Diagnosis of alpha-1 antitrypsin deficiency : a population-based study

Altres ajuts: This study was funded by unrestricted grants from Grifols, Fundació Catalana de Pneumologia, and the Spanish Society of Pneumology and Thoracic Surgery.Alpha-1 antitrypsin deficiency (AATD) remains an underdiagnosed condition despite initiatives developed to increase awareness. The objective was to describe the current situation of the diagnosis of AATD in primary care (PC) in Catalonia, Spain. We performed a population-based study with data from the Information System for Development in Research in Primary Care, a population database that contains information of 5.8 million inhabitants (80% of the population of Catalonia). We collected the number of alpha-1 antitrypsin (AAT) determinations performed in the PC in two periods (2007-2008 and 2010-2011) and described the characteristics of the individuals tested. A total of 12,409 AAT determinations were performed (5,559 in 2007-2008 and 6,850 in 2010-2011), with 10.7% of them in children. As a possible indication for AAT determination, 28.9% adults and 29.4% children had a previous diagnosis of a disease related to AATD; transaminase levels were above normal in 17.7% of children and 47.1% of adults. In total, 663 (5.3%) individuals had intermediate AATD (50-100 mg/dL), 24 (0.2%) individuals had a severe deficiency (<50 mg/dL), with a prevalence of 0.19 cases of severe deficiency per 100 determinations. Nine (41%) of the adults with severe deficiency had a previous diagnosis of COPD/emphysema, and four (16.7%) were diagnosed with COPD within 6 months. The number of AAT determinations in the PC is low in relation to the prevalence of COPD but increased slightly along the study period. The indication to perform the test is not always clear, and patients detected with deficiency are not always referred to a specialist

Rationale, design and organization of the delayed antibiotic prescription (DAP) trial: a randomized controlled trial of the eficacy and safety of delayed antibiotic prescribing strategies in the non-complicated acute respiratory tract infections in general practice

Background: Respiratory tract infections are an important burden in primary care and it's known that they are usually self-limited and that antibiotics only alter its course slightly. This together with the alarming increase of bacterial resistance due to increased use of antimicrobials calls for a need to consider strategies to reduce their use. One of these strategies is the delayed prescription of antibiotics. Methods: Multicentric, parallel, randomised controlled trial comparing four antibiotic prescribing strategies in acute non-complicated respiratory tract infections. We will include acute pharyngitis, rhinosinusitis, acute bronchitis and acute exacerbation of chronic bronchitis or chronic obstructive pulmonary disease (mild to moderate). The therapeutic strategies compared are: immediate antibiotic treatment, no antibiotic treatment, and two delayed antibiotic prescribing (DAP) strategies with structured advice to use a course of antibiotics in case of worsening of symptoms or not improving (prescription given to patient or prescription left at the reception of the primary care centre 3 days after the first medical visit). Discussion: Delayed antibiotic prescription has been widely used in Anglo-Saxon countries, however, in Southern Europe there has been little research about this topic. The DAP trial wil evaluate two different delayed strategies in Spain for the main respiratory infections in primary care

Spanish COPD Guidelines (GesEPOC) 2021: Updated Pharmacological treatment of stable COPD

The Spanish COPD Guidelines (GesEPOC) were first published in 2012, and since then have undergone a series of updates incorporating new evidence on the diagnosis and treatment of COPD. GesEPOC was drawn up in partnership with scientific societies involved in the treatment of COPD and the Spanish Patients' Forum. Their recommendations are based on an evaluation of the evidence using GRADE methodology, and a narrative description of the evidence in areas in which GRADE cannot be applied. In this article, we summarize the recommendations on the pharmacological treatment of stable COPD based on 9 PICO questions. COPD treatment is a 4-step process: 1) diagnosis, 2) determination of the risk level, 3) initial and subsequent inhaled therapy, and 4) identification and management of treatable traits. For the selection of inhaled therapy, high-risk patients are divided into 3 phenotypes: non-exacerbator, eosinophilic exacerbator, and non-eosinophilic exacerbator. Some treatable traits are general and should be investigated in all patients, such as smoking or inhalation technique, while others affect severe patients in particular, such as chronic hypoxemia and chronic bronchial infection. COPD treatment is based on long-acting bronchodilators with single agents or in combination, depending on the patient's risk level. Eosinophilic exacerbators must receive inhaled corticosteroids, while non-eosinophilic exacerbators require a more detailed evaluation to choose the best therapeutic option. The new GesEPOC also includes recommendations on the withdrawal of inhaled corticosteroids and on indications for alpha-1 antitrypsin treatment. GesEPOC offers a more individualized approach to COPD treatment tailored according to the clinical characteristics of patients and their level of complexity.Peer reviewe

Spanish COPD Guidelines (GesEPOC) 2021 Update Diagnosis and Treatment of COPD Exacerbation Syndrome

[ES] En este artículo se presentan las recomendaciones sobre el diagnóstico y tratamiento del síndrome de agudización de la enfermedad pulmonar obstructiva crónica (EPOC) (SAE) de GesEPOC 2021. Como principales novedades, la guía propone una definición y aproximación sindrómica, una nueva clasificación de gravedad y el reconocimiento de diferentes rasgos tratables (RT), lo que supone un nuevo paso hacia la medicina personalizada. La evaluación de la evidencia se realiza mediante la metodología Grading of Recommendations Assessment, Development and Evaluation (GRADE), con la incorporación de seis nuevas preguntas con enfoque paciente, intervención, comparación y resultados (PICO). El proceso diagnóstico comprende cuatro etapas: 1) establecer el diagnóstico del SAE, 2) valorar la gravedad del episodio, 3) identificar el factor desencadenante y 4) abordar los RT. En este proceso diagnóstico se diferencia una aproximación ambulatoria, en la que se recomienda incluir una batería básica de pruebas y una hospitalaria, más exhaustiva, en la que se contempla el estudio de diferentes biomarcadores y pruebas de imagen. El tratamiento broncodilatador destinado al alivio inmediato de los síntomas se considera esencial para todos los pacientes, mientras que el uso de antibióticos, corticoides sistémicos, oxigenoterapia, ventilación asistida o el tratamiento de las comorbilidades variará en función de la gravedad y de los posibles RT. El empleo de antibióticos estará especialmente indicado ante un cambio en el color del esputo, cuando se requiera asistencia ventilatoria, en los casos que cursen con neumonía y también para aquellos con proteína-C reactiva elevada (≥ 20 mg/L). Los corticoides sistémicos se recomiendan en el SAE que necesita ingreso y se sugieren en el SAE moderado. La eficacia de estos fármacos es mayor en pacientes con recuento de eosinófilos en sangre ≥ 300 células/mm3. La ventilación mecánica no invasiva en fase aguda se establece fundamentalmente para pacientes con SAE que cursen con acidosis respiratoria, a pesar del tratamiento inicial.[EN] This article details the GesEPOC 2021 recommendations on the diagnosis and treatment of COPD exacerbation syndrome (CES). The guidelines propose a definition-based syndromic approach, a new classification of severity, and the recognition of different treatable traits (TT), representing a new step toward personalized medicine. The evidence is evaluated using GRADE methodology, with the incorporation of 6 new PICO questions. The diagnostic process comprises four stages: 1) establish a diagnosis of CES, 2) assess the severity of the episode, 3) identify the trigger, and 4) address TTs. This diagnostic process differentiates an outpatient approach, that recommends the inclusion of a basic battery of tests, from a more comprehensive hospital approach, that includes the study of different biomarkers and imaging tests. Bronchodilator treatment for immediate relief of symptoms is considered essential for all patients, while the use of antibiotics, systemic corticosteroids, oxygen therapy, and assisted ventilation and the treatment of comorbidities will vary depending on severity and possible TTs. The use of antibiotics will be indicated particularly if sputum color changes, when ventilatory assistance is required, in cases involving pneumonia, and in patients with elevated C-reactive protein (≥ 20 mg/L). Systemic corticosteroids are recommended in CES that requires admission and are suggested in moderate CES. These drugs are more effective in patients with blood eosinophil counts ≥ 300 cells/mm3. Acute-phase non-invasive mechanical ventilation is specified primarily for patients with CES who develop respiratory acidosis despite initial treatment.Peer reviewe

Guia de lípids i risc cardiovascular

Colesterol; Risc coronari; HipercolesterolèmiaCholesterol; Coronary risk; HypercholesterolemiaColesterol; Riesgo coronario; HipercolesterolemiaL’objectiu general d’aquesta guia és disposar d’unes recomanacions basades en l’evidència científica sobre el maneig dels lípids segons el risc cardiovascular (RCV). Aquesta guia engloba tot el procés assistencial i inclou els objectius comuns per tal d’augmentar la qualitat assistencial i disminuir la variabilitat assistencial en l’abordatge dels lípids i l’RCV

Procesos clínics integrats: marc genèric per al disseny de rutes assistencials (RA)

Ruta assistencial; Assistència mèdica integrada; ImplementacióRuta asistencial; Asistencia médica integrada; ImplementaciónHealth care route; Integrated medical assistance; ImplementationLes directrius que es deriven del Pla de salut 2011-2015 determinen, com a Projecte estratègic 2.1 del PPAC, el desplegament de l’atenció als deu processos clínics integrats de més impacte pel que fa a malalties cròniques. L’objectiu general d’aquest projecte és millorar l’abordatge clínic dels pacients amb aquestes malalties –dins de l’àmbit territorial– amb el recurs assistencial més adient segons el grau i la fase evolutiva, per tal de reduir-ne la morbiditat i la mortalitat i millorar la seva qualitat de vida i l’autocontrol sobre la seva patologia. Aquest document descriu el marc genèric de referència per al disseny de rutes assistencials. Descriu el concepte, estructura i facilita recomanacions per al disseny i l'èxit de la implantació i indicadors.Las directrices que se derivan del Plan de Salud 2011-2015 determinan, como Proyecto estratégico 2.1 del PPAC, el despliegue de la atención a los diez procesos clínicos integrados de mayor impacto en cuanto a enfermedades crónicas. El objetivo general de este proyecto es mejorar el abordaje clínico de los pacientes con estas enfermedades -dentro del ámbito territorial- con el recurso asistencial más adecuado según el grado y la fase evolutiva, para reducir la morbilidad y la mortalidad y mejorar su calidad de vida y el autocontrol sobre su patología. Este documento describe el marco genérico de referencia para el diseño de rutas asistenciales. Describe el concepto, estructura y facilita recomendaciones para el diseño y el éxito de la implantación e indicadores.The guidelines derived from the 2011-2015 Health Plan determine, as a Strategic Project 2.1 of the PPAC, the development of care in the ten integrated clinical processes that have the greatest impact on chronic illnesses. The overall objective of this project is to improve the clinical approach of patients with these diseases - within the territorial scope - with the most appropriate medical care according to the degree and the evolutionary phase, in order to reduce their morbidity and Mortality and improve your quality of life and self-control over your pathology. This document describes the generic reference framework for the design of health care routes. Describes the concept, structure and facilitates recommendations for the design and success of the implementation and also indicators

Recomanacions per a la realització d’espirometries a l’atenció primària en l’entorn COVID-19 [fullet]

Coronavirus SARS-CoV-2; COVID-19; 2019-CoV; Espirometries; Atenció primàriaCoronavirus SARS-CoV-2; COVID-19; 2019-CoV; Espirometrías, Atención primariaCoronavirus SARS-CoV-2; COVID-19; 2019-CoV; Spirometry; Primary careEn aquest fullet s'exposen recomanacions i altres indicacions i contraindicacions sobre la realització d'espirometries a l'atenció primària, tenint el compte el context de la pandèmia per COVID-19

Recursos asistenciales en atención primaria para manejo del asma: proyecto Asmabarómetro

Objetivo: Describir la situación actual con respecto a la dotación de recursos básicos para el manejo del asma en los centros de atención primaria (AP). Disen ̃o: Estudio transversal, encuesta cuantitativa ad hoc. Emplazamiento y participantes: trescientos ochenta médicos de AP en Espan ̃a. Intervenciones y mediciones principales: Análisis de las percepciones de manejo y uso de recur- sos materiales, humanos y organizativos básicos de los que deberían estar dotados los centros de AP para garantizar una correcta asistencia clínica a los pacientes con asma. Resultados: Los encuestados afirman no disponer de profesional médico o de enfermería refe- rente en enfermedad respiratoria en su centro, en un 64% y un 62% respectivamente. El 92% dispone de espirómetro, el 70% de medidor de pico flujo y el 93% de dispositivos inhaladores placebo. Han recibido en el último an ̃o formación teórico-práctica específica promovida por el centro (46%) y por terceros (83%). Se dispone de material educativo para pacientes (78%). No existe protocolo asistencial específico (36%). El 43% no dispone de protocolo de derivación. Se utiliza entrevista clínica para el seguimiento del paciente (90%), pero no cuestionarios validados para medir la adherencia terapéutica (85%), ni checklist para verificar la técnica de inhalación (83%). Se observan diferencias en variables relevantes en el análisis por comunidades autónomas (CC. AA.). Conclusiones: El acceso a determinados recursos en la atención al paciente con asma es limitado en aspectos de coordinación entre niveles, variable según CC. AA. y mejorable en la mayoría de los recursos de salud en asma

Recursos asistenciales en atención primaria para manejo del asma: proyecto Asmabarómetro.

The objective of this study was to describe the current provision of basic resources for asthma management in Primary Health Care (PHC). Cross-sectional study, with an ad hoc quantitative survey. A total of 380 primary healthcare physicians in Spain. Analysis of perceptions of management and use of basic human, organisational and material resources to ensure appropriate care provision to asthma patients. Survey respondents stated that their centre did not have a consultant doctor (64%) or nurse (62%) in respiratory disease. Almost all (92%) of the centres have spirometers, of which 70% have peak flow meters, and 93% have placebo inhalers. In the last year, respondents have received specific theoretical/practical training from the centre (46%), and by third parties (83%). More than three-quarters (78%) of the centres has educational material available for patients. There is no specific healthcare protocol in 36% of the centres, and 43% had no referral protocol. A clinical interview is conducted to monitor the patient (90%), but there are no validated questionnaires to measure therapeutic adherence (85%), or a checklist to check inhalation technique (83%). Differences are observed in the relevant variables in the analysis of each Spanish Autonomous Community. Access to certain resources in the care of patients with asthma is limited in aspects of coordination between levels, varied according to Spanish Autonomous Community, and improved in most health resources in Asthma