[Quality of inpatient care and risk of early readmission in acute exacerbation of COPD]. / Calidad de la asistencia hospitalaria y riesgo de ingreso precoz en la exacerbación aguda de la EPOC.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is one of the diseases that causes more readmissions in our hospitals. The objective of our study was to establish the influence of quality of inpatient care on the risk of early readmission in the acute exacerbation of COPD. DESIGN: case and controls study. SETTING: general acute care hospital. SUBJECTS OF STUDY: random sample of admissions with acute exacerbation of COPD and discharged alive. CASES: patients who were readmitted within 30 days with a related diagnosis. CONTROLS: patients who were not readmitted and finished alive the mentioned period. INTERVENTIONS: audit of clinical charts with evaluation of clinical severity and adherence to explicit criteria of quality of inpatient care in OCFA. Bivariate and multivariate logistic regression (LR) analysis. RESULTS: 45 cases and 45 controls were analyzed. LR model detected the risk of readmission within 1 month was explained by the higher severity of patients (Apache III: OR 1,03) and their principal diagnosis(emphysema: OR 6,9 and bronchiectasias: OR 2,2, respect to chronic bronchitis). The less score of quality of care scale was predictive of the risk of readmission in the subgroup of patients who were readmitted within 1 week (OR 0,9). CONCLUSIONS: Risk of readmission within 1 month in the acute exacerbation of COPD were explained mainly by the clinical characteristics of patients. Otherwise, readmissions within 1 week were related to quality of care, so it could be a valid indicator of quality of inpatient care.

[Analysis of admissions for chronic obstructive pulmonary disease in Andalusia in 2000]. / Análisis de los ingresos por enfermedad pulmonar obstructiva crónica en Andalucía, año 2000.

OBJECTIVE: To analyze the impact of admissions for chronic obstructive pulmonary disease (COPD) in Andalusia during 2000. METHODS: All patients with DRG codes 088 and 541, which would receive ICD-9 codes 491, 492, 493.2, 494 and 496 in the cause of admission field, were extracted from the Minimum Basic Data Set for Andalusia. We compiled descriptive statistics from these data, calculated the cost per day of hospitalization for our own hospital, and then extrapolated to estimate the cost for Andalusia. RESULTS: COPD exacerbations generated 10,386 admissions in 2000, leading to 117,011 days of hospitalization. Eighty-three percent of the patients were men and the mean age was 70 12 years. The average hospital stay was 11 10 days. Huelva was the province with the shortest hospital stay (9 days). Mortality was 6.7%. The minimum expenditure generated was E 27 million, not counting the cost of intensive care unit admissions. CONCLUSIONS: Admissions due to COPD have great impact on the Andalusian health care system. Further studies are needed to evaluate alternatives to hospitalization.

A shuttle walk test for assessment of functional capacity in chronic heart failure.

BACKGROUND: Peak oxygen uptake (peak VO(2)) is a reference parameter in the assessment of functional capacity of patients with chronic heart failure, but the procedure for cardiopulmonary exercise testing with expired gas analysis is complex and expensive, so more simple and available methods are desirable. METHODS: We compared the usefulness of a time-limited walk test, the 6-minute walk test (6-MT), with that of a symptom-limited walk test, the shuttle walk test (SWT), in the evaluation of patients with moderate to severe chronic heart failure. We prospectively studied 46 clinically stable patients in New York Heart Association class II to IV heart failure with left ventricular ejection fraction <40% (aged 53 +/- 10 years, ejection fraction 23% +/- 8%, New York Heart Association functional class 2.8 +/- 0.7). Each patient performed two 6-MT, two SWT and a cardiopulmonary exercise testing within 2 weeks. RESULTS: We found a close correlation between distance walked in SWT and peak VO(2 ) (r = 0.83, P <.001) and a moderate correlation between distance in 6-MT and peak VO(2) (r = 0.69, P <.001). Both walk tests showed to be reproducible after just one practice walk. All patients who walked > 450 m in SWT had a peak VO(2) >14 mL/kg/min. The overall discriminatory accuracy for SWT distance was greater than that for 6-MT distance for predicting a peak VO(2 ) <14 mL/kg/min (area under receiver operator characteristic curves 0.97 and 0.83 respectively, P =.02). Stepwise multivariate regression analysis, including clinical, exercise testing, echocardiographic, radionuclide-angiographic, and rest hemodynamic data, showed that distance walked in SWT was the only independent predictor of peak VO(2) (P <.001) and the strongest predictor of percent achieved of age- and sex-predicted peak VO(2) (%PVO(2)) (P <.001), with only age offering additional information (P =.02). CONCLUSIONS: The SWT shows to be a feasible and safe method to evaluate patients with chronic heart failure that strongly and independently predicts peak VO(2) and %PVO(2.) This symptom-limited walk test seems to be more useful than 6-MT in the assessment of functional capacity in these patients.

[Reproducibility of a shuttle walking test in patients with chronic obstructive pulmonary disease]. / Reproducibilidad de un test de paseo de carga progresiva (shuttle walking test) en pacientes con enfermedad pulmonar obstructiva crónica.

To analyze the reproducibility of the shuttle walking test (SWT) in comparison to the six min walking test in patients with chronic obstructive pulmonary disease (COPD). The stress tests were performed by 13 patients diagnosed of COPD with moderate-to-severe air flow obstruction (FEV1 45.85 +/- 18.82% of theoretical values). Each patient performed the SWT six times (twice a week over three consecutive weeks). The 6 min walking test was performed an equal number of times. At baseline and at the end of both types of test, heart rate and degree of dyspnea (on a modified version of Borg's scale) were recorded, as well as the level reached and the number of meters walked. No significant differences in distance walked, heart rate or degree of dyspnea were found for the six SWTs performed. The interclass correlation coefficients for the aforementioned parameters were 0.875, 0.879 and 0.896, respectively; the variation coefficient for distance covered ranged between -10.7% and 10.2%. In the six min walking test significant differences were seen between distance walked in the first two tests and the other four tests. The variation co-efficient ranged between 11.4% and 17.5%. The SWT is a reproducible stress test in which the patient must exert progressively greater effort. The low degree of variability observed assures that the level of effort attained is steady and consistent.

[Comparison of a shuttle walking test with an exertion test with cycloergometer in patients with COPD]. / Comparación de un test de paseo de carga progresiva (shuttle walking test) con una prueba de esfuerzo en cicloergómetro en pacientes con EPOC.

To validate a shuttle walking test in a group of patients with COPD, comparing responses to those produced by a conventional stress test limited by symptoms on the cycle ergometer, and to analyze the relation between the shuttle walking test and maximal effort parameters. We enrolled 20 patients with COPD, mean age 60 years (SD 7), FEV1/46.6% (SD 19.2) of theoretical value and FEV1/FVC% 47.3% (SD 11.2). All the patients underwent a maximal effort test on the cycle ergometer, determination of initial dyspnea by applying Mahler's baseline dyspnea index, and a quality of life questionnaire specific to COPD the Chronic Respiratory Disease Questionnaire). To compare the responses of patients to the two tests, we analyzed heart rate, dyspnea and lactic acid at the end of each test. To see the relations between the two tests, we examined distance walked and maximal effort parameters. The relation between the walking test and lung function parameters at rest, initial dyspnea and quality of life were also analyzed. No statistically significant differences were found for heart rate [128.2 (SD 19.8) versus 131.6 (SD 12.9)], dyspnea 17.1 (SD 1.78) versus 7.24 (SD 2.64)] or lactic acid [5.24 (SD 2.34) versus 6.19 (SD 2.12)] at the end of the tests. Distance covered on the shuttle walking test correlated significantly with V'O2ml/min/Kgmax (r = 0.71), as well as with the remaining parameters of maximal effort. There was only a slight relation between lung function at rest and quality of life. The COPD patient's cardiovascular, metabolic and subjective responses to the shuttle walking test are similar to those of the cycle ergometer test, and oxygen consumption is significantly correlated. The shuttle walking test gives a valid estimate of the functional capacity of COPD patients.

[Hypercapnic stimulation and ventilation response in the syndrome of sleep obstructive apnea. Comparison of reinhalation and steady state]. / Estimulación hipercápnica y respuesta ventilatoria en el síndrome de apnea obstructiva del sueño. Comparación de reinhalación y estado-estable.

The objective of this study was to assess ventilatory response to stimulation with CO2 in patients suffering obstructive sleep apnea syndrome (OSAS) but without chronic obstructive pulmonary disease (COPD), by examining differences between hyper- and normocapnic patients and comparing the results obtained with the usual techniques used to stimulate hypercapnia (rebreathing and stable-state). To this end, we studied 15 obese patients, all with an apnea-hypopnea index greater than 10 from a polysomnograph lasting a full night. The following lung function tests were performed: spirometry, air way resistance measures and static lung volumes by plethysmograph and arterial gasometry. We later analyzed ventilatory response by the stable-state method, with increasing CO2 concentrations (from 1 to 9%) and by the rebreathing method. Results from the two methods were similar for all patients: delta VE/delta PCO2 (0.64 +/- 0.35 vs 0.67 +/- 0.48 l/min/mmHg; p = 0.59), delta Vt/delta PCO2 (28.33 +/- 16.23 vs 26.42 +/- 16.94 ml/mmHg; p = 0.9), delta Vt/Ti/delta PCO2 (28.82 +/- 20.9 vs 29.41 +/- 23.78 ml/s/mmHg; p = 0.89) y delta P0.1/delta PCO2 (0.11 +/- 0.07 vs 0.117 +/- 0.05 cmH2O/mmHg; p = 0.58). We compared the results obtained by the two techniques by dividing the sample into two groups of 7 and 8 patients, respectively, depending on whether PaCO2 level before stimulation was higher or lower than 45 mmHg. The hypercapnic patients (group I) were older (61 +/- 3.5 vs 50 +/- 9 years; p = 0.04) but were not different with respect to body mass from the normocapnic patients (group II) (37.59 +/- 6.4 vs 34.56 +/- 4.75 kg/m2; p = 0.33). The results from the two techniques for stimulating hypercapnia were similar within each group, with a statistically significant decrease (p < 0.03) in patients with daytime hypercapnia in delta VE/delta PCO2 delta Vt/delta PCO2, delta Vt/Ti/delta PCO2 and delta P0.1/delta PCO2. We conclude that there are no differences in the results obtained with the rebreathing and stable state techniques. Likewise, ventilatory response to stimulation with CO2 in individuals with OSAS and daytime hypoventilation is less than of normocapnic patients.

[Accuracy and validity of the lactic threshold compared to other noninvasive methods of measuring the anaerobic threshold in patients with metabolic myopathies]. / Exactitud y validez del umbral láctico frente a otros métodos no invasivos de medición del umbral anaerobio en pacientes con miopatías metabólicas.

UNLABELLED: Poor correlation among the various methods for measuring anaerobic threshold (AT) has been reported, and some authors have even reported interobserver variability within a single method. It is unknown whether such variability exists in patients with metabolic myopathies (MM). OBJECTIVE: To determine intra- and interobserver variability in the measurement of AT in patients with MM and analyze the differences for each method used. We enrolled 16 patients with differing forms of MM for exercise testing. AT was determined by 4 methods: lactic threshold (LT), semi-log LT, respiratory equivalent and V-slope. AT was assessed by 2 observers, who analyzed plots in random order on 2 different occasions, locating the AT in each plot. The respiratory equivalent method gave the best intraobserver correlation (r' = 0.95; p < 0.05) and was superior to the LT method (r' = 0.68; p < 0.05). Interobserver correlation was equally acceptable for all except the V-slope method (r' = 0.36; p > 0.05). The most important finding after comparison of the methods was the significant difference in VO2 (ml/min) in AT between the LT method and the non invasive methods (LT = 1,006; respiratory equivalent 1,312; p < 0.05; LT = 1,095; V-slope = 1,251; p < 0.05). CONCLUSION: Intra- and interobserver variability is slight in patients with MM; the best method in this respect is that of the V-slope. AT appears later with non invasive methods and for that reason, invasive measurement (LT) is preferable.

[Abdominal respiratory muscle activity in patients with stable chronic obstructive pulmonary disease]. / Actividad de la musculatura espiratoria abdominal en pacientes con enfermedad pulmonar obstructiva crónica estable.

With the purpose of defining the pattern of abdominal respiratory muscle activity in patients with chronic obstructive pulmonary disease (COPD), we studied the electromyogram of the rectus abdominis (RA), the external oblique (EO) and transversus (TM) muscles in 14 patients with different degrees of airways obstruction (FEV1: 41 +/- 12%; FEV1/FVC: 45 +/- 10%; RV: 198 +/- 38%; PaO2: 75.8 +/- 12 y PaCO2: 41.4 +/- 5.7 mmHg). The EMG was obtained by insertion of bipolar electrodes guided by an ultrasound image of the abdominal wall to locate the position of the muscles. The measurements were recorded in supine decubitus position in 5 situations: a) breathing at tidal volume; b) slow expiration until RV; c) with inspiratory load; d) with expiratory load, and e) during relaxed breathing with the arms raised. Recordings were also made in the same situations with 10 patients sitting. Eight patients presented phasic expiratory activity during relaxed breathing (TM activity alone or accompanied by EO). We found no significant differences in degree of hyperinflation or in arterial gases between patients with phasic expiratory activity and those without. There were significant differences between these 2 groups, however, as to degree of airways obstruction, for absolute values of FEV1 (p < 0.02) and in raw values (p < 0.04). Slow breathing until RV recruited muscular activity in 13 patients; the muscles did not operate in unison, however, with TM acting first. Recruitment was also observed when inspiratory and expiratory loads were placed, although in this case the 3 muscles acted simultaneously. Phasic activity was observed in only 2 patients for recordings made with arms raised, at which time there was greater tonic muscle activity. The phasic activity pattern recorded when patients were sitting was very similar to that obtained in supine position. In summary, some patients with stable COPD have phasic expiratory activity of the abdominal muscles when resting. These muscles do not appear to act as a unit and this phasic expiratory activity is related to severity of upper airways obstruction.

[An intrathoracic meningocele in von Recklinghausen's disease. A case report]. / Meningocele intratorácico en la enfermedad de von Recklinghausen. Presentación de un caso.

Posterior mediastinal tumors in young people are most often neurogenic. The presence of a meningocele has occasionally been described as causing mass in the region and cases reported have mainly been in patients with neurofibromatosis. We describe a patient with type I neurofibromatosis and intrathoracic meningocele.