Víctor Bustamante

Redox balance following magnetic stimulation training in the quadriceps of patients with severe COPD.

In severe COPD patients, oxidative stress, which is involved in their peripheral muscle dysfunction, increases in response to exercise. In this study, muscle oxidative stress was explored after quadriceps magnetic stimulation training. A randomized controlled study was conducted on very severe COPD patients, who underwent quadriceps magnetic stimulation training for 8 weeks. A control group was also studied. In both groups, vastus lateralis specimens were obtained before and after the 8-week period. Muscle protein carbonylation and nitration and antioxidant enzymes were determined using immunoblotting and proportions and sizes of type I and II fibres using immunohistochemistry. Compared to controls, magnetic stimulation muscle training did not modify redox balance, whilst inducing a significant increase in type I fibre sizes. In severe COPD patients, it is concluded that quadriceps magnetic stimulation training was a well-tolerated therapeutic intervention, which did not enhance muscle oxidative stress, while increasing the size of slow-twitch fibres.

Moving Towards Patient-Centered Medicine for COPD Management: Multidimensional Approaches versus Phenotype-Based Medicine—A Critical View

Abstract For decades, chronic obstructive pulmonary disease (COPD) has been considered a relentlessly progressive disease in which the deterioration of lung function is associated with an increase in symptoms, interrupted only by periods of exacerbation. However, this paradigm of COPD severity based on FEV1 has been challenged by currently available evidence. So far, three main approaches, though with contradictory aspects, have been proposed in order to address the complexity of COPD as well as to develop appropriate diagnostic, prognostic and therapeutic strategies for the disease: 1) the use of independent, clinically relevant variables, 2) the use of multidimensional indices, and 3) disease approaches based on clinical phenotypes. Multivariable systems seem superior to FEV1 in predicting prognosis and defining disease severity. However, selection of variables available from current literature must be confronted with issues of medical practice. Future evidence will be needed to reveal their effective relationship with disease long-term prognosis and to demonstrate the most adequate cutoff values to be used in clinical settings. Multidimensional scores provide a good prognostic instrument for the identification of patients with a particular degree of disease severity. Clinical phenotyping can help clinicians identify the patients who respond to specific pharmacological interventions; however, there is some controversy about the phenotypes to select and their long-term implications. Although these approaches are not perfect, they represent the first step towards patient-centered medicine for COPD. In the near-future, these different approaches should converge towards one new field to focus on the better management of COPD patients.

Usefulness of Noninvasive Methods for the Study of Bronchial Inflammation in the Control of Patients with Asthma

Bronchial asthma is one of the most prevalent respiratory conditions. Although it is defined as an inflammatory disease, the current guidelines for both diagnosis and follow-up of patients are based only on clinical and lung function parameters. Current research is focused on finding markers that can accurately predict future risk, and on assessing the ability of these markers to guide medical treatment and thus improve prognosis. The use of noninvasive methods to study airway inflammation is gaining increasing support. The study of eosinophils in induced sputum has proved useful for the diagnosis of asthma; however, its clinical implementation is complex. Some studies have shown that the measurement of exhaled nitric oxide (FeNO) may also be useful to establish disease phenotypes and improve control. Others have found that the measurement of pH and certain markers of oxidative stress, cytokines and prostanoids in exhaled breath condensate (EBC) may also be useful as well as the measurement of the temperature of exhaled breath and the analysis of volatile organic compounds (VOCs). In conclusion, since asthma is an inflammatory disease, it seems appropriate to try to control it through the study of airway inflammation using noninvasive methods. In this regard, the analysis of induced sputum cells has proved very useful, although the clinical implementation of this technique seems difficult. Other techniques such as temperature measurement, the analysis of FeNO, the analysis of the VOCs in exhaled breath, or the study of certain biomarkers in EBC require further study in order to determine their clinical applicability.

Evaluación económica e impacto presupuestario de un procedimiento de telemedicina para el control de calidad de las espirometrías en atención primaria

OBJECTIVE To evaluate the economic impact of a telemedicine procedure designed to improve the quality of lung function testing (LFT) in primary care in a public healthcare system, compared with the standard method. MATERIALS AND METHODS The economic impact of 9,039 LFTs performed in 51 health centers (2010-2013) using telespirometry (TS) compared to standard spirometry (SS) was studied. RESULTS TS costs more per unit than SS (€47.80 vs. €39.70) (2013), but the quality of the TS procedure is superior (84% good quality, compared to 61% using the standard procedure). Total cost of TS was €431,974 (compared with €358,306€ for SS), generating an economic impact of €73,668 (2013). The increase in cost for good quality LFT performed using TS was €34,030 (2010) and €144,295 (2013), while the costs of poor quality tests fell by €15,525 (2010) and 70,627€ (2013). CONCLUSION The cost-effectiveness analysis concludes that TS is 23% more expensive and 46% more effective. Healthcare costs consequently fall as the number of LFTs performed by TS rises. Avoiding poor quality, invalid LFTs generates savings that compensate for the increased costs of performing LFTs with TS, making it a cost-effective method.

Lights and shadows of non-invasive mechanical ventilation for chronic obstructive pulmonary disease (COPD) exacerbations.

Despite the overwhelming evidence justifying the use of non-invasive ventilation (NIV) for providing ventilatory support in chronic obstructive pulmonary disease (COPD) exacerbations, recent studies demonstrated that its application in real-life settings remains suboptimal. European clinical audits have shown that 1) NIV is not invariably available, 2) its availability depends on countries and hospital sizes, and 3) numerous centers declare their inability to provide NIV to all of the eligible patients presenting throughout the year. Even with an established indication, the use of NIV in acute respiratory failure due to COPD exacerbations faces important challenges. First, the location and personnel using NIV should be carefully selected. Second, the use of NIV is not straightforward despite the availability of technologically advanced ventilators. Third, NIV therapy of critically ill patients requires a thorough knowledge of both respiratory physiology and existing ventilatory devices. Accordingly, an optimal team-training experience, the careful selection of patients, and special attention to the selection of devices are critical for optimizing NIV outcomes. Additionally, when applied, NIV should be closely monitored, and endotracheal intubation should be promptly available in the case of failure. Another topic that merits careful consideration is the use of NIV in the elderly. This patient population is particularly fragile, with several physiological and social characteristics requiring specific attention in relation to NIV. Several other novel indications should also be critically examined, including the use of NIV during fiberoptic bronchoscopy or transesophageal echocardiography, as well as in interventional cardiology and pulmonology. The present narrative review aims to provide updated information on the use of NIV in acute settings to improve the clinical outcomes of patients hospitalized for COPD exacerbations.

Archivos de Bronconeumología recupera el factor de impacto

The impact factor is one of the best-known bibliometric indicators, if not the best, to evaluate the quality of journals in biomedical sciences and other fields of knowledge. Since quite a few years, the Institute of Scientific Information (ISI) Web of Knowledge platform, managed by Thomson Reuters, uses various parameters to monitor and assess good performance of scientific journals. From the data in the Web of Knowledge platform drafted annually, since 1997, a report on the various scientific journals, classified by disciplines, known as Journal Citation Report (JCR) is being developed. Of all the indicators published in this platform, the most commonly used by scientists and researchers’ curriculum evaluators is the impact factor.1 The impact factor is the index that assesses the influence of a journal on a particular discipline through the number of citations received from other journals within the same discipline or others, also included in the JCR. Thus, the higher the impact factor of a journal is, the greater its influence on the scientific community, and more specifically on the disciplines to which it belongs. These disciplines are identified as “categories” in the Web of Knowledge platform, which in the case of Archivos de Bronconeumología falls under the category of Respiratory System.1 Most of the journals usually belong to one single category, although there are journals that belong to two or even three categories. This provides them with a greater number of potential readers and/or authors interested in their contents, hence potentially increasing the number of citations of a given journal. In the category of the Respiratory System various journals share the same classification with Critical Care Medicine. The impact factor of a journal is defined as the ratio of the total number of citations from other journals (external citations) and from the journal itself (self-citations), to the number of articles published in the journal over the previous two years.1 The impact factor is calculated annually and always refers to the previous year and not to the current year. This is because it is not possible to calculate the total number of citations received in a given year until this has not finished. The Web of Knowledge platform is responsible for

Current controversies in the stepping up and stepping down of inhaled therapies for COPD at the patient level: Stepping up and down COPD therapies

The implementation of potential new step‐up or step‐down treatment recommendations in response to current guidelines is one of the main challenges currently faced in actual daily practice settings. In the present narrative review, we aim to discuss the relevance of these step‐up and step‐down proposals at the patient level in daily clinical practice. In particular, we aim to review the challenges associated with inhaled maintenance therapy for chronic obstructive pulmonary disease (COPD) in four clinical scenarios. First, we discuss the step up from single to double bronchodilation, including current controversies regarding the addition of a second bronchodilator versus initial treatment with two bronchodilators. Second, we discuss the step up from double bronchodilation to triple therapy while challenging current indications for inhaled steroid therapy and discussing triple therapy designs. Third, we discuss the step down from triple therapy to double bronchodilation while evaluating the effect of this downshift in risk categories on the patient according to the new classifications. Finally, we discuss the step down from double to single bronchodilation, with a special focus on safety. We believe this review will help to highlight the most relevant discussion points regarding the treatment of COPD in a manner that will stimulate and guide related clinical research.

El nombre de la EPOC: semiótica y precisión

Is it asthma or COPD? Solving this commonly encountered dilemma can lead us through a maze no less complex than the labyrinthine medieval library of the famous novel of the late author and semiotician, Umberto Eco. Perhaps Professor Eco could have helped us define what we understand as disease, syndrome, overlap, comorbidity, phenotype or endotype. Our intention here is to review these concepts in an attempt to avoid confusion and indiscriminate use.

Trasplante pulmonar: Año SEPAR 2013

“SEPAR years” aim to promoting different topics of particular interest in an area of respiratory medicine every year. The Spanish Society of Pneumology and Thoracic Surgery (SEPAR) has devoted the year 2013 to lung transplantation (LT) and has designed activities targeted to professionals, patients, and the general population in order to foster its development and raise the awareness of LT reality. Archivos de Bronconeumología has decided to join this initiative and has, therefore, lent its pages to a series of review articles in which renowned authors, national leaders in LT, have discussed relevant aspects. In Spain there are seven teams in charge of LT, who work in University hospitals and are geographically distributed as follows: Vall d’Hebron Hospital (Barcelona), La Fe Hospital(Valencia), Reina Sofía Hospital (Córdoba), A Coruña Hospital Complex, Marqués de Valdecilla Hospital (Santander), and Doce de Octubre and Puerta de Hierro-Majadahonda Hospitals (Madrid). Currently, cardiopulmonary transplantations are also performed in the last center as well as in Valencia and Cordoba hospitals, whereas pediatric transplantations are carried out in the center located in Barcelona and Córdoba. In all seven centers, a total of 200–250 interventions are performed each year,1 in patients coming from anywhere in the country. Such a figure is essentially limited by the availability of organ donors. Far from being an exception, LT has become a real example in our health system, intimately related to the National Transplant Organization, whose activity has enabled our health system to rank to the international leadership as to the number of transplantations.2 The high percentage of donations in Spain would not be understood without the awareness in our society on the relevance of this therapeutic resource, characterized by a universal and equal accessibility to all citizens, which is exclusively based on medical criteria and availability of graft organs. For the respiratory community, LT remains challenging, with various unsolved controversies and with results that still lie far away from those obtained in other organs’ transplantations, such as the heart, liver or kidney. For example, in adults subject to LT, the average probability of survival at one and three years is 72% and 60%, respectively. In the pediatric population, however, survival at