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2.
Respir Res ; 19(1): 261, 2018 Dec 27.
Artigo em Inglês | MEDLINE | ID: mdl-30591055

RESUMO

BACKGROUND: Chronic obstructive pulmonary disease (COPD) patients may experience an acute exacerbation (AECOPD) that requires hospitalisation. The length of hospital stay (LHS) has a great economic impact on the health-care system. Knowing the predictors of prolonged LHS could help to identify possible interventions. METHODS: We performed a prospective study to identify the clinical predictors of prolonged LHS in patients hospitalised for AECOPD. We divided the study sample by LHS into normal (≤7 days) and prolonged LHS (> 7 days) groups. Outcomes were the need for non-invasive and invasive mechanical ventilation (NIMV and IMV), intensive care unit (ICU) admission, and the 3-year mortality. RESULTS: We enrolled 437 patients, of which 213 and 224 had normal LHS and prolonged LHS, respectively. Patients with a prolonged LHS had more prior hospitalisations for AECOPD, a worse mMRC (modified Medical Research Council) dyspnoea score, a higher prevalence of long-term oxygen therapy and a higher rate of congestive heart disease. During the current admission, this group also tended to require NIMV, IMV and ICU admission and the mortality risks at 6 months, 1 year and 3 years were higher. In the multivariate regression analysis, an mMRC dyspnoea score ≥ 2 (odds ratio-OR 2.24; 95% confidence interval-CI 1.34 to 3.74; p = 0.002) and the presence of acute respiratory acidosis (OR 2.75; 95% CI 1.49 to 5.05; p = 0.001) predicted a prolonged LHS at admission. CONCLUSIONS: The presence of an mMRC ≥2 and acute respiratory acidosis at admission independently increased the risk of a prolonged LHS for AECOPD.


Assuntos
Progressão da Doença , Tempo de Internação/tendências , Doença Pulmonar Obstrutiva Crônica/mortalidade , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Índice de Gravidade de Doença , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Valor Preditivo dos Testes , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Fatores de Risco , Fatores de Tempo
3.
Sci Rep ; 8(1): 9236, 2018 06 18.
Artigo em Inglês | MEDLINE | ID: mdl-29915333

RESUMO

The coexistence of both Chronic Obstructive Pulmonary Disease (COPD) and bronchiectasis (BE) define an emerging phenotype with a worse prognosis; however, data about these patients do not consider baseline characteristics as confounders. We evaluate the impact of BE on outcomes of hospitalized patients with acute exacerbation of COPD (AECOPD). We prospectively considered AECOPD patients, analysed using a propensity score matching (PSM) method. The outcomes included length of hospital stay, use of non-invasive and invasive mechanical ventilation, intensive care unit admission, and mortality up to 3-years. Out of the 449 patients enrolled, 160 had associated BE. AECOPD with BE were older, had lower body mass index and greater functional impairment and severity of symptoms than AECOPD without BE. After PSM, 91 patients were considered for each group and no significant differences were found for all baseline characteristics. In full cohort, the cumulative mortality rate, the survival time, the Kaplan-Meier survival curves and the risk of death were worse in AECOPD with BE in the follow-up of 6-months, 1-year and 3-years. After PSM, data on mortality were similar between AECOPD with and without BE. In conclusion, in AECOPD patients the presence of BE does not influence mortality in a long-term follow-up.


Assuntos
Bronquiectasia/fisiopatologia , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Idoso , Progressão da Doença , Feminino , Mortalidade Hospitalar , Hospitalização , Humanos , Unidades de Terapia Intensiva , Estimativa de Kaplan-Meier , Tempo de Internação , Masculino , Estudos Prospectivos
4.
Respir Res ; 19(1): 119, 2018 06 15.
Artigo em Inglês | MEDLINE | ID: mdl-29907113

RESUMO

BACKGROUND: Antimicrobial treatment for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) remains controversial. In some cases AECOPD are caused by microorganisms that are resistant to treatments recommended by guidelines. Our aims were: 1) identify the risk factors associated with infection by microorganisms resistant to conventional treatment (MRCT), 2) Compare the clinical characteristics and outcomes of patients with AECOPD resulting from MRCT against those with AECOPD from other causes. METHODS: We prospective analysed a cohort of patients admitted with severe AECOPD (2009 to 2015) who were assigned to three groups: patients with MRCT (those patients with germs resistant to antibiotics recommended in guidelines), patients with microorganisms sensitive to conventional antimicrobial treatment (MSCT), and patients with negative microbiology results who had not previously received antibiotics. Multinomial logistic regression analyses were used to examine the associations between microbial aetiology groups and risk factors. The association between LOS and risk factors was also tested in simple and multiple analyses, and similar inclusion criteria were applied for the linear regression analysis. RESULTS: Of the 451 patients admitted, 195 patients (43%) were included. Respiratory cultures were positive in 86(44%) and negative in 109(56%). MRCT were isolated in 34 cases (40%) and MSCT in 52 (60%). Patients with MRCT had more AECOPD in the previous year, received more antibiotic treatment in the previous three months, had more severe disease, higher dyspnoea and a positive respiratory culture in the previous year (mainly for Pseudomonas aeruginosa). The following conditions were independent factors for MRCT isolation: non-current smoker (odds ratio [OR] 4.19 [95% confidence interval [CI] 1.29-13.67], p = 0.017), ≥ 2 AECOPD or ≥ 1 admission for AECOPD in the previous year (OR 4.13 [95% CI 1.52-11.17], p = 0.005), C-reactive protein < 5 mg/dL; (OR 3.58 [95% CI 1.41-9.07], p = 0.007). Mortality rates were comparable at 30-days, one year and 3 years; however, patients in the MRCT group had longer hospital stays. CONCLUSION: In conclusion, there are risk factors for resistant germs in AECOPD; however, the presence of these germs does not increase mortality. Patients with isolation of MRCT had longer length of stay.


Assuntos
Anti-Infecciosos/uso terapêutico , Farmacorresistência Bacteriana Múltipla/efeitos dos fármacos , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Doença Pulmonar Obstrutiva Crônica/microbiologia , Escarro/efeitos dos fármacos , Escarro/microbiologia , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Anti-Infecciosos/farmacologia , Estudos de Coortes , Progressão da Doença , Farmacorresistência Bacteriana Múltipla/fisiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/patologia
5.
Respir Med ; 145: 219-225, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-29398283

RESUMO

BACKGROUND: Patients with Chronic Obstructive Pulmonary Disease (COPD) may suffer episodes of exacerbation (ECOPD) that require hospitalization and worsen their health status, and prognosis. We hypothesized that a detailed interrogation of health-care "big data" databases can provide valuable information to better understand the risk factors and outcomes of these episodes. MATERIAL AND METHODS: We interrogated four databases of the Catalan health-care system (>8,000,000 registries) to identify patients hospitalized because of ECOPD for the first time (index event) between 2010 and 2012. Analysis was carried forward since the index event until the end of 2014 or the death of the patient. The two years that preceded the index event were also investigated. RESULTS: We identified 17,555 patients, (≥50 years of age) hospitalized because of ECOPD (ICD9 v.9 codes at discharge) for the first time between 2010 and 2012. In this population we observed that: (1) 23% of patients die within a year after being discharged from their first ECOPD hospitalization; (2) in the remaining patients, all-cause mortality was related to the number of re-hospitalizations, particularly with early (<30 days) readmissions; (3) despite this being a 'respiratory' cohort, prescription and dispensation of drugs for cardiovascular diseases was higher than for obstructive airway diseases; and, finally, (4) lower winter ambient temperatures are associated with hospital admissions for ECOPD particularly in early re-admitters. CONCLUSIONS: Overall these results indicate under appreciation of the burden of COPD in patients hospitalized for the first time because ECOPD.


Assuntos
Hospitalização/estatística & dados numéricos , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Estudos de Coortes , Temperatura Baixa/efeitos adversos , Efeitos Psicossociais da Doença , Bases de Dados Factuais , Progressão da Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doença Pulmonar Obstrutiva Crônica/mortalidade , Fatores de Risco , Fatores de Tempo
7.
ERJ Open Res ; 2(3)2016 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-27730204

RESUMO

Chronic obstructive pulmonary disease (COPD) is characterised by pulmonary and systemic inflammation that bursts during exacerbations of the disease (ECOPD). The NLRP3 inflammasome is a key regulatory molecule of the inflammatory response. Its role in COPD is unclear. We investigated the NLRP3 inflammasome status in: 1) lung tissue samples from 38 patients with stable COPD, 15 smokers with normal spirometry and 14 never-smokers; and 2) sputum and plasma samples from 56 ECOPD patients, of whom 41 could be reassessed at clinical recovery. We observed that: 1) in lung tissue samples of stable COPD patients, NLRP3 and interleukin (IL)-1ß mRNA were upregulated, but both caspase-1 and ASC were mostly in inactive form, and 2) during infectious ECOPD, caspase-1, oligomeric ASC and associated cytokines (IL-1ß, IL-18) were significantly increased in sputum compared with clinical recovery. The NLRP3 inflammasome is primed, but not activated, in the lungs of clinically stable COPD patients. Inflammasome activation occurs during infectious ECOPD. The results of this study suggest that the inflammasome participates in the inflammatory burst of infectious ECOPD.

8.
PLoS One ; 11(3): e0150737, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26943928

RESUMO

BACKGROUND AND OBJECTIVE: Twenty per cent of chronic obstructive pulmonary disease (COPD) patients are readmitted for acute exacerbation (AECOPD) within 30 days of discharge. The prognostic significance of early readmission is not fully understood. The objective of our study was to estimate the mortality risk associated with readmission for acute exacerbation within 30 days of discharge in COPD patients. METHODS: The cohort (n = 378) was divided into patients readmitted (n = 68) and not readmitted (n = 310) within 30 days of discharge. Clinical, laboratory, microbiological, and severity data were evaluated at admission and during hospital stay, and mortality data were recorded at four time points during follow-up: 30 days, 6 months, 1 year and 3 years. RESULTS: Patients readmitted within 30 days had poorer lung function, worse dyspnea perception and higher clinical severity. Two or more prior AECOPD (HR, 2.47; 95% CI, 1.51-4.05) was the only variable independently associated with 30-day readmission. The mortality risk during the follow-up period showed a progressive increase in patients readmitted within 30 days in comparison to patients not readmitted; moreover, 30-day readmission was an independent risk factor for mortality at 1 year (HR, 2.48; 95% CI, 1.10-5.59). In patients readmitted within 30 days, the estimated absolute increase in the mortality risk was 4% at 30 days (number needed to harm NNH, 25), 17% at 6-months (NNH, 6), 19% at 1-year (NNH, 6) and 24% at 3 years (NNH, 5). CONCLUSION: In conclusion a readmission for AECOPD within 30 days is associated with a progressive increased long-term risk of death.


Assuntos
Progressão da Doença , Alta do Paciente , Readmissão do Paciente , Doença Pulmonar Obstrutiva Crônica/mortalidade , Idoso , Estudos de Coortes , Feminino , Seguimentos , Hospitalização , Humanos , Estimativa de Kaplan-Meier , Masculino , Análise Multivariada , Probabilidade , Modelos de Riscos Proporcionais , Doença Pulmonar Obstrutiva Crônica/microbiologia , Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
9.
COPD ; 13(1): 82-92, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26451913

RESUMO

Although pharmacological treatment of COPD exacerbation (COPDE) includes antibiotics and systemic steroids, a proportion of patients show worsening of symptoms during hospitalization that characterize treatment failure. The aim of our study was to determine in-hospital predictors of treatment failure (≤ 7 days). Prospective data on 110 hospitalized COPDE patients, all treated with antibiotics and systemic steroids, were collected; on the seventh day of hospitalization, patients were divided into treatment failure (n = 16) or success (n = 94). Measures of inflammatory serum biomarkers were recorded at admission and at day 3; data on clinical, laboratory, microbiological, and severity, as well data on mortality and readmission, were also recorded. Patients with treatment failure had a worse lung function, with higher serum levels of C-reactive protein (CRP), procalcitonin (PCT), tumour necrosis factor-alpha (TNF-α), interleukin (IL) 8, and IL-10 at admission, and CRP and IL-8 at day 3. Longer length of hospital stay and duration of antibiotic therapy, higher total doses of steroids and prevalence of deaths and readmitted were found in the treatment failure group. In the multivariate analysis, +1 mg/dL of CRP at admission (OR, 1.07; 95% CI, 1.01 to 1.13) and use of penicillins or cephalosporins (OR, 5.63; 95% CI, 1.26 to 25.07) were independent variables increasing risk of treatment failure, whereas cough at admission (OR, 0.20; 95% CI, 0.05 to 0.75) reduces risk of failure. In hospitalized COPDE patients CRP at admission and use of specific class of antibiotics predict in-hospital treatment failure, while presence of cough has a protective role.


Assuntos
Antibacterianos/uso terapêutico , Glucocorticoides/uso terapêutico , Hospitalização , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Proteína C-Reativa/metabolismo , Calcitonina/metabolismo , Peptídeo Relacionado com Gene de Calcitonina , Estudos de Coortes , Progressão da Doença , Feminino , Volume Expiratório Forçado , Humanos , Interleucina-1/metabolismo , Interleucina-10/metabolismo , Interleucina-6/metabolismo , Interleucina-8/metabolismo , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Entrevista Psiquiátrica Padronizada , Pessoa de Meia-Idade , Mortalidade , Análise Multivariada , Readmissão do Paciente/estatística & dados numéricos , Pneumonia Bacteriana/tratamento farmacológico , Prognóstico , Estudos Prospectivos , Precursores de Proteínas/metabolismo , Doença Pulmonar Obstrutiva Crônica/metabolismo , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Fatores de Risco , Fatores de Tempo , Falha de Tratamento , Fator de Necrose Tumoral alfa/metabolismo
10.
Respir Med ; 109(4): 500-9, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25771036

RESUMO

BACKGROUND: Despite well established clinical guidelines, performance of long-term oxygen therapy (LTOT) programs shows marked variability among territories. The current study assessed the LTOT program and the health status of patients on LTOT prior to the deployment of community-based integrated care in an urban health district of Barcelona (Spain). AIMS: To assess: i) the LTOT program and health status of the patients on LTOT in the health district; ii) their frailty profile; and, iii) the requirements for effective deployment of integrated care services for these patients. METHODS: Cross-sectional observational study design including all patients (n = 406) on LTOT living in the health district. Health status, frailty, arterial blood gases, forced spirometry and hand-grip muscle strength were measured. Network analysis of frailty was carried out. RESULTS: Adequacy of LTOT prescription (n = 362): 47% and 31% of the patients had PaO2 ≤ 60 mmHg and ≤55 mmHg, respectively. Adherence to LTOT: 31% of all patients used LTOT ≥15 h/d; this figure increased to 67% in those with PaO2≤60 mmHg. Assessment of frailty: Overall, LTOT patients presented moderate to severe frailty. Care complexity was observed in 42% of the patients. CONCLUSIONS: Adequacy and adherence to LTOT was poor and many patients were frail and complex. The outcomes of the network analysis may contribute to enhance assessment of frailty in LTOT patients. These observations suggest that an integrated care strategy has the potential to improve the health outcomes of these patients.


Assuntos
Oxigenoterapia , Doença Pulmonar Obstrutiva Crônica , Idoso , Idoso de 80 Anos ou mais , Gasometria/métodos , Estudos Transversais , Prestação Integrada de Cuidados de Saúde/métodos , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Feminino , Necessidades e Demandas de Serviços de Saúde , Disparidades nos Níveis de Saúde , Humanos , Assistência de Longa Duração/métodos , Assistência de Longa Duração/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Oxigenoterapia/efeitos adversos , Oxigenoterapia/métodos , Oxigenoterapia/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Doença Pulmonar Obstrutiva Crônica/terapia , Espanha/epidemiologia , Espirometria/métodos , Tempo
11.
COPD ; 12(3): 306-14, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25279441

RESUMO

Recurrent hospitalizations in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients have clinical and economic consequences; particularly those readmitted soon after discharge. The aim of our observational study was to determine predictors of early readmission to hospital (30 days from discharge). Prospective data on 125 hospitalized AECOPD patients were collected over a 30-month period at two Spanish university hospitals. Based on readmission after discharge, patients were divided into non-readmitted (n = 96) and readmitted (n = 29). Measures of serum inflammatory biomarkers were recorded on admission to hospital, at day 3 and at discharge; data on clinical, laboratory, microbiological and severity features were also recorded. In a multivariate model, C-reactive protein (CRP) at discharge ≥ 7.6 mg/L, presence of diabetes and ≥ 1 hospitalization for AECOPD during previous year were significant risk factors for predicting readmission. Presence of all 3 risk factors perfectly identified the readmitted patients (positive and negative predictive values of 1.000; 95% CI, 1.00-1.00). A combination of 3 readily available clinical and biochemical parameters is accurate in identifying hospitalized AECOPD patients at risk for early readmission.


Assuntos
Proteína C-Reativa/análise , Diabetes Mellitus/epidemiologia , Readmissão do Paciente , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Idoso , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Análise Multivariada , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de Risco , Espanha/epidemiologia
12.
Respir Care ; 59(10): 1550-9, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25074943

RESUMO

BACKGROUND: Inhaled corticosteroids are anti-inflammatory medications that can down-regulate the immunologic response in patients with COPD; however, their role at onset of COPD exacerbation is still not understood. The aim of this study was to assess the early inflammatory response and clinical presentation of patients with COPD exacerbation mediated by inhaled corticosteroids. METHODS: Prospective data were collected on 123 hospitalized subjects with COPD exacerbation over a 30-month period at 2 Spanish university hospitals. Based on domiciliary use, comparative analyses were performed between subjects who did not use inhaled corticosteroids (n = 58) and subjects who did (n = 65). Measurements of serum biomarkers were recorded on admission to the hospital (day 1) and on day 3; clinical, physiological, microbiological, and severity data and mortality/readmission rates were also recorded. RESULTS: At days 1 and 3, both groups showed a similar inflammatory response; fluticasone produced lower levels of interleukin-8 compared with budesonide (P < .01). All clinical features considered were similar in the 2 groups; multivariate analysis predicting clinical complications on hospitalization showed air-flow obstruction severity as the only predictive factor (odds ratio 3.13, 95% CI 1.13-8.63, P = .02). CONCLUSIONS: Our study demonstrates a lack of inhaled corticosteroid influence in the early systemic inflammatory response to and clinical presentation of COPD exacerbation.


Assuntos
Corticosteroides/administração & dosagem , Androstadienos/administração & dosagem , Budesonida/administração & dosagem , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Doença Pulmonar Obstrutiva Crônica/imunologia , Administração por Inalação , Idoso , Biomarcadores/sangue , Comorbidade , Feminino , Fluticasona , Hospitalização , Humanos , Interleucina-8/sangue , Masculino , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Índice de Gravidade de Doença , Espanha
13.
Respir Res ; 15: 17, 2014 Feb 11.
Artigo em Inglês | MEDLINE | ID: mdl-24517318

RESUMO

BACKGROUND: Acute exacerbations of COPD (AECOPD) are often associated with infectious agents, some of which may be non-usual, including Aspergillus spp. However, the importance of Aspergillus spp. in the clinical management of AECOPD still remains unclear. OBJECTIVES: The aims of the study were to analyze the prevalence and risk factors associated with Aspergillus spp. isolation in AECOPD, and to investigate the associated clinical outcomes during a 1-year follow-up period. METHODS: Patients presenting with an AECOPD requiring hospitalization were prospectively included from four hospitals across Spain. Clinical, radiological and microbiological data were collected at admission and during the follow-up period (1, 6 and 12 months after discharge), and re-admissions and mortality data collected during the follow-up. RESULTS: A total of 240 patients with severe AECOPD were included. Valid sputum samples were obtained in 144 (58%) patients, and in this group, the prevalence of Aspergillus spp. isolation was 16.6% on admission and 14.1% at one-year follow-up. Multivariate logistic-regression showed that AECOPD in the previous year (OR 12.35; 95% CI, 1.9-29.1; p < 0.001), concurrent isolation of pathogenic bacteria (OR 3.64; 95% CI 1.65-9.45, p = 0.001) and concomitant isolation of Pseudomonas aeruginosa (OR 2.80; 95% IC, 1.81-11.42; p = 0.001) were the main risk factors for Aspergillus spp. isolation. CONCLUSIONS: The main risk factors for Aspergillus spp. isolation were AECOPD in the previous year and concomitant isolation of Pseudomonas aeruginosa. However, although Aspergillus spp. is often isolated in sputum samples from patients with AECOPD, the pathogenic and clinical significance remains unclear.


Assuntos
Aspergillus/isolamento & purificação , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/microbiologia , Índice de Gravidade de Doença , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Prevalência , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Fatores de Risco
14.
Chest ; 144(4): 1134-1142, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-23828375

RESUMO

BACKGROUND: Community-acquired pneumonia (CAP) is a frequent event in patients with COPD, although it is not currently considered an acute exacerbation of COPD (AECOPD). To our knowledge, no studies have compared the inflammatory response of patients with COPD who develop CAP or AECOPD. The aim of our study was to compare clinical and evolutive manifestations and biologic signaling of AECOPD and CAP + COPD. METHODS: Prospective data were collected from 249 consecutively hospitalized patients with COPD. Comparative analyses were performed in patients with AECOPD (n = 133) and patients with CAP + COPD (n = 116). Measures of clinical characteristics, blood biomarkers, and evolution were recorded on admission, after 3 and 30 days, and in a follow-up period of 30 days, 90 days, and 1 year. RESULTS: Patients with CAP + COPD had higher FEV1 compared with patients with COPD without pneumonia. In-hospital and long-term outcomes (1 year) were similar for both populations. However, patients with AECOPD had more readmissions, and patients with CAP had more prior episodes of pneumonia. At day 1 and day 3, patients with CAP + COPD had significantly (P < .001) higher serum levels of C-reactive protein (CRP), procalcitonin, tumor necrosis factor-α, and IL-6. Repetition of the analyses after stratifying patients based on severity of disease, current inhaled pharmacotherapy, and noninfectious AECOPD cause confirmed higher levels of the same biomarkers in patients with CAP + COPD. Chills, pleuritic pain, sputum purulence, and CRP levels at day 1 were independent clinical predictors of CAP + COPD. CONCLUSIONS: Our study confirms that two different clinical and inflammatory profiles exist in hospitalized patients with COPD in response to CAP (stronger response) and AECOPD, although with similar short-term and long-term outcomes.


Assuntos
Pneumonia/complicações , Doença Pulmonar Obstrutiva Crônica/complicações , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Idoso , Infecções Comunitárias Adquiridas/complicações , Progressão da Doença , Feminino , Humanos , Inflamação/etiologia , Masculino , Estudos Prospectivos
15.
Eur J Clin Invest ; 43(6): 602-15, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23590593

RESUMO

BACKGROUND: Because the current economic crisis has led to austerity in health policies, with severe restrictions on public health care, avoiding unnecessary admissions and shortening hospital stays is rapidly becoming an urgent priority. Alternatives to hospitalisation replace or shorten hospital processes, including diagnosis, monitoring, treatment and follow-up. This review aims to present the available evidence on alternatives to conventional hospitalisation for medical disorders; options for surgery, psychiatry and palliative care are largely excluded. MATERIALS AND METHODS: Narrative review. RESULTS: The main alternatives to conventional hospitalisation include day centres (DC), quick diagnosis units (QDU), hospital at home (HaH) and, in some circumstances, telemonitoring. DC increase patient comfort, reduce costs and can improve efficiency. In generally healthy patients with suspected severe disease, QDU may be a good alternative to hospitalisation for diagnostic procedures. However, their cost-effectiveness remains to be clearly proven. Randomised controlled trials have shown that hospital-at-home (HaH) can lead to earlier hospital discharges, improve outcomes and reduce costs in patients with prevalent chronic diseases. Although telemonitoring seems to be promising and its use is increasing, methodologically sounder studies with a higher level of evidence are needed to assess its clinical effectiveness. CONCLUSIONS: Factors such as ageing, the need for an earlier diagnosis of suspected severe disease, the increasing complexity of medical care and the increasing costs of hospitalisation mean that, whenever possible, giving priority to less expensive alternatives to hospital admission, such as QDU, DC, HaH and telemedicine, is an urgent task in the current economic crisis.


Assuntos
Assistência Ambulatorial/organização & administração , Hospitalização/economia , Assistência Ambulatorial/economia , Doença Crônica/economia , Doença Crônica/terapia , Análise Custo-Benefício , Hospital Dia/economia , Hospital Dia/organização & administração , Serviços Hospitalares de Assistência Domiciliar/economia , Serviços Hospitalares de Assistência Domiciliar/organização & administração , Humanos , Ambulatório Hospitalar/economia , Ambulatório Hospitalar/organização & administração , Ensaios Clínicos Controlados Aleatórios como Assunto , Encaminhamento e Consulta/economia , Consulta Remota/economia , Consulta Remota/organização & administração
18.
Eur Respir J ; 40(6): 1344-53, 2012 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-22523352

RESUMO

In patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) needing hospitalisation, sputum purulence is associated with bacteria in the lower respiratory tract. We performed a prospective non-randomised interventional pilot study applying a sputum purulence-guided strategy of antibiotic treatment and investigating the relationship between sputum purulence and biomarkers. In hospitalised patients with acute exacerbation of COPD antibiotics were restricted to those with purulent sputum. The primary end-point was rate of therapeutic failure during hospitalisation. Secondary end-points were parameters reflecting short- and long-term outcomes. We included 73 patients, 34 with non-purulent sputum. No differences were observed on therapeutic failure criteria (9% non-purulent versus 10% purulent (p=0.51)). Serum C-reactive protein (CRP) was significantly increased in the purulent group at admission (11.6 versus 5.3, p=0.006) and at day 3 (2.7 versus 1.2, p=0.01). Serum procalcitonin (PCT) was similar between the groups. No differences were found in short-term outcomes. The exacerbation rate at 180 days was higher in the purulent group. These results support the hypothesis of performing a randomised trial using a sputum purulence-guided antibiotic treatment strategy in patients with acute exacerbations of COPD. CRP, but not PCT, may be a useful parameter to increase confidence of the absence of bacterial bronchial infection.


Assuntos
Antibacterianos/uso terapêutico , Infecções Bacterianas/tratamento farmacológico , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Escarro/efeitos dos fármacos , Idoso , Infecções Bacterianas/complicações , Infecções Bacterianas/microbiologia , Biomarcadores/sangue , Biomarcadores/metabolismo , Proteína C-Reativa/metabolismo , Calcitonina/metabolismo , Peptídeo Relacionado com Gene de Calcitonina , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos , Precursores de Proteínas/metabolismo , Doença Pulmonar Obstrutiva Crônica/microbiologia , Sistema Respiratório/microbiologia , Escarro/metabolismo , Fatores de Tempo , Resultado do Tratamento
19.
Respiration ; 84(1): 17-26, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22327370

RESUMO

BACKGROUND: It is crucial to identify risk factors for poor evolution of patients admitted to hospital with chronic obstructive pulmonary disease (COPD) in order to provide adequate intensive therapy and closer follow-up. OBJECTIVES: To identify predictors of adverse outcomes in patients hospitalised for exacerbation of COPD. METHODS: A prospective, observational study was conducted in patients admitted for exacerbation of COPD. Demographic and clinical parameters were evaluated, including different multidimensional prognostic scores. Adverse outcomes included the following: death during hospitalisation or 1-month follow-up, intensive care unit admission, invasive or non-invasive mechanical ventilation, prolonged hospitalisation (>11 days) and COPD-related emergency visit or readmission within 1 month after discharge. Univariate and multivariate analysis were performed. RESULTS: Of 155 patients included, an adverse outcome occurred in 69 (45%). Patients with an adverse outcome had lower forced expiratory volume in 1 s (p = 0.004) and more frequent exacerbations (p = 0.011), more frequently used oxygen at home (p = 0.042) and presented with lower pH (p < 0.001), lower ratio of arterial oxygen pressure to the fraction of inspired oxygen (p = 0.006), higher arterial carbon dioxide pressure (p < 0.001) and a worse score on several prognostic indices at admission. Independent predictors of adverse outcome were exacerbation of COPD in the previous year [odds ratio 3.9, 95% confidence interval (CI) 1.6-9.9; p = 0.004], hypercapnia (odds ratio 9.4, 95% CI 3.7-23.6; p < 0.001) and hypoxaemia (odds ratio 4.3, 95% CI 1.5-12.6; p = 0.008). In the presence of all three characteristics, the probability of an adverse outcome was 95%, while hypercapnia was the strongest prognostic factor with a risk of 54%. CONCLUSIONS: Patients with previous exacerbation of COPD, hypercapnia and hypoxaemia had the highest risk of an unfavourable evolution. The calculation of prognostic indices did not provide additional discriminative power.


Assuntos
Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Doença Pulmonar Obstrutiva Crônica/terapia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Progressão da Doença , Feminino , Volume Expiratório Forçado , Hospitalização , Humanos , Hipercapnia/etiologia , Hipóxia/etiologia , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Prognóstico , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/complicações , Respiração Artificial/estatística & dados numéricos , Fatores de Risco , Resultado do Tratamento
20.
Arch Bronconeumol ; 46 Suppl 3: 28-31, 2010.
Artigo em Espanhol | MEDLINE | ID: mdl-20620690

RESUMO

Chronic obstructive pulmonary disease (COPD) is a chronic disease causing increasing healthcare costs worldwide. Another respiratory disease causing high costs and morbidity is community-acquired pneumonia (CAP). Because of the constant growth in the population with both diseases (CAP and COPD), analyzing their clinical characteristics is important. Several cellular factors are known to contribute to differences in clinical expression: some lead to COPD exacerbations while others lead to symptoms of pneumonia. The use of new biomarkers (procalcitonin, pro-adrenomedullin and copeptin) help to distinguish among these clinical pictures. To decrease morbidity and mortality, clinical guidelines on antibiotic therapy must be followed and this therapy should be prescribed to patients with CAP and COPD. There are also prevention measures such as the pneumococcal vaccine whose role in the prevention of pneumococcal CAP should be further studied. The present review aims to elucidate some of the above-mentioned issues.


Assuntos
Pneumonia/complicações , Doença Pulmonar Obstrutiva Crônica/complicações , Humanos , Pneumonia/diagnóstico , Pneumonia/terapia , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/terapia , Fatores de Risco
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