Spanish multidisciplinary consensus on the characteristics of severe asthma patients on biologic treatment who are candidates for at-home administration.

BACKGROUND AND OBJECTIVE: Biologic therapies are known to reduce exacerbations and improve severe uncontrolled asthma management. The at-home administration of biologics has increased during the COVID-19 pandemic, but the characteristics of severe uncontrolled asthma patients who may benefit from at-home administration of biologic therapy have yet to be identified. MATERIALS AND METHODS: This project is based on the Delphi method, designed to reach an expert consensus through a multidisciplinary scientific committee addressing the following questions: clinical characteristics, treatment adherence, patient or caregiver administration ability, patient self-care, relationship with the healthcare professional, patient preference, and access to the hospital. RESULTS: One hundred and thirty-one healthcare professionals (pulmonologists, allergists, nurses, and hospital pharmacists) completed two Delphi consensus questionnaires. Fourteen items were identified as priority characteristics, the first five being: 1. The patient follows the healthcare team's indications/recommendations to control their disease, 2. The patient is capable of detecting any deterioration in their disease and of identifying exacerbation triggers, 3. The patient receives biologic therapy and has stable disease with no vital risk, 4. The patient takes responsibility for their self-care, 5. The patient has occupational/educational obligations that prevent them from going to the hospital regularly. CONCLUSION: Disease stability and control plus the ability to identify exacerbation triggers are the most important characteristics when opting for at-home administration for a patient with severe uncontrolled asthma on biologic therapy. These recommendations could be applicable in clinical practice.

Effect of continuous positive airway pressure in very elderly with moderate-to-severe obstructive sleep apnea pooled results from two multicenter randomized controlled trials.

STUDY OBJECTIVE: There is very limited information about the effect of continuous positive airway pressure (CPAP) in the very elderly. Here we aimed to analysed the effect of CPAP on a clinical cohort of patients with obstructive sleep apnea (OSA) ≥80 years old. METHODS: Post-hoc pooled analysis of two open-label, multicenter clinical trials aimed to determine the effect of CPAP in a consecutive clinical cohort of elderly (≥70 years old) with moderate-to-severe OSA (apnea-hipopnea index ≥15 events/hour) randomized to receive CPAP or no CPAP for three months. Those consecutive patients ≥80 years old were included in the study. The primary endpoint was the change in Epworth Sleepiness scale (ESS). Secondary outcomes included sleep-related symptoms, quality of life, neurocognitive and mood status as well as office blood pressure measurements. RESULTS: From the initial 369 randomized individuals with ≥70 years, 97 (26.3%) with ≥80 years old were included (47 in the CPAP group and 50 in the no-CPAP group). The mean (SD) age was 81.5 (2.4) years. Average use of CPAP was 4.3 (2.6) hours/night (53% with good adherence) Patients in the CPAP group significantly improved snoring and witnessed apneas as well as AHI (from 41.9 to 4.9 events/hour). However no clinical improvements were seen in ESS (-1.2 points, 95%CI, 0.2 to -2.6), any domain of QSQ, any neurocognitive test, OSA-related symptoms, depression/anxiety or blood pressure levels. CONCLUSIONS: The present study does not support the use of CPAP in very elderly patients with moderate-to-severe OSA.

Relationship between type 2 diabetes mellitus and markers of cutaneous melanoma aggressiveness: an observational multicentric study in 443 patients with melanoma.

BACKGROUND: Some studies have suggested a relationship between type 2 diabetes mellitus (T2DM) and increased incidence of melanoma. Efforts are under way to identify preventable and treatable factors associated with greater melanoma aggressiveness, but no studies to date have examined the relationship between T2DM and the aggressiveness of cutaneous melanoma at diagnosis. OBJECTIVES: To explore potential associations between T2DM, glycaemic control and metformin treatment and the aggressiveness of cutaneous melanoma. METHODS: We conducted a cross-sectional multicentric study in 443 patients diagnosed with cutaneous melanoma. At diagnosis, all patients completed a standardized protocol, and a fasting blood sample was extracted to analyse their glucose levels, glycated haemoglobin concentration and markers of systemic inflammation. Melanoma characteristics and aggressiveness factors [Breslow thickness, ulceration, tumour mitotic rate (TMR), sentinel lymph node (SLN) involvement and tumour stage] were also recorded. RESULTS: The mean (SD) age of the patients was 55·98 (15·3) years and 50·6% were male. The median Breslow thickness was 0·85 mm. In total, 48 (10·8%) patients were diagnosed with T2DM and this finding was associated with a Breslow thickness > 2 mm [odds ratio (OR) 2·6, 95% confidence interval (CI) 1·4-4·9; P = 0·004)] and > 4 mm (OR 3·6, 95% CI 1·7-7·9; P = 0·001), TMR > 5 per mm2 (OR 4·5, 95% CI 1·4-13·7; P = 0·009), SLN involvement (OR 2·3, 95% CI 1-5·7; P = 0·038) and tumour stages III-IV (vs. I-II) (OR 3·4, 95% CI 1·6-7·4; P = 0·002), after adjusting for age, sex, obesity, alcohol intake and smoking habits. No significant associations emerged between glycated haemoglobin levels, metformin treatment and melanoma aggressiveness. CONCLUSIONS: T2DM, rather than glycaemic control and metformin treatment, is associated with increased cutaneous melanoma aggressiveness at diagnosis.

Effect of an ambulatory diagnostic and treatment programme in patients with sleep apnoea.

The aim of this study to evaluate the efficacy of a home-based programme on clinical response, continuous positive airway pressure (CPAP) compliance and cost in a population of high pre-test probability of suffering obstructive sleep apnoea syndrome (OSAS). Patients were randomised into the following three groups. Group A: home respiratory polygraphy (RP) and home follow-up; group B: hospital polysomnography and hospital follow-up; and group C: home RP and hospital follow-up. Evaluation during 6 months included Epworth Sleepiness Scale (ESS), Functional Outcomes Sleep Questionnaire (FOSQ), and daily activity and symptom questionnaires. Compliance was assessed by memory cards (group A) and using an hourly counter (groups B and C). 66 patients were included (22 per branch), 83% were males, aged mean±sd 52±10 yrs, body mass index 34±7kg·m(-2), apnoea/hypopnoea index 43±20 h(-1), CPAP pressure 8±2 cmH(2)O, with no between-group differences. Clinical response showed an ESS of mean±sd 15±3 to 6±4, a FOSQ of 16±3 to 18±2, symptoms of 43±7 to 25±7, and activity of 37±11 to 25±8. At the end of the study, compliance was: group A 73%, group B 68% and group C 57%. The cost per patient was: group A €590±43, group B €894±11 and group C €644±93 (p<0.001). In conclusion, patients with a high initial probability of having OSAS can be diagnosed and treated in a home setting, with a high level of CPAP compliance and lower cost than using either a hospital-based approach or home RP/hospital follow-up.

Fiberoptic bronchoscopy during nasal non-invasive ventilation in acute respiratory failure.

BACKGROUND: Various methods have been described for safely performing fiberoptic bronchoscopy (FB) while applying non-invasive positive pressure ventilation (NIPPV) in patients with acute respiratory failure (ARF). OBJECTIVES: To evaluate the safety of a new method to perform FB in patients with ARF. METHODS: Patients with ARF in whom FB was indicated were studied. The primary end-point was a mean drop in oxygen saturation (S(a)O(2)) after the procedure. During nasal NIPPV, FB was performed via the mouth using a bite block sealed with an elastic glove finger allowing bronchoscope insertion. RESULTS: Thirty-five patients were included in the final study (63 ± 17 years, 74% men, P(a)O(2)/F(i)O(2) ratio 168 ± 63). A total of 35 bronchoaspirates, 21 protected brushings, 11 bronchoalveolar lavages and 8 bronchial biopsies were done. The cardiorespiratory variables at the start and end of FB were: S(a)O(2) 93 ± 3 to 94 ± 5%, heart rate 95 ± 17 to 99 ± 22 b.p.m. and respiratory rate 24 ± 11 to 25 ± 11 respirations/min. The lowest S(a)O(2) value reached during the procedure was 86 ± 3% and the maximal ETCO(2) rise was 41 ± 4 mm Hg. Leakage was <50 ml/s in 32 patients. The clinical course was favorable in 66%. Invasive ventilation was necessary in 11%, 5 ± 4 days after FB. Twelve patients (33%) died 3 ± 2 days after FB as a result of their underlying disease. CONCLUSIONS: The system allowed to perform FB safely in patients with ARF. Although there is a relatively high rate of intubation and invasive mechanical ventilation due to illness severity, there was no worsening of oxygenation or complications attributable to the procedure.

Tuberculous empyema necessitatis. A rare cause of cutaneous abscess in the XXI century.

A 24-year-old Moroccan man was admitted to the hospital because of a tumor of the abdominal wall, fever, and purulent sputum. Imaging tests showed the presence of a pleural effusion and tumor in the right abdominal wall. The organized collection of liquid in the mass was contiguous with the thoracic collection and that of the subphrenic space. Thoracocentesis removed purulent material suggestive of empyema. Cultures and polymerase chain reaction (PCR) tests confirmed the diagnosis of tuberculous empyema. Empyema necessitatis refers to empyema that extends into the extrapleural space through a defect in the pleural surface. Various infectious etiologies may be responsible. Tuberculous empyema necessitatis is a rare complication of tuberculosis (TB); our case is even more unusual because this condition presented as an abdominal wall abcess and the patient was immunocompetent. His only predisposing factors were his country of origin, where there is a high prevalence of TB and the delay in diagnosis due to a lack of access to health care.

[Description of a new procedure for fiberoptic bronchoscopy during noninvasive ventilation through a nasal mask in patients with acute respiratory failure]. / Descripción de un nuevo procedimiento para la realización de fibrobroncoscopia durante ventilación no invasiva mediante mascarilla nasal en pacientes con insuficiencia respiratoria aguda.

A new method is described for performing oral fiberoptic bronchoscopy during noninvasive ventilation through the nose. The technique was successfully applied in 2 patients suffering from acute respiratory failure. The bronchoscope was inserted through a glove finger fitted into a mouth guard. The system works as a valve and does not affect performance of the bronchoscopy procedure or the pressures administered during noninvasive ventilation. We conclude that the procedure has potential advantages over bronchoscopy through the nose and face masks or helmets, particularly for the management of secretions or in special clinical circumstances (hemoptysis or presence of foreign bodies). This method can be used to substitute for or complement other bronchoscopy techniques performed with other interfaces.

[Thoracic actinomycosis: an old disorder with new clinical manifestations]. / Actinomicosis torácica: una vieja entidad con nuevas expresiones clínicas.

Three cases of thoracic actinomycosis are described, two associated to bronchial obstruction (foreign body and bronchogenic carcinoma) and one in a patient with empyema. The clinical and radiological manifestations and diagnostic criteria are reviewed and all published cases in the Spanish literature are thoroughly analyzed.

[Tuberculosis epidemiology in area 15 of the Spanish autonomous community of Valencia: evolution from 1987 through 2001]. / Evolución de las características epidemiológicas de la tuberculosis en el Area 15 de la Comunidad Valenciana en el período 1987-2001.

OBJECTIVES: To describe the evolution of tuberculosis epidemiology in Area 15 of the Autonomous Community of Valencia. MATERIAL AND METHODS: Cases of tuberculosis were identified by active case finding in Area 15 from January 1987 through December 2001. Clinical and epidemiological data were extracted from case records and a patient interview. RESULTS: Four hundred seventy-six diagnosed cases of mycobacterial infection were identified (459 tuberculosis, 16 atypical, and 1 mixed); 423 tuberculosis patients were residents of Area 15. The mean annual incidence rate was 24.6/100 000 population, representing a rate decrease of 41.5% from 1990. The most frequent risk factors were smoking (38%), alcoholism (20%), human immunodeficiency virus (HIV) infection (18%), and contact with a tuberculosis patient (14%). The site of tuberculosis involvement was the lung in 61% (49% bacillus positive, with a nonsignificant trend to decrease over time), nonpulmonary in 26%, and mixed in 13%. The radiographic pattern observed most often was pulmonary infiltrates (67%), and lower lobe involvement tended to increase over time. Diagnosis was by acid-fact bacillus stain for 77%, clinical picture for 16%, and histological for 7%. Isoniazid resistance was detected in 1.5% and rifampicin resistance in 0.3%. Patients were hospitalized during diagnosis in 79% of cases; the mean stay was 18 days. CONCLUSIONS: The incidence of tuberculosis has decreased in spite of the HIV pandemic. Risk factors have not changed, bacteriological diagnosis has improved, and the location of pulmonary infiltrates has changed. No influence of immigration on the incidence rate of tuberculosis has been detected to date.

Impact of the human immunodeficiency virus on the epidemiology of tuberculosis in area 15 of the Valencian community in Spain.

SETTING: Area 15 in Valencia. OBJECTIVES: To describe the epidemiology (1987-2001) of tuberculosis (TB) in human immunodeficiency virus (HIV) patients. METHODS: Study of annual incidence, age distribution, excess cases attributed to HIV, etiological risk fraction (ERF), population attributable fraction (PAF) and f factor. RESULTS: Of 476 cases diagnosed, 459 were TB, 16 environmental and one mixed; 76% of environmental cases were HIV-positive (P < 0.001). There was a mean annual TB incidence of 24.6/100000, with an annual reduction of 4%. Seventy-three patients were HIV coinfected (16%) (mean incidence 3834/100 000 seropositives). The principal risk factor was drug use (59%) for HIV+ and contact with TB for HIV-. We found no difference in pulmonary or extra-pulmonary location between groups, contrary to mixed cases (P < 0.001). In HIV+ there was a lower frequency of infiltrates (P < 0.001) and cavitation (P < 0.01), and a higher frequency of adenitis (P < 0.001), miliary or nodular pattern and normal X-ray (P < 0.001). Seropositives had a 174 times higher probability of developing TB. The mean ERF attributed to HIV was 99%, the PAF was 16% and the f factor was 1.19. Highly active antiretroviral therapy (HAART) reduced the risk of TB in HIV+ by 80%. CONCLUSIONS: TB has continued its decline, although HIV generated an excess of cases in the 1990s. HAART has reduced the TB risk in HIV+ and possibly the overall rate of TB.