Development of a decision tree to assess the severity and prognosis of stable COPD.

The aim of this study was to develop and validate a new method: a classification and regression tree (CART) based on easily accessible measures to predict mortality in patients with stable chronic obstructive pulmonary disease (COPD). This was a prospective study of two independent prospective cohorts: a derivation cohort with 611 recruited patients and a validation cohort with 348 patients, all followed for 5 yrs. CART analysis was used to predict 5-yr mortality risk using the following covariates from the derivation cohort: age, % predicted forced expiratory volume in 1 s (FEV(1)), dyspnoea, physical activity, general health and number of hospital admissions for COPD exacerbations in the previous 2 yrs. Age (≥ 75 or <75 yrs) provided the first branch of the COPD-CART. The highest mortality risk (0.74) was seen in patients >75 yrs of age with higher levels of dyspnoea and FEV(1) <50% pred. Patients with the lowest risk of 5-yr mortality (0.04) were <55 yrs of age with FEV(1) >35% pred and one or no recent hospitalisations for COPD exacerbations. A simple decision tree that uses variables commonly gathered by physicians can provide a quick assessment of the severity of the disease, as measured by the risk of 5-yr mortality.

Impact of changes in physical activity on health-related quality of life among patients with COPD.

The aim of this study was to evaluate whether changes in regular physical activity (PA) affect health-related quality of life (HRQoL) among patients with chronic obstructive pulmonary disease (COPD). 611 patients (mean age 67.2+/-8.4 yrs; forced expiratory volume in 1 s 49.7+/-14.6) completed the St George's Respiratory Questionnaire (SGRQ), the Chronic Respiratory Questionnaire (CRQ) and the Medical Outcomes Short Form (SF-36) questionnaire. PA, defined as patients' self-reported regular walking times, was classified as low, moderate and high. After 5 yrs, 391 survivors completed these instruments again. After adjustment for relevant confounders, patients who reported low PA at baseline and who increased their PA over the study period improved their SGRQ and CRQ scores by 15.9 and 8.7 points, respectively. Patients who moved from moderate to high PA improved their SGRQ scores by 18.4 and their CRQ scores by 14.8. Slightly smaller increases were observed for patients who maintained a high level of PA throughout the study period. Maintaining a low level of PA or decreasing PA over the study period was associated with a significant HRQoL decline. Among COPD patients, a reduction in time spent engaging in PA or maintaining a low level may impair HRQoL, whereas an increase in PA can improve HRQoL parameters.

Classifying the severity of COPD: are the new severity scales better than the old?

BACKGROUND: Forced expiratory volume in 1 second cut-off points establish the severity of chronic obstructive pulmonary disease (COPD). OBJECTIVES: To compare how the American Thoracic Society (ATS), the British Thoracic Society (BTS), the Global Initiative for COPD (GOLD) and the ATS-European Respiratory Society (ATS-ERS) guidelines for rating COPD severity predict several significant outcomes. DESIGN: Five-year prospective cohort study. Spirometry was performed and health-related quality of life (HRQoL) assessed using the Short Form 36 Health Survey and the Saint George's Respiratory Questionnaire. Hospital admissions resulting from COPD exacerbation and mortality during a 5-year follow-up period were recorded. RESULTS: In all guidelines, the number of admissions was directly associated with COPD severity. The sensitivity and specificity for 5-year respiratory mortality were respectively 0.21 and 0.97 for the GOLD/ATS-ERS, 0.51 and 0.79 for the BTS, and 0.37 and 0.89 for the ATS guidelines. A similar pattern was seen for all-cause mortality. For HRQoL, statistically significant differences between guidelines were seen only for the BTS and ATS scales. CONCLUSIONS: These guidelines did not consistently stratify patients with regard to 5-year mortality and HRQoL. Although the BTS system was slightly superior, none of the guidelines were closely related to these outcomes. Other instruments are needed for a better determination of the severity of COPD.

A simple score for assessing stable chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is usually assessed using FEV(1) to establish the diagnosis and the severity of the disease. However, COPD is now considered a systemic disease. AIM: To evaluate the utility of the Health-Activity-Dyspnoea-Obstruction (HADO) score for classifying the severity of COPD and predicting outcomes. DESIGN: Prospective longitudinal clinical study. METHODS: We studied 611 consecutive patients with stable COPD in five out-patient clinics of a teaching hospital. We measured dyspnoea degree, pulmonary function (by spirometry), self-reported level of daily physical activity and overall health condition. Outcome measures included health-related quality of life (HRQoL) parameters (as measured by the generic SF-36 Health Survey and by two specific questionnaires, the St George Respiratory Questionnaire and the Chronic Respiratory Questionnaire) and mortality at 3 years follow-up. RESULTS: Based on the HADO score, COPD was classified as mild in 26.7% of patients, moderate in 53.3%, and severe in 20%. There were statistically significant correlations between these three levels of severity and HRQoL parameters and vital status. After adjustment for relevant covariates, the HADO score reliably predicted survival and vital status. DISCUSSION: The HADO score can be easily obtained in an out-patient clinic, and distinguishes groups of COPD patients by their disease severity. The HADO score is better than FEV(1%) alone for predicting mortality at 3 years.

Proximal ileitis secondary to anisakiasis.

Intestinal anisakiasis is a disease caused by human infection by Anisakis larva that can be found in undercooked fish that is increasing worldwide. The symptoms, typically abdominal pain, develop within 5-7 days after the fish intake. The diagnosis may be suspected based on common anamnesis (unfrozen fish intake) with abdominal pain or bowel obstruction and confirmed by blood serology. Resective surgery is only used in severe cases.

[Description of a sample of patients with chronic obstructive pulmonary disease treated at hospital-supervised respiratory clinics at primary care centers]. / Descripción de una muestra de pacientes con enfermedad pulmonar obstructiva crónica atendidos en las consultas del área de neumología dependientes de un hospital.

OBJECTIVE: To study the general characteristics, health perception and limitations of patients with chronic obstructive pulmonary disease (COPD) treated at respiratory clinics at primary care centers staffed by pulmonologists from our hospital service. METHOD: The study was carried out at 5 primary care centers that enrolled the patients consecutively. Questionnaires were used to collect information on sociodemographic aspects, perception of health, and limitations to activities of daily living. We also collected information on the treatments patients were receiving and comorbidities. Spirometry was also performed. RESULTS: Six hundred eleven patients with a mean age of 67.2 years were included in the study; 97.7% were male. The most common comorbidities were spinal column pathology (43%) and osteoarthritis (37%). The mean forced expiratory volume in 1 second (FEV1) was 1.37 L and FEV1% was 49.7% of predicted. Medications taken for COPD were mainly beta-adrenergics and anticholinergics; 66% of patients used inhaled steroids. The majority of patients (52.7%) referred to their health as fair and 59.9% declared having some degree of limitation to their activities of daily living which they attributed to their respiratory disease. Statistical differences were found between the degree of limitation and the degree of dyspnea (P<.0001), perception of health (P<.0001), and FEV1 (P=.001). CONCLUSIONS: Our study outlines the general characteristics of COPD patients and shows that dyspnea is closely related to the perception patients have of their degree of limitation.

[Reference figures for pulmonary artery pressures after effective treatment of Graves' disease]. / Normalización de las cifras de presión en la arteria pulmonar tras tratamiento efectivo de la enfermedad de Graves.

We report the case of a 48-year-old woman with a diagnosis of pulmonary hypertension and hyperthyroidism (Graves' disease) in whom pulmonary artery pressures became normal after treatment of thyroid disease. The possible pathogenic mechanisms involved in this association include the presence of hyperdynamic heart failure and/or the presence of immune alterations underlying both conditions.

[Tuberculosis in La Rioja from 1988 to 1993. Clinical course, localization, influence of human immunodeficiency virus infection, and sensitivity of mycobacterial tests]. / Tuberculosis en La Rioja de 1988 a 1993. Evolución, localizaciones, influencia de la infección por el virus de la inmunodeficiencia humana y sensibilidad de la baciloscopia.

BACKGROUND: The present study was performed to analyze the evolution of the incidence of tuberculosis in La Rioja (Spain) from January 1988 to March 1993. The influence of factors such as HIV infection and alcoholism was analyzed. The sensitivity of the bacilloscopy in the diagnosis was studied. METHODS: The cases were collected from the Regional Tuberculosis Program of the Public Health Department in La Rioja, with clinical histories being collected from the Internal Medicine Department of the Hospital San Millán in Logroño. Cases of tuberculosis were microbiologically confirmed by cultures of Mycobacterium tuberculosis. RESULTS: The total number of cases studied was 649 with the incidence of tuberculosis in La Rioja being 51 cases/100,000 inhabitants in 1992. The mean age of all the patients was 45 years with 80% of the tuberculosis being pulmonary and 20% extrapulmonary. Twelve percent of the patients were HIV+; 18% being extrapulmonary tuberculosis and 10.8% pulmonary tuberculosis, p < 0.02. Pleural and urogenital tuberculosis were present in fewer HIV+ patients. Bacilloscopy was negative requiring a culture for diagnosis in 28.6% of the cases with this circumstance more frequently occurring in the pleural and urogenital forms of the diseases. Treatment has evolved from the use of ethambutol in the first few years to the present use of pyrazinamide. CONCLUSIONS: No trend towards an increase in the incidence of tuberculosis in the time period studied was observed in La Rioja. Extrapulmonary tuberculosis was the type of tuberculosis most frequently found in HIV positive patients, with pleural and urogenital forms of the disease being less frequently found in these patients. In these case the bacilloscopy was also found to be negative more frequently.

[Prolonged febrile syndrome as a manifestation of Coxiella burnetii infection, presentation of infrequent clinical cases]. / Síndrome febril prolongado como manifestación de infección por Coxiella burnetii, presentando casos clínicos poco frecuentes.

We present two cases of infection by Coxiella burnetii which developed with sustained fever symptoms. During its evolution, the first case presented granulomatous hepatitis, whereas the second case presented left Cosofemoral Arthritis. We describe the clinical-evolutive characteristics of these clinical forms and within the evolution of the chronic forms of Q fever.

[Erythroderma caused by carbamazepine. Diagnosis with skin patch]. / Eritrodermia por carbamacepina. Su diagnóstico mediante parche cutáneo.

We present two cases of cutaneous erythroderma induced by carbamazepine therapy, both cases with just cutaneous affection and only one suspicious drug. A cutaneous patch study, with standard battery from the Spanish Contact Dermatitis Research Group, vaseline with carbamazepine at 10% and lectures at 48 and 96 hours, was conducted. The result was positive for carbamazepine and negative for all other patches in both cases. All controls were negative. This is a very simple test, easy to perform, specific and with low side effects, allowing the diagnosis of this pathology.

[Hyponatremia upon admission in patients over 65 years of age. Relation with medium length of stay and hospital mortality]. / Hiponatremia al ingreso en pacientes mayores de 65 años. Relación con la estancia media y la mortalidad hospitalaria.

OBJECTIVE: To determine the relation between natremia levels equal to or lower than 130 mEq/l upon admission, and average length of stay and hospital mortality in patients with more than 65 years of age. DESIGN: Prospective case-control study lasting one year. LOCATION: Complejo Hospitalario San Millán-San Pedro (second-level hospital) in Logroño (La Rioja). CASES: patients with more than 65 years of age and natremia levels equal to or lower than 130 mEq/l upon admission. CONTROL: normonatremic patients matched by age and sex. VARIABLES: average length of stay and hospital mortality. Comparative tests: Z-test comparing two mean values and Yate's chi-square continuity correction. RESULTS: With a 95% confidence, we have verified that the average length of stay of hyponatremic patients is between 1.44 and 9.2 days longer than in the case of normonatremic patients and the mortality rate is between 2.1 and 28.1% greater. CONCLUSION: Patients with hyponatremia upon admission have a longer average length of stay and a greater mortality. Plasmatic sodium levels equal to or lower than 130 mEq/l upon admission are associated to a poor prognosis in the latter evolution of the patient.

[Course and prognosis of levels of CD4 molecules in HIV-infected patients]. / Evolución y valor pronóstico de la concentración de moléculas CD4 en pacientes infectados por el VIH.

OBJECTIVE: To measure CD4 molecule concentration on lymphocyte surface. And observe its evolution during one year, in HIV infected patients. To assess the importance of this measure as a prognostic marker for disease progression, compared with the total number of CD4 lymphocytes. METHODS: Clinical and analytical data from 107 patients were collected; 64 fulfilled a one-year follow-up. 45 were initially asymptomatic (ASN), 13 had AIDS-related complex (CRS) and 6 had AIDS. CD4 cell count was higher than 500 in 16, between 500 and 200 in 20, and lower than 200 in 28. CD4 molecule concentration in lymphocytes was measured with immunoassay capcellia CD4/CD8 (Pasteur Institute, Paris). During one year 12 patients progressed cunically. RESULTS: There was significant decrease of T4 lymphocytes in the following groups whole population, CRS, more than 500 (initially). There were significant decreases of CD4 molecules in the following groups: whole population, ASN, CRS, more than 500 (initially), between 500 and 200 (initially), the mean number of T4 lymphocytes was 140/mm3 in progressors versus 358 in non-progressors (p < 0.05). Initial CD4 molecule concentration was 3.87 pmol/l in progressors versus 11.50 pmol/l in non-progressors (p < 0.05). CONCLUSIONS: Both total number of T4 lymphocytes and CD4 molecule concentration decrease with time. However, in asymptomatic patients only CD4 molecule decrease reaches statistical signification. Both T4 lymphocyte number and CD4 molecule concentration were lower in progressors. Measurement of CD4 molecule concentration is a parameter of similar value with respect to T4 lymphocyte count, and with similar value as progression marker.

[Brucellosis: 50 cases. Clinico-epidemiologic study and evaluation of diagnostic methods]. / Brucelosis: 50 casos. Estudio epidemiológico-clínico y valoración de métodos diagnósticos.

Fifty cases of brucellosis attending our Service of Internal Medicine during the period 1985-1990 are restrospectively studies. The number of patients in which the potential transmission mechanism and the risk factor involved are unknown is very high, being the percentage higher among women from urban areas (50%). Thus, greater attention should be paid to transmission sources considered unfrequent and to survival of the germ in several biological environments, as well as to consumption of non-pasteurized dairy products. The evolution period of the disease until hospitalization and diagnosis is large (48.6 days), especially in its oligosymptomatic forms. The diagnostic method is based mainly in clinical observations plus agglutinations, with positive hemocultive as the diagnostic method in just 6% of the cases. Treatment with streptomycin and tetracycline is still highly effective.

[Primary malignant melanoma of the mucosa of the nasal septum. A case report]. / Melanoma maligno primario de mucosa del tabique nasal. A propósito de un caso.

Mucosal melanomas are rare, representing 3% of malignant nasosinusal tumors. Their prognosis is poor. A case of malignant melanoma of the nasal septum is presented. A bibliographic review was made and the incidence, clinical features, diagnosis, treatment, and prognosis of these tumors are discussed.