Determinants of lung disease progression measured by lung clearance index in children with cystic fibrosis.

The lung clearance index (LCI) measured by the multiple breath washout (MBW) test is sensitive to early lung disease in children with cystic fibrosis. While LCI worsens during the preschool years in cystic fibrosis, there is limited evidence to clarify whether this continues during the early school age years, and whether the trajectory of disease progression as measured by LCI is modifiable.A cohort of children (healthy and cystic fibrosis) previously studied for 12 months as preschoolers were followed during school age (5-10 years). LCI was measured every 3 months for a period of 24 months using the Exhalyzer D MBW nitrogen washout device. Linear mixed effects regression was used to model changes in LCI over time.A total of 582 MBW measurements in 48 healthy subjects and 845 measurements in 64 cystic fibrosis subjects were available. The majority of children with cystic fibrosis had elevated LCI at the first preschool and first school age visits (57.8% (37 out of 64)), whereas all but six had normal forced expiratory volume in 1 s (FEV1) values at the first school age visit. During school age years, the course of disease was stable (-0.02 units·year-1 (95% CI -0.14-0.10). LCI measured during preschool years, as well as the rate of LCI change during this time period, were important determinants of LCI and FEV1, at school age.Preschool LCI was a major determinant of school age LCI; these findings further support that the preschool years are critical for early intervention strategies.

Lung Clearance Index to Track Acute Respiratory Events in School-Age Children with Cystic Fibrosis.

Rationale: The lung clearance index (LCI) is responsive to acute respiratory events in preschool children with cystic fibrosis (CF), but its utility to identify and manage these events in school-age children with CF is not well defined.Objectives: To describe changes in LCI with acute respiratory events in school-age children with CF.Methods: In a multisite prospective observational study, the LCI and FEV1 were measured quarterly and during acute respiratory events. Linear regression was used to compare relative changes in LCI and FEV1% predicted at acute respiratory events. Logistic regression was used to compare the odds of a significant worsening in LCI and FEV1% predicted at acute respiratory events. Generalized estimating equation models were used to account for repeated events in the same subject.Measurements and Main Results: A total of 98 children with CF were followed for 2 years. There were 265 acute respiratory events. Relative to a stable baseline measure, LCI (+8.9%; 95% confidence interval, 6.5 to 11.3) and FEV1% predicted (-6.6%; 95% confidence interval, -8.3 to -5.0) worsened with acute respiratory events. A greater proportion of events had a worsening in LCI compared with a decline in FEV1% predicted (41.7% vs. 30.0%; P = 0.012); 53.9% of events were associated with worsening in LCI or FEV1. Neither LCI nor FEV1 recovered to baseline values at the next follow-up visit.Conclusions: In school-age children with CF, the LCI is a sensitive measure to assess lung function worsening with acute respiratory events and incomplete recovery at follow-up. In combination, the LCI and FEV1 capture a higher proportion of events with functional impairment.

Gestión de un policlínico de terapia de anticoagulación oral / Clinical gestion ambulatory oral anticoagulation therapy

Objetivo: Formulación de una auditoria para el policlínico de terapia de anticoagulación oral y determinar la gestión, en términos de parámetros de control y cumplimiento con el protocolo, antes y después de la implementación de una guía clínica de anticoagulación oral junto a un programa de educación de los pacientes, según los criterios internacionales. Método: Todos los pacientes con terapia crónica atendidos en el policlínico de anticoagulación del Hospital de Carabineros de Chile. Fueron incluidos en un estudio prospectivo. La pautas incluyeron INR <8,0, entre el rango 5-8, menos de 1,5 y el tiempo en los rangos +/- 0,5 y +/- 1,0 unidades del INR de la pauta. En Noviembre de 2007 y en Marzo de 2008 se efectuó un análisis completo del control de todos los pacientes. Entre los meses de Diciembre de 2007 y Febrero de 2008 se efectuó el análisis de una muestra resumen de todos los exámenes, entre los rangos de INR >8, entre 5 y 8, menos de 1,5. Resultados: Hubo una mejoría en el control de anticoagulación (p<0,02), con menos episodios de pacientes con un INR elevado (p<0,0000002). No hubo diferencias en el porcentaje de INR menor que 1,5. Hubo una mejoría en pacientes obteniendo el rango +/- 1,0 unidades del INR (p<0,05), pero no en el rango +/- 0,5 unidades. La mejoría se observó tanto entre los grupos, como en el control de cada paciente. Conclusiones: Se demostró que con educación del paciente y un control más estricto, es posible mejorar el control de anticoagulación en un policlínico de anticoagulación, disminuyendo el número de pacientes con un INR elevado y, por lo tanto, un elevado riesgo de hemorragia.

Objective: An audit of the clinical gestion of a ambulatory anticoagulation clinic, before and after implementing a clinical guide, an education programme for patients and management criteria based on international guidelines. Methods: All patients with oral anticoagulation attending the Outpatients clinic in the Hospital de Carabineros de Chile were included in the prospective study. Measured criteria included, percent of patients with an INR > 8, in the range 5-8 and < 1,5. The period of time with an INS +/- 0,5 and +/- 1,0 of the target INR was calculated. In November 2007 and March 2008 a complete analysis of all patients was carned out, while in December 2007 January and February 2008 a summary was analysed. Results: The overall control of anticoagulation significantly improved in the 4 month period (p<0.02), with less patients having an INR >5 (p<0.0000002), the percentage of patients with an INS <1.5 remained unchanged. The time spent within +/- 1.0 units INR significantly improved (p<0.05), although in the range +/- 0,5 there was no change. Conclusions: We have demonstrated that with patient education and stricter controls the management of outpatient anticoagulation can be improved in the short term, decreasing the number of patients with an INR > 5,0 with the risk of haemorrhage.