Marc Miravitlles

Attitudes Toward the Diagnosis of Chronic Obstructive Pulmonary Disease in Primary Care

OBJECTIVEnAlthough the prevalence of chronic obstructive pulmonary disease (COPD) has increased among women, it is still considered a disease that mainly affects men. This study aimed to identify the diagnostic attitudes of primary care physicians toward patients with COPD according to gender and spirometric results.nnnMETHODSnA representative sample of 839 primary care physicians participated in the study. Each physician dealt with 1 of 8 hypothetical cases based on a patient diagnosed with COPD. In half the cases, the physician was told the patient was a man. The other half of the physicians were told the same patient was a woman. After presentation of the medical history and results of physical examination, the physicians were asked to state a probable diagnosis and indicate the diagnostic tests that were necessary. They were then told the results of spirometry, which indicated obstruction ranging from moderate to severe. Negative results of bronchodilator tests and oral corticosteroid tests were then communicated.nnnRESULTSnCOPD was more likely to be the preliminary diagnosis for male patients than for females (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.15-2.1). This gender bias disappeared once the physicians were shown the abnormal results of spirometry. Patients with severe obstruction were more likely to be diagnosed with COPD than those with moderate obstruction (OR, 1.5; 95% CI, 1.08-2.09).nnnCONCLUSIONSnThere is gender bias in the diagnosis of COPD. Patients with moderate obstruction are often believed not to have COPD. These biases may compromise the early diagnosis of the disease in a group of patients with ever increasing risk.

Results of a case-detection programme for α1-antitrypsin deficiency in COPD patients

α1-Antitrypsin (α1-AT) deficiency is an underdiagnosed condition in patients with chronic obstructive pulmonary disease (COPD). The present authors have conducted a nationwide case detection programme of α1-AT deficiency in unselected patients with COPD using dried blood spots. The first phase analysed samples from 971 patients by determining α1-AT concentrations and identifying the deficient Z allele by genotyping using rapid real-time PCR. The second phase analysed 1,166 samples with α1-AT concentrations and identified both the S and the Z allele, but only in samples with low α1-AT concentrations. A total of eight (0.37%) individuals with the severe deficiency PiZZ were detected. In addition, three patients were identified with the PiSZ genotype in the second phase (0.3%). The global cost of the programme was #8364;41,512, which represents #8364;19.42 per sample and #8364;5,189 per PiZZ detected. A sensitivity analysis demonstrated that performing Z genotype to all samples would have resulted in increased costs of #8364;28 per sample and #8364;7,479.5 per PiZZ case identified. In conclusion, a case detection programme of α1-antitrypsin deficiency in patients with chronic obstructive pulmonary disease using dried blood spots is feasible and at a reasonable cost per case detected. Diagnostic yield and costs depend largely on inclusion criteria and the protocol for processing of samples.

Moxifloxacino frente a amoxicilina en el tratamiento de la neumonía adquirida en la comunidad en América Latina. Resultados de un ensayo clínico multicéntrico

Since community-acquired pneumonia (CAP) is a common disease with a high morbidity rate, it is important to obtain information concerning its etiology and susceptibility to antibiotics across different geographic areas. This study presents data obtained in 5 Latin American counties in the course of an international clinical trial that evaluated the efficacy and safety of treatment with either moxifloxacin or amoxicillin administered for 10 days to patients suspected of having CAP caused by a pneumococcal infection. Details are given of the pathogens identified, the patterns of sensitivity to antibiotics observed, and the clinical and microbiological results obtained.A total of 84 patients were studied, of whom 70 (83.3%) were evaluated at the end of the trial to determine the efficacy and safety of the treatment received. Gram-positive bacteria were found in samples from 29 patients (80.5%). The pathogen was Streptococcus pneumoniae in 28 of those cases (77.7%). Gram-negative bacteria were found in 7 patients (19.4%), the most common being Haemophilus influenzae in 3 patients (8.3%). The presence of atypical microorganisms was detected in 18 of the 70 patients (25%), mainly Mycobacterium pneumoniae (n=11), and in 6 cases (8.5%) the infection was mixed. Ten strains of S. pneumoniae (35.7%) were shown to be susceptible to penicillin, 2 (7.1%) were highly resistant, and 16 (57.1%) showed moderate resistance. The clinical success rate at the final visit after treatment was 94.1% for moxifloxacin and 91.7% for amoxicillin. The results of this trial demonstrate a high prevalence of S. pneumoniae with reduced susceptibility to penicillin in patients with CAP in Latin America. It also revealed a high incidence of atypical pathogens and mixed infection in 8.6% of patients. This information should be taken into account when establishing protocols for empirical treatment of CAP in Latin America.

Programa de cribado para el déficit de α-antitripsina en pacientes con EPOC mediante el uso de gota de sangre en papel secante

El deficit de α-antitripsina (AAT) es una enfermedad in-fradiagnosticada, por lo que se recomienda establecer pro-gramas de cribado en pacientes con EPOC. Presentamos los resultados de la fase piloto de un programa de cribado del deficit de AAT, con el objetivo de evaluar la tecnica utiliza-da, los circuitos de envio de muestras y los resultados obte-nidos Participaron en el estudio 5 centros, que recogieron du-rante el periodo de un mes muestras de todos los pacientes con EPOC en los que nunca se hubieran determinado las concentraciones plasmaticas de AAT o el fenotipo Pi. Se aplicaron gotas de sangre capilar sobre discos de papel se-cante, que posteriormente se enviaban por correo postal al laboratorio central del estudio. Las muestras se procesaron para la determinacion cuantitativa de los valores de AAT mediante un metodo de inmunonefelometria y, para la de-terminacion del genotipo de AAT, con un analizador de ADN del tipo LightCycler. Se analizaron muestras de 86 pa-cientes con EPOC (76 varones, 10 mujeres) con una edad media de 68,2 anos. En 74 pacientes (86%) se descarto el de-ficit por presentar concentraciones de AAT por encima del punto de corte establecido, aunque uno de ellos fue heteroci-goto MZ por genotipificacion. De los 12 restantes (13,9%), solo 2 individuos presentaban tambien un alelo Z. El resto correspondio a pacientes con concentraciones por debajo del umbral establecido y sin evidencia del alelo Z (10 pacientes; 11,6%). La frecuencia observada del alelo Z (3/172; 1,74%) es muy similar a la encontrada en la poblacion general Los resultados de esta fase inicial permiten comprobar el correcto funcionamiento del circuito utilizado para la obten-cion y envio de las muestras. Es un metodo aplicable, como-do y bien aceptado por los medicos participantes y permite la cuantificacion de AAT, asi como la deteccion del alelo de-ficitario Z en las muestras con una excelente correlacion con las tecnicas estandar que usan muestras de sangre total

Manejo de la enfermedad pulmonar obstructiva crónica en la medicina primaria

En el tratamiento del paciente con EPOC hemos de tener en cuenta tres elementos de intervención: a) La aplicación de aquellas medidas terapéuticas potencialmente eficaces, seleccionadas de forma individualizada para cada caso, en base a las características que dominan el trastorno de la función respiratoria. b) El adiestramiento del paciente para que se adapte y se sienta capacitado para vivir con su limitación funcional. c) La mejoría de la calidad de vida, la cual no siempre depende de intervenciones estrictamente terapéuticas, sino también de otros factores de índole emotiva como la seguridad de una pronta, cómoda y eficaz atención o el mantenimiento de la propia autoestima en función de su capacidad para realizar por sí mismo las actividades cotidianas. Evidentemente, para poner en práctica estos elementos se requiere de un equipo multidisciplinar integrado por diferentes profesionales: neumólogo, fisioterapeuta, enfermera/o y médico de atención primaria son, entre otros, en los que recae en mayor medida la actividad de este equipo. Si tenemos en cuenta que el paciente con EPOC requiere tres diferentes niveles de intervención, hospitalario, ambulatorio y domiciliario, resulta igualmente evidente que, como en otras enfermedades crónicas, el eje establecido entre el especialista (en este caso el neumólogo) y el equipo de atención primaria es esencial para el adecuado mantenimiento de estos pacientes. Sin embargo, el intento de delimitar las funciones de cada uno de estos dos profesionales no resulta nada fácil, y no precisamente porque la personalidad típicamente individualista del médico le haga poco proclive al trabajo en equipo, sino porque tropezamos con multitud de defectos organizativos y de infraestructura de nuestro sistema sanitario, los cuales dificultan

Accuracy of a New Algorithm to Identify Asthma–COPD Overlap (ACO) Patients in a Cohort of Patients with Chronic Obstructive Airway Disease

OBJECTIVESnWe aimed to characterize the clinical, functional and inflammatory features of patients diagnosed diagnosed with ACO according to a new algorithm and to compare them with those of other chronic obstructive airway disease (COAD) categories (asthma and COPD).nnnMETHODSnACO was diagnosed in a cohort of COAD patients in those patients with COPD who were either diagnosed with current asthma or showed significant blood eosinophilia (≥300cells/μl) and/or a very positive bronchodilator response (>400ml and >15% in FEV1).nnnRESULTSnEighty-seven (29.8%) out of 292 patients fulfilled the ACO diagnostic criteria (12.8% asthmatics who smoked <20 pack-years, 100% of asthmatics who smoked ≥20 pack-years, 47.7% of COPD with >200eosinophils/μl in blood and none with non-eosinophilic COPD). ACO, asthma and COPD patients showed no differences in symptoms or exacerbation rate. Mean pre-bronchodilator FEV1 in ACO and asthma were similar (1741 vs 1771ml), higher than in COPD (1431ml, p<0.05). DLCO was lower in ACO than in asthma (68.1 vs 84.1%) and similar to COPD (64.5%). Mean blood eosinophil count was similar in ACO and asthma (360 vs 305cells/μl) and higher than in COPD (170cells/μl). Periostin levels were similar in ACO to COPD (36.6 and 36.5IU/ml) and lower than in asthma (41.5IU/ml, p<0.05), whereas FeNO levels in ACO were intermediate.nnnCONCLUSIONnThis algorithm classifies as ACO all smoking asthmatics with non-fully reversible airway obstruction and a considerable proportion of e-COPD patients, highlighting those who can benefit from inhaled corticosteroids.

Importancia de la medición de la interleucina 6 en suero como mediador de inflamación sistémica en pacientes con deficiencia de alfa-1-antitripsina

El objetivo de este estudio fue conocer si la actividad in-flamatoria sistemica que presentan los enfermos con deficiencia de alfa-l-antitripsina (DAAT) puede estar condicio-nada en parte por concentraciones circulantes elevadas de interleucina (IL) 6 y/o de su receptor soluble (RSIL-6). Con este objetivo se cuantificaron las concentraciones de la IL-6 y del RSIL-6 en suero de 7 pacientes con DAAT en fase estable. La edad media de los pacientes era de 51 anos (DE, 5,2) y el volumen espiratorio forzado en el primer segundo (FEV 1 ) medio, del 35,5% (DE, 15%). La concentracion de la IL-6 y de su RSIL-6 se comparo con las concentraciones de estas sustacias en un grupo de 23 pacientes con enfermedad pulmonar obstructiva cronica (EPOC) sin DAAT y con similar alteracion funcional respiratoria (edad media, 63 anos [DE, 10,1], FEV 1 , del 38,3% [DE, 11%]) Los pacientes con DAAT presentaron unos valores medios de IL-6 de 4,7xa0pg/ml (amplitud intercuartil [AI], 4,0) y de RSIL-6 de 29,1xa0ng/ml (AI, 31,5). Los pacientes con EPOC presentaron unos valores de IL-6 de 4,1xa0pg/ml (AI, 4,2) y de RSIL-6 de 140,8xa0ng/ml (AI, 71). No se observaron diferen-cias significativas entre las concentraciones halladas para ambas citocinas entre los pacientes con DAAT y el grupo EPOC (prueba no parametrica de la U de Mann-Whitney; p > 0,05). Tan solo un paciente con DAAT presento concen-traciones de IL-6 por encima de las consideradas normales En conclusion, las concentraciones sericas de IL-6 y RSIL-6 en pacientes con DAAT no son diferentes de las halladas en pacientes con EPOC con similar alteracion funcional respiratoria y concentraciones normales de alfa-1-antitripsina (AAT). Estos resultados no apoyan el papel de dicha citocina en la es-timulacion inflamatoria sistemica en pacientes con DAAT

Clinical and inflammatory characteristics of Asthma-COPD overlap in workers with occupational asthma

Introduction Although Asthma-COPD Overlap (ACO) has been described among populations of subjects with COPD or asthma, ACO has never been described among a population of subjects with occupational asthma (OA). Objectives The aims of this study were to: 1. identify ACO in a population of subjects with OA; and 2. compare the clinical characteristics between ACO and OA. Methods This retrospective study included all subjects diagnosed with OA between 2000 and 2017 in an OA referral center. Occupational Asthma-COPD Overlap (OACO) was defined as post-bronchodilator FEV1/FVC < 70% and smoking history ≥ 10 pack-years, along with a diagnosis of OA. Results Three hundred and four subjects were included, 262 (86.2%) were classified as OA and 42 (13.8%) as OACO. OA subjects presented higher sputum eosinophil counts after a specific-inhalation challenge than subjects with OACO (median [IQR]: 6.5 [17.0] vs 2.3 [3.5]). After adjusting for confounding factors, subjects with OACO were older (OR: 1.10 [1.05; 1.14]) and were taking higher doses of inhaled corticosteroids than OA subjects (OR, 5.20 [1.77; 16.48]). Subjects with OACO were less often atopic than OA subjects (OR, 0.19 [0.07; 0.62]). Conclusions Subjects with OACO constitute a distinct clinical and inflammatory phenotype from subjects with OA.