Consensus document on the overlap phenotype COPD-asthma in COPD

IntroductionAlthough 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.MethodsA 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 statement was elaborated with a structured “brainstorming” method; (2) consensus was reached with two rounds of e-mails, using a Likert-type scale.ResultsConsensus 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.ConclusionsIt is necessary to expand our knowledge about this phenotype in order to establish adequate guidelines and recommendations for its diagnosis and treatment.     

Bone loss determined by quantitative ultrasonometry correlates inversely with disease activity in patients with endogenous glucocorticoid excess due to adrenal mass

OBJECTIVE: Glucocorticoid excess is widely recognized as one of the most important causes of bone loss. The mechanism of glucocorticoid-induced osteoporosis is presumably multifactorial, and consists of the loss of organic and non-organic compounds. Efforts have been made to develop simple physical methods for the assessment of bone tissue for the screening of subjects at high risk of osteoporosis, without the use of radioactive sources or ionizing radiation. Quantitative ultrasonometry (QUS) has been suggested as a useful method for monitoring patients undergoing glucocorticoid therapy, which is the most common cause of glucocorticoid excess. QUS appears to detect more structural bone changes than the traditional methods and allows assessment of bone density and elasticity, both characteristics influenced by organic and non-organic bone compounds. However, the use of QUS has not yet been extensively investigated in subjects with endogenous cortisol excess. The aim of this study was to evaluate the usefulness and predictive power of QUS in assessing bone loss in subjects with differing degrees of endogenous cortisol excess due to adrenal mass. DESIGN: Thirty-four patients (20 women and 14 men) aged between 21 and 59 years were evaluated; fifteen (9 women and 6 men; median age, 42 years) were affected by overt Cushing's syndrome (CS) and nineteen (11 women and 8 men; median age, 44 years) by subclinical CS, defined as lacking clinical signs of hormone excess despite the presence of at least two abnormalities in hypothalamic-pituitary-adrenal axis function, as assessed by routine endocrine tests. All women included were eumenorrhoic. METHODS: QUS measurement of amplitude-dependent speed of sound was performed on the 2nd to 5th proximal phalanges of the non-dominant hand using a DBM Sonic 1200R bone profiler (Igea S.r.l, Italy). The results were compared with bone density assessed on lumbar vertebrae (L1-L4) and femoral neck sites by dual-energy X-ray absorptiometry (DEXA). RESULTS: A strongly significant bone loss was detected by finger QUS measurement when the patients were considered either all together or as two subgroups (P<0.001, all). The bone density decrease in the fingers was similar to that found at the lumbar spine and femoral neck by the DEXA technique. Lumbar and finger Z-scores correlated inversely with 24 h urinary free cortisol (UFF) excretion (P<0.01, both). Finger Z-scores also correlated inversely with the estimated duration of subclinical CS (P<0.05). Concerning disease activity, only UFF was confirmed by multivariate analysis to be an independent factor influencing bone loss (P<0.05). A positive correlation between the results of the two techniques was found in controls (P<0.05) but not in patients. The lack of correlation between the two techniques in patients can probably be attributed to the different parameters of bone alteration measured by the techniques. CONCLUSIONS: The detection of bone loss in subclinical CS similar to that in overt CS suggests that all subjects with endogenous cortisol excess should be evaluated for bone mass. QUS measurement appears to be a reliable, radiation-free, simple and fast tool for the identification of bone alteration in subjects with endogenous cortisol excess.     

Importance of chronic musculoskeletal problems in the population of Catalonia (Spain): prevalence and effect on self-perceived health, activity restriction and use of health services

Objective

To determine the importance of chronic musculoskeletal problems in the adult population of Catalonia (Spain) and their effect on self-perceived health, activity restriction and use of health services.

Methods

A population-based survey of 15,926 adults was performed. Multistage stratified sampling was performed. The variables gathered were sociodemographic characteristics, self-reported chronic health problems, self-perceived health, activity restriction and use of health services. Musculoskeletal problems were grouped into four categories: osteoarthritis-arthritis or rheumatism (OA), chronic dorsal or lumbar pain (LBP), chronic cervical pain (UBP), and osteoporosis.

Results

Chronic health problems were reported by 77.4% of the adult population. The most frequent health problem was LBP, followed by UBP and OA. After adjustment by age was performed, female sex increased the risk of reporting OA, LBP, UBP and osteoporosis (OR = 2.6, 1.5, 2.3, and 5.3, respectively). The prevalence increased with greater age and with lower socioeconomic status. After adjustment was performed by age, sex, social class and obesity, self-perceived health was worse in people with these problems (42.7% vs 11%). The four categories were the main causes of activity restriction in the last year (OR 2.70) and the last 15 days (OR = 2.32) and were associated with a higher use of health services.

Conclusiones

Los problemas reumáticos son los principales problemas de salud crónicos declarados por la población adulta. La prevalencia es mayor es las mujeres, aumenta con la edad y en las clases desfavorecidas. Hay una asociación significativa entre declarar problemas musculoesqueléticos y salud autopercibida mala o regular, y mayor restricción de actividades y uso de servicios sanitarios.     

Delayed aortic aneurysm enlargement due to endotension after endovascular abdominal aortic aneurysm repair

Abdominal aortic aneurysm (AAA) enlarges after successful endovascular repair, because of persistent blood flow within the aneurysm sac, or endoleak. In the absence of detectable endoleak, AAA may still expand, in part because of persistent pressurization within the excluded aneurysm, or endotension. We report three patients who underwent successful endovascular AAA repair in whom postoperative surveillance showed aneurysm regression, yet delayed AAA enlargement without demonstrable endoleak developed in all three patients. Endotension was confirmed in all three patients at elective open conversion. Our study underscores the significance of endotension as a mechanism of delayed aneurysm enlargement after successful endovascular AAA repair.     

High incidence and prevalence of rheumatoid arthritis in Pima Indians

A longitudinal epidemiologic study has been conducted to estimate the incidence and prevalence of rheumatoid arthritis in an American Indian population, the Pima and Papago Indians of Arizona. Clinical, serologic, and radiologic data were collected during biennial examinations of subjects aged 20 years or more during the period 1967-1986. Rheumatoid arthritis was diagnosed by criteria for the active and the inactive disease. Age-adjusted to the 1980 US population at least 20 years of age, the prevalence of classical and definite rheumatoid arthritis in 1984 was 5.3% (3.23% in males and 6.95% in females), a rate appreciably higher than that reported in studies in Rochester, Minnesota, and in Hiroshima and Nagasaki, Japan. Among Pimas, during the study period, 70 incident cases of rheumatoid arthritis occurred. The age-adjusted incidence rate was 42.2 cases per 10,000 person-years (29.7 in males and 51.8 in females), 10.3 times as high as the age-adjusted rate in Rochester (4.1/10,000 person-years), and 5.7 times as high as in Japan (7.4/10,000 person-years). Rates generally increased with age. No secular trend was found. On the basis of both prevalence and incidence data, this study confirms that rheumatoid arthritis does not have uniform occurrence in different populations. This has to be taken into account in the search for the factors related to the differences in risk of disease.     

Auditory discrimination, attention, learning, and memory in paranoid schizophrenics.

The present research was designed to assess auditory discrimination, attention, memory, and learning in paranoid schizophrenic patients using a dichotic listening procedure consisting of attending to a signal or a story channeled only to one ear. A sample of 24 paranoid schizophrenics and 24 normal controls volunteered. In Experiment 1, 12 schizophrenics and 12 controls attended to the signal while shadowing the story. The task of the other 12 clinical and 12 normal subjects in Experiment 2 was identical to Experiment 1 with the exception that the subjects did not shadow the story. In each experiment, subjects completed three trials as well as three evaluations of the story. The results indicated that schizophrenics showed substantial attentional deficits in comparison to normal controls.     

Itraconazole in the treatment of coccidioidomycosis.

Sixteen patients with coccidioidomycosis were treated with itraconazole for one year. Sixteen suffered from pulmonary coccidioidomycosis, two of them had associated mediastinal lesions, and one suffered from skin coccidioidomycosis. The daily dose used was 400 mg during the one-year period. Patients were clinically evaluated every month and tested for mycosis every three months. All patients except for one showed negative cultures on the third month after treatment began. Effectiveness achieved was excellent in eight patients (50 percent); a very good response was found in seven patients (44 percent); no response was seen in one patient (6 percent). There were four (25 percent) relapses and one dropout. Side effects seen were high blood pressure (19 percent) and lower limb edema (6 percent), which was temporary and at no time required discontinuing the drug therapy. We believe that itraconazole is an effective drug to treat coccidioidomycosis with a wide safety margin. It is well tolerated, and the incidence of relapses was low.