Factors affecting quality of life of asthma patients in Spain: the importance of patient education.

OBJECTIVES: Assessment of demographic and clinical factors that have an impact on the quality of life (QoL) of patients with asthma in Spain. PATIENTS AND METHODS: Multicenter, prospective, observational, cohort study, conducted in 40 Spanish Pneumology Units during a 12-month period. Data on sociodemographic, clinical variables, asthma treatment and QoL were collected in a case report form. RESULTS: 536 patients (64.6% women, mean age: 54) were recruited. Reported QoL was better for patients from Northern and Central Spain as compared with those from the South and the East (p<0.001), students and employed patients as compared with housewives and unemployed (p<0.01), for those who had received asthma information (p<0.01), for those with milder daytime symptoms (p<0.01) and for patients with higher level of education (p<0.05). CONCLUSIONS: Among the factors that have a significant effect on patients' QoL only symptom control and patient education on asthma control are modifiable. Therefore, all the strategies should be tailored to improve such factors when managing asthma patients.

Diagnostic value of the bronchial provocation test with methacholine in asthma. A Bayesian analysis approach.

The Bayesian analysis was used in this study to investigate the diagnostic value of the bronchial provocation test with methacholine in patients with asthma. The best cutoff value of accumulated concentration of methacholine administered that caused a 20 percent fall in FEV1 post-saline (PC20) in our sample, determined with a receiver operator characteristic curve, was 15 mg/ml. The interval security of the test was established by a pretest probability between 0.16 and 0.87 and the best test results were obtained when pretest probability was 0.48. The positive final diagnostic gain of the test was maximal at this pretest probability. We conclude that the application of Bayes' theorem, considering the pretest probability of asthma and the sensitivity and specificity of the individual PC20 obtained, increases the accuracy of the bronchial provocation test with methacholine in the diagnosis of asthma.

Immunotherapy with transfer factor of recurrent herpes simplex type I.

This clinical trial of Transfer Factor, an immunomodulator, in the treatment of herpes simplex type I, proved this agent to be more effective as regards duration of acute phase recurrences as well as the frequency of the reappearance of relapses of this disease. The evaluation was made in 20 patients whose disease had been treated before with other therapeutic agents (including acyclovir) which permitted them to be their own controls for the comparative data obtained and submitted to statistical analysis of the two parameters mentioned, duration of the acute phase and frequency of relapses. Patients with compromised cellular immunity or with any additional disease were excluded from the study. Transfer factor, one unit, was administered subcutaneously daily for 3 to 4 days during the acute phase of the disease, and subsequently at 15-day intervals for the first 6 months; followed by a continuation of monthly injections until the termination of the study period. In six of the 20 patients there was a recurrence of the disease while receiving maintenance dosages of TF. These patients were again given the full initial dosage schedule and reinstated again with the maintenance dosage. In the initial eight patients, an immune status profile was obtained, and all results were found to be in the normal range. This was considered sufficient evidence that the criteria for the selection of patients excluded any with detectable variations in the profile of the immune status, and it was decided to eliminate this as a prerequisite for participating in the study. The results showed an important improvement in the response to transfer factor immune modulation therapy. A statistically significant reduction in the frequency of recurrences within a one month period, the Student t test gave a p = 0.0001 in TF treated patients. The average duration in days of the acute phase also showed an important difference in favor of the TF treatment. The U Mann-Whitney test gave a p = 0.0005. These results suggest that, at present, TF may be considered the therapeutic agent of choice in the treatment of herpes simplex type 1 disease.

[Current use, methodology and evaluation of nonspecific bronchial provocation tests in our country]. / Implantación, metodología y valoración de las pruebas de provocación bronquial inespecíficas en nuestro país.

With the aim of determining the current use of non-specific bronchial inhalation challenge (BIC) testing in Spain, 147 questionnaires were sent to hospitals with pneumology departments or units. The questionnaire covered general, technical and methodological aspects of this diagnostic procedure, as well as its assessment and interpretation. Of the 42 informants who returned questionnaires, mainly from large urban hospitals, 34 reported using BIC. The most widespread criterion applied in deciding to use BIC was the presence of atypical asthma symptoms (33/34). The stimulus most often used was methacholine inhalation (33/34). We found that technical preparation of the drug was highly standardized, but that administration and follow-up protocols differed greatly. There was also great variety in the PC20/PD20 value assigned to indicate bronchial hyperresponsiveness. This study contributes to our better understanding of the current use of BIC in Spain and highlights the need to work toward greater standardization for this diagnostic procedure, to enable us to assess and interpret the results more consistently.

[Profile of a pneumology regional health service]. / Perfil de una consulta de neumología de ámbito comarcal.

This study analyzes patient demand in a regional public health pulmonology practice. The following data were recorded for all first-visit patients for a period of two years: age, sex, referral source, initial diagnosis by the referring physician, final diagnosis by the pulmonologist, and destination. The service studied 1,486 patients (men/women: 1.5). Most (71%) were between 40 and 80 years old. Referrals were from the family doctor (60%), health center (9%), emergency service (10%), hospital (12%), other specialists (6%), and others (3%). The most frequent reasons for remission were upper airway disease (UAD) (36%), specifically chronic obstructive pulmonary disease (COPD) and asthma, and the presentation of symptoms (28%) such as dyspnea, cough, hemoptysis and chest pain. Analysis of the final diagnoses for the patients presenting with symptoms showed that no disease could be detected in one third of those with dyspnea and hemoptysis or in half of those who complained of chest pain; acute respiratory infection was diagnosed in 45% of those complaining of persistent cough. UAD was the most frequent cause of symptoms. The index of doctor's visit/inhabitant was 0.97% for patients referred by family doctors and 0.38% for those from health centers, but the initial and final diagnosis profiles of these patients were not statistically different. Patients referred by emergency services had significantly more (p < 0.001) in number of radiological findings and hemoptysis. Those sent from hospitals more often suffered pneumonia. In conclusion, this profile of a regional public health pulmonology practice shows that: 1) UAD and clinical symptoms are the most frequent reasons for patient remission; 2) family doctors generate three times mor demand for services than do health centers, and 3) 14% of patients can be considered normal.

[Gain, loss and agreement between respiratory specialists and generalists in the diagnosis of asthma]. / Ganancia, pérdida y concordancia en el diagnóstico de asma entre neumólogos y no neumólogos.

OBJECTIVE: To determine and analyze the degree of agreement and disagreement in the diagnosis of bronchial asthma (BA) by respiratory disease specialists and generalists in regional hospital and primary care settings. MATERIAL AND METHODS: Ninety-six outpatients (16 to 70 years of age) were studied; all had been assigned a diagnosis of BA by the referring physician or by the respiratory disease specialist. We recorded 1) clinical symptoms, determining the initial probability of a diagnosis (IPD)of BA to be high, medium or low; 2) results of spirometry and bronchodilator testing (BDT), peak flow variability and methacholine challenge testing; 3) prick test results, eosinophil levels and total serum IgE levels. Three diagnoses were recorded: the initial diagnosis (ID) by the referring physician to whom follow-up data were unavailable; diagnosis by the respiratory disease specialist based only on clinical symptoms (RSS); and the final diagnosis(FD). To arrive at a FD of BA, it was necessary to have a high or medium IPD and a positive BDT. A Kappa test was used to analyze the degree of agreement among the three diagnoses. Group features associated with greater or lesser agreement were analyzed by chi-square tests and analysis of variance. RESULTS: Agreement was acceptable between RSS and FD (K = 0.63) but very low between ID and RSS and between ID and FD. In the latter two cases, agreement was greatest for patients diagnosed in hospital and for those with high IgE levels (p < 0.05), with high IPD, longer course of disease and a history of asthma (p < 0.01) (odds ratio =59.8). Diagnostic disagreement occurred mainly for patients for whom a BA diagnosis was gained later, the of under-diagnosis being 39%. The patients involved visited the physician only because they had observed an isolated symptom related to asthma (odds ratio = 119) and to arrive at a diagnosis bronchomotor tests other than BDT were required (p < 0.01). CONCLUSIONS: a) The degree of agreement for a diagnosis of BA is low. b)The functional profile of patients for whom diagnostic agreement exists differs from that of patients for whom diagnosis is gained through testing. c) In the context of this study, a high rate of under-diagnosis is evident.

[Descriptive study of patients diagnosed with asthma in a regional respiratory medicine practice]. / Estudio descriptivo de los pacientes diagnosticados de asma en una consulta neumológica de ámbito comarcal.

OBJECTIVE: To describe the characteristics of patients diagnosed of bronchial asthma (BA) in a regional respiratory medicine practice. METHODS: Over a period of two years, 88 adult patients followed a prospective-diagnostic protocol for BA that included taking of patient history to determine the probability of initial diagnosis (PID) of asthma, assessment of atopy and a lung function test that included spirometry with a bronchodilator test, recording of forced expiratory volume, and a methacholine challenge test. BA was diagnosed when symptoms denoting high or moderate PID were present and there was a positive reversibility and/or bronchial hyperreactivity test. The severity of disease was evaluated using the consensus criteria of the Global Initiative for Asthma (GINA). A student-t test and a chi 2 test were performed to compare data. RESULTS: BA was diagnosed in 24 men (30%) and 56 women (70%) with a mean age of 43.0 +/- 17.6 years (range 16 to 68). Significant differences between men and women were detected only for function parameters and cigarette consumption (p < 0.05). Fifty-three patients (66%) were referred by general practitioners, 22 (27%) were referred by hospital, and 5 came from other sources. The first group had a shorter history of disease course (p = 0.05) upon first evaluation. Sixty-one patients (76%) had mild asthma; these patients were younger and had had symptoms for a shorter period of time than those with more serious degrees of disease (16 with moderate asthma and 3 with severe asthma) (p < 0.05). Symptoms indicated a high PID in 57 cases (71%), and this figure increased significantly to 89.5% for those with more severe asthma (p < 0.05). Asthma was intrinsic for 39 patients and extrinsic for 41, with significant differences in age and total IgE between the two groups (p < 0.01). CONCLUSIONS: 1. BA is more than twice as common among women as among men. 2. Two thirds of patients are referred by general practitioners. 3. Mild asthma clearly predominates. 4. Clinical symptoms point to asthma, the PID in most cases being high.

[Bilateral adrenal hemorrhage secondary to heparin treatment: a case report]. / Hemorragia suprarrenal bilateral, secundaria a tratamiento con heparina: descripción de un caso.

Bilateral suprarenal haemorrhage (BSH) has not been often described as a cause of chronic suprarenal insufficiency. The diagnosis before death is difficult and it was rare until the CAT scan became a routine diagnostic tool. Of 25 cases reported since 1981, 23 were diagnosed by CAT scan. We report a case of a patient that developed bilateral suprarenal haemorrhage (BSH) during heparin therapy for pulmonary embolism. The early clinical picture resembled a septic shock, and the diagnosis of Addison disease was made later. We reviewed the medical literature and we emphasized the clinical problems in which we should suspect the diagnosis of BSH, where early therapy with steroids may be critical to save the patient's life.

Nifedipine decreases sensitivity and reactivity to methacholine in mild asthmatics.

The protective effect of the calcium antagonist nifedipine (20 mg sublingually) on methacholine-induced bronchospasms was investigated in 14 mild asthmatics, 8 extrinsic and 6 intrinsic, in stable situations and with FEV1 greater than or equal to 80% of the one predicted. On separate days cumulative dose-response curves to methacholine were constructed, basal and 20 min after nifedipine administration; on both occasions basal FEV1 varied less than 5%. The sensitivity threshold (PD20) and reactivity (slope of the curve) were obtained. The shape of the curves analyzed from the PD20 point on, was linear (r2 = 0.99). There was a strong hyperbolic correlation between sensitivity and reactivity (r2 = 0.89). Nifedipine did not modify basal FEV1. After nifedipine, the sensitivity to methacholine decreased from 36.7 +/- 10.5 to 61.0 +/- 15.8 SEM (p less than 0.01) and likewise the reactivity from 2.2 +/- 0.7 to 1.1 +/- 0.5 SEM (p less than 0.02). Protection was greater when the basal sensitivity was higher (r = 0.59, p less than 0.05) but no such correlation was found for reactivity. Protection is explained by the blocking effect of nifedipine of calcium flux through voltage-dependent channels, provided that muscarinic agonists, at low doses, act preferentially through electromechanical coupling. These results indicate that a distinction between sensitivity and reactivity does not provide more information than each separate parameter.

The significance of the reflex bronchoconstriction provoked by gastroesophageal reflux in bronchial asthma.

To demonstrate the existence and assess the magnitude of reflex bronchoconstriction in asthmatics, triggered by gastroesophageal reflux, pulmonary function studies (forced expiratory spirogram, flow-volume loops and airway resistance) were performed during a Bernstein test in 21 adult patients with intrinsic asthma and in 15 controls. Six asthmatics and 7 controls had symptomatic reflux test and a positive standard acid reflux test. Bernstein test was positive in all symptomatic individuals and in 2 asthmatics with a negative standard acid reflux test. Changes in pulmonary function occur only in asthmatics with symptomatic reflux. Decreases were: FEV1 8.4 +/- 3.4; FEF25-75% 45 +/- 7.3; Vmax 15 +/- 8.4; and Sgaw 16 +/- 3.7. Although changes were statistically significant (p less than 0.05), the magnitude of decrease is rather small and unlikely to be felt by an asthmatic or produce wheezy dyspnea. Therefore, even though the presence of acid in the lower esophagus may produce reflex bronchoconstriction in some asthmatics with symptomatic reflux, this appears to be of little significance.

Factors predicting a hospital stay of over 3 days in patients with acute exacerbation of chronic obstructive pulmonary disease.

OBJECTIVE: To investigate the factors predicting a hospital stay of over 3 days in patients who required hospitalization for acute exacerbation of chronic obstructive pulmonary disease (COPD). DESIGN AND SETTING: A cross-sectional study was done at a tertiary hospital serving an area of 500 000 inhabitants. SUBJECTS: A total of 273 patients (alpha=0.05; accuracy=5.94%) who had been admitted consecutively to the Short Stay Medical Unit at the Juan Canalejo Hospital in A Coruña, from February 1998 to March 1999, with a diagnosis focusing on exacerbation of COPD. Methods. Demographic variables, past medical history, symptoms, arterial blood gases, functional tests, treatment and the cause of exacerbation were studied in each patient. The hospital stay was dichotomized into 3 days. The prognostic factors of a hospital stay were determined by log regression. Results. The mean stay was 4.6 +/- 5.1 days (range: 1-64). After monitoring the associated covariables, the following were found to have an independent effect on the prediction of a hospital stay of over 3 days: weekend admissions (OR=4.17; 95% CI: 2.42-7.18), the presence of cor pulmonale (OR=2.19; 95% CI: 1.27-3.78), and the respiratory rate on admission (OR=1.09; 95% CI: 1.03-1.14). Arterial blood gases and functional tests showed no independent effect. Conclusions. The factors having an independent prognostic value in determining the length of hospital stays in patients with COPD are weekend admission, cor pulmonale and respiratory rate. Additional studies are required to validate these findings.

Factors affecting quality of life of asthma patients in Spain: The importance of patient education

OBJECTIVES: Assessment of demographic and clinical factors that have an impact on the quality of life (QoL) of patients with asthma in Spain. PATIENTS AND METHODS: Multicenter, prospective, observational, cohort study, conducted in 40 Spanish Pneumology Units during a 12-month period. Data on sociodemographic, clinical variables, asthma treatment and QoL were collected in a case report form. RESULTS: 536 patients (64.6% women, mean age: 54) were recruited. Reported QoL was better for patients from Northern and Central Spain as compared with those from the South and the East (p < 0.001), students and employed patients as compared with housewives and unemployed (p < 0.01), for those who had received asthma information (p < 0.01), for those with milder daytime symptoms (p < 0.01) and for patients with higher level of education (p < 0.05). CONCLUSIONS: Among the factors that have a significant effect on patients' QoL only symptom control and patient education on asthma control are modifiable. Therefore, all the strategies should be tailored to improve such factors when managing asthma patients

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Un raro traumatismo obstétrico: fractura desplazada de metáfisis femoral en un recién nacido sano / A rare obstetrical injury: displaced fracture of femoral metaphysis at birth in an otherwise healthy infant

Se presenta el caso de un niño varón, nacido a término por cesárea en presentación podálica, tras el parto, sin realización de maniobras obstétricas agresivas, presentó una fractura oblicua y desplazada de la metáfisis femoral. En este artículo se anliza tanto la forma atípica de presentación clínica como de localización, y se evalúa la respuesta al tratamiento y las posibles secuelas durante el primer año de vida

In this article, we report the case of a male infant who was delivered by cesarean section due to breech presentation. After the delivery, which had not involved the performance of aggressive obstetrical maneuvers, it was discovered that he had sustained a displaced fracture of the femoral metaphysis. In this article, the authors analyze both the atypical clinical presentation and fracture site, as well as the response to treatment and sequelae throughout his first year of life

Anamnesis del tabaquismo y consejo antitabaco en 200 informes de alta sucesivos de los servicios médicos. Comparación de dos hospitales. Años 2003-2004 / Smoking anamnesis and counseling to stop smoking in 100 successive discharge reports of the medical services. Comparison of two hospitals. Year 2003-2004

Objetivo: El objetivo de este trabajo es conocer el interés de los médicos hospitalarios en general por el tabaquismo en los pacientes que ingresan, evaluando la anamnesis y el consejo médico del informe de alta. Pacientes y métodos: Hicimos un trabajo retrospectivo de 200 informes de alta de pacientes ingresados en 14 servicios médicos del HUCA (100) y en el Hospital Comarcal de Gandía (Comunidad Valenciana)(100), y se estudiaron parámetros epidemiológicos, de anamnesis y consejo antitabaco. Posteriormente, se hicieron comparaciones estadísticas utilizando la χ2, la odds ratio y los intervalos de confianza. Resultados: Los informes de alta de los 200 pacientes correspondían a 108 varones, de los cuales 47 pertenecían al HUCA y 61 al Hospital de Gandia; y 92 mujeres, 53 del HUCA y 39 del Hospital de Gandia y una edad media de 64,69 ± 17,69 años sin diferencias estadísticamente significativas entre ambos hospitales. La anamnesis de tabaquismo se realizó en un 40% de los informes. (HUCA 49%, H de Gandia 31%) con d.e.s. (χ2 = 6,750; p < 0,007) En el HUCA, había 49 pacientes con anamnesis, de los cuales 18 eran no fumadores, 16 fumadores y 24 exfumadores. En el Hospital de Gandía había un total de 31 pacientes a los que se les había hecho anamnesis2 eran no fumadores, 20 fumadores y 9 exfumadores. La diferencia era estadísticamente significativa (χ2 = 11,265) habiendo mayor proporción de fumadores en Gandía. De los 16 fumadores del HUCA 6 recibieron consejo, y en el Hospital de Gandía de 20 fumadores, 8 recibieron consejo, sin diferencias significativas. La mitad de los diagnósticos (49,5%) estaban relacionados etiologicamente con el tabaquismo sin diferencia entre ambos hospitales. Ninguno de los pacientes fumadores fue remitido a la consulta especializada de tabaquismo en ninguno de los 2 hospitales. Conclusiones: Dada la importancia etiológica del tabaquismo en estos pacientes, la anamnesis y el consejo antitabaco deberían de ser mejorados en ambos hospitales (AU)

Objective: This study aims to know the interest of the hospital physicians in general about smoking in the patients admitted to hospital, evaluating the anamnesis and medical counseling of the discharge report. Patients and methods: We conducted a retrospective study of 200 discharge reports of patients admitted to 14 medical departments of the HUCA (100) and in the Regional Hospital of Gandia (Valencian Community) (100) and studied epidemiological, anamnesis and antismoking counseling parameters. Subsequently, statistical comparisons were made using the χ2, odds ratio and confidence intervals. Results: The discharge reports of 200 patients corresponded to 108 men, 47 of whom belonged to the HUCA and 61 to the Hospital of Gandia and 92 women, 53 from the HUCA and 39 from the Hospital of Gandia with mean age of 64.69±17.69 years without statistically significant differences between both hospitals. The smoking anamnesis was conducted in 40% of the reports (HUCA 49%, Hospital of Gandia 31%) con with S.D. (χ2 = 6.750; p< 0.007) There were 49 patients in the HUCA with anamnesis, 18 of whom did not smoke, 16 who smoked and 24 who were ex-smokers. In theHospital of Gandia, there was a total of 31 patients in whom anamnesis was made: 2 were non-smokers, 20 smoked and 9 ex-smokers. The difference was statistically significant (χ2 = 11.265), there being a greater proportion of smokers in Gandia. Six of the 16 smokers in the HUCA received counseling and 8 of the 20 smokers in the Hospital of Gandia received counseling, without significant differences. Half of the diagnoses (49.5%) were etiologically related with smoking, without any difference between both hospitals. None of the patients who smoked were referred to the specialized tobacco consultation in either of the 2 hospitals. Conclusions: Given the etiological importance of smoking in these patients, the anamnesis and anti-smoking counseling should be improved in both hospitals (AU)