Cost-effectiveness of the COPD Patient Management European Trial home-based disease management program.

Purpose: Efficient management of COPD represents an international challenge. Effective management strategies within the means of limited health care budgets are urgently required. This analysis aimed to evaluate the cost-effectiveness of a home-based disease management (DM) intervention vs usual management (UM) in patients from the COPD Patient Management European Trial (COMET). Methods: Cost-effectiveness was evaluated in 319 intention-to-treat patients over 12 months in COMET. The analysis captured unplanned all-cause hospitalization days, mortality, and quality-adjusted life expectancy. Costs were evaluated from a National Health Service perspective for France, Germany, and Spain, and in a pooled analysis, and were expressed in 2015 Euros (EUR). Quality of life was assessed using the 15D health-related quality-of-life instrument and mapped to utility scores. Results: Home-based DM was associated with improved mortality and quality-adjusted life expectancy. DM and UM were associated with equivalent direct costs (DM reduced costs by EUR -37 per patient per year) in the pooled analysis. DM was associated with lower costs in France (EUR -806 per patient per year) and Spain (EUR -51 per patient per year), but higher costs in Germany (EUR 391 per patient per year). Evaluation of cost per death avoided and cost per quality-adjusted life year (QALY) gained showed that DM was dominant (more QALYs and cost saving) in France and Spain, and cost-effective in Germany vs UM. Nonparametric bootstrapping analysis, assuming a willingness-to-pay threshold of EUR 20,000 per QALY gained, indicated that the probability of home-based DM being cost-effective vs UM was 87.7% in France, 81.5% in Spain, and 75.9% in Germany. Conclusion: Home-based DM improved clinical outcomes at equivalent cost vs UM in France and Spain, and in the pooled analysis. DM was cost-effective in Germany with an incremental cost-effectiveness ratio of EUR 2,541 per QALY gained. The COMET home-based DM intervention could represent an attractive alternative to UM for European health care payers.

Spontaneous regression of metastatic squamous cell lung cancer.

Spontaneous regression (SR) of cancer is a rare but confirmed spectacular phenomenon, and it is even rarer in the context of advanced NSCLC. It is essential to understand this phenomenon in order to elucidate the nature of neoplastic disease and develop new treatment methods.

Más Platón y menos Prozac(R): llega el ASMA-ZUMAB / More Platon And Less Prozac(R): The Arrival Of ASTHMA-ZUMAB

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Monitoring Noninvasive Ventilation in Patients with Obesity Hypoventilation Syndrome: Comparison between Ventilator Built-in Software and Respiratory Polygraphy.

BACKGROUND: Polygraphy (PG) remains the standard method of assessing noninvasive ventilation (NIV) effectiveness. Built-in software (BIS) of recent NIV equipment provides estimates of some ventilator parameters, but their usefulness is unclear. OBJECTIVES: To assess the reliability of BIS compared with PG in a cohort of obesity hypoventilation syndrome (OHS) patients on NIV. METHODS: Thirty stable OHS patients on NIV were evaluated in an outpatient setting with simultaneous PG and BIS recordings. The automated apnea-hypopnea event index (EIAUT) provided by Rescan and manual scoring based on available traces obtained from the software (EIBIS) were compared with manual PG scoring (EIPG). Each manual scoring was separately performed by 2 trained operators. Agreement between the 2 operators was assessed using the kappa coefficient. Pearson correlation and Bland-Altman plots were used to evaluate agreement between EIAUT, EIBIS, and EIPG. RESULTS: Twenty-six cases were valid for analysis (age ±61 years, 17 men). All patients were ventilated in the spontaneous/timed mode (mean inspiratory positive airway pressure 17 ± 3 cm H2O, mean expiratory positive airway pressure 10 ± 3 cm H2O). Cohen's kappa agreement between the operators was 0.7 for EIBIS and 0.84 for EIPG. EIBIS showed good correlation with EIPG (r2 = 0.79 p < 0.001), better than scoring provided by the automated analysis (r2 = 0.71, p < 0.006 for EIAUT vs. EIPG). CONCLUSIONS: In stable OHS patients on NIV, unattended home-based monitoring using Rescan is reproducible and reliable to assess quality of ventilation when compared with PG. In addition, manual scoring of events using data obtained with this device is more consistent than software-based automated analysis.

Design of a numerical model of lung by means of a special boundary condition in the truncated branches.

BACKGROUND: The need for a better understanding of pulmonary diseases has led to increased interest in the development of realistic computational models of the human lung. METHODS: To minimize computational cost, a reduced geometry model is used for a model lung airway geometry up to generation 16. Truncated airway branches require physiologically realistic boundary conditions to accurately represent the effect of the removed airway sections. A user-defined function has been developed, which applies velocities mapped from similar locations in fully resolved airway sections. The methodology can be applied in any general purpose computational fluid dynamics code, with the only limitation that the lung model must be symmetrical in each truncated branch. RESULTS: Unsteady simulations have been performed to verify the operation of the model. The test case simulates a spirometry because the lung is obliged to rapidly perform both inspiration and expiration. Once the simulation was completed, the obtained pressure in the lower level of the lung was used as a boundary condition. The output velocity, which is a numerical spirometry, was compared with the experimental spirometry for validation purposes. CONCLUSIONS: This model can be applied for a wide range of patient-specific resolution levels. If the upper airway generations have been constructed from a computed tomography scan, it would be possible to quickly obtain a complete reconstruction of the lung specific to a specific person, which would allow individualized therapies.

An international randomized study of a home-based self-management program for severe COPD: the COMET.

INTRODUCTION: Most hospitalizations and costs related to COPD are due to exacerbations and insufficient disease management. The COPD patient Management European Trial (COMET) is investigating a home-based multicomponent COPD self-management program designed to reduce exacerbations and hospital admissions. DESIGN: Multicenter parallel randomized controlled, open-label superiority trial. SETTING: Thirty-three hospitals in four European countries. PARTICIPANTS: A total of 345 patients with Global initiative for chronic Obstructive Lung Disease III/IV COPD. INTERVENTION: The program includes extensive patient coaching by health care professionals to improve self-management (eg, develop skills to better manage their disease), an e-health platform for reporting frequent health status updates, rapid intervention when necessary, and oxygen therapy monitoring. Comparator is the usual management as per the center's routine practice. MAIN OUTCOME MEASURES: Yearly number of hospital days for acute care, exacerbation number, quality of life, deaths, and costs.

Community-Acquired Moraxella catarrhalis Bacteremic Pneumonia: Two Case Reports and Review of the Literature.

Moraxella (formerly Branhamella) catarrhalis was discovered at the end of the nineteenth century, and for many decades it was considered to be a harmless commensal of the upper respiratory tract. It is a Gram-negative, aerobic diplococcus considered to be the third most common pathogen isolated in childhood sinusitis and otitis media and in adult chronic lower respiratory disease, as well as an etiological agent of pneumonia in immunosuppressed patients or those with chronic obstructive pulmonary disease. Moraxella catarrhalis pneumonia is rarely associated with bacteremia. Here, we present two cases of community-acquired Moraxella catarrhalis bacteremic pneumonia.

Poncet's disease mimicking rheumatoid arthritis in a patient with suspected Crohn's disease.

Poncet's disease is a rarely reported entity with an unknown pathogenesis. However, because it has a very favorable prognosis with antituberculosis drugs, we believe it should be considered as a differential diagnosis for patients with fever and polyarthritis of unknown cause, particularly if active tuberculosis is suspected.

Community-Acquired Pneumonia and Empyema Caused by Citrobacter koseri in an Immunocompetent Patient.

Citrobacter species, belonging to the family Enterobacteriaceae, are environmental organisms commonly found in soil, water, and the intestinal tracts of animals and humans. Citrobacter koseri is known to be an uncommon but serious cause of both sporadic and epidemic septicemia and meningitis in neonates and young infants. Most cases reported have occurred in immunocompromised hosts. The infections caused by Citrobacter are difficult to treat with usual broad spectrum antibiotics owing to rapid generation of mutants and have been associated with high death rates in the past. We believe this is the first case described in the literature of a community-acquired pneumonia and empyema caused by Citrobacter koseri in an immunocompetent adult patient.

Community-acquired bacteremic Streptomyces atratus pneumonia in animmunocompetent adult: a case report.

INTRODUCTION: Streptomyces spp. are aerobic, Gram-positive bacteria of the order Actinomycetales, known for their ability to produce antimicrobial molecules such as streptomycin. Pneumonia due to Streptomyces is considered to be rare and limited to immunocompromised patients. Streptomyces spp. are only rarely associated with invasive systemic infections. To our knowledge, we report the first documented case of community-acquired Streptomyces atratus bacteremic pneumonia in an immunocompetent patient. CASE PRESENTATION: We describe a case of Streptomyces atratus bacteremic pneumonia in an otherwise healthy, 77-year-old Spanish man. Streptomyces identified by 16S ribosomal RNA sequencing grew in multiple blood cultures and bronchoalveolar lavage cultures. The infection resolved completely after treatment with imipenem and amoxicillin/clavulanic acid for 2 months. CONCLUSIONS: The majority of cases reported in the literature make reference to the difficulty of determining the pathogenic role of Streptomyces spp. Usually considered a contaminant, the pathogenic role of Streptomyces spp. is easier to confirm when the species is isolated from a catheter tip and, in the case of blood cultures, in more than one sample with a high count of colonies. To our knowledge, we report the first documented case of Streptomyces atratus bacteremic pneumonia in an immunocompetent patient. As the experience is limited, further studies are needed to better understand the interpretation of the isolates of the genus Streptomyces; the predisposing factors for infection; and the course, treatment, and evolution of these infections.

Amiloidosis traqueobronquial: diagnóstico, tratamiento y evolución en 5 casos / Tracheobronchial amyloidosis: Diagnosis, treatment and evolution in 5 patients

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Air embolism: a complication of computed tomography-guided transthoracic needle biopsy.

Air embolism is a pathological condition caused by the entry of gas into vascular structures. It is a rare but feared complication due to its serious morbidity. We report two male patients who were diagnosed with air embolism as a complication of computed tomography-guided transthoracic needle biopsy. Both patients referred respiratory symptoms minutes after the procedure. The chest computed tomography of one of the patients showed air in the left ventricle and ascending aorta, and in the other, air was noted only in the left ventricle. Both patients suffered myocardial infarction without associated mortality. One patient showed anthracotic dust deposits in the lung biopsy suggestive of pneumoconiosis, and there was no definitive diagnosis in the other. We strongly believe that because of the very low incidence but high mortality of this entity, all physicians should be aware of this complication in order to know how to proceed in this situation.

From cytology to histology: diagnosis of a relapsed mediastinal lymphoma by endobronchial ultrasound transbronchial histological needle.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is highly accurate in diagnosing mediastinal lymphadenopathies of lung cancer and benign disorders, with the advantage that it is a minimally invasive technique, unlike open surgery and mediastinoscopy. However, the diagnostic accuracy of EBUS-TBNA for the diagnosis of lymphoma in patients with mediastinal lymphadenopathy is not well defined. The lack of tissue architecture obtained by cytological needles decreases the diagnostic accuracy for diagnosis and subtyping of de novo and relapsed mediastinal lymphomas. We present the first described case in the literature of an anaplastic large cell lymphoma relapsed, diagnosed on tissue fragments obtained by EBUS-TBNA with the particularity of using a histological needle.

Impact of environmental air pollutants on disease control in asmathic patients.

PURPOSE: Asthmatics are adversely affected by the presence of air pollutants, the concentrations of which can nowadays be measured. However, the utility of this information in clinical practice has not been defined in a group of asthmatics in stable condition. Our objective was to determine what impact the level of air pollutants had on the control of their asthma and the degree of airway inflammation. METHODS: We performed a cross-sectional study of adult asthmatics in stable condition. From the regional environmental authority, we obtained the concentrations of ambient nitric oxide (NO2), ozone (O3), suspended particulate matter up to 10 micrometers in diameter (PM10) and sulphur dioxide (SO2) at fixed geographical points. Disease control was assessed using asthma control test (ACT) scores, and airway inflammation using fraction of exhaled nitric oxide (FeNO) values. Correlation and linear regression studies were performed using ACT scores as the dependent variable. RESULTS: The study included 99 asthmatics, aged 39 years (SD 8), 55% women. Mean ACT value was 17.2 (SD 6.5), and FeNO 33.7 (SD 16). Of the pollutants studied, only NO2 was correlated with ACT scores (CC = 0.45, p < 0.001). We found no relationship between pollutants and airway inflammation. Multivariate analysis showed that ACT score was predicted by ambient air NO2 concentration and, to a lesser extent, mean FeNO. CONCLUSIONS: Information on the concentration of ambient NO2 in our environment can help the clinician to interpret the evolution of asthmatic patients.

Desmoplastic small round cell tumor of the lung: A case report and literature review.

Desmoplastic small round cell tumor (DSRCT) is a rare, aggressive and malignant tumor that is characterized by nests of small tumor cells surrounded by a cellular and vascular collagenous stroma and predominantly affects young adolescent males. This tumor most commonly originates in the abdomen; however, in rare cases, DSRCT can originate in other body regions. The main manifestations of DSRCT are chest pain and respiratory symptoms, and patients' average survival after diagnosis is less than two years. In this report, we describe a case involving DSRCT of the lung that proved to be difficult to diagnose, and we conduct a literature review.

T-cell profiling and the immunodiagnosis of latent tuberculosis infection in patients with inflammatory bowel disease.

BACKGROUND: Factors associated with performance of interferon-γ release assays (IGRA) and the tuberculin skin test (TST) in screening for latent tuberculosis infection in patients with inflammatory bowel diseases (IBD) are still poorly understood. The influence of peripheral T-cell subset counts on the results also remain unclear. METHODS: Prospective single-center study in 205 patients with IBD. Latent tuberculosis infection screening included a chest radiograph, TST (retest if negative), and 2 IGRAs: QuantiFERON-TB Gold In-Tube (QFT-GIT) and TSPOT-TB (TSPOT). T-cell subpopulations were determined by flow cytometry. RESULTS: Twenty-one (10.2%) patients had an abnormal chest radiograph, 55 (26.8%) had a positive TST, 16 (7.8%) had a positive QFT-GIT, and 25 (12.6%) had a positive TSPOT. TST positivity was lower in patients on ≥2 immunosuppressants compared with the controls (5-aminosalicylic acid treatment) (10.4% versus 38.2%, respectively) (P = 0.0057). No other drugs influenced TST or IGRA positivity. In patients on corticosteroid treatment, anti-TNF treatment, or ≥2 immunosuppressants, IGRAs detected 10 cases of latent tuberculosis infection not identified by TST. TSPOT and QFT-GIT increased yield by 56% and 22%, respectively. No significant differences in T-cell subpopulations were found between patients with positive or negative TST or TSPOT results. However, patients with positive QFT-GIT findings had more CD8 T cells (mean, 883 ± 576 versus 484 ± 385 cells per microliter in patients with negative results) (P = 0.022). CONCLUSIONS: IGRAs can improve TST-based screening in patients with IBD on immunosuppressive therapy. A low CD8 count can affect QFT-GIT results. We suggest combining TSPOT and TST screening in patients with IBD on immunosuppressants.

Espirometría / Spirometry

La espirometría es la principal prueba de función pulmonar, y resulta imprescindible para la evaluación y el seguimiento de las enfermedades respiratorias. Su utilidad trasciende el ámbito de la neumología, adquiere una creciente importancia en atención primaria e incluso se han descrito aplicaciones fuera del campo de las enfermedades respiratorias. Por ello, este documento pretende servir de apoyo a todos los profesionales de la salud que utilicen la espirometría, proporcionando recomendaciones basadas en las mejores evidencias científicas disponibles. Se propone una actualización de las indicaciones y contraindicaciones de la prueba. El documento establece recomendaciones sobre los requerimientos necesarios para los espirómetros convencionales y los equipos portátiles de oficina, así como sobre las medidas de higiene y de control de calidad de los espirómetros. Se definen los parámetros espirométricos que deben ser considerados, la realización de las maniobras, los criterios de aceptabilidad y repetibilidad de las medidas y su control de calidad. También se establece una propuesta para la presentación de los resultados y se recomienda una evaluación e interpretación acorde a la información generada en los últimos años. Por último, se consideran las líneas de adaptación e integración de la espirometría en el campo de las nuevas tecnologías (AU)

Spirometry is the main pulmonary function test and is essential for the evaluation and monitoring of respiratory diseases. Its utility transcends the field of Respiratory Medicine, is becoming increasingly important in primary care and applications have even been described outside the field of respiratory diseases. This document is therefore intended to serve as support for all health professionals who use spirometry, providing recommendations based on the best scientific evidence available. An update of the indications and contraindications of the test is proposed. The document sets out recommendations on the requirements necessary for conventional spirometers and portable office equipment, as well as on spirometer hygiene and quality control measures. Spirometric parameters that must be considered, performance of manoeuvres, criteria for acceptability and repeatability of measurements and their quality control are defined. A proposal is also established for presentation of the results and an evaluation and interpretation is proposed according to information generated in recent years. Finally, lines of adaptation and integration of spirometry in the field of new technologies are considered (AU)