Design of an Intelligent Decision Support System Applied to the Diagnosis of Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA), characterized by recurrent episodes of partial or total obstruction of the upper airway during sleep, is currently one of the respiratory pathologies with the highest incidence worldwide. This situation has led to an increase in the demand for medical appointments and specific diagnostic studies, resulting in long waiting lists, with all the health consequences that this entails for the affected patients. In this context, this paper proposes the design and development of a novel intelligent decision support system applied to the diagnosis of OSA, aiming to identify patients suspected of suffering from the pathology. For this purpose, two sets of heterogeneous information are considered. The first one includes objective data related to the patient's health profile, with information usually available in electronic health records (anthropometric information, habits, diagnosed conditions and prescribed treatments). The second type includes subjective data related to the specific OSA symptomatology reported by the patient in a specific interview. For the processing of this information, a machine-learning classification algorithm and a set of fuzzy expert systems arranged in cascade are used, obtaining, as a result, two indicators related to the risk of suffering from the disease. Subsequently, by interpreting both risk indicators, it will be possible to determine the severity of the patients' condition and to generate alerts. For the initial tests, a software artifact was built using a dataset with 4400 patients from the Álvaro Cunqueiro Hospital (Vigo, Galicia, Spain). The preliminary results obtained are promising and demonstrate the potential usefulness of this type of tool in the diagnosis of OSA.

Design and Conceptual Proposal of an Intelligent Clinical Decision Support System for the Diagnosis of Suspicious Obstructive Sleep Apnea Patients from Health Profile.

Obstructive Sleep Apnea (OSA) is a chronic sleep-related pathology characterized by recurrent episodes of total or partial obstruction of the upper airways during sleep. It entails a high impact on the health and quality of life of patients, affecting more than one thousand million people worldwide, which has resulted in an important public health concern in recent years. The usual diagnosis involves performing a sleep test, cardiorespiratory polygraphy, or polysomnography, which allows characterizing the pathology and assessing its severity. However, this procedure cannot be used on a massive scale in general screening studies of the population because of its execution and implementation costs; therefore, causing an increase in waiting lists which would negatively affect the health of the affected patients. Additionally, the symptoms shown by these patients are often unspecific, as well as appealing to the general population (excessive somnolence, snoring, etc.), causing many potential cases to be referred for a sleep study when in reality are not suffering from OSA. This paper proposes a novel intelligent clinical decision support system to be applied to the diagnosis of OSA that can be used in early outpatient stages, quickly, easily, and safely, when a suspicious OSA patient attends the consultation. Starting from information related to the patient's health profile (anthropometric data, habits, comorbidities, or medications taken), the system is capable of determining different alert levels of suffering from sleep apnea associated with different apnea-hypopnea index (AHI) levels to be studied. To that end, a series of automatic learning algorithms are deployed that, working concurrently, together with a corrective approach based on the use of an Adaptive Neuro-Based Fuzzy Inference System (ANFIS) and a specific heuristic algorithm, allow the calculation of a series of labels associated with the different levels of AHI previously indicated. For the initial software implementation, a data set with 4600 patients from the Álvaro Cunqueiro Hospital in Vigo was used. The results obtained after performing the proof tests determined ROC curves with AUC values in the range 0.8-0.9, and Matthews correlation coefficient values close to 0.6, with high success rates. This points to its potential use as a support tool for the diagnostic process, not only from the point of view of improving the quality of the services provided, but also from the best use of hospital resources and the consequent savings in terms of costs and time.

Serum exosome inflamma-miRs are surrogate biomarkers for asthma phenotype and severity.

BACKGROUND: Asthma is a heterogeneous disease with several phenotypes, endotypes and severity degrees, in which different T-cell subpopulations are involved. These cells express specific miRNAs (i.e. inflamma-miRs) that can be released to serum in exosomes after activation and be used as biomarkers of underlying inflammation. Thus, we aim to evaluate specific T-cell miRNA signatures in serum exosomes from different subgroups of asthmatic patients. METHODS: Samples from healthy donors (N = 30) and patients (N = 119) with different asthma endotypes (T2high -Atopic/T2high -Non-atopic/T2low ) and severity degrees (mild/MA and moderate-severe/MSA) were used. Demographic, clinical, haematological and biochemical characteristics were collected. Twelve miRNAs previously associated with different Th subsets were preselected and their levels in serum exosome samples were measured using RTqPCR. RESULTS: We detected five miRNAs with high confidence in serum exosomes: miR-16-5p, miR-21-5p, miR-126-3p, miR146a-5p and miR-215-5p. All of them, except miR-16-5p were upregulated in MSA patients compared to MA. A logistic regression model including each of these miRNAs was created to discriminate both conditions, rendering a ROC curve AUC of 0.896 (0.830-0.961). miR-21-5p and miR-126-3p, both involved in Th1/Th2 differentiation, were specifically augmented in T2high -Atopic patients. Of note, all these changes were found in samples collected in autumn. On the contrary, IL-6high patients with MSA, which were more obese, older, with higher neutrophil and basophil counts and TNF levels, displayed a decrease of miR-21-5p, miR-126-3p and miR-146a-5p. CONCLUSION: Immune-related miRNAs, including miR-21-5p, miR-126-3p, miR-146a-5p and miR-215-5p, can be used as clinically relevant non-invasive biomarkers of the phenotype/endotype and severity of asthma.

Efficacy of mepolizumab in usual clinical practice and characteristics of responders.

BACKGROUND: Severe eosinophilic asthma is a high-burden disease. Mepolizumab has been effective in several randomized clinical trials. However, such success might not be applicable to patients treated in usual clinical practice. The objectives of this article are to evaluate the efficacy of mepolizumab in severe uncontrolled eosinophilic asthma under usual clinical practice, and to determine characteristics associated with the response to this treatment. METHODS: We have conducted a retrospective, multicentre study, including all adult patients with severe uncontrolled eosinophilic asthma in Galicia, Spain, on whom mepolizumab treatment was started before June 2020, at least 6 months before the time of inclusion, and had received at least one dose of the drug. Patient characteristics, clinical data, respiratory function and comorbidities were collected at baseline and at the 6-month-follow-up. Responders and super-responders were defined according to clinical response and requirement of systemic corticosteroids. RESULTS: 122 patients (mean age 58 years old) were included. In the follow-up treatment 6 months later, 75.4% of the patients were well-controlled, displaying a significant reduction in blood eosinophil counts (p < 0.001), hospital admissions and disease exacerbations (p < 0.001), and had their systemic glucocorticosteroid dose significantly reduced (p < 0.001). The inhaled corticosteroid dose was also lowered (p < 0.01) after 6 months of treatment. Around two-thirds had a clinically significant increase in FEV1, 95% of the patients were considered responders and 43% super-responders. CONCLUSION: In routine clinical practice, mepolizumab is effective in patients with severe eosinophilic asthma and it has a good safety profile.

Increasing Competitiveness through the Implementation of Lean Management in Healthcare.

The main aim of this paper was two-fold: first, to design a participative methodology that facilitates lean management implementation in healthcare by adopting the action research approach; second, to illustrate the usefulness of this methodology by applying it to the sleep unit of a public hospital in Spain. This methodology proposes the implementation of lean management in its broadest sense: adopting both lean principles and some of its practical tools or practices in order to achieve competitive advantage. The complete service value chain was considered when introducing changes through lean management implementation. This implementation involved training and involving staff in the project (personnel pillar), detecting and analysing "waste" in value chain processes (processes pillar) and establishing control and measurement mechanisms in line with objectives (key performance indicators pillar) and putting in place improvement actions to achieve these objectives. The application of this methodology brought about an improvement in the management of patient flow in terms of effectiveness, efficiency and quality but also an internal transformation towards lean culture.

Perfil social de los pacientes que ingresan por una agudización de EPOC. Un análisis desde una perspectiva de género / Social Profile of Patients Admitted for COPD Exacerbations. A Gender Analysis

OBJETIVO: Describir y comparar desde una perspectiva de género el perfil social de los pacientes ingresados por agudizaciones de EPOC (AEPOC) en un servicio de neumología. METODOLOGÍA: Estudio transversal en pacientes con AEPOC graves donde se recogieron variables demográficas, clínicas y de la esfera social (situación económica, cuidados, dependencia en las actividades básicas e instrumentales, riesgo social, sobrecarga de cuidador, uso de servicios sociales) utilizando cuestionarios e índices como Barthel, Lawton-Brody, Zarit, Barber y Gijón. Se realiza un análisis descriptivo de la situación sociosanitaria que se compara en función del género. RESULTADOS: Se incluyeron 253 pacientes, edad de 68,9 ± 9,8 años, 58 (23%) mujeres, FEV1 42,1 ± 14,2% e índice de Charlson 1,8 ± 0,9, 37,9% fumadores activos. El 55,2% cobran menos de 800 €/mes, el 46,2% tienen alguna dependencia para actividades básicas y el 89,3% para actividades instrumentales, el 89% presentan fragilidad social y el 64% están en situación de problema/riesgo social. Disponen de cuidador el 49%: el 83% no formales y el 90,9% mujeres, con alguna sobrecarga en el 69,2%. El 21,4% viven solos. El 22,9% han contactado con los servicios sociales. Las mujeres con AEPOC son más jóvenes, fuman más activamente y tienen menos comorbilidades. Disponen de menos recursos económicos y ayuda y peor situación sociofamiliar, pero son menos dependientes para algunas actividades. CONCLUSIONES: El perfil social de los pacientes con AEPOC graves que ingresan en neumología es muy desfavorable, especialmente en las mujeres. Estas desigualdades parecen ir más allá de las diferencias de la expresión de la EPOC en función del género

OBJECTIVE: To describe and compare from a gender perspective the social profile of patients admitted to a respiratory unit for COPD exacerbations (COPDE). METHODOLOGY: A cross-sectional study in patients with serious COPDE in which demographic, clinical, and social data (economic situation, care, dependency for basic and instrumental activities, social risk, caregiver overload, use of social services) were collected using questionnaires and indices such as Barthel, Lawton-Brody, Zarit, Barber, and Gijón. A descriptive analysis was made of patients' social and healthcare situation, compared on the basis of gender. RESULTS: We included 253 patients, aged 68.9 ± 9.8 years, 58 (23%) women, FEV1 42.1 ± 14.2%, and Charlson index 1.8 ± 0.9; 37.9% were active smokers. In total, 55.2% had an income of less than € 800/month, 46.2% had some dependency for basic activities, and 89.3% for instrumental activities, 89% presented social fragility, while 64% were in a situation of social problem/risk; 49% had a caregiver, 83% in a non-formal arrangement, 90.9% of whom were women, with some overload reported by 69.2%. A total of 21.4% lived alone, and 22.9% had contacted social services. Women with COPDE are younger, smoke more actively, and have fewer comorbidities. They have more scant economic resources and assistance and are in a poorer socio-familiar situation, but they are less dependent for some activities. CONCLUSIONS: The social profile of patients with serious COPDE admitted to respiratory units is very unfavorable, especially among women. These inequalities appear to go beyond differences in the expression of COPD, and are associated with gender

Social Profile of Patients Admitted for COPD Exacerbations. A Gender Analysis. / Perfil social de los pacientes que ingresan por una agudización de EPOC. Un análisis desde una perspectiva de género.

OBJECTIVE: To describe and compare from a gender perspective the social profile of patients admitted to a respiratory unit for COPD exacerbations (COPDE). METHODOLOGY: A cross-sectional study in patients with serious COPDE in which demographic, clinical, and social data (economic situation, care, dependency for basic and instrumental activities, social risk, caregiver overload, use of social services) were collected using questionnaires and indices such as Barthel, Lawton-Brody, Zarit, Barber, and Gijón. A descriptive analysis was made of patients' social and healthcare situation, compared on the basis of gender. RESULTS: We included 253 patients, aged 68.9±9.8years, 58 (23%) women, FEV1 42.1±14.2%, and Charlson index 1.8±0.9; 37.9% were active smokers. In total, 55.2% had an income of less than €800/month, 46.2% had some dependency for basic activities, and 89.3% for instrumental activities, 89% presented social fragility, while 64% were in a situation of social problem/risk; 49% had a caregiver, 83% in a non-formal arrangement, 90.9% of whom were women, with some overload reported by 69.2%. A total of 21.4% lived alone, and 22.9% had contacted social services. Women with COPDE are younger, smoke more actively, and have fewer comorbidities. They have more scant economic resources and assistance and are in a poorer socio-familiar situation, but they are less dependent for some activities. CONCLUSIONS: The social profile of patients with serious COPDE admitted to respiratory units is very unfavorable, especially among women. These inequalities appear to go beyond differences in the expression of COPD, and are associated with gender.

Assessing adherence to inhaled medication in asthma: Impact of once-daily versus twice-daily dosing frequency. The ATAUD study.

INTRODUCTION: This study was aimed at evaluating whether once-daily regimens (od-r) show benefits in adherence when compared to twice-daily (td-r). METHODS: Prospective, multicenter, 6-month follow-up study with two visits. The main objective was to compare adherence assessed by the electronic prescription refill rate (EPRR) and by the 10-item Test of Adherence to Inhalers (TAI) in patients with od-r and td-r. Suboptimal adherence was defined as TAI < 50 or EPRR ≤ 80%. The effect of suboptimal adherence on meaningful clinical outcomes and the concordance between EPRR and TAI were also examined. RESULTS: One hundred and ninety-seven patients (47.3 ± 15.9 years, 65% women) were included and 180 completed the study. TAI score was <50 in 29.8% od-r patients and 46.9% in td-r (p = 0.01) and EPRR was ≤80% in 22.6% and 37.5% respectively (p = 0.02). The correlation between the two methods was moderate (rho = 0.548; p < 0.001). There were no significant differences in FEV1 (%), symptoms or exacerbations between patients with optimal and suboptimal adherence. During follow-up, five patients (6%) with o-dr and 17 patients (17.7%) with t-dr suffered an exacerbation (p = 0.013). At visit two, 13.1% of the patients with o-dr and 31.3% with t-dr had uncontrolled asthma (p = 0.003), although more patients with o-dr were receiving inhaled corticosteroids in the high-dose stratum (25.8% vs. 11.5%; p = 0.001). CONCLUSION: Mean adherence rates were greater with od-r than with td-r, but we did not observe an effect on clinical outcomes.