Inmaculada Alfageme Michavila

Clinical Application of the COPD Assessment Test: Longitudinal Data From the COPD History Assessment in Spain (CHAIN) Cohort

OBJECTIVE The COPD Assessment Test (CAT) has been proposed for assessing health status in COPD, but little is known about its longitudinal changes. The objective of this study was to evaluate 1-year CAT variability in patients with stable COPD and to relate its variations to changes in other disease markers. METHODS We evaluated the following variables in smokers with and without COPD at baseline and after 1 year: CAT score, age, sex, smoking status, pack-year history, BMI, modified Medical Research Council (mMRC) scale, 6-min walk distance (6MWD), lung function, BODE (BMI, obstruction, dyspnea, exercise capacity) index, hospital admissions, Hospital and Depression Scale, and the Charlson comorbidity index. In patients with COPD, we explored the association of CAT scores and 1-year changes in the studied parameters. RESULTS A total of 824 smokers with COPD and 126 without COPD were evaluated at baseline and 441 smokers with COPD and 66 without COPD 1 year later. At 1 year, CAT scores for patients with COPD were similar (± 4 points) in 56%, higher in 27%, and lower in 17%. Of note, mMRC scale scores were similar (± 1 point) in 46% of patients, worse in 36%, and better in 18% at 1 year. One-year CAT changes were best predicted by changes in mMRC scale scores (β-coefficient, 0.47; P < .001). Similar results were found for CAT and mMRC scale score in smokers without COPD. CONCLUSIONS One-year longitudinal data show variability in CAT scores among patients with stable COPD similar to mMRC scale score, which is the best predictor of 1-year CAT changes. Further longitudinal studies should confirm long-term CAT variability and its clinical applicability. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01122758; URL: www.clinicaltrials.gov.

Cyclooxygenase-2 polymorphisms confer susceptibility to sarcoidosis but are not related to prognosis.

BACKGROUND The aim of this multicenter study was to investigate the relationship between single nucleotide polymorphisms (SNPs) of the cyclooxygenase-2 (COX2) gene and susceptibility to sarcoidosis, as well as the relation between these SNPs and the evolution of the disease. MATERIAL AND METHODS This multicenter investigation involved seven hospitals in Spain. We used a case-control design followed by a prospective follow-up study. Sarcoid patients were recruited from the participating institutions during outpatient routine visits. Age- and gender-matched control subjects were recruited mainly from among outpatients attending the participating hospitals. Four SNPs in the COX2 gene (COX2.5909 T > G, COX2.8473 T > C, COX2.926 G > C, and COX2.3050 G > C) were genotyped using fluorescent hybridization probes among 131 patients with sarcoidosis (63 males; mean age: 47 +/- 15 years) and 157 healthy controls (83 males; mean age: 50 +/- 16 years). We employed a binomial multiple logistic regression analysis to test the association between the selected SNPs and disease susceptibility. The clinical, functional and radiological prognosis of the sarcoidosis patients was determined after a mean follow-up of 37.4 +/- 30.4 months. RESULTS Carriers of the homozygous CC genotype of the COX2.8473 T > C polymorphism had a higher risk of sarcoidosis compared with TT carriers (OR: 3.08; 95% CI: 1.2-7.7; p = 0.035). 84% of patients achieved improvement or complete remission at follow-up. No association between the investigated SNPs and prognosis was seen. CONCLUSIONS Our data suggest that the homozygous CC genotype of the COX2.8473 T > C polymorphism may be associated with sarcoidosis susceptibility. No significant association with prognosis was detected.

Prevalencia, conocimiento y actitudes acerca del consumo de tabaco en los miembros de SEPAR

The aims of this study were to estimate the prevalence of smoking among SEPAR members, and their approach to smoking cessation in their patients. An online survey was completed by 640 members (496 pulmonologists, 45 nurses, 34 thoracic surgeons, 37 physiotherapists, and 28 other specialists). Of the members interviewed, 5% confessed that they were smokers: 3.5% pulmonologists; 8.9% nurses; 8.8% thoracic surgeons, and 13.5% physiotherapists. A total of 96% of members assign a lot or quite a lot of importance to setting an example; 98% of members always or often ask their patients about their smoking habit. The most effective anti-smoking intervention, according to 77% of members, is a combination of drugs and psychological support. These results are an indicator of the awareness and commitment of SEPAR members to smoking and its cessation.

Recomendaciones para la evaluación médica de la capacidad laboral en el enfermo respiratorio crónico

Chronic respiratory diseases often cause impairment in the functions and/or structure of the respiratory system, and impose limitations on different activities in the lives of persons who suffer them. In younger patients with an active working life, these limitations can cause problems in carrying out their normal work. Article 41 of the Spanish Constitution states that «the public authorities shall maintain a public Social Security system for all citizens guaranteeing adequate social assistance and benefits in situations of hardship». Within this framework is the assessment of fitness for work, as a dual-nature process (medico-legal) that aims to determine whether it is appropriate or not to recognise a persons right to receive benefits which replace the income that they no longer receive as they cannot carry out their work, due to loss of health. The role of the pulmonologist is essential in evaluating the diagnosis, treatment, prognosis and functional capacity of respiratory patients. These recommendations seek to bring the complex setting of fitness for work evaluation to pulmonologists and thoracic surgeons, providing action guidelines that allow them to advise their own patients about their incorporation into working life.

Qué ha cambiado en la neumonía adquirida en la comunidad en los últimos años

La neumonía adquirida en la comunidad (NAC) incluye un amplio espectro de presentaciones que oscilan desde un cuadro leve a formas más graves que pueden necesitar ingreso hospitalario e incluso estancia en la UCI. En personas mayores de 65 años es una de las principales causas de mortalidad y la mayor dentro de las enfermedades infecciosas1. Que continúa siendo un problema actual, lo pone de manifiesto un reciente estudio que demuestra un incremento de hasta el 8,8% de las hospitalizaciones en los últimos años, y un aumento de su etiología por enterobacteriáceas2. Desde la aparición de la gripe A y con el uso cotidiano de las técnicas de detección molecular hay cada vez mayor evidencia de la participación de los virus como agentes etiológicos y/o acompañantes de las NAC. En general, el virus influenza A y el virus sincitial respiratorio siguen siendo los principales virus implicados. Sin embargo, la irrupción en los últimos años de epidemias con alta letalidad de coronavirus y de zoonosis de virus influenza hace que sea necesario mostrarse alerta ante estos nuevos patógenos emergentes3. Las neumonías víricas han modificado las comorbilidades previamente incluidas en las escalas de riesgo como factores de gravedad, y así, otros factores como la obesidad y la gestación se han considerado factores de gravedad en este tipo de neumonías. La valoración del riesgo siempre ha estado dirigida a predecir la mortalidad intrahospitalaria, sin embargo, hay evidencias que indican un incremento en la mortalidad a los 30 días después de una NAC, e incluso en los siguientes 5 años, debido principalmente a enfermedades cardiológicas. También dan lugar a tasas de reingresos de hasta el 18%, por la misma neumonía o por complicaciones extrapulmonares, fundamentalmente cardiovasculares4, así como a retrasos en la reincorporación a la actividad cotidiana, sobre todo de personas mayores. Por tanto, las escalas pronósticas tal vez no deberían limitarse a evaluar la mortalidad a corto plazo o intrahospitalaria, sino que tendrían que ser capaces de predecir otras variables importantes en la supervivencia y calidad de vida de los pacientes que sufren una NAC. Por otra parte, estas escalas no son exactas para predecir la gravedad de la NAC y, por tanto, la ubicación adecuada para

Valoración de la discapacidad en los enfermos respiratorios

The evaluation of the disabilities of patients with respiratory disease is regulated by the Spanish Ministry of Labor and Social Security, as are disabilities of any other type. We believe, however, that in respiratory pathologies this evaluation is especially complicated because, as they are chronic processes, they inter-relate with other systems. Furthermore, they tend to have occasional exacerbations; therefore, normal periods may alternate with other periods of important functional limitations. The present document arises from the desire of SEPAR to update this topic and to respond to the requests of respiratory disease patient associations who have asked us to do so. In this paper, we analyze the current situation of work disability legislation as well as the determination of degrees and percentages, including the current criteria for assigning disabilities due to respiratory tract deficiencies. Lastly, we propose work guidelines that would improve the existing scenario and outline this evaluation for specific pathologies.

Anticholinergics in the Management of COPD

pulmonary disease (COPD) has changed dramatically from defeatist to one of hope. COPD is no longer considered an irreversible bronchial obstruction but a multifactorial disease that includes a partially reversible obstructive component. In fact, depending on the evaluation criterion used, between 23% and 42% of patients present some degree of bronchodilator responsiveness, and this reversibility can be clinically noteworthy in patients with severe obstruction. There are numerous mechanisms that can cause chronic airflow limitation in COPD. The thickness of airway smooth muscle is almost normal and the strength of this muscle is hardly influenced by the degree of airflow obstruction. Such obstruction is therefore believed to be caused primarily by airway wall thickening and loss of elastic load owing to destruction of lung parenchyma and parenchymal attachments surrounding the airways. These irreversible structural changes enhance the effect of changes in airway muscle tone, which is regulated mainly by cholinergic activity. Overstimulation of muscarinic receptors M1 and M3 with acetylcholine leads to airway narrowing. Airways of patients with COPD present increased cholinergic tone, as reflected by the stronger bronchodilator effect of anticholinergic drugs. Cholinergic tone increases with the severity of obstruction; therefore the increase in airway caliber depends not only on the degree of smooth muscle relaxation but also on geometric factors. The obstruction produced by structural changes, such as thickening of the airway wall, increases the relaxation–contraction effect of the smooth muscle on the diameter of the airway, a factor which can be especially apparent in patients with greater airflow obstruction. Anticholinergics act by producing a competitive blockade of acetylcholine at the muscarinic cholinergic receptors, thus inhibiting bronchoconstriction and bronchial hypersecretion, thereby increasing airflow. Two such drugs are currently available: ipratropium bromide and tiotropium. Tiotropium is a new anticholinergic bronchodilator that is administered once daily and, unlike other anticholinergics, acts through prolonged antagonism of M3, thus sustaining airway patency for 24 hours. In patients with COPD, functional improvement after administration of bronchodilators is not always reflected in changes in forced expiratory volume in 1 second (FEV1); in fact, it is noteworthy that FEV1 is only weakly related to patientreported variables such as dyspnea, exercise tolerance, and health-related quality of life (HRQL). These 3 variables are the ones that have the most impact on patients’ perception of their disease and the resulting limitations; therefore, evaluation of other parameters—such as forced vital capacity, lung volume, or inspiratory capacity—may be necessary to document physiological improvement. In view of the above, continuous 24-hour cholinergic blockade in the airways has important repercussions on functional, clinical, and evolution parameters of patients with COPD. Casaburi et al showed that tiotropium had superior bronchodilator efficacy compared to placebo and ipratropium—the other available anticholinergic—by measuring increased FEV1. Furthermore, the improvement with tiotropium was sustained for the following 12 months with no tachyphylaxis. Tiotropium was also more effective compared with a placebo and ipratropium at improving dyspnea, exercise tolerance, dynamic and static hyperinflation, inspiratory capacity, and HRQL. Other authors such as Dusser et al and Niewoehner et al compared tiotropium with a placebo and found that treatment with tiotropium led to significant reduction in frequency of exacerbations and use of health care services among patients with moderate and severe COPD. The Cochrane Airways Group recently prepared a metaanalysis to determine the efficacy of tiotropium, other bronchodilators used to treat stable COPD, and a placebo on the principal variables of clinical evaluation, such as exacerbations, hospitalizations, symptom scales, and lung function. The results of 9 randomized controlled trials (a total of 6584 patients) were included in the meta-analysis. According to the findings, compared with placebo or ipratropium bromide, tiotropium reduced the odds of a COPD exacerbation (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.66-0.83) and related hospitalization (OR, 0.64; 95% CI, 0.51-0.82). When tiotropium was administered to patients with an annual baseline risk of exacerbations of 45% and related hospitalization of 10%, the number of patients needed to treat for 1 year with tiotropium, compared to placebo and ipratropium, was 14

Día mundial del pulmón

The Forum of International Respiratory Societies is better known by the acronym FIRS. FIRS is an association of the most important global health institutions dedicated to the advocacy of respiratory health. It was formed in 2001, and brings together more than 70 000 health professionals throughout the world who devote their lives to the prevention, control, diagnosis, and treatment of respiratory diseases.1 On September 25, 2017, the FIRS will celebrate “World Lung Day”. The main aim of this event is to raise awareness among the general public and also managers of public and private health systems of the immense global health problem generated by respiratory diseases: every year more than 4 million people die prematurely due to chronic respiratory diseases.2 Five respiratory diseases are responsible for this high mortality: COPD, asthma, lower respiratory infections, tuberculosis, and lung cancer.2,3 The first and last are caused mainly by the active and passive consumption of tobacco, although other causes have also been described: exposure to biomass fuel, fumes from car engines, radon, asbestos, and other known carcinogens. Although lower respiratory infections and tuberculosis are caused by well-defined etiological agents, the course and prognosis of these diseases are affected by voluntary or involuntary exposure to these contaminants. The disease course of asthma is similarly modulated by exposure to these substances.4 It is important to bear in mind that today, more than 2 billion people are exposed to toxic pollutants in the home, more than 1 billion are exposed to air pollution outside the home, and 1 billion are exposed to tobacco smoke.5 It is imperative to raise awareness of this among all stakeholders, including health and non-health workers, health managers and politicians, journalists, and associations of patients, so that together we can demand that decisions be made to ultimately control exposure to environmental tobacco

Preguntas y respuestas relacionadas con tabaquismo en pacientes con EPOC. Aplicación de metodología con formato PICO

The ALAT and SEPAR Treatment and Control of Smoking Groups have collaborated in the preparation of this document which attempts to answer, by way of PICO methodology, different questions on health interventions for helping COPD patients to stop smoking. The main recommendations are: (i)moderate-quality evidence and strong recommendation for performing spirometry in COPD patients and in smokers with a high risk of developing the disease, as a motivational tool (particularly for showing evidence of lung age), a diagnostic tool, and for active case-finding; (ii)high-quality evidence and strong recommendation for using intensive dedicated behavioral counselling and drug treatment for helping COPD patients to stop smoking; (iii)high-quality evidence and strong recommendation for initiating interventions for helping COPD patients to stop smoking during hospitalization with improvement when the intervention is prolonged after discharge, and (iv)high-quality evidence and strong recommendation for funding treatment of smoking in COPD patients, in view of the impact on health and health economics.

Editorial¿Qué ha cambiado en la neumonía adquirida en la comunidad en los últimos años?What has Changed in Community-Acquired Pneumonia in Recent Years?

La neumonía adquirida en la comunidad (NAC) incluye un amplio espectro de presentaciones que oscilan desde un cuadro leve a formas más graves que pueden necesitar ingreso hospitalario e incluso estancia en la UCI. En personas mayores de 65 años es una de las principales causas de mortalidad y la mayor dentro de las enfermedades infecciosas1. Que continúa siendo un problema actual, lo pone de manifiesto un reciente estudio que demuestra un incremento de hasta el 8,8% de las hospitalizaciones en los últimos años, y un aumento de su etiología por enterobacteriáceas2. Desde la aparición de la gripe A y con el uso cotidiano de las técnicas de detección molecular hay cada vez mayor evidencia de la participación de los virus como agentes etiológicos y/o acompañantes de las NAC. En general, el virus influenza A y el virus sincitial respiratorio siguen siendo los principales virus implicados. Sin embargo, la irrupción en los últimos años de epidemias con alta letalidad de coronavirus y de zoonosis de virus influenza hace que sea necesario mostrarse alerta ante estos nuevos patógenos emergentes3. Las neumonías víricas han modificado las comorbilidades previamente incluidas en las escalas de riesgo como factores de gravedad, y así, otros factores como la obesidad y la gestación se han considerado factores de gravedad en este tipo de neumonías. La valoración del riesgo siempre ha estado dirigida a predecir la mortalidad intrahospitalaria, sin embargo, hay evidencias que indican un incremento en la mortalidad a los 30 días después de una NAC, e incluso en los siguientes 5 años, debido principalmente a enfermedades cardiológicas. También dan lugar a tasas de reingresos de hasta el 18%, por la misma neumonía o por complicaciones extrapulmonares, fundamentalmente cardiovasculares4, así como a retrasos en la reincorporación a la actividad cotidiana, sobre todo de personas mayores. Por tanto, las escalas pronósticas tal vez no deberían limitarse a evaluar la mortalidad a corto plazo o intrahospitalaria, sino que tendrían que ser capaces de predecir otras variables importantes en la supervivencia y calidad de vida de los pacientes que sufren una NAC. Por otra parte, estas escalas no son exactas para predecir la gravedad de la NAC y, por tanto, la ubicación adecuada para