[Bronchodilator response in elderly patients]. / Respuesta a broncodilatadores en pacientes ancianos.

Asthma in the elderly is more severe and a decreased bronchodilating response has been suggested as a contributing factor. There is no agreement on the best way of expressing reversibility. The aim of this study was to evaluate bronchodilator response in elderly patients with asthma with different levels of airway obstruction and expressing reversibility by different indices. A total of 72 asthmatic patients were studied: (FEV1/FVC < 1.64 SEE below predicted). Two groups were considered: Group I: > or = 65 years (71.0 +/- 11.7 years; FEV1 54.0 +/- 16.7% of predicted) and Group II: < 40 years (23.0 +/- 7.7 years, FEV1 67.6 +/- 16.1%). Response to bronchodilators expressed as delta absolute, delta%predicted or delta%maximal was not different between the two groups. Reversibility expressed as delta%initial, however, was lower in younger patients (> 65 years: 22.2 +/- 16.6% vs 40 years: 11.8 +/- 9.9%, p = < 0.005). A covariance analysis was performed using baseline FEV1 as covariate and bronchodilator response was not different between the two groups. Neither delta absolute (r = 0.13, p = NS), delta%predicted (r = 0.06, p = NS) nor delta maximal (r = 0.09, p = NS) showed correlation with age. delta%initial showed weak but significant correlation with age (r = 0.28, p = < 0.05) and marked dependence on baseline FEV1 (r = 0.47, p = < 0.001). Bronchodilator reversibility in the elderly asthmatics is preserved. Expressing reversibility as delta%initial produces differences depending on baseline airway obstruction.

Respuesta a broncodilatadores en pacientes ancianos. / [Bronchodilator response in elderly patients]

Asthma in the elderly is more severe and a decreased bronchodilating response has been suggested as a contributing factor. There is no agreement on the best way of expressing reversibility. The aim of this study was to evaluate bronchodilator response in elderly patients with asthma with different levels of airway obstruction and expressing reversibility by different indices. A total of 72 asthmatic patients were studied: (FEV1/FVC < 1.64 SEE below predicted). Two groups were considered: Group I: > or = 65 years (71.0 +/- 11.7 years; FEV1 54.0 +/- 16.7

of predicted) and Group II: < 40 years (23.0 +/- 7.7 years, FEV1 67.6 +/- 16.1

). Response to bronchodilators expressed as delta absolute, delta

predicted or delta

maximal was not different between the two groups. Reversibility expressed as delta

initial, however, was lower in younger patients (> 65 years: 22.2 +/- 16.6

vs 40 years: 11.8 +/- 9.9

, p = < 0.005). A covariance analysis was performed using baseline FEV1 as covariate and bronchodilator response was not different between the two groups. Neither delta absolute (r = 0.13, p = NS), delta

predicted (r = 0.06, p = NS) nor delta maximal (r = 0.09, p = NS) showed correlation with age. delta

initial showed weak but significant correlation with age (r = 0.28, p = < 0.05) and marked dependence on baseline FEV1 (r = 0.47, p = < 0.001). Bronchodilator reversibility in the elderly asthmatics is preserved. Expressing reversibility as delta

initial produces differences depending on baseline airway obstruction.

[Medical ethics in the world's market. Hippocratic fidelity or enterprise fidelity]. / La ética médica en el mundo del mercado. Fidelidad hipocrática o fidelidad a la empresa.

The advance which resulted in the mean survival increase from 50 to 75 years between 1920 and 1990 also provoked the rise in health care costs, and the so called "health crisis". In order to contain it, market tactics were put to action, health care was considered a commodity, patients "consumers" and hospitals or physicians "providers". Economists, accountants and business advisors in charge of "Health Maintenance Organizations" (HMO) started the very profitable activity of intervening between patients and physicians. Rationing, use of general practice guides, suboptimal treatments, risk avoidance and other market tactics changed the practice of a profession into a business enterprise. The HMO decides if, when, how and how much will be given to any "consumer". Use of technology more impersonal and easily administered is the leading feature of to-day's medicine over the intellectual activity of the physician who hears, understands, makes the physical examination, diagnosis and treatment. The increasing depreciation of his task obliges the physician to enlarge the number and decrease his communication with his patients. His fiduciary obligation is subordinated to market needs and his practice increasingly compromises his moral integrity. The HMO boasts of the quality of the service given, this is the timely use of to-day's appropriate resources. Nobody wants the 1950 car or medical practice. Tomorrow's practice however depends on increasing knowledge, that is, on research, an activity which is not the HMO object. The academic-medical center, the very place where the interaction of teaching and investigating promotes the excellence is discriminated by the HMO because of its compromise with fiduciary activity imposed by 2500 years of jewish-christian philosophy. The future of these institutions (state's Cinderella's) is progressively compromised; when we loose them how long will it take to recover them? The politicians are always ready to create new hospitals, after they are built consuming large amounts of money, they become disinterested. All hospitals in our country are completely active only 4 hours/day, their physicians travel afterwards to their diverse places of activity consuming much of their time in getting there and complying with the bureaucratic tasks imposed by HMO. In our country with 14% unemployment and 1/3 of the population without any health coverage, the institution of universal health insurance is mandatory. Preventive medicine is not effective for people who lack the means for adequate nutrition, education or transportation, they do not visit doctors or use medicines.

La ética médica en el mundo del mercado. Fidelidad hipocrática o fidelidad a la empresa. / [Medical ethics in the worlds market. Hippocratic fidelity or enterprise fidelity]

The advance which resulted in the mean survival increase from 50 to 75 years between 1920 and 1990 also provoked the rise in health care costs, and the so called [quot ]health crisis[quot ]. In order to contain it, market tactics were put to action, health care was considered a commodity, patients [quot ]consumers[quot ] and hospitals or physicians [quot ]providers[quot ]. Economists, accountants and business advisors in charge of [quot ]Health Maintenance Organizations[quot ] (HMO) started the very profitable activity of intervening between patients and physicians. Rationing, use of general practice guides, suboptimal treatments, risk avoidance and other market tactics changed the practice of a profession into a business enterprise. The HMO decides if, when, how and how much will be given to any [quot ]consumer[quot ]. Use of technology more impersonal and easily administered is the leading feature of to-days medicine over the intellectual activity of the physician who hears, understands, makes the physical examination, diagnosis and treatment. The increasing depreciation of his task obliges the physician to enlarge the number and decrease his communication with his patients. His fiduciary obligation is subordinated to market needs and his practice increasingly compromises his moral integrity. The HMO boasts of the quality of the service given, this is the timely use of to-days appropriate resources. Nobody wants the 1950 car or medical practice. Tomorrows practice however depends on increasing knowledge, that is, on research, an activity which is not the HMO object. The academic-medical center, the very place where the interaction of teaching and investigating promotes the excellence is discriminated by the HMO because of its compromise with fiduciary activity imposed by 2500 years of jewish-christian philosophy. The future of these institutions (states Cinderellas) is progressively compromised; when we loose them how long will it take to recover them? The politicians are always ready to create new hospitals, after they are built consuming large amounts of money, they become disinterested. All hospitals in our country are completely active only 4 hours/day, their physicians travel afterwards to their diverse places of activity consuming much of their time in getting there and complying with the bureaucratic tasks imposed by HMO. In our country with 14

unemployment and 1/3 of the population without any health coverage, the institution of universal health insurance is mandatory. Preventive medicine is not effective for people who lack the means for adequate nutrition, education or transportation, they do not visit doctors or use medicines.

Evaluation of bronchodilator response in patients with airway obstruction.

The aim of this study was to define the most useful index of expressing bronchodilator response and to distinguish between asthma and COPD. A prospective study was carried out of bronchodilator response in 142 asthmatics and 58 COPD patients in a university hospital. Reversibility was expressed as: 1. absolute change (delta abs); 2. % of initial (delta %init); 3. % of predicted (delta %pred) and 4. % of maximum possible response (delta %max). Dependence on forced expirations volume in 1 sec (FEV1) as % of predicted and sensitivity and specificity for diagnosis of asthma were established. A relationship between delta abs and initial FEV1 was not found in asthma (delta abs vs. % initial FEV1. r = 0.07) or COPD (r = 0.02). delta %pred did not show a correlation in asthma (r = 0.10) or COPD (r = 0.06). delta %init was dependent on the baseline value in asthma (r = 0.38, P < or = 0.001) but not in COPD (r = 0.18, P = n.s.). delta max was dependent in both. The combination of best sensitivity and specificity to separate asthma and COPD was obtained with delta abs (70.4 or 70.6%). The worst specificity for asthma diagnosis was obtained with delta %init (50%). The best likelihood ratios were obtained with delta abs and delta %pred and the worst likelihood ratio with delta %init. delta %init is not recommended as an index for differential diagnosis between asthma and COPD; 2) delta %init overscores bronchodilator response in patients with low FEV1. The independence of each bronchodilator response index should be verified in clinical trials for each selected sample.

[Beta-agonists: new perspective in the treatment of asthma?]. / Beta-agonistas una nueva perspectiva en el tratamiento del asma?

Beta-agonists (beta 2) are the first treatment for acute asthma. Metered dose inhalers are preferable to nebulizers. During regular treatment, long-acting beta 2 show better results than sabutamol. Clinically relevant antiinflammatory activity has not been demonstrated. During regular treatment, tolerance to bronchodilator effects has not been detected but decrease of bronchoprotective effect is seen. These findings do not show clinical relevance. Short or long-acting beta 2 remain an appropriate and reliable treatment option for patients with asthma. Salmeterol and formoterol show similar action and adverse effects. The most rational treatment strategy seems to be: a) use inhaled steroids as the first and main regular treatment; b) when doses higher than 1,000-1,200 mcg/d of BCM or BUD are required, try long-acting beta-agonists; c) if that treatment is not effective enough, continue to increase inhaled steroid doses to identify patients responsive to higher doses.

Beta-agonistas una nueva perspectiva en el tratamiento del asma? / [Beta-agonists: new perspective in the treatment of asthma?]

Beta-agonists (beta 2) are the first treatment for acute asthma. Metered dose inhalers are preferable to nebulizers. During regular treatment, long-acting beta 2 show better results than sabutamol. Clinically relevant antiinflammatory activity has not been demonstrated. During regular treatment, tolerance to bronchodilator effects has not been detected but decrease of bronchoprotective effect is seen. These findings do not show clinical relevance. Short or long-acting beta 2 remain an appropriate and reliable treatment option for patients with asthma. Salmeterol and formoterol show similar action and adverse effects. The most rational treatment strategy seems to be: a) use inhaled steroids as the first and main regular treatment; b) when doses higher than 1,000-1,200 mcg/d of BCM or BUD are required, try long-acting beta-agonists; c) if that treatment is not effective enough, continue to increase inhaled steroid doses to identify patients responsive to higher doses.

Is asthma in the elderly really different?

To examine the nature of asthma in the elderly, we compared older (group 1: 65 years or older, n = 50) with younger patients (group 2: <40 years, n = 99) and to determine the influence of long-standing disease, elderly asthmatics with early onset (group A: onset before 40, n = 22) were compared with patients developing symptoms later in their lives (group B: onset after 40, n = 22). Blood eosinophilia and IgE value >/=100 IU/l were more frequent in younger patients. Short symptom-free periods were more frequent among older asthmatics (78.5 vs. 45.4%, p < 0.001). Only 31.2% of older patients had only mild symptoms. Requirement of systemic steroids was higher in the elderly population. The worst FEV1 was lower in older patients (54.4 +/- 17.3 vs. 71.8 +/- 18.5%, p