Understanding Severe Asthma Through Small and Big Data in Spanish Hospitals: The PAGE Study.

BACKGROUND: Data on the prevalence of severe asthma (SA) are limited. Electronic health records (EHRs) offer a unique research opportunity to test machine learning (ML) tools in epidemiological studies. Our aim was to estimate the prevalence of SA among asthma patients seen in hospital asthma units, using both ML-based and traditional research methodologies. Our secondary objective was to describe patients with nonsevere asthma (NSA) and SA over a follow-up of 12 months. METHODS: PAGE is a multicenter, controlled, observational study conducted in 36 Spanish hospitals and split into 2 phases: a cross-sectional phase for estimation of the prevalence of SA and a prospective phase (3 visits in 12 months) for the follow-up and characterization of SA and NSA patients. A substudy with ML was performed in 6 hospitals. Our ML tool uses EHRead technology, which extracts clinical concepts from EHRs and standardizes them to SNOMED CT. RESULTS: The prevalence of SA among asthma patients in Spanish hospitals was 20.1%, compared with 9.7% using the ML tool. The proportion of SA phenotypes and the features of patients followed up were consistent with previous studies. The clinical predictions of patients' clinical course were unreliable, and ML found only 2 predictive models with discriminatory power to predict outcomes. CONCLUSION: This study is the first to estimate the prevalence of SA in hospitalized asthma patients and to predict patient outcomes using both standard and ML-based research techniques. Our findings offer relevant insights for further epidemiological and clinical research in SA.

PAGE Study: Summary of a Study Protocol to Estimate the Prevalence of Severe Asthma in Spain Using Big Data Methods.

BACKGROUND AND OBJECTIVES: Background: The proposal and the initiative for the Prevalence of Severe Asthma in Hospital Units in Spain (PAGE) study came about because of the widespread implementation of electronic medical records and the limited data available on the prevalence of severe asthma in hospitals in our setting. Objectives: The primary objective was to determine the prevalence of severe asthma in the outpatient clinics of allergy and pulmonology departments in Spain. The secondary objectives were to describe the most prevalent characteristics and phenotypes of severe asthma, to evaluate the selection criteria for receiving approved biological treatments for this disease, and to estimate consumption of resources. Furthermore, digital technology and new data collection sources made it possible to reuse information stored in electronic medical records (Big Data). The study was performed using one such tool, Savana. METHODS: The PAGE study was a multicenter, nonexperimental, observational, cross-sectional study in the first phase and a prospective study in the second phase. The study was controlled and population-based, with 2-stage selection of patients by random sampling. The research was carried out in 40 hospitals selected using convenience sampling in order to ensure geographical representativeness in Spain. RESULTS: This manuscript describes the study design and protocol. CONCLUSIONS: Our study design was sufficiently robust to avoid bias and to establish the prevalence of patients with severe asthma in Spanish hospitals. It was also the first to incorporate new tools that can help in routine clinical practice and research, such as big data analysis software, and to evaluate the reliability and efficiency of these tools.

[The management of asthma as a chronic inflammatory disease and global health problem: A position paper from the scientific societies]. / El manejo del asma como enfermedad inflamatoria crónica y problema sanitario global: documento de posicionamiento de las sociedades científicas.

Asthma is the most prevalent respiratory disease worldwide and it can affect people of all ages and is potentially fatal. Today, maintenance treatments are available that are effective in most patients, yet a significant proportion have poorly controlled disease, despite the resources on offer. This document, endorsed by members of the Spanish medical societies involved in the treatment of asthma, is intended to draw the attention of society and professionals to this problem in Spain. It focuses on the clinical, diagnostic and therapeutic aspects of asthma, and proposes some actions for improvement as regards patients and healthcare professionals which, in view of the current results arising from inadequate asthma control, might be beneficial to improve outcomes for both patients and public health.

Referral Criteria for Asthma: Consensus Document.

Asthma is one of the most prevalent chronic diseases in Spain. Current treatments ensure that the disease is controlled in most cases. However, disease is often uncontrolled in daily clinical practice, mainly owing to underdiagnosis, loss to follow-up, and poor adherence to therapy. In order to improve this situation, we must coordinate all those health professionals who intervene in patient care. Therefore, the Spanish Society of Allergology and Clinical Immunology (SEAIC), the Spanish Society of Primary Care Physicians (SEMERGEN), the Spanish Society of Family and Community Medicine (semFYC), the Spanish Society of General and Family Physicians (SEMG), and the Spanish Society of Pneumology and Thoracic Surgery (SEPAR) have drawn up a consensus document in which they establish criteria for referral and guidelines for the diagnosis, control, and follow-up of patients with asthma. The document aims to facilitate continuing and improved care in this area.

Variability in the prevalence of premenstrual asthma.

Our aim is to analyse the differences in the prevalence of premenstrual asthma (PMA) according to a set of criteria, the relationship between them and the influence of asthma severity. The answer "Yes" to "Does your asthma get worse before menstruation?" was considered subjective PMA. A daily respiratory symptoms register of fertile asthmatic females was taken during two consecutive menstrual cycles. For the semi-objective diagnosis, an exacerbation of > or =20% was required in the symptoms register. Objective diagnosis was a premenstrual worsening of > or =20% of peak flow. We selected 103 patients. Subjective premenstrual deterioration was perceived in 43.7%. The semi-objective deterioration of symptoms in the first cycle occurred in 44.7%, and in 22.3% in both cycles. A total of 54.3% of females with semi-objective criteria in the first cycle perceived a subjective deterioration of symptoms, versus 35.1% of those without semi-objective criteria (p = 0.05). PMA was present at all levels of asthma severity, with no clear link to the degree of severity. The detection of PMA prevalence, the subjective perception of this deterioration and its presence at all levels of asthma severity lead us to urge research into possible premenstrual deterioration in all fertile asthmatic females.

[Distribution of pulmonologists and chest surgeons in Spain]. / Distribución de neumólogos y cirujanos torácicos en España.

OBJECTIVE: To study the real situation of respiratory medicine specialists and chest surgeons in the Spanish health service. SUBJECTS AND METHOD: Using the database of the secretary of the Spanish Society of Respiratory Medicine and Chest Surgery (SEPAR) for 1999, we gathered data on 326 Spanish hospitals. We were thus able to ascertain the level of staffing of respiratory medicine and chest surgery departments. The results were expressed as simple percentages showing distribution by age, duties and geographic area. The number of specialists per 100,000 inhabitants in each community was also calculated based on population data provided by the National Statistics Institute for 1997. RESULTS: We studied 1,786 physicians or surgeons (1,245 pneumologists, 185 surgeons and 356 from other specialties). The mean age was 41 9 years for pneumologists, 44 10 years for surgeons and 51 8 years for the others. We observed unequal distribution by geographic area, with a high of 6.66 pneumologists and 0.9 surgeons per 100,000 inhabitants in Asturias and Madrid, respectively and a low of 1.4 pneumologists per 100,000 inhabitants in Murcia and 0 surgeons in Extremadura. CONCLUSIONS: Specialist coverage by pneumologists and chest surgeons is inadequate in many provinces and communities in Spain. The professional market is not saturated, indicating that future specialists can look forward to market demand.

[Risk factors for bronchial asthma in patients with rhinitis]. / Factores de riesgo asociados con asma bronquial en pacientes con rinitis.

OBJECTIVES: To identify risk factors for bronchial asthma in a large sample of patients with rhinitis. PATIENTS AND METHODS: One thousand seven hundred sixty patients with rhinitis treated at the respiratory medicine out-patient service of Hospital Universitario Virgen de Rocío in Seville (Spain) in 1997 and 1998 were studied. Six hundred forty-one (36.4%) had isolated rhinitis and 1,119 (63.6%) had rhinitis and bronchial asthma. The following variables were analyzed for both groups: 1) age, 2) sex, 3) clinical diagnosis, 4) age of onset of symptoms, 5) a family history of asthma and/or atopy, 6) housing conditions, 7) smoking, 8) a history of skin allergy, 9) recurrent episodes of respiratory infection with wheezing during early childhood, 10) a diagnosis of nasosinus polyposis, 11) atopy and sensitivity (pollens and/or household allergens), 12) peripheral blood eosinophil count. RESULTS: The variables that best differentiated the group with rhinitis from the group with both rhinitis and asthma were age, family history of asthma and/or atopy, exposure to household humidity or damp, a history of skin allergy, recurrent episodes of respiratory infection with wheezing in early childhood, atopy, sensitivity to household allergens and peripheral blood eosinophil count. The probability of correctly classifying patients in the appropriate group using this model was 69.7%. Among atopic patients, the best predictive variables were the same, with the exception of household humidity/damp. The probability of correct classification using this model was 69.7%. CONCLUSIONS: Patients with rhinitis have risk factors for bronchial asthma. As many such patients as possible should be identified so that long-term follow-up can take place and strategies to prevent bronchial asthma can be implemented.

[Community acquired pneumonia in patients older than 60 years. Incidence of atypical agents and clinical-radiological progression]. / Neumonías adquiridas en la comunidad en pacientes mayores de 60 años. Incidencia de gérmenes atípicos y evolución clinicorradiológica.

BACKGROUND: Seventy five patients older than 60 years with a community acquired pneumonia followed up in an outpatient clinic, were prospectively studied in order to determine the incidence of atypical agents, clinical-radiological characteristics, progression and the differences with pneumonia in younger patients. METHOD: Clinical-radiological evaluation protocols were activated in the first visit and in two subsequent controls. Etiological diagnosis was made by means of serology (in the first visit and three weeks later). RESULTS: Initially, 85 patients older than 60 years were included of which 75 non hospitalized were fully followed up. Also, in the comparative study, 216 outpatient clinic patients 60 years old or younger were followed up during the same period. In the first group the frequency of atypical agents was 33.3%. The most frequently isolated bacteria was Coxiella burnetii (13.3%)followed by virus and Legionella pneumophila. No case of Mycoplasma pneumoniae was diagnosed. The most frequent radiological onset was alveolar infiltrate (85%). The comparative study between the two populations (older or younger than 60 years), found few clinical differences (dyspnea more frequent in older,feverish chill in younger) and auscultation (crackles more frequent in older). We did not find differences remaining clinical-radiological or laboratory data. Most patients presented a favourable clinical and radiological progression. Only 2 patients needed hospital admission (2.7%). CONCLUSIONS: In outpatient clinic patients older than 60 years with community acquired pneumonia a high number of atypical agents have been found. The clinical-radiological evolution was satisfactory for most of them. Age was not a decisive element in determining hospital admissions.

[Results of a psychotherapeutic program for smoking after 12 months of follow-up]. / Resultados de un programa psicoterapéutico de deshabituación tabáquica tras 12 meses de seguimiento.

OBJECTIVE: To compare the efficacy of psychological counseling for smokers in a cessation program in comparison with treatment based only on providing information about damage caused by tobacco and advice for quitting, and to determine the reasons patients started to smoke. PATIENTS AND METHODS: We studied 249 patients who came to a preliminary interview; 226 began treatment for smoking cessation. The average level of dependence, quantified the Fagerstrom test was 7.26 +/- 1.85 points. Two treatment groups were formed: the first patients seen made up the control group (n = 37), which received information about the dangers of tobacco and strategies for quitting, and the psychological counseling group (n = 189). Follow-up examinations were performed three, six and twelve months after treatment, with abstinence checked by measurement of CO in exhaled air. Only patients with CO levels less than 5 ppm (particles per million) in exhaled air were considered non-smokers. RESULTS: Most patients of both sexes named social pressure as the reason for starting to smoke. The rate of abstinence in the information and strategies group was 8.1% at all three follow-up visits, whereas the rate was 37%, 25.4% and 24.3% at three, six and twelve months, respectively, in the group receiving counseling. The differences between the two groups were significant at all visits. CONCLUSIONS: Social pressure is the main reason for starting to smoke. We observed a success rate of 24.3% after one year of follow-up after psychological treatment only, a rate that was significantly higher than that of the group that received only information. We believe that psychological counseling is an effective alternative for smokers who want to quit.

[School-age smoking in the province of Seville. Epidemiology and influence of personal and social environment (smoking prevention campaign, 1998-1999)]. / Tabaquismo escolar en la provincia de Sevilla. Epidemiología e influencia del entorno personal y social (campaña de prevención del tabaquismo 1998-1999).

OBJECTIVE: To study the prevalence os smoking in school children in Sevilla and the influence of personal and social environment on smoking patterns. METHODS: This study was part of a preventative anti-smoking campaign in schools. Students filled in anonymous questionnaires based on the World Health Organization survey instrument for population attitudes and habits. RESULTS: We surveyed 3385 students between 10 and 19 years of age at 47 schools in Seville and 28 villages in the surrounding province. Current smoking was reported by 19.1% of the students; slightly more girls (19.8%) than boys (18.3%) smoked. Smoking was related to having an older brother or sister who smoked and particularly to having friends who smoked (OR 20.5). The adolescents reported that parents were less permissive than the rest of their environment. Smokers associated tobacco with values such as independence and freedom; they believed that smoking might have an impact on health, although their conviction was less strong than that of non-smokers, regular smokers had high expectations of continuing. CONCLUSIONS: We found a high proportion of smokers among students of both sexes. Starting and continuing to smoke during adolescence is considerably influenced by the social environment of peers and is possibly affected by messages of independence and freedom transmitted through tobacco industry advertising.

[A randomized comparative study of 3 days of azithromycin treatment and 10 days of cefuroxime treatment in exacerbations in patients with chronic obstructive pulmonary disease]. / Estudio comparativo, aleatorio entre 3 días de tratamiento con azitromicina y 10 días de tratamiento con cefuroxima en las exacerbaciones de pacientes con enfermedad pulmonar obstructiva crónica.

BACKGROUND: The aim of this study was to prospectively evaluate the clinical and gasometric evolution and the side effects of two treatment schedules in the exacerbations of patients with chronic obstructive pulmonary disease (COPD): 500 mg/24 h of azithromycin (AZM) for three days versus 500 mg/12 h of acetyl cefuroxime (ACF) for 10 days. PATIENTS AND METHODS: Patients were randomized included into each therapeutic schedule. The patients were seen three times (days 1 and 4, and at 15-21 days) to evaluate clinical symptoms scores. Forced spirometry and arterial gasometry were performed the first and the last time the patients were seen. The number of patients requiring admission during follow up and the secondary effects of each antibiotic were quantified. RESULTS: A total de 50 patients were treated with AZM and 51 with ACF. The evolution of the symptoms was similar although with a trend to greater improvement in those treated with AZM. This improvement was significant for the characteristics of expectoration (p < 0.05). Functional and gasometric evolution was similar in the two schedules. Three patients treated with AZM required hospital admission, as did 5 treated with ACF. A greater number of secondary effects were observed in patients treated with ACF (18%) than in those receiving AZM (10%), with gastrointestinal side effects being the most commonly observed. CONCLUSIONS: Treatment with short schedule of AZM may have the same activity as longer schedule of ACF, with fewer secondary effects thereby suggesting that AZM may be an effective alternative in the treatment of exacerbations in patients with COPD.

[School-age smoking in the province of Seville: results from the first phase of an anti-smoking campaign]. / Tabaquismo escolar en la provincia de Sevilla: resultados de la primera fase de una campaña de prevención del tabaquismo.

OBJECTIVES: To study the prevalence and intensity of smoking among school-age children in Seville by sex, age and type of population, as well as to examine expectations of future smoking. METHODS: This study was part of a school anti-smoking campaign. The students completed an anonymous questionnaire based on the one formulated by the World Health Organization on population attitudes and habits. RESULTS: Of 895 school-age subjects surveyed, 879 questionnaires were valid (428 boys and 451 girls). Ages ranged from 12 to 19 years (mean for boys: 15.4 +/- 1.6 years; for girls 14.6 +/- 1.5 years; p < 0.01). As many as 300 girls (67%) and 278 boys (65%) reported having tried a cigarette at some time. Active smoking was reported by 35% (16% occasionally and 19% daily) with no significant differences between boys and girls. The number of smokers increased with age, coming to represent more than half of subjects over 16 years of age, the proportion being even higher for girls aged 14 years and older. Smoking became well established at age 14 or older for most subjects. More rural than urban or large town dwellers reported smoking. The mean number of cigarettes smoked was higher for boys (8.7 +/- 7.4) than for girls (6.4 +/- 6.2) (p < 0.01). We found differences in boys' and girls' future expectations of smoking, as well as differences between habitual and occasional smokers, the latter group being less certain about whether to continue smoking in the future or not.

[Outpatient emergency care in pneumology. A method to alleviate pressure of hospital emergency services]. / Atención urgente extrahospitalaria en neumología. Un método para aliviar la presión asistencial de servicios de urgencias hospitalarios.

We analyze the result of using a pneumological rapid-attention facility for diagnosis and immediate treatment of patients with respiratory symptoms arriving at the emergency room of University Hospital Virgen del Rocío in Seville (Spain). In the first six months the outpatient service saw 321 patients (male/female ratio 2.6), most of whom were between 55 and 75 years of age and had never before seen a pneumologist (83.4%). Dyspnea was the most common respiratory symptom named (by 35% of patients), and acute exacerbation of chronic obstructive pulmonary disease was the most usual diagnosis (in 19.1%). Only 21 (7%) were admitted to the hospital. We that creating the outpatient unit effectively met a societal need for rapid diagnosis and treatment of patients with respiratory complaints in the area served by our hospital emergency service.

[Blood levels of eosinophil cationic protein in patients with allergic rhinitis. Evolution after treatment with corticoids]. / Niveles séricos de proteína catiónica del eosinófilo en pacientes con rinitis alérgica. Evolución tras tratamiento con corticoides.

We analyze changes in eosinophilic cationic protein (ECP) serum levels after treatment with intranasal corticoids. Fifty-three healthy individuals (control group) and 21 patients diagnosed of allergic rhinitis, with or without bronchial asthma, were enrolled at a time when they had only nasal symptoms. Data were collected from skin Prick tests, forced spirometry, methacholine challenge, and complete blood workups, including IgE measurement, eosinophil counts and ECP serum levels determined by immunofluorescence. The patients received intranasal budesonide at a dose of 200 micrograms/24 h. ECP levels and eosinophil counts were determined before (baseline levels) and during treatment (on days 21 and 60). We found significant differences (p < 0.01) in baseline ECP levels of the controls (9.34 +/- 5.76) and patients (16.47 +/- 15.28). These values were significantly lower than baseline 21 and 60 days after treatment, although the changes between days 21 and 60 were not significant. Eosinophil counts did not fall significantly. We also found that eosinophil counts and ECP levels were correlated (r = 0.53) at baseline but not after treatment (r = 0.25). No patient experienced bronchial symptoms during the study. We conclude that ECP serum levels in patients with symptoms of rhinitis are significantly higher than levels in non symptomatic individuals. These levels fall significantly, possibly due to intranasal corticoid treatment, although eosinophil counts remain constant. ECP levels can therefore be used to monitor inflammatory activity in patients with allergic rhinitis.

[Inflammation mediators (eosinophilic cationic protein, ECP) in a normal population and in patients with bronchial asthma or allergic rhinitis]. / Mediadores de la inflamación (proteína catiónica del eosinófilo, ECP) en población normal y pacientes con asma bronquial o rinitis alérgica.

We analyzed serum levels of eosinophilic cationic protein (ECP), one of the 4 main eosinophilic proteins; ECP is released from an activated cell and acts as a mediator of inflammation. Serum samples from 139 persons were studied prospectively. Fifty-three individuals from the general population provided the control group. Eighty-six consecutive patients were also studied: 69 with bronchial asthma and 17 with allergic rhinitis and no signs of asthma. The level of severity of disease was established in the asthmatics by the method proposed by Aas (Aas score), based on symptoms and medications received within the last year. We also classified these patients as having mild, moderate or severe asthma according to the latest criteria issued by the International Consensus for Diagnosis and Treatment of Asthma. Atopic status was estimated by skin Prick tests. ECP levels in the control group (9.34 +/- 5.76 micrograms/l) were significantly lower (p < 0.001) than those of the total population of patients (17.59 +/- 16.85 micrograms/l). The mean for patients with rhinitis was 14.76 +/- 10.94 micrograms/l, whereas it was 18.29 +/- 18 micrograms/l in the asthmatics; the levels for both groups were statistically different from that of the control group (p < 0.03 and p < 0.001, respectively). Levels by degrees of severity established at the time of revision and by sensitivity to allergens were also significantly different from the level of the control group, although the mean levels were low in the group of severely affected patients who had received treatment with inhaled corticoids.(ABSTRACT TRUNCATED AT 250 WORDS)

[An analysis of the prevalence of respiratory symptomatology in the general population]. / Análisis de la prevalencia de sintomatología respiratoria en la población general.

This paper is a report of a cross-sectional epidemiological study that formed part of multicenter European project; the aim was to estimate the prevalence of respiratory symptoms and signs related to asthma over a period of 12 months in the city of Seville. A sample of 4,000 persons of both sexes, aged between 20 and 44 years old, was surveyed first by mail questionnaire and later by telephone interview. We analyzed the response index obtained with the mail survey for the epidemiological study of asthma in the area and for the frequency of respiratory symptoms and their distribution by age and sex. The response index was 53.36% and was similar for men and for women. Forty-nine percent reported at least one respiratory symptom, with nocturnal coughing attacks (27.7%) and wheezing (22.2%) being the most frequent. The frequency of these symptoms was different by sex, however, with the former more often reported by women (p < 0.02) and the latter by men (p < 0.001). We found that 14.9% of the population had rhinitis and that women reported this symptom more often (p < 0.02). Symptoms related to asthma were nocturnal attacks of breathlessness, the use of asthma medication and an asthma attack diagnosed by a physician within the last 12 months. With these criteria the estimated prevalence of asthma was 11.72%, a proportion that held steady for all age groups except the middle-aged and for both sexes.(ABSTRACT TRUNCATED AT 250 WORDS)