Análisis del tratamiento de la deshabituación tabáquica y abstinenia. Estudio farmacoeconómico

Tesis doctoral inédita leída en la Universidad Autónoma de Madrid, Facultad de Medicina, Departamento de Cirugía. Fecha de lectura: 6-09-201

Descriptive study of the use of mannitol as a diagnostic test of bronchial hyperreactivity in Albacete

The Mannitol test is used for the diagnosis of bronchial hyperreactivity. It is in the asthma diagnostic algorithm Aims. Make a descriptive review of the tests we had done and their usefulness. Settings and Design: Retrospective descriptive study. Methods and Material. Patients who have performed the mannitol test in the laboratory of functional respiratory tests between May 29, 2017 and December 3, 2018. Statistical analysis used. Study of frequencies in qualitative variables and measures of central tendency in quantitative. The relationships were studied with nonparametric tests: F of Fisher for qualitative variables and U of Mann-Whitney for quantitative variables. The significance was set at p≤0.05. Results. There were 54 patients, 81.5% women of 49.06 years. The most frequent adverse effect was cough that occurred in 85.4% and with a dose of 5 mg. The result was positive at 14.8%. The positives are among those older than 40 years (p = 0.04), so those who cough (p = 0.018). There are significant differences in the dose received and the fall in FEV1. There was no relationship between coughing and the positivity or negativity of the test (p=0.56), nor was there any relationship between gender and cough or positivity. Conclusions. The mannitol test is a useful test to detect hyperreactivity. The most frequent adverse effect is cough

Pneumococcal vaccines have costs and the complications in the unvaccinated have higher

Objective: To analyze the economic impact of vaccination of the 65-year-old cohort with the 13-valent conjugated pneumococcal vaccine (VNC13) in the Autonomous Community of Castilla-La Mancha. Methods: A dynamic transmission model based on differential equations was adapted to analyze the burden of pneumococcal disease (ND) in the 65+ year old population over 5 years, with 59% being vaccinated annually. An efficacy of VNC13 of 52.5% (CAPITA study), coverage of vaccine serotypes of 60.1% (CAPA study) and incidence of EN in the Community of 258.5 / 100,000 cases year (CMBD 2011-2015) was applied. The perspective was that of the SESCAM; costs of hospitalized EN cases according to the CBCA's CMBD (hospitalized pneumonia, € 4,675, invasive pneumonia, € 4,792, meningitis, € 11,9342, primary bacteremia, € 4,792) and cost of extra-hospital pneumonia of € 358. Results: Vaccination with VNC13 would reduce the incidence of EN by 75%, up to 324.7 cases / 100,000 accumulated in 5 years. As a c n sequence, it is expected to avoid 1,219 cases of EN; 715 hospitalized pneumonias, 437 extra-hospital pneumonias and 67 cases of invasive disease. The expected cost of vaccination in 5 years of 2.3 million euros would be fully compensated by avoiding 3.9 million euros of medical costs of illness, with a cumulative net saving of 1.4 million Euros (discount rate of 3 %). The sensitivity analysis with different scenarios was robust. Conclusion: The costs of complications from pneumococcal disease are greater than those of a VNC13 pneumococcal vaccination campaign in 65-year-old adults. Death increases in unvaccinated patients

Factors associated with successful treatment of smoking

Objectives: To assess the success of smoking cessation treatment, according to sex, comorbidities and treatments used. Method: Retrospective, descriptive study of the results obtained after analyzing the sample of all patients who attended the “Specialized Smoking Treatment” Unit in the University Hospital of Albacete from the 1st of January 2008 until the 31st of December 2009 and the subsequent posterior year follow-up. Results: 838 patients sent from Primary Care and Pneumology Service were included. 53.7% were men. The average age of the sample was 46.18 years. The average daily cigarette consumption was over a pack daily with 27.30 cigarettes per day. Most of the patients had comorbidities; among which was psychiatric comorbidity (37.7%), cardiovascular risk factors (CVRFs); among which the most common factor was dyslipidemia followed by hypertension and diabetes, and respiratory comorbidity (COPD, obstructive sleep apnea, asthma and chronic carriers of Domiciliary Oxygen Therapy). The global success in patients who attended the first consultation was (13.8%), while the success in patients who did not abandon the study without starting the treatment was 27.6%). With the variable “Respiratory Diseases / Cardiovascular Diseases” (RD/CVD) it was observed that having a respiratory or a cardiovascular disease does not influence the success of smoking cessation. There are hardly any differences in the success probability according to whether the patient is suffering or not hypertension, diabetes, dyslipidemia, psychiatric disorder, alcoholism or neoplasias. However statistical difference between success and the possibility of being diagnosed or not with SAHS was observed (p <0.028). Nor were found differences regarding the number of previous attempts to quit before starting the treatment and success. Moreover, the success was calculated according to the number of cigarettes smoked per day, but no statistically significant difference was found for a 95% confidence interval. Conclusions: In our study, cardiovascular or psychiatric comorbidities have no influence on quitting smoking success

Factores asociados al éxito de los tratamientos del tabaquismo

Objectives: To assess the success of smoking cessation treatment, according to sex, comorbidities and treatments used. Method: Retrospective, descriptive study of the results obtained after analyzing the sample of all patients who attended the “Specialized Smoking Treatment” Unit in the University Hospital of Albacete from the 1st of January 2008 until the 31st of December 2009 and the subsequent posterior year follow-up. Results: 838 patients sent from Primary Care and Pneumology Service were included. 53.7% were men. The average age of the sample was 46.18 years. The average daily cigarette consumption was over a pack daily with 27.30 cigarettes per day. Most of the patients had comorbidities; among which was psychiatric comorbidity (37.7%), cardiovascular risk factors (CVRFs); among which the most common factor was dyslipidemia followed by hypertension and diabetes, and respiratory comorbidity (COPD, obstructive sleep apnea, asthma and chronic carriers of Domiciliary Oxygen Therapy). The global success in patients who attended the first consultation was (13.8%), while the success in patients who did not abandon the study without starting the treatment was 27.6%). With the variable “Respiratory Diseases / Cardiovascular Diseases” (RD/CVD) it was observed that having a respiratory or a cardiovascular disease does not influence the success of smoking cessation. There are hardly any differences in the success probability according to whether the patient is suffering or not hypertension, diabetes, dyslipidemia, psychiatric disorder, alcoholism or neoplasias. However statistical difference between success and the possibility of being diagnosed or not with SAHS was observed (p <0.028). Nor were found differences regarding the number of previous attempts to quit before starting the treatment and success. Moreover, the success was calculated according to the number of cigarettes smoked per day, but no statistically significant difference was found for a 95% confidence interval. Conclusions: In our study, cardiovascular or psychiatric comorbidities have no influence on quitting smoking success.Objetivos: Evaluar el éxito de tratamiento de la deshabituación tabáquica, según sexo, comorbilidades y tratamientos utilizados.MétodoEstudio retrospectivo, descriptivo, de los resultados obtenidos tras analizar la muestra de todos los pacientes que acudieron a la Unidad de Tratamiento Especializado en Tabaquismo del Complejo Hospitalario Universitario de Albacete desde el 1 de Enero de 2008 hasta el 31 de Diciembre de 2009 y su posterior seguimiento hasta completar un año.De la base de datos se recogieron diversas variables tanto cualitativas (sexo, procedencia o Servicio de remisión, tipo de tabaco consumido, presencia de reacciones alérgicas medicamentosas conocidas, comorbilidades presentes en el paciente, dependencia física, motivación del paciente, tipos de tratamiento utilizados, causas de abandono del tratamiento, abandono sin iniciar tratamiento, tratamiento sin abandonar, fracaso de tratamiento, recaída, éxito de tratamiento) como cuantitativas (edad, edad de inicio al consumo de tabaco, número de cigarrillos/día consumidos, número de intentos previos de abandono, tiempo máximo en días de abstinencia en periodos previos, puntuación del test de Fagerström y del test de Richmond, tensión arterial sistólica y diastólica, valor inicial de cooximetría y días de abstinencia desde inicio del tratamiento). Una vez recogidas se realizó un análisis estadístico descriptivo y predictivo.ResultadosParticipan 838 pacientes, de los que solamente acudieron 559, un 53,7 % eran varones enviados desde Atención Primaria y el Servicio de Neumología.La edad media de la muestra fue de 46,18 años. El consumo medio de cigarrillos supera el paquete diario con 27,30 cigarrillos por día.Los pacientes habían realizado al menos 1,41 intentos previos de abandono y se habían mantenido 228,68 días de abstinencia media.El tipo de tabaco más frecuentemente consumido fue el rubio (77,5 %).La mayoría de los pacientes presentaban comorbilidad, de entre las que destacamos la comorbilidad psiquiátrica (37,7 %) , los factores de riesgo cardiovascular (FRCV), entre los que el más frecuente era la dislipemia, seguido de la HTA y la DM, y la comorbilidad respiratoria (EPOC, SAHS, asma y portadores crónicos de OCD).El 32,7 % de los pacientes no recibió tratamiento, el 34,5 % fue tratado con TSN (chicles, parches o en combinación con vareniclina), el 22,9 % con vareniclina y 9,8 % con bupropión.No se encontraron diferencias estadísticamente significativas en el tratamiento ni en el número de intentos previos según el sexo, ni en padecer ECV, DLP, HTA y DM.Es la parte más importante del estudio, que es la valoración del éxito del tratamiento, tomado como la abstinencia continua durante 1 año, aunque también se comentan las tasas de abstinencia continua a los 3, 6 y 9 meses, tanto del global de la muestra como de los pacientes que no abandonan sin iniciar tratamiento y también estratificados por sexos.El éxito obtenido en el global de los pacientes que fueron a la primera consulta fue del 13,8 %) mientras que el éxito obtenido en los pacientes que no abandonaron sin iniciar tratamiento fue del 27,6 %).Con la variable ER/ECV se observó que tener Enfermedad Respiratoria o catdiovascular no influye para el éxito de la abstinencia.Apenas existen diferencias en la probabilidad de éxito según el paciente tenga o no HTA, DM o DLP, trastorno psiquiátrico, alcoholismo o neoplasias. Sin embargo se observó diferencia estadística entre la posibilidad de estar diagnosticado de SAHS y tener éxito que de no tenerlo (p < 0,028).Tampoco se han encontrado diferencias en cuanto al número de intentos de abandono del tabaco previos al tratamiento y el éxito obtenido.Tras comparar la abstinencia continua en aquellos pacientes que han recibido tratamiento y en los que no, el porcentaje de pacientes con éxito era estadísticamente mayor (18,4 %) al tener tratamiento que cuando no lo recibía (4,4 %). Además, se calculó el éxito según el número de cigarrillos consumidos al día, no se encontró diferencia estadísticamente significativa para un 95 % de confianza.Conclusiones:En nuestro estudio tener comorbilidades cardiovasculares o psiquiátricas no influyen en el éxito para dejar de fumar

Premature menopause and autoimmune primary ovarian insufficiency in two international multi-center cohorts

Objective To investigate markers of premature menopause (<40 years) and specifically the prevalence of autoimmune primary ovarian insufficiency (POI) in European women. Design Postmenopausal women were categorized according to age at menopause and self-reported reason for menopause in a cross-sectional analysis of 6870 women. Methods Variables associated with the timing of menopause and hormone measurements of 17β-estradiol and follicle-stimulating hormone were explored using multivariable logistic regression analysis. Specific immunoprecipitating assays of steroidogenic autoantibodies against 21-hydroxylase (21-OH), side-chain cleavage enzyme (anti-SCC) and 17alpha-hydroxylase (17 OH), as well as NACHT leucine-rich-repeat protein 5 were used to identify women with likely autoimmune POI. Results Premature menopause was identified in 2.8% of women, and these women had higher frequencies of nulliparity (37.4% vs 19.7%), obesity (28.7% vs 21.4%), osteoporosis (17.1% vs 11.6%), hormone replacement therapy (59.1% vs 36.9%) and never smokers (60.1% vs 50.9%) (P < 0.05), compared to women with menopause ≥40 years. Iatrogenic causes were found in 91 (47%) and non-ovarian causes in 27 (14%) women, while 77 (39%) women were classified as POI of unknown cause, resulting in a 1.1% prevalence of idiopathic POI. After adjustments nulliparity was the only variable significantly associated with POI (odds ratio 2.46; 95% CI 1.63–3.42). Based on the presence of autoantibodies against 21 OH and SCC, 4.5% of POI cases were of likely autoimmune origin. Conclusion Idiopathic POI affects 1.1% of all women and almost half of the women with premature menopause. Autoimmunity explains 4.5% of these cases judged by positive steroidogenic autoantibodies

Effectiveness of 23-valent pneumococcal polysaccharide vaccination in preventing community-acquired pneumonia hospitalization and severe outcomes in the elderly in Spain

Pneumococcal pneumonia is a serious cause of morbidity and mortality in the elderly, but investigation of the etiological agent of community-acquired pneumonia (CAP) is not possible in most hospitalized patients. The aim of this study was to estimate the effect of pneumococcal polysaccharide vaccination (PPSV23) in preventing CAP hospitalization and reducing the risk of intensive care unit admission (ICU) and fatal outcomes in hospitalized people aged ≥65 years. We made a multicenter case-control study in 20 Spanish hospitals during 2013-2014 and 2014-2015. We selected patients aged 65 years hospitalized with a diagnosis of pneumonia and controls matched by sex, age and date of hospitalization. Multivariate analysis was performed using conditional logistic regression to estimate vaccine effectiveness and unconditional logistic regression to evaluate the reduction in the risk of severe and fatal outcomes. 1895 cases and 1895 controls were included; 13.7% of cases and 14.4% of controls had received PPSV23 in the last five years. The effectiveness of PPSV23 in preventing CAP hospitalization was 15.2% (95% CI -3.1-30.3). The benefit of PPSV23 in avoiding ICU admission or death was 28.1% (95% CI -14.3-56.9) in all patients, 30.9% (95% CI -32.2-67.4) in immunocompetent patients and 26.9% (95% CI -38.6-64.8) in immunocompromised patients. In conclusion, PPSV23 showed a modest trend to avoidance of hospitalizations due to CAP and to the prevention of death or ICU admission in elderly patients hospitalized with a diagnosis of CAP

Cost of Hospitalizations due to Exacerbation in Patients with Non-Cystic Fibrosis Bronchiectasis.

Knowing the cost of hospitalizations for exacerbation in bronchiectasis patients is essential to perform cost-effectiveness studies of treatments that aim to reduce exacerbations in these patients. To find out the mean cost of hospitalizations due to exacerbations in bronchiectasis patients, and to identify factors associated with higher costs. Prospective, observational, multicenter study in adult bronchiectasis patients hospitalized due to exacerbation. All expenses from the patients' arrival at hospital to their discharge were calculated: diagnostic tests, treatments, transferals, home hospitalization, admission to convalescence centers, and hospitals' structural costs for each patient (each hospital's tariff for emergencies and 70% of the price of a bed for each day in a hospital ward). A total of 222 patients (52.7% men, mean age 71.8 years) admitted to 29 hospitals were included. Adding together all the expenses, the mean cost of the hospitalization was EUR 5,284.7, most of which correspond to the hospital ward (86.9%), and particularly to the hospitals' structural costs. The adjusted multivariate analysis showed that chronic bronchial infection by Pseudomonas aeruginosa, days spent in the hospital, and completing the treatment with home hospitalization were factors independently associated with a higher overall cost of the hospitalization. The mean cost of a hospitalization due to bronchiectasis exacerbation obtained from the individual data of each episode is higher than the cost per process calculated by the health authorities. The most determining factor of a higher cost is chronic bronchial infection due to P. aeruginosa, which leads to a longer hospital stay and the use of home hospitalization