Mortality rate in rheumatoid arthritis-related interstitial lung disease: the role of radiographic patterns.

BACKGROUND: To assess mortality rate (MR) and standardized mortality rate (SMR) of rheumatoid arthritis-related interstitial lung disease (RA-ILD) patients and to evaluate the role of radiographic patterns in mortality. METHODS: A longitudinal multicentric study was conducted in RA-ILD patients from 2005 to 2015 and followed-up until October 2018 in Madrid. Patients were included in the Neumologia-Reumatología y Enfermedades Autoinmunes Registry, from diagnosis of ILD. The main outcome was all-cause mortality. The radiographic pattern at baseline [usual interstitial pneumonia (UIP), nonspecific interstitial pneumonia (NSIP), or others] was the independent variable. Covariables included sociodemographic and clinical data. Survival techniques were used to estimate MR, expressed per 1000 persons-year with their 95% confidence intervals [CI]. Cox multiple regression model was run to examine the influence of radiographic patterns on survival. SMR [CI] was calculated comparing MR obtained with MR expected in the general population of Madrid by indirect age-gender standardization. RESULTS: 47 patients were included with a follow-up 242 patients-year. There were 16 (34%) deaths, and most frequent causes were acute ILD exacerbation and pneumonia. MR was 64.3 [39.4-104.9], and 50% of the patients died at 8.3 years from ILD diagnosis. After adjusting for confounders, (UIP compared to NSIP was associated with higher mortality risk. The overall SMR was 2.57 [1.4-4.17]. Women of 60-75 years of age were the group with the highest SMR. CONCLUSIONS: RA-ILD is associated with an excess of mortality compared to general population. Our results support that UIP increases the risk of mortality in RA-ILD, regardless other factors.

Oxygenation With a Single Portable Pulse-Dose Oxygen-Conserving Device and Combined Stationary and Portable Oxygen Delivery Devices in Subjects With COPD.

BACKGROUND: Portable oxygen devices simplify and facilitate patient therapy. This study was designed to compare S(pO2) and patient satisfaction with a portable oxygen concentrator or a combined system consisting of a fixed device with continuous-flow oxygen dispensation and a portable device with pulse dispensation for ambulation. METHODS: This crossover trial assessed 25 subjects with COPD (92% men, mean age of 72.2 ± 7.4 y, mean FEV1 of 34.14 ± 12.51% of predicted) at 4 hospitals in Madrid. All subjects had previously used the combined system, consisting of a fixed oxygenation system and a portable system for ambulation, with 16 (64%) using stationary and portable concentrators and 9 (36%) using a stationary reservoir and portable liquid oxygen bag. Oxygenation settings at rest and while walking were determined at baseline. Subjects were maintained on the previous combined system for 1 week and then switched to the portable oxygen concentrator for 1 week. Mean S(pO2) over 24 h was calculated using the software in the oximeter, and compliance was monitored (Visionox). RESULTS: Low S(pO2) (< 90%) was significantly more frequent during use of the portable concentrator alone than with the combined system (37.1% vs 18.4%, P < .05). The portable system alone was preferred by 43% of subjects, and the combined system was preferred by 36%, whereas 21% were not sure. CONCLUSIONS: Subjects preferred using a single portable oxygenation system both at home and during ambulation. Portable systems alone, however, did not supply the same levels of oxygenation as the combination of fixed and portable systems. Before the widespread adoption of portable systems as a single device, additional studies are needed to determine best-practice protocols for adjustment of daytime and nighttime oxygenation settings. (ClinicalTrials.gov registration NCT02079753).

Atención y prestación de servicios en materia de tabaquismo / Tobacco addiction: care and services

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Treatment with the immunomodulator AM3 improves the health-related quality of life of patients with COPD.

BACKGROUND: COPD has a severe impact on patient quality of life. AM3 is an orally effective immunomodulator that can normalize the defective antimicrobial functions of the immune system effector cells of COPD patients. OBJECTIVES: We analyzed the effect of AM3 on exacerbation frequency and health-related quality of life (HRQL) of COPD patients with moderate disease. DESIGN: A randomized, double-blind, placebo-controlled trial. SETTING: Outpatient departments of 21 hospitals. METHODS: A total of 253 COPD patients with a mean age of 67.7 years (SD, 8.1 years) and mean FEV(1) percentage of predicted of 49.6% (SD, 10.2%) were evaluated. Patients received (orally) either 3 g/d AM3 or a matched placebo for 180 consecutive days. Patient quality of life was measured using the St. George's Respiratory Questionnaire (SGRQ). RESULTS: There were no differences in the exacerbation frequency of the two groups (0.82 episodes per patient in the AM3 arm vs 0.84 in the placebo arm), and 55.3% of patients were exacerbation free in the AM3 arm compared to 48.8% in the placebo arm (p = 0.11). At the end of treatment, quality of life was significantly better in the AM3 arm than in the placebo arm (SGRQ total score, 32.9; SD, 16.4, compared to 37.5; SD, 17.5 [p < 0.05]: activity score, 47.5; SD, 22.4, compared to 54.6; SD, 20.5 [p < 0.05]). The improvements in total SGRQ scores were 8.9 U (SD, 13.4 U) in the AM3 arm and 5.6 U (SD, 15.9 U) in the placebo arm (p = 0.076). Improvements on the symptoms subscale were 15.9 U (SD, 20.7 U) for the AM3 arm and 10.2 U (SD, 21.3 U) for the placebo arm (p < 0.05). Both AM3 and the placebo were clinically, biochemically, and hematologically well tolerated. CONCLUSIONS: AM3 is a safe, easily tolerated, effective treatment that improves the quality of life of COPD patients as measured by SGRQ scores. This effect was observed with no significant reduction in the frequency of exacerbations.

Pulmonary infection due to Mycobacterium szulgai.

A 75-year-old man was admitted with cough, purulent sputum, fatigue and weight loss of 10 kg of some months' duration. His chest radiograph showed poorly defined opacities in the right lung. Eleven years before admission an epidermoid carcinoma of the right lung had been diagnosed and a right bilobar resection had been performed. The patient remained asymptomatic for 8 years. Cultures of 4 consecutive sputum samples were positive for mycobacteria that were identified as Mycobacterium szulgai by gas chromatography. A 6-month regimen of rifampin, isoniazid and pyrazinamide resulted in complete eradication of the mycobacterium. M. szulgai is an unusual pathogen in humans. In the English literature, only 35 cases of pulmonary disease have been reported. Its clinical and radiological characteristics are similar to tuberculosis but in contrast to the rest of the non-tuberculous mycobacteria, M. szulgai has shown in vitro and in vivo susceptibility to most primary antituberculosis drugs.

Prevalence of sleep-disordered breathing in children with Down syndrome: polygraphic findings in 108 children.

STUDY OBJECTIVES: To assess the prevalence of sleep-disordered breathing in a nonselected group of children with Down syndrome and to determine significant predisposing factors for this condition. DESIGN: Prospective study. SETTING: Tertiary care university hospital in Madrid, Spain. PATIENTS: The study population included 108 consecutive children with Down syndrome (mean [SD] age, 7.9 [4.5] years; range, 1-18 years) independently of whether or not suggestive clinical features of sleep-disordered breathing were present. INTERVENTIONS: In addition to history, physical examination, and lateral radiographs of the nasopharynx, all participants underwent an overnight cardiorespiratory polygraphy at the hospital using a portable ambulatory device (Apnoescreen II plus). An apnea-hypopnea index of at least 3 was required for defining the presence of sleep-disordered breathing. RESULTS: The prevalence of sleep-disordered breathing was 54.6%, with a significantly higher prevalence in boys (64.7%) than in girls (38.5%) (P < .05). The group with sleep-disordered breathing was significantly younger (6.4 [3.9] years) than those with normal polysomnographic recordings (9.6 [4.6] years) (P < .001). In the multivariate analysis, age (less than 8 years old) (odds ratio [OR], 3.36; 95% confidence interval [CI], 1.40, 8.06); male sex (OR, 3.32; 95% CI, 1.32, 8.12); and tonsillar hyperplasia (OR, 5.24; 95% CI, 1.52, 19.03) were significantly associated with sleep-disordered breathing. Body mass index, adenoid hyperplasia, previous tonsillectomy or adenoidectomy, congenital heart disease, malocclusion, and macroglossia did not affect the prevalence of sleep-disordered breathing. CONCLUSIONS: The prevalence of sleep-disordered breathing in children with Down syndrome is very high, particularly in boys. Tonsillar hyperplasia may play a role in the pathophysiology of sleep-disordered breathing in these patients. Adenoid hyperplasia, obesity, and congenital heart disease were not important risk factors for sleep-disordered breathing.

Speed of recovery from acute exacerbations of chronic obstructive pulmonary disease after treatment with antimicrobials : results of a two-year study.

OBJECTIVE: We performed a multicentre study under a 2-year observational protocol that included data on time to recovery from acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) in patients receiving moxifloxacin and comparator antimicrobials. PATIENTS AND METHODS: Outpatients with moderate or severe COPD were recruited from respiratory clinics throughout Spain. Moxifloxacin was available in year 2, and was to be prescribed to 50% of patients in that period in a non-randomised allocation. Time to recovery was compared in successfully treated AE-COPD; cross-sectionally for all AE-COPD over 2 years, first AE-COPD and all AE-COPD in year 2, and longitudinally in patients receiving comparator antimicrobials for AE-COPD in year 1 and moxifloxacin in year 2. RESULTS: 614 AE-COPD were treated in 441 patients over 2 years (mean age 66.7 +/- 8.3 years, 98% males, mean forced expiratory volume in 1 second [FEV(1)] 35.9 +/- 8.8%). Mean time to recovery overall was 4.6 days (SD 3.3) with moxifloxacin 400 mg/day for 5 days, and 5.8 days (SD 4.6) with comparators (p < 0.01), which were most frequently amoxicillin/clavulanic acid 500/125mg/8h, clarithromycin 500mg/12h and cefuroxime axetil 500mg/12h for 7-10 days. Longitudinal analysis showed that 27 patients treated with moxifloxacin in the second year of the study recovered in a mean of 3.7 days (SD 3.1), and the same patients treated with comparator antimicrobials in year one recovered in a mean of 6.8 days (SD 4.6) [p = 0.02]. In contrast, in 66 patients treated with comparator antimicrobials in both years, mean time to recovery was 7.4 days (SD 7.3) in year one and 5.5 days (SD 3.5) in year two (p = 0.24). All subgroup analyses showed a statistically significant reduction of 18-25% in time to recovery with moxifloxacin compared with other antibiotics. CONCLUSIONS: Moxifloxacin significantly reduced time to recovery from AE-COPD in patients with moderate to severe disease by approximately 20% (>1 day) compared with other antimicrobials. Faster recovery should result in earlier return to work or normal activities, and to social and economic savings.

Long-term effects of treatment with nasal continuous positive airway pressure on lung function in patients with overlap syndrome.

We assessed the effects of chronic nasal continuous positive airway pressure (CPAP) therapy on lung function in a series of unselected patients with overlap syndrome, and we determined whether there were differences in the response induced by CPAP between hypercapnic (PaCO2 > or =45 mm Hg) and eucapnic patients with overlap syndrome. The study population included 55 unselected patients (48 men, mean age of 58.5 +/- 10.5 years) with a concurrent diagnosis of chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea-hypopnea syndrome (OSAHS) who had been referred to the Department of Pulmonology of our hospital over 2 consecutive years and in whom work-up studies resulted in the prescription of nasal CPAP therapy. An apnea-hypopnea index (AHI) greater than or equal to 10 in the cardiorespiratory polygraphy was required for the diagnosis of OSAHS. A forced expiratory volume in one second (FEV1) less than 80% and FEV1-forced vital capacity (FVC) ratio less than 70% of the reference values were required for the diagnosis of COPD. Control lung function studies and arterial blood gas measurements were performed at 6 and 18 months of CPAP therapy. These patients with overlap syndrome accounted for 28.5% of all patients with OSAHS treated with CPAP during the study period. The mean AHI was 37.3 +/- 26.1 and the mean CPAP level 7.3 +/- 1.3 cm H2O. Thirty-three patients were hypercapnic (PaCO2 > or = 45 mm Hg) and 22 eucapnic. The hypercapnic group had higher AHI value (44.3 +/- 26.9) than the eucapnic group (28.6 +/- 21.9) (P < 0.05). After 6 months of CPAP therapy, there were statistically significant increases in PaO2, FEV1, and FVC, accompanied by significant decreases in PaCO2, serum bicarbonate levels, and alveolar-arterial oxygen difference. Response of overlap syndrome patients to CPAP therapy was superior in the hypercapnic group, particularly in relation to improvement of arterial blood gases. However, statistically significant differences in all parameters for the comparison between 6 and 18 months were not recorded.

Cigarette smoking behavior and respiratory alterations during sleep in a healthy population.

BACKGROUND AND STUDY OBJECTIVE: The importance of tobacco smoking in the origin of sleep ventilatory abnormalities is disputed. The purpose of our study was to evaluate the influence of cigarette smoking behavior on the sleep respiratory alterations in a healthy population. DESIGN AND METHODS: We studied 38 healthy volunteers (21 M, 17 F; age 42 +/- 12 years; BMI 23.7 +/- 3.6 kg/m(2)) who were divided into two matched groups: current tobacco smokers (n = 18; over 10 pack-years) and nonsmokers (n = 20). All individuals underwent a single nocturnal domiciliary polygraphic study (Polygraphics CNS, Minneapolis, Minnesota). Apnea (AI), apnea-hypopnea (AHI), and desaturation (DI) indexes were defined according to conventional criteria. A nocturnal hypoxia index (NHI) was calculated as an index of the magnitude and duration of oxyhemoglobin desaturation during sleep. The mean transcutaneous oxygen saturation (SpO(2)) of the first 60 seconds of oxymetric registration (subject supine and awake) was considered basal SpO(2). Venous carboxyhemoglobin (COHb) levels were measured (CO-Oximeter AVL-912, Basel, Switzerland) in all individuals before (22:00 h) and after (10:00 h) sleep. A correction factor of 0.9 x COHb was applied to the basal SpO(2) values to calculate the corrected basal SpO(2) (SpO(2 corr)). RESULTS: AI, AHI, and DI were not significantly different between smokers and nonsmokers. The smokers have significantly higher NHI than nonsmokers [median (25th percentile-75th percentile): 5.3 (0-39.7) vs. 0.5 (0-1.7); p = 0.017]. There were significant correlations (P < 0.05) in smokers between NHI and pack-years index, between NHI and COHb levels, and between current smoking intensity and COHb levels. As expected, smokers had higher COHb levels at 10:00 as well as at 22:00 hours. The SpO(2 corr) was significantly lower (p < 0.001) among smokers than nonsmokers (88.9 +/- 3.3% vs. 94.7 +/- 1.3%). In multiple regression analyses, AHI and DI showed a significant correlation (p = 0.02 and p = 0.05, respectively) with habitual snoring, and NHI with pack-years and BMI (p = 0.02 and p = 0.04, respectively). CONCLUSIONS: Cigarette smoking does not seem to be associated with increased apneic activity during sleep. However, it is associated with a decrease in nocturnal oxygen saturation.