Documento de consenso sobre el fenotipo mixto EPOC-asma en la EPOC

Introduction

Although asthma and COPD are different pathologies, many patients share characteristics from both entities. These cases can have different evolutions and responses to treatment. Nevertheless, the evidence available is limited, and it is necessary to evaluate whether they represent a differential phenotype and provide recommendations about diagnosis and treatment, in addition to identifying possible gaps in our understanding of asthma and COPD.

Methods

A nation-wide consensus of experts in COPD in two stages: 1) during an initial meeting, the topics to be dealt with were established and a first draft of statements was elaborated with a structured «brainstorming» method; 2) consensus was reached with two rounds of e-mails, using a Likert-type scale.

Results

Consensus was reached about the existence of a differential clinical phenotype known as «Overlap Phenotype COPD-Asthma», whose diagnosis is made when 2 major criteria and 2 minor criteria are met. The major criteria include very positive bronchodilator test (increase in FEV₁ ≥ 15% and ≥ 400 ml), eosinophilia in sputum and personal history of asthma. Minor criteria include high total IgE, personal history of atopy and positive bronchodilator test (increase in FEV₁ ≥ 12% and ≥ 200 ml) on two or more occasions. The early use of individually-adjusted inhaled corticosteroids is recommended, and caution must be taken with their abrupt withdrawal. Meanwhile, in severe cases the use of triple therapy should be evaluated. Finally, there is an obvious lack of specific studies about the natural history and the treatment of these patients.

Conclusions

It is necessary to expand our knowledge about this phenotype in order to establish adequate guidelines and recommendations for its diagnosis and treatment.     

Increased afterload induces pathological cardiac hypertrophy: a new in vitro model

Increased afterload results in ‘pathological’ cardiac hypertrophy, the most important risk factor for the development of heart failure. Current in vitro models fall short in deciphering the mechanisms of hypertrophy induced by afterload enhancement. The aim of this study was to develop an experimental model that allows investigating the impact of afterload enhancement (AE) on work-performing heart muscles in vitro. Fibrin-based engineered heart tissue (EHT) was cast between two hollow elastic silicone posts in a 24-well cell culture format. After 2?weeks, the posts were reinforced with metal braces, which markedly increased afterload of the spontaneously beating EHTs. Serum-free, triiodothyronine-, and hydrocortisone-supplemented medium conditions were established to prevent undefined serum effects. Control EHTs were handled identically without reinforcement. Endothelin-1 (ET-1)- or phenylephrine (PE)-stimulated EHTs served as positive control for hypertrophy. Cardiomyocytes in EHTs enlarged by 28.4?% under AE and to a similar extent by ET-1- or PE-stimulation (40.6 or 23.6?%), as determined by dystrophin staining. Cardiomyocyte hypertrophy was accompanied by activation of the fetal gene program, increased glucose consumption, and increased mRNA levels and extracellular deposition of collagen-1. Importantly, afterload-enhanced EHTs exhibited reduced contractile force and impaired diastolic relaxation directly after release of the metal braces. These deleterious effects of afterload enhancement were preventable by endothelin-A, but not endothelin-B receptor blockade. Sustained afterload enhancement of EHTs alone is sufficient to induce pathological cardiac remodeling with reduced contractile function and increased glucose consumption. The model will be useful to investigate novel therapeutic approaches in a simple and fast manner.     

Coronary Stent Infections: A Case Report and Literature Review

Although rare, coronary artery stent infections are associated with a high mortality rate. Since the introduction of coronary stents in 1987, only 16 cases of infection have been reported. We report a new case in a 66-year-old woman who had undergone a difficult percutaneous coronary intervention procedure, during which 3 overlapping stents were implanted in the mid portion of the right coronary artery. Twenty-two days after the procedure, the patient died. Autopsy revealed the cause of death to be pericardial tamponade due to rupture of the right ventricular myocardium. The stented portion of the right coronary artery was enveloped by an abscess, and purulent material completely occluded the stents. Cultures of the myocardium were positive for methicillin-resistant Staphylococcus aureus. We conducted a review of the literature on coronary artery stent infections. Data suggest that early-onset infections (<10 days after stent implantation) are potentially amenable to medical therapy alone, but late-onset infections (≥10 days after implantation) or major complications necessitate combined surgical and medical therapy. Medical therapy consists of broad-spectrum antibiotics. Surgical intervention includes stent removal if possible, and abscess drainage or perforation repair when indicated.Key words: Blood vessel prosthesis implantation/adverse effects, coronary stent infections, prosthesis-related infections/complications/diagnosis/therapy, stents/adverse effects, Staphylococcus aureusCoronary artery stents have been in use for more than 2 decades. Stent infections are rare, hard to treat, and potentially devastating. Our treatment of a patient with a coronary stent abscess prompted us to review the literature. From our experience and the evaluation of previously reported cases,^1–14 we propose an approach for diagnosing and treating these infections.     

Metastatic colon cancer involving the right atrium

Colorectal cancer rarely metastasizes to the heart. In the world medical literature, we identified only 7 cases of well-documented colorectal cancer metastasis to the right atrium. Herein, we describe the case of a 72-year-old man in whom metastatic mucinous adenocarcinoma of the colon involved the right atrium and caused superior vena cava syndrome. To our knowledge, this is the first case report of sudden cardiac death due to embolization of metastatic colon cancer from the right atrium. We also present the first comprehensive case series review of this rare entity.Given improvements in diagnostic and therapeutic methods that have increased the longevity of many cancer patients, the detection of cardiac metastases is likely to increase in frequency. Accordingly, we recommend that previously asymptomatic cancer patients with a history of colorectal cancer who develop cardiac symptoms undergo prompt investigation for possible cardiac metastasis.     

Physical activity in chronic home-living and sub-acute hospitalized stroke patients using objective and self-reported measures

Background: Despite confirmed reduced physical activity (PA) after stroke in various stages of recovery, the type of activities stroke patients executed and the time spent at different activity levels have not been sufficiently verified with stroke-validated assessment tools.

Design: Observational study.

Objective: To determine PA of sub-acute stroke patients hospitalized in a rehabilitation centre (HOS) compared to chronic home-living stroke patients (HOM) using objective and self-reported measures during 2 weekdays and 1 weekend day.

Methods: Fifteen HOS and 15 HOM patients wore a Sense Wear Pro 2 accelerometer (METs*minutes/24 h) and a knee-worn pedometer Yamax Digi Walker SW 200 (steps) and filled in a coded activity diary (kcal/24 h; METs*minutes/24 h) during three consecutive days.

Results: In HOM significantly more steps (steps_{total HOM} = 18722.6 ± 10063.6; steps_{total HOS} = 7097.8 ± 5850.5) and higher energy expenditure (EE) levels (EE_{total HOM} = 7759.34 ± 2243.04; EE_{total HOS} = 5860.15 ± 1412.78) were measured. In this group less moderate activity (≥3–6 ≤ METs) was performed on a weekday (p_day1 = 0.006; p_day2 = 0.027) and in total (p = 0.037). Few therapy hours (physical, occupational and speech therapy, and psychological support) were provided in HOM compared to HOS (p < 0.001). Vigorous activities were only seen in HOM. In both groups few patients executed sport activities.

Conclusions: In HOM significantly more steps were performed and higher EE values were measured. However, participation in moderate activities and time spent on therapy were less in HOM. Evaluating PA with quantitative measures is feasible in both chronic home-living and sub-acute hospitalized patients with stroke.     

The Isolation of Numerals at the Semantic Level

Abstract

In this study, we examine the case of a patient (NM) who could comprehend and produce numerals despite impairment on comprehension tasks and a high degree of anomia for other categories of words. It will be claimed that NM suffered from an impairment to the semantic system affecting all categories except numerals and the series of days and months. The case of a patient presenting with the exact reverse dissociation has been described a few years ago by Cipolotti et al. (Brain 1991; 114: 619–37). We conclude that NM's pattern of performance provides evidence that numerals constitute a relevant and perhaps a distinct category at the semantic level.     

Cognitive characterization of SCAR10 caused by a homozygous c.132dupA mutation in the ANO10 gene

ABSTRACT

Autosomal recessive spinocerebellar ataxia type 10 (SCAR10) caused by a homozygous c.132dupA mutation in the anoctamin 10 gene is infrequent and little is known about its cognitive profile. Three siblings (1 male) with this mutation were assessed with a neuropsychological battery measuring multiple cognitive domains. The deficits observed in one patient were in executive functions whereas the other two patients showed deficits in practically all the functions. Cognitive impairment seems to be a characteristic of the SCAR10 produced by this mutation, with a range from mild impairment, especially involving prefrontal systems, to a severe cognitive impairment suggesting widespread cerebral involvement.