.9 was obtained. TE and VEOT errors were the most common. CONCLUSIONS: Nearly 15% of the subjects failed to fulfill all the ATS/ERS 2005 criteria for spirometry performed even though they were coached by a qualified and regularly trained technician in a hospital lung function laboratory. The fact that the ATS/ERS 2005 criteria cannot be met by all patients in optimal technical conditions should be further considered and explored.

Passive smoking at home is a risk factor for community-acquired pneumonia in older adults: a population-based case-control study

Objective To assess whether passive smoking exposure at home is a risk factor for community-acquired pneumonia (CAP) in adults. Setting A population-based case-control study was designed in a Mediterranean area with 860u2005000 inhabitants >14u2005years of age. Participants 1003 participants who had never smoked were recruited. Primary and secondary outcome measures Risk factors for CAP, including home exposure to passive smoking, were registered. All new cases of CAP in a well-defined population were consecutively recruited during a 12-month period. Methods A population-based case-control study was designed to assess risk factors for CAP, including home exposure to passive smoking. All new cases of CAP in a well-defined population were consecutively recruited during a 12-month period. The subgroup of never smokers was selected for the present analysis. Results The study sample included 471 patients with CAP and 532 controls who had never smoked. The annual incidence of CAP was estimated to be 1.14 cases×10–3 inhabitants in passive smokers and 0.90×10−3 in non-passive smokers (risk ratio (RR) 1.26; 95% CI 1.02 to 1.55) in the whole sample. In participants ≥65u2005years of age, this incidence was 2.50×10−3 in passive smokers and 1.69×10−3 in non-passive smokers (RR 1.48, 95% CI 1.08 to 2.03). In this last age group, the percentage of passive smokers in cases and controls was 26% and 18.1%, respectively (p=0.039), with a crude OR of 1.59 (95% CI 1.02 to 2.38) and an adjusted (by age and sex) OR of 1.56 (95% CI 1.00 to 2.45). Conclusions Passive smoking at home is a risk factor for CAP in older adults (65u2005years or more).

Risk factors for community-acquired pneumonia in adults: Recommendations for its prevention

Community-acquired pneumonia (CAP) remains an important cause of morbidity and mortality in developed countries. The disease is one of the top 10 causes of death and up to the present time, standard aggressive medical care has not resulted in a decrease in mortality. Knowledge of risk factors for CAP is essential to the design of preventive measures to reduce its incidence. Preventive strategies promoting effective vaccines or identifying and acting on modifiable risk factors are of paramount importance in reducing CAP-related death. Most studies have been performed in patients referred for inpatient care or in CAP cases in which a specific pathogen has been identified, but data from population-based studies are scarcer. We present a review of the main risk factors for CAP in adults, classified in the following categories: (a) Comorbidities and their treatments, (b) demographic and socioeconomic factors, (c) lifestyle factors and (d) environmental factors. We conclude with some brief recommendations on preventive measures and vaccination.

Características de la enfermedad pulmonar obstructiva crónica en fase estable relacionadas con la inflamación sistémica

BACKGROUND AND OBJECTIVEnChronic obstructive pulmonary disease (COPD) is characterized by a systemic inflammation. The aim of this study was to evaluate the association between systemic inflammation, measured with C reactive protein (CRP), and clinical and functional outcomes of the disease.nnnPATIENTS AND METHODSnA randomized sample of 413 COPD patients from 31 primary health care centers of Barcelona was evaluated. Medical history, anthropometric measurements, toxic habits, treatments, Chronic Respiratory Questionnaire (CRQ) and dyspnea were registered. Spirometry, exhaled CO concentration and CRP in capillary blood were performed.nnnRESULTSnMedian (standard deviation) of the age was 72 (8.4) years and forced expiratory volume in one second (FEV(1)) postbronchodilatador 1.65 (0.65) l. The correlation was negative between CRP and FEV(1) postbronchodilatador(r=-0.25, P<0.001) and between CRP and CRQ scores (r=-0.098, P=0.048) and positive between CRP and CO (r=0.1, P=0.039). The ratio of patients with elevated CRP was higher in advanced GOLD stage (P<0.001), worst dyspnea (P=0.042), patients treated with inhaled corticosteroids (P=0.018) and if they had been hospitalized during the last year (P=0.026). The multivariant analysis showed, as independent factors of elevated CRP, FEV(1) postbronchodilator and CO concentration.nnnCONCLUSIONnIn COPD patients, active smoking habit and the airways obstruction degree are associated with a greater intensity of the inflammatory systemic response measured by the CRP.

El control del cáncer de pulmón en España: un análisis de la situación actual. Informe SESPAS 2008

Resumen El cancer de pulmon es actualmente la causa mas frecuente de muerte por cancer en el mundo. Por ello, es pertinente analizar periodicamente el desarrollo y los resultados de las estrategias dirigidas a reducir su incidencia, mortalidad y morbilidad en Espana. Aspectos preventivos La reduccion de la mortalidad por cancer de pulmon entre los hombres contrasta con el incremento observado entre las mujeres, lo cual plasma los cambios experimentados en la exposicion al tabaco durante las ultimas decadas. Es necesario desarrollar programas de prevencion dirigidos especificamente a las mujeres y a los jovenes y, asimismo, ampliar y aplicar en toda su extension la vigente Ley de Prevencion del Tabaquismo. Aspectos relacionados con el diagnostico precoz De momento no hay suficiente evidencia cientifica para iniciar ningun cribado poblacional del cancer de pulmon. Son necesarios unos circuitos asistenciales preferentes que aseguren la coordinacion entre centros y niveles asistenciales y reduzcan sustancialmente las demoras actuales en el diagnostico y el tratamiento del cancer de pulmon. Aspectos relacionados con el tratamiento Todos los pacientes con cancer de pulmon deberian tratarse sobre la base de decisiones colegiadas y la evidencia cientifica. La atencion paliativa ha de recibir la misma prioridad que los tratamientos oncologicos. Hay que incrementar la participacion de los pacientes con cancer de pulmon en las decisiones terapeuticas que les atanen. Se requieren mejores sistemas de informacion para la evaluacion y la investigacion clinica de esta enfermedad.