Evaluación de la calidad asistencial en la enfermedad pulmonar obstructiva crónica en el ámbito de consultas externas de neumología.

La enfermedad pulmonar obstructiva crónica (EPOC) es una enfermedad pulmonar común, prevenible y tratable que se caracteriza por síntomas respiratorios persistentes y limitación del flujo de aire que se debe anomalías alveolares y/o de las vías respiratorias generalmente causadas por una exposición significativa a partículas o gases nocivos, con un alto impacto sanitario en morbilidad, mortalidad y que genera una importante repercusión en el sistema sanitario. Estas connotaciones la hacen ser considerada como una enfermedad de primera magnitud en la que la calidad asistencial debe ser primordial para garantizar la correcta utilización de los recursos que consigan mejorar la situación clínica de los pacientes. En la actualidad disponemos de diversas herramientas para valorar la calidad asistencial que reciben nuestros pacientes y el cumplimiento de las guías de práctica clínica por parte de los profesionales sanitarios. Dentro de estas herramientas disponemos de las auditorías clínicas las cuales pueden definirse como el análisis crítico y sistemático de la calidad de la asistencia médica, incluyendo procedimientos diagnósticos y terapéuticos, el uso de recursos y los resultados de los mismos en cuanto a desenlaces clínicos y la calidad de vida del paciente. A pesar de la relevancia clínica de la enfermedad y su importancia epidemiológica, hasta hace unos años, en España no existía un programa de auditorías clínicas específico para la EPOC. Hasta el momento ningún proyecto español ha aportado información sobre la calidad asistencial y la adecuación a guías de práctica clínica en el paciente con EPOC en el ámbito especializado ambulatorio de Neumología. La presente Tesis Doctoral se enmarca por tanto en este proceso de mejora continua de la atención sanitaria centrándose en la evaluación de la calidad asistencial de la EPOC en consultas externas de Neumología. Los objetivos principales de esta Tesis Doctoral son 1) Evaluar los recursos sanitarios disponibles para la atención médica al paciente con EPOC en el ambito de la Atención Especializada ambulatoria en Neumología. 2) Evaluar la variabilidad de la práctica clínica asistencial en la EPOC en el ambito de la Atención Especializada ambulatoria en Neumología. 3) Evaluar la variabilidad de la adecuación a las guías clínicas de EPOC en el ambito de la Atención Especializada ambulatoria en Neumología Para ello hemos diseñado un estudio piloto observacional transversal de auditoría clínica en el ambito de la Atención Especializada ambulatoria en Neumología en Andalucía. Se seleccionaron 10 hospitales públicos andaluces (6 hospitales regionales, 2 hospitales de especialidades y 1 hospital comarcal). La población de estudio engloba a aquellos casos con un diagnóstico firme de la EPOC en función de factores de riesgo, síntomas clínicos y una espirometría post-broncodilatador con una relación FEV1/FVC fijo por debajo de 0,7. Se recogieron 80 casos por centro, 20 por cada estadío GOLD, Se realizaron dos bases de datos diferentes: la base de datos de recursos y la base de datos clínicos. La base de datos de recursos registró información sobre los recursos y la organización de la atención del centro en relación en relación a las instalaciones de la clínica ambulatoria. La base de datos clínicos registraba la información de la auditoría para cada caso clínico incluido. La auditoría se llevó a cabo a lo largo de un año ( Octubre 2013- Septiembre 2014). Durante el año de estudio se analizaron 621 historias repartidas durante los 4 trimestres del año. En cuanto a la evaluación de los recursos sanitarios disponibles en el ámbito de la Atención Especializada ambulatoria en Neumología para los pacientes con EPOC. 4 centros disponían de consulta monográfica de EPOC. 3 centros hacían educación sobre el uso de inhaladores, la cual en el 80% de los casos era impartida por parte del médico. Todos los centros que tenían programa de rehabilitación respiratoria lo hacían en el hospital de manera ambulatoria con recomendaciones posteriores para el domicilio. Con respecto a las pruebas complementarias todos los centros disponían de las mas habituales ( espirometría, radiología simple de tórax, TAC de torax, Ecocardiograma, IgE, Alfa1 antitripsina, microbiología de esputo). El Test de la marcha de 6 minutos se realizaba en 6 centros y el test de esfuerzo en 3 centros. El porcentaje de centros que referían disponer de CAT de manera rutinaria era del 33%. En cuanto a la evaluación de la variabilidad de la práctica clínica asistencial Los pacientes eran mayoritariamente hombres, en la séptima década de la vida, con un porcentaje de fumadores activos del 26,2%, un considerable número de comorbilidades y mayoritariamente del ámbito urbano. La gravedad espirométrica oscilaba entre moderada y grave y un 4,7% tenía una espirometría no obstructiva en el momento del diagnóstico. El empleo de los índices multidimensionales y de las normativas GesEPOC y GOLD. para catalogar a los pacientes presentaba también una importante variabilidad. En general el uso de estas herramientas era bajo, pero BODEx era más usado que BODE. El tratamiento farmacológico era más frecuentemente recogido que el no farmacológico. Las vacunaciones eran recogidas en menor frecuencia que el ejercicio habitual. La satisfacción con el dispositivo de inhalación y los efectos adversos de la medicación eran recogidos escasamente. La espirometría era el estudio complementario mas solicitado, seguido de la radiografía simple de tórax. Por último con respecto a la variabilidad de la adecuación a las guías clínicas de EPOC, la adherencia a las diferentes guías presentó una considerable variabilidad entre los diferentes hospitales participantes, con una adherencia excelente o buena para el registro de síntomas, uso de MRC o CAT, evaluación del estado de fumar, espirometría o terapia de broncodilatación. Las áreas más sobresalientes para mejorar fueron el uso del índice BODE, el monitoreo de tratamientos, la determinación de alfa1-antitripsina, la realización de pruebas de ejercicio y recomendaciones de vacunación. Como conclusiones podemos decir que la presente Tesis Doctoral aporta información sobre los recursos disponibles, la variabilidad de la práctica clínica y la adecuación a guías en la atención sanitaria del paciente con EPOC. Esta adecuación presenta una considerable variabilidad con algunos puntos fuertes y otras áreas de mejora. Las auditorías clínicas son herramientas enmarcadas en la corriente de mejora continua que proveen de información válida que debe ser utilizada para mejorar la atención sanitaria. Por ello es necesario sistematizar la recogida de datos en la entrevista clínica con objeto de que la información recogida sea lo más homogénea posible, de manera que nos permita tomar decisiones terapéuticas adaptadas a cada caso

A New European Bauhaus for a Culture of Transversality and Sustainability

This article provides a critical study of a New European Bauhaus initiative in the context of transversality, relational nature and sustainability of construction, architecture and civil engineering. Social and environmental factors in this ecosystem of innovation are highlighted, as well as the perspectives of actors within it. The relationships between art, technology and science of historical Bauhaus are assessed. The investigation of transversality was carried out using a visual tool developed by the authors, CATI, considering sustainability as the backbone. The New European Bauhaus is a pool of innovation that is supported by governments, academia, industry, society and the (natural) environment. It aims at social, environmental and cultural sustainability and includes ideas of social transformation. It is necessary to absorb the impact and overwhelming cultural consequences of previous and current Industrial Revolutions, principally relying on cyber–physical systems to generate spaces and collective intelligence. The climate crisis and the COVID-19 pandemic have increased the need for new approaches, expanding the concept of smart cities to smart territories, taking into account participation in society and general inclusivity

Clinical features and health-related quality of life in adult patients with mucopolysaccharidosis IVA: the Spanish experience

Elosulfasa alfa; Qualitat de vida relacionada amb la salut; Síndrome de Morquio AElosulfasa alfa; Calidad de vida relacionada con la salud; Síndrome de Morquio AElosulfase alfa; Health-related quality of life; Morquio A syndromeBackground Mucopolysaccharidosis (MPS) IVA or Morquio A syndrome is a progressive and disabling disease characterized by a deficiency of the enzyme N-acetylgalactosamine-6-sulphate sulphatase. Its clinical presentation is very heterogeneous and poorly understood in adults. The aim of this study was to describe the clinical manifestations of MPS IVA in adult patients in Spain and to assess their health-related quality of life (HRQoL). Results Thirty-three patients from nine reference centres participated in the study. The median age was 32 (interquartile range [IQR]: 20.5–40.5) years. The phenotype was classical in 54.5% of patients, intermediate in 33.3% of patients, and non-classical in 12.1% of patients. The most common clinical manifestation was bone dysplasia, with a median height of 118 (IQR: 106–136) cm. Other frequent clinical manifestations were hearing loss (75.7%), ligamentous laxity (72.7%), odontoid dysplasia (69.7%), limb deformities that required orthopaedic aids (mainly hip dysplasia and genu valgus) (63.6%), and corneal clouding (60.6%). In addition, 36.0% of patients had obstructive sleep apnoea/hypopnoea syndrome and 33.3% needed non-invasive ventilation. Cervical surgery and varisation osteotomy were the most common surgical interventions (36.4% each). Almost 80% of patients had mobility problems and 36.4% used a wheelchair at all times. Furthermore, 87.9% needed help with self-care, 33.3% were fully dependent, and 78.8% had some degree of pain. HRQoL according to the health assessment questionnaire was 1.43 (IQR: 1.03–2.00) in patients with the non-classical phenotype, but 2.5 (IQR: 1.68–3.00) in those with the classical phenotype. Seven patients were initiated on enzyme replacement therapy (ERT), but two of them were lost to follow-up. Lung function improved in four patients and slightly worsened in one patient. The distance achieved in the six-minute walk test increased in the four patients who could perform it. HRQoL was better in patients treated with elosulfase alfa, with a median (IQR) of 1.75 (1.25–2.34) versus 2.25 (1.62–3.00) in patients not treated with ERT. Conclusions The study provides real-world data on patients with MPS IVA. Limited mobility, difficulties with self-care, dependence, and pain were common, together with poor HRQoL. The severity and heterogeneity of clinical manifestations require the combined efforts of multidisciplinary teams.BioMarin Pharmaceuticals España SL. funded the writing of this paper

Erythrocyte Membrane Nanomechanical Rigidity Is Decreased in Obese Patients

This work intends to describe the physical properties of red blood cell (RBC) membranes in obese adults. The hypothesis driving this research is that obesity, in addition to increasing the amount of body fat, will also modify the lipid composition of membranes in cells other than adipocytes. Forty-nine control volunteers (16 male, 33 female, BMI 21.8 ± 5.6 and 21.5 ± 4.2 kg/m2, respectively) and 52 obese subjects (16 male and 36 female, BMI 38.2± 11.0 and 40.7 ± 8.7 kg/m2, respectively) were examined. The two physical techniques applied were atomic force microscopy (AFM) in the force spectroscopy mode, which allows the micromechanical measurement of penetration forces, and fluorescence anisotropy of trimethylammonium diphenylhexatriene (TMA-DPH), which provides information on lipid order at the membrane polar–nonpolar interface. These techniques, in combination with lipidomic studies, revealed a decreased rigidity in the interfacial region of the RBC membranes of obese as compared to control patients, related to parallel changes in lipid composition. Lipidomic data show an increase in the cholesterol/phospholipid mole ratio and a decrease in sphingomyelin contents in obese membranes. ω-3 fatty acids (e.g., docosahexaenoic acid) appear to be less prevalent in obese patient RBCs, and this is the case for both the global fatty acid distribution and for the individual major lipids in the membrane phosphatidylcholine (PC), phosphatidylethanolamine (PE) and phosphatidylserine (PS). Moreover, some ω-6 fatty acids (e.g., arachidonic acid) are increased in obese patient RBCs. The switch from ω-3 to ω-6 lipids in obese subjects could be a major factor explaining the higher interfacial fluidity in obese patient RBC membranes.This work was supported in part by the Basque Government Department of Economic Development, grant No. KK-2019/00028 (OBINTER); the Basque Government Department of Education, grants No. IT1264-19, IT1281-19, IT1270-19, and IT1625-22; the Basque Government Department of Health, grants No. 2019-222030, 2020-333023; Fundación Ramón Areces; and by Centre for the Development of Industrial Technology (CDTI) of the Spanish Ministry of Science and Innovation under the grant agreement: TECNOMIFOOD project (CER-20191010) and Basque Government: IT1625-22

Quantification of inaccurate diagnosis of COPD in primary care medicine: an analysis of the COACH clinical audit

[Background] Inaccurate diagnosis in COPD is a current problem with relevant consequences in terms of inefficient health care, which has not been thoroughly studied in primary care medicine. The aim of the present study was to evaluate the degree of inaccurate diagnosis in Primary Care in Spain and study the determinants associated with it.[Methods] The Community Assessment of COPD Health Care (COACH) study is a national, observational, randomized, non-interventional, national clinical audit aimed at evaluating clinical practice for patients with COPD in primary care medicine in Spain. For the present analysis, a correct diagnosis was evaluated based on previous exposure and airway obstruction with and without the presence of symptoms. The association of patient-level and center-level variables with inaccurate diagnosis was studied using multivariate multilevel binomial logistic regression models.[Results] During the study 4,307 cases from 63 centers were audited. The rate of inaccurate diagnosis was 82.4% (inter-regional range from 76.8% to 90.2%). Patient-related interventions associated with inaccurate diagnosis were related to active smoking, lung function evaluation, and specific therapeutic interventions. Center-level variables related to the availability of certain complementary tests and different aspects of the resources available were also associated with an inaccurate diagnosis.[Conclusions] The prevalence data for the inaccurate diagnosis of COPD in primary care medicine in Spain establishes a point of reference in the clinical management of COPD. The descriptors of the variables associated with this inaccurate diagnosis can be used to identify cases and centers in which inaccurate diagnosis is occurring considerably, thus allowing for improvement.Peer reviewe

Effectiveness and Safety of the Sequential Use of a Second and Third Anti-TNF Agent in Patients With Inflammatory Bowel Disease: Results From the Eneida Registry

Background: The effectiveness of the switch to another anti-tumor necrosis factor (anti-TNF) agent is not known. The aim of this study was to analyze the effectiveness and safety of treatment with a second and third anti-TNF drug after intolerance to or failure of a previous anti-TNF agent in inflammatory bowel disease (IBD) patients. Methods: We included patients diagnosed with IBD from the ENEIDA registry who received another anti-TNF after intolerance to or failure of a prior anti-TNF agent. Results: A total of 1122 patients were included. In the short term, remission was achieved in 55% of the patients with the second anti-TNF. The incidence of loss of response was 19% per patient-year with the second anti-TNF. Combination therapy (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.8-3; P < 0.0001) and ulcerative colitis vs Crohn's disease (HR, 1.6; 95% CI, 1.1-2.1; P = 0.005) were associated with a higher probability of loss of response. Fifteen percent of the patients had adverse events, and 10% had to discontinue the second anti-TNF. Of the 71 patients who received a third anti-TNF, 55% achieved remission. The incidence of loss of response was 22% per patient-year with a third anti-TNF. Adverse events occurred in 7 patients (11%), but only 1 stopped the drug. Conclusions: Approximately half of the patients who received a second anti-TNF achieved remission; nevertheless, a significant proportion of them subsequently lost response. Combination therapy and type of IBD were associated with loss of response. Remission was achieved in almost 50% of patients who received a third anti-TNF; nevertheless, a significant proportion of them subsequently lost response

Clinical Audits in Outpatient Clinics for Chronic Obstructive Pulmonary Disease: Methodological Considerations and Workflow

Objectives: Previous clinical audits for chronic obstructive pulmonary disease (COPD) have provided valuable information on the clinical care delivered to patients admitted to medical wards because of COPD exacerbations. However, clinical audits of COPD in an outpatient setting are scarce and no methodological guidelines are currently available. Based on our previous experience, herein we describe a clinical audit for COPD patients in specialized outpatient clinics with the overall goal of establishing a potential methodological workflow.Methods: A pilot clinical audit of COPD patients referred to respiratory outpatient clinics in the region of Andalusia, Spain (over 8 million inhabitants), was performed. The audit took place between October 2013 and September 2014, and 10 centers (20% of all public hospitals) were invited to participate. Cases with an established diagnosis of COPD based on risk factors, clinical symptoms, and a post-bronchodilator FEV1/FVC ratio of less than 0.70 were deemed eligible. The usefulness of formally scheduled regular follow-up visits was assessed. Two different databases (resources and clinical database) were constructed. Assessments were planned over a year divided by 4 three-month periods, with the goal of determining seasonal-related changes. Exacerbations and survival served as the main endpoints.Conclusions: This paper describes a methodological framework for conducting a clinical audit of COPD patients in an outpatient setting. Results from such audits can guide health information systems development and implementation in real-world settings.This study was financially supported by an unrestricted grant from Laboratorios Menarini, SA (Barcelona, Spain)

Clonal chromosomal mosaicism and loss of chromosome Y in elderly men increase vulnerability for SARS-CoV-2

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, COVID-19) had an estimated overall case fatality ratio of 1.38% (pre-vaccination), being 53% higher in males and increasing exponentially with age. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, we found 133 cases (1.42%) with detectable clonal mosaicism for chromosome alterations (mCA) and 226 males (5.08%) with acquired loss of chromosome Y (LOY). Individuals with clonal mosaic events (mCA and/or LOY) showed a 54% increase in the risk of COVID-19 lethality. LOY is associated with transcriptomic biomarkers of immune dysfunction, pro-coagulation activity and cardiovascular risk. Interferon-induced genes involved in the initial immune response to SARS-CoV-2 are also down-regulated in LOY. Thus, mCA and LOY underlie at least part of the sex-biased severity and mortality of COVID-19 in aging patients. Given its potential therapeutic and prognostic relevance, evaluation of clonal mosaicism should be implemented as biomarker of COVID-19 severity in elderly people. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, individuals with clonal mosaic events (clonal mosaicism for chromosome alterations and/or loss of chromosome Y) showed an increased risk of COVID-19 lethality

Autoantibodies against type I IFNs in patients with critical influenza pneumonia

In an international cohort of 279 patients with hypoxemic influenza pneumonia, we identified 13 patients (4.6%) with autoantibodies neutralizing IFN-alpha and/or -omega, which were previously reported to underlie 15% cases of life-threatening COVID-19 pneumonia and one third of severe adverse reactions to live-attenuated yellow fever vaccine. Autoantibodies neutralizing type I interferons (IFNs) can underlie critical COVID-19 pneumonia and yellow fever vaccine disease. We report here on 13 patients harboring autoantibodies neutralizing IFN-alpha 2 alone (five patients) or with IFN-omega (eight patients) from a cohort of 279 patients (4.7%) aged 6-73 yr with critical influenza pneumonia. Nine and four patients had antibodies neutralizing high and low concentrations, respectively, of IFN-alpha 2, and six and two patients had antibodies neutralizing high and low concentrations, respectively, of IFN-omega. The patients' autoantibodies increased influenza A virus replication in both A549 cells and reconstituted human airway epithelia. The prevalence of these antibodies was significantly higher than that in the general population for patients 70 yr of age (3.1 vs. 4.4%, P = 0.68). The risk of critical influenza was highest in patients with antibodies neutralizing high concentrations of both IFN-alpha 2 and IFN-omega (OR = 11.7, P = 1.3 x 10(-5)), especially those <70 yr old (OR = 139.9, P = 3.1 x 10(-10)). We also identified 10 patients in additional influenza patient cohorts. Autoantibodies neutralizing type I IFNs account for similar to 5% of cases of life-threatening influenza pneumonia in patients <70 yr old

Monitorización analítica de drogas de abuso en el medio hospitalario

Se explora la situación actual de los programas de tratamiento con metadona (PTM) en Andalucía, definida por los profesionales implicados y cómo ellos valoran que dicho programa debiera ser en términos de excelencia. Para ello se ofrecen propuestas y medidas de mejora con las que acercar las situaciones descritas. Material y métodos. Reunión de expertos articulada con una variante del grupo nominal. Participaron 9 profesionales. Resultados. La situación ideal y en términos de excelencia de los PTM no concuerda en buena parte de sus cláusulas con la realidad actual de estas intervenciones. Los aspectos más destacados sobre cómo debieran ser los PTM son la dispensación, la agilidad y rapidez de los programas, junto a la existencia de una buena coordinación entre los recursos. La descripción y valoración de la situación actual de los PTM es menos favorable con rela ción a la situación ideal definida por los asistentes. Se recogen y puntúan propuestas y medidas de mejora con las que acercar ambas situaciones. Conclusiones. Aunque los PTM sean intervenciones de eficacia comprobada por la evidencia científica, son susceptibles de mejora. Para ello recoger la voz de los protagonistas directos en estas prácticas es importante para asegurar su continuidad y dotarlos de mayor calida