Enfermedad pulmonar obstructiva crónica. Actualización 2014

La enfermedad pulmonar obstructiva crónica (EPOC) es un problema socio-sanitario de primera magnitud por su elevada prevalencia (10% en nuestro País), incidencia creciente (la Organización Mundial de la Salud estima que será la tercera causa de muerte en el mundo en 2020) y elevados costes socio-económicos asociados. En los últimos años se han producido avances notables en el conocimiento y tratamiento de la enfermedad que es ya considerada una enfermedad “prevenible y tratable”. El texto que sigue resume los principales aspectos diagnósticos y terapéuticos de la EPOC a partir de la última versión (2014) del documento de la estrategia GOLD (Global Strategy for the Diagnosis, Management and Prevention of chronic obstructive pulmonary disease), el documento de referencia mundial en este ámbito. Hace énfasis especial en la nueva forma de determinar la gravedad de la enfermedad, basada en una valoración multi-dimensional de la EPOC que tiene en cuenta no sólo la severidad de la limitación al flujo aéreo (como se había hecho tradicionalmente hasta ahora), sino que añade dos dimensiones de gran valor clínico y pronóstico (el nivel de síntomas del paciente y la historia previa de agudizaciones de la enfermedad). Con estas tres dimensiones, los pacientes con EPOC se clasifican actualmente en uno de cuatro posibles grupos (A, B, C o D) y el tratamiento farmacológico recomendado se ajusta a esta clasificación.Chronic obstructive pulmonary disease (COPD) is a major public health problem because of its high prevalence (10% in Spain), raising incidence (the World Health Organization predicts that it will be the third cause of death in the world by the year 2020) and high associated socio-economic cost. Over the last few years, there have been very significant advances in the understanding and treatment of COPD, so it is now considered a “preventable and treatable disease”. The following text summarizes the main diagnostic and therapeutic aspects of this disease according to the last version (2014) of the GOLD (Global Strategy for the Diagnosis, Management and Prevention of chronic obstructive pulmonary disease) strategy document, which is the global reference for this disease. In particular, it is of note that the current recommendation for the assessment of COPD is multidimensional. It includes the assessment of the level of current symptoms, as well as the traditional assessment of airflow limitation severity and the previous history of exacerbations that can help in predicting the risk of future events. According to these three dimensions, four different groups of patients can be identified (A, B, C, and D), and specific pharmacological treatment is recommended for each of them.

Effectiveness of community-based integrated care in frail COPD patients: a randomised controlled trial

Background: Chronic obstructive pulmonary disease (COPD) generates a high burden on health care, and hospital admissions represent a substantial proportion of the overall costs of the disease. Integrated care (IC) has shown efficacy to reduce hospitalisations in COPD patients at a pilot level. Deployment strategies for IC services require assessment of effectiveness at the health care system level. Aims: The aim of this study was to explore the effectiveness of a community-based IC service in preventing hospitalisations and emergency department (ED) visits in stable frail COPD patients. Methods: From April to December 2005, 155 frail community-dwelling COPD patients were randomly allocated either to IC (n=76, age 73 (8) years, forced expiratory volume during the first second, FEV1 41(19) % predicted) or usual care (n=84, age 75(9) years, FEV1 44 (20) % predicted) and followed up for 12 months. The IC intervention consisted of the following: (a) patient’s empowerment for self-management; (b) an individualised care plan; (c) access to a call centre; and (d) coordination between the levels of care. Thereafter, hospital admissions, ED visits and mortality were monitored for 6 years. Results: IC enhanced self-management (P=0.02), reduced anxiety–depression (P=0.001) and improved health-related quality of life (P=0.02). IC reduced both ED visits (P=0.02) and mortality (P=0.03) but not hospital admission. No differences between the two groups were seen after 6 years. Conclusion: The intervention improved clinical outcomes including survival and decreased the ED visits, but it did not reduce hospital admissions. The study facilitated the identification of two key requirements for adoption of IC services in the community: appropriate risk stratification of patients, and preparation of the community-based work force

ARTICLE Effectiveness of community-based integrated care in frail COPD patients: a randomised controlled trial

BACKGROUND: Chronic obstructive pulmonary disease (COPD) generates a high burden on health care, and hospital admissions represent a substantial proportion of the overall costs of the disease. Integrated care (IC) has shown efficacy to reduce hospitalisations in COPD patients at a pilot level. Deployment strategies for IC services require assessment of effectiveness at the health care system level. AIMS: The aim of this study was to explore the effectiveness of a community-based IC service in preventing hospitalisations and emergency department (ED) visits in stable frail COPD patients. METHODS: From April to December 2005, 155 frail community-dwelling COPD patients were randomly allocated either to IC (n = 76, age 73 (8) years, forced expiratory volume during the first second, FEV 1 41(19) % predicted) or usual care (n = 84, age 75(9) years, FEV 1 44 (20) % predicted) and followed up for 12 months. The IC intervention consisted of the following: (a) patient's empowerment for self-management; (b) an individualised care plan; (c) access to a call centre; and (d) coordination between the levels of care. Thereafter, hospital admissions, ED visits and mortality were monitored for 6 years. RESULTS: IC enhanced self-management (P = 0.02), reduced anxiety-depression (P = 0.001) and improved health-related quality of life (P = 0.02). IC reduced both ED visits (P = 0.02) and mortality (P = 0.03) but not hospital admission. No differences between the two groups were seen after 6 years. CONCLUSION: The intervention improved clinical outcomes including survival and decreased the ED visits, but it did not reduce hospital admissions. The study facilitated the identification of two key requirements for adoption of IC services in the community: appropriate risk stratification of patients, and preparation of the community-based work force

Некоторые подходы к совершенствованию регионально-институциональной основы курортно-гостиничных услуг в Автономной республике Крым

Рассмотрены подходы (институциональный, региональный, проблемно-ориентированный и маркетинговый) к разработке регионально-институциональной модели курортно-гостиничного хозяйства как одной из важнейших составляющих институциональной модели курортно-рекреационного комплекса Автономной Республики Крым.Розглядаються підходи (інституційний, регіональний, проблемно-орієнтований і маркетинговий) до розробки регіонально-інституційної моделі курортно-готельного господарства як однієї з найважливіших складових інституційної моделі курортно-рекреаційного комплексу Автономної Республіки Крим

Identification of genetic variants associated with Huntington's disease progression: a genome-wide association study

Background Huntington's disease is caused by a CAG repeat expansion in the huntingtin gene, HTT. Age at onset has been used as a quantitative phenotype in genetic analysis looking for Huntington's disease modifiers, but is hard to define and not always available. Therefore, we aimed to generate a novel measure of disease progression and to identify genetic markers associated with this progression measure. Methods We generated a progression score on the basis of principal component analysis of prospectively acquired longitudinal changes in motor, cognitive, and imaging measures in the 218 indivduals in the TRACK-HD cohort of Huntington's disease gene mutation carriers (data collected 2008–11). We generated a parallel progression score using data from 1773 previously genotyped participants from the European Huntington's Disease Network REGISTRY study of Huntington's disease mutation carriers (data collected 2003–13). We did a genome-wide association analyses in terms of progression for 216 TRACK-HD participants and 1773 REGISTRY participants, then a meta-analysis of these results was undertaken. Findings Longitudinal motor, cognitive, and imaging scores were correlated with each other in TRACK-HD participants, justifying use of a single, cross-domain measure of disease progression in both studies. The TRACK-HD and REGISTRY progression measures were correlated with each other (r=0·674), and with age at onset (TRACK-HD, r=0·315; REGISTRY, r=0·234). The meta-analysis of progression in TRACK-HD and REGISTRY gave a genome-wide significant signal (p=1·12 × 10−10) on chromosome 5 spanning three genes: MSH3, DHFR, and MTRNR2L2. The genes in this locus were associated with progression in TRACK-HD (MSH3 p=2·94 × 10−8 DHFR p=8·37 × 10−7 MTRNR2L2 p=2·15 × 10−9) and to a lesser extent in REGISTRY (MSH3 p=9·36 × 10−4 DHFR p=8·45 × 10−4 MTRNR2L2 p=1·20 × 10−3). The lead single nucleotide polymorphism (SNP) in TRACK-HD (rs557874766) was genome-wide significant in the meta-analysis (p=1·58 × 10−8), and encodes an aminoacid change (Pro67Ala) in MSH3. In TRACK-HD, each copy of the minor allele at this SNP was associated with a 0·4 units per year (95% CI 0·16–0·66) reduction in the rate of change of the Unified Huntington's Disease Rating Scale (UHDRS) Total Motor Score, and a reduction of 0·12 units per year (95% CI 0·06–0·18) in the rate of change of UHDRS Total Functional Capacity score. These associations remained significant after adjusting for age of onset. Interpretation The multidomain progression measure in TRACK-HD was associated with a functional variant that was genome-wide significant in our meta-analysis. The association in only 216 participants implies that the progression measure is a sensitive reflection of disease burden, that the effect size at this locus is large, or both. Knockout of Msh3 reduces somatic expansion in Huntington's disease mouse models, suggesting this mechanism as an area for future therapeutic investigation

Enfermedad pulmonar obstructiva crónica. Actualización 2014

La enfermedad pulmonar obstructiva crónica (EPOC) es un problema socio-sanitario de primera magnitud por su elevada prevalencia (10% en nuestro País), incidencia creciente (la Organización Mundial de la Salud estima que será la tercera causa de muerte en el mundo en 2020) y elevados costes socio-económicos asociados. En los últimos años se han producido avances notables en el conocimiento y tratamiento de la enfermedad que es ya considerada una enfermedad "prevenible y tratable". El texto que sigue resume los principales aspectos diagnósticos y terapéuticos de la EPOC a partir de la última versión (2014) del documento de la estrategia GOLD (Global Strategy for the Diagnosis, Management and Prevention of chronic obstructive pulmonary disease), el documento de referencia mundial en este ámbito. Hace énfasis especial en la nueva forma de determinar la gravedad de la enfermedad, basada en una valoración multi-dimensional de la EPOC que tiene en cuenta no sólo la severidad de la limitación al flujo aéreo (como se había hecho tradicionalmente hasta ahora), sino que añade dos dimensiones de gran valor clínico y pronóstico (el nivel de síntomas del paciente y la historia previa de agudizaciones de la enfermedad). Con estas tres dimensiones, los pacientes con EPOC se clasifican actualmente en uno de cuatro posibles grupos (A, B, C o D) y el tratamiento farmacológico recomendado se ajusta a esta clasificación