Asma bronquial i medi ambient

L'asma bronquial és una malaltia que es caracteritza per la presentació d'episodis d'obstrucció bronquial secundaris a una hiperreactivitat de les vies aèries, els quals desapareixen de forma espontània o bé per l'acció del tractament broncodilatador. El medi ambient, i de forma més específica les característiques de l'aire que respirem, incideix en el desenvolupament de crisis d'agudització en la majoria de malalts asmàtics. No hi ha dubte dels efectes nocius dels increments de pol·lució atmosfèrica sobre la mortalitat i la morbilitat dels individus amb patologia crònica de tipus càrdio-respiratori. En aquest sentit, són nombrosos els estudis que demostren que les condicions meteorològiques i els nivells de contaminants tenen un paper en el nombre i la gravetat de les crisis d'agudització d'aquests malalts. ..

¿Cómo garantizar el suministro de alimentos durante las pandemias? Repensar los sistemas alimentarios locales desde el comportamiento de los actores estratégicos peri-urbanos: El caso de estudio de la Región Metropolitana de Barcelona

The Covid-19 pandemic has acted as a warning for the world’s current food system, especially in urban contexts with global food dependence. This article aims to analyse the food system behaviour of the Barcelona Metropolitan Region (in the northeast of Spain) during the first stage of the pandemic by deepening the behaviour of different peri-urban agricultural areas in which local food supply is promoted. Semi-structured interviews to 11 entities and institutions located in the peri-urban area of the BMR based on its productive and management profile have been carried out from March to May 2020. The results obtained highlight the socio-economic, environmental, and health perspective of food supply during the pandemic. Main results show 1) shortcomings in the operation and logistics of the metropolitan food system; 2) the complicity between the local producer and the urban consumer through new sales and distribution initiatives, 3) the role of peri-urban agricultural areas for ensuring food supply and land preservation, and 4) the need to initiate cooperation and mutual aid activities between the different agents involved in the food system. Furthermore, agents underlined the need for rethinking the agroeconomic model to strengthening the producer-consumer nexus and promoting local food policy based on food sustainability, sovereignty, and governance.La pandemia del Covid-19 ha supuesto una advertencia para el sistema alimentario actual a nivel mundial, especialmente en contextos urbanos con dependencia alimentaria global. Este artículo tiene como objetivo analizar el comportamiento del sistema alimentario de la Región Metropolitana de Barcelona (en el noreste de España) durante la primera etapa de la pandemia, profundizando en el comportamiento de diferentes áreas agrícolas periurbanas en las que se promueve el suministro local de alimentos. Entre marzo y mayo de 2020 se realizaron entrevistas semiestructuradas a 11 entidades e instituciones ubicadas en el área peri-urbana de la BMR en base a su perfil productivo y de gestión. Los resultados obtenidos destacan la perspectiva socioeconómica, ambiental y de salud del suministro de alimentos durante la pandemia. Los principales resultados muestran 1) deficiencias en la operación y logística del sistema alimentario metropolitano; 2) la complicidad entre el productor local y el consumidor urbano a través de nuevas iniciativas de venta y distribución, 3) el papel de las áreas agrícolas periurbanas para asegurar el suministro de alimentos y la preservación de la tierra, y 4) la necesidad de iniciar actividades de cooperación y ayuda mutua entre los diferentes agentes implicados en el sistema alimentario. Así mismo, los agentes subrayaron la necesidad de repensar el modelo agroeconómico para fortalecer el nexo productor-consumidor y promover con ello la política alimentaria local basada en la sostenibilidad, la soberanía y la gobernanza alimentarias

Clinical decision support system to enhance quality control of spirometry using information and communication technologies

BACKGROUND: We recently demonstrated that quality of spirometry in primary care could markedly improve with remote offline support from specialized professionals. It is hypothesized that implementation of automatic online assessment of quality of spirometry using information and communication technologies may significantly enhance the potential for extensive deployment of a high quality spirometry program in integrated care settings. OBJECTIVE: The objective of the study was to elaborate and validate a Clinical Decision Support System (CDSS) for automatic online quality assessment of spirometry. METHODS: The CDSS was done through a three step process including: (1) identification of optimal sampling frequency; (2) iterations to build-up an initial version using the 24 standard spirometry curves recommended by the American Thoracic Society; and (3) iterations to refine the CDSS using 270 curves from 90 patients. In each of these steps the results were checked against one expert. Finally, 778 spirometry curves from 291 patients were analyzed for validation purposes. RESULTS: The CDSS generated appropriate online classification and certification in 685/778 (88.1%) of spirometry testing, with 96% sensitivity and 95% specificity. CONCLUSIONS: Consequently, only 93/778 (11.9%) of spirometry testing required offline remote classification by an expert, indicating a potential positive role of the CDSS in the deployment of a high quality spirometry program in an integrated care setting

Multimorbidity as a predictor of health service utilization in primary care: a registry-based study of the Catalan population

Background: Multimorbidity is highly relevant for both service commissioning and clinical decision-making. Optimization of variables assessing multimorbidity in order to enhance chronic care management is an unmet need. To this end, we have explored the contribution of multimorbidity to predict use of healthcare resources at community level by comparing the predictive power of four different multimorbidity measures. Methods: A population health study including all citizens ≥18 years (n = 6,102,595) living in Catalonia (ES) on 31 December 2014 was done using registry data. Primary care service utilization during 2015 was evaluated through four outcome variables: A) Frequent attendants, B) Home care users, C) Social worker users, and, D) Polypharmacy. Prediction of the four outcome variables (A to D) was carried out with and without multimorbidity assessment. We compared the contributions to model fitting of the following multimorbidity measures: i) Charlson index; ii) Number of chronic diseases; iii) Clinical Risk Groups (CRG); and iv) Adjusted Morbidity Groups (GMA). Results: The discrimination of the models (AUC) increased by including multimorbidity as covariate into the models, namely: A) Frequent attendants (0.771 vs 0.853), B) Home care users (0.862 vs 0.890), C) Social worker users (0.809 vs 0.872), and, D) Polypharmacy (0.835 vs 0.912). GMA showed the highest predictive power for all outcomes except for polypharmacy where it was slightly below than CRG. Conclusions: We confirmed that multimorbidity assessment enhanced prediction of use of healthcare resources at community level. The Catalan population-based risk assessment tool based on GMA presented the best combination of predictive power and applicability

Clinical Decision Support Systems (CDSS) for preventive management of COPD patients

Background The use of information and communication technologies to manage chronic diseases allows the application of integrated care pathways, and the optimization and standardization of care processes. Decision support tools can assist in the adherence to best-practice medicine in critical decision points during the execution of a care pathway. Objectives The objectives are to design, develop, and assess a clinical decision support system (CDSS) offering a suite of services for the early detection and assessment of chronic obstructive pulmonary disease (COPD), which can be easily integrated into a healthcare providers' work-flow. Methods The software architecture model for the CDSS, interoperable clinical-knowledge representation, and inference engine were designed and implemented to form a base CDSS framework. The CDSS functionalities were iteratively developed through requirement-adjustment/development/validation cycles using enterprise-grade software-engineering methodologies and technologies. Within each cycle, clinical-knowledge acquisition was performed by a health-informatics engineer and a clinical-expert team. Results A suite of decision-support web services for (i) COPD early detection and diagnosis, (ii) spirometry quality-control support, (iii) patient stratification, was deployed in a secured environment on-line. The CDSS diagnostic performance was assessed using a validation set of 323 cases with 90% specificity, and 96% sensitivity. Web services were integrated in existing health information system platforms. Conclusions Specialized decision support can be offered as a complementary service to existing policies of integrated care for chronic-disease management. The CDSS was able to issue recommendations that have a high degree of accuracy to support COPD case-finding. Integration into healthcare providers' work-flow can be achieved seamlessly through the use of a modular design and service-oriented architecture that connect to existing health information systems

Synergy-COPD: a systems approach for understanding and managing chronic diseases.

Chronic diseases (CD) are generating a dramatic societal burden worldwide that is expected to persist over the next decades. The challenges posed by the epidemics of CD have triggered a novel health paradigm with major consequences on the traditional concept of disease and with a profound impact on key aspects of healthcare systems. We hypothesized that the development of a systems approach to understand CD together with the generation of an ecosystem to transfer the acquired knowledge into the novel healthcare scenario may contribute to a cost-effective enhancement of health outcomes. To this end, we designed the Synergy-COPD project wherein the heterogeneity of chronic obstructive pulmonary disease (COPD) was addressed as a use case representative of CD. The current manuscript describes main features of the project design and the strategies put in place for its development, as well the expected outcomes during the project life-span. Moreover, the manuscript serves as introductory and unifying chapter of the different papers associated to the Supplement describing the characteristics, tools and the objectives of Synergy-COP

Fatal airway disease in an adult with chronic graft-versus-host disease

Chronic graft-versus-host disease (GVHD) is a syndrome of disordered immunity in which a variety of opportunistic respiratory infections have been documented. Restrictive pulmonary disease without advanced fibrotic changes has been also known to occur; obstructive lower airways disease related to chronic GVHD has apparently not been referred to. We report a patient with chronic GVHD and irreversible airways obstruction who died in respiratory failure caused by generalised bronchiolar damage progressing over a few months. Lung function studies showed severe airflow limitation and a leftward shift in the pressure-volume curve indicating a loss of elastic recoil pressure. Postmortem pulmonary lesions were consistent with a necrotising obliterative bron chiolitis. Our purpose is to describe this unusual complication not previously reported in chronic GVHD and discuss the pulmonary mechanics

Risk and temporal order of disease diagnosis of comorbidities in patients with COPD: a population health perspective

Introduction: Comorbidities in patients with chronic obstructive pulmonary disease (COPD) generate a major burden on ealthcare. Identification of costeffective strategies aiming at preventing and enhancing management of comorbid conditions in patients with COPD requires deeper knowledge on epidemiological patterns and on shared biological pathways xplaining cooccurrence of diseases. Methods: The study assesses the co-occurrence of several chronic conditions in patients with COPD using two different datasets: Catalan Healthcare Surveillance System (CHSS) (ES, 1.4 million registries) and Medicare (USA, 13 million registries). Temporal order of disease diagnosis was analysed in the CHSS dataset. Results The results demonstrate higher prevalence of most of the diseases, as comorbid conditions, in elderly (>65) patients with COPD compared with non-COPD subjects, an effect observed in both CHSS and Medicare datasets. Analysis of temporal order of disease diagnosis showed that comorbid conditions in elderly patients with COPD tend to appear after the diagnosis of the obstructive disease, rather than before it. Conclusion: The results provide a population health perspective of the comorbidity challenge in patients with COPD, indicating the increased risk of developing comorbid conditions in these patients. The research reinforces the need for novel approaches in the prevention and management of comorbidities in patients with COPD to effectively reduce the overall burden of the disease on these patients

Predictive medicine: outcomes, challenges and opportunities in the Synergy-COPD project

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is a major challenge for healthcare. Heterogeneities in clinical manifestations and in disease progression are relevant traits in COPD with impact on patient management and prognosis. It is hypothesized that COPD heterogeneity results from the interplay of mechanisms governing three conceptually different phenomena: 1) pulmonary disease, 2) systemic effects of COPD and 3) co-morbidity clustering. OBJECTIVES: To assess the potential of systems medicine to better understand non-pulmonary determinants of COPD heterogeneity. To transfer acquired knowledge to healthcare enhancing subject-specific health risk assessment and stratification to improve management of chronic patients. METHOD: Underlying mechanisms of skeletal muscle dysfunction and of co-morbidity clustering in COPD patients were explored with strategies combining deterministic modelling and network medicine analyses using the Biobridge dataset. An independent data driven analysis of co-morbidity clustering examining associated genes and pathways was done (ICD9-CM data from Medicare, 13 million people). A targeted network analysis using the two studies: skeletal muscle dysfunction and co-morbidity clustering explored shared pathways between them. RESULTS: (1) Evidence of abnormal regulation of pivotal skeletal muscle biological pathways and increased risk for co-morbidity clustering was observed in COPD; (2) shared abnormal pathway regulation between skeletal muscle dysfunction and co-morbidity clustering; and, (3) technological achievements of the projects were: (i) COPD Knowledge Base; (ii) novel modelling approaches; (iii) Simulation Environment; and, (iv) three layers of Clinical Decision Support Systems. CONCLUSIONS: The project demonstrated the high potential of a systems medicine approach to address COPD heterogeneity. Limiting factors for the project development were identified. They were relevant to shape strategies fostering 4P Medicine for chronic patients. The concept of Digital Health Framework and the proposed roadmap for its deployment constituted relevant project outcomes

Pulmonary hemodynamic profile in chronic obstructive pulmonary disease

Introduction: Few data are available in regards to the prevalence of pulmonary hypertension (PH) in the broad spectrum of COPD. This study was aimed at assessing the prevalence of PH in a cohort of COPD patients across the severity of airflow limitation, and reporting the hemodynamic characteristics at rest and during exercise. Methods: We performed a retrospective analysis on COPD patients who underwent right-heart catheterization in our center with measurements obtained at rest (n=139) and during exercise (n=85). PH was defined as mean pulmonary artery pressure (mPAP) >/25 mmHg and pulmonary capillary wedge pressure 3. Results: PH was present in 25 patients (18%). According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification, PH prevalence in GOLD 2 was 7% (3 patients); 25% (14 patients) in GOLD 3; and 22% (8 patients) in GOLD 4. Severe PH (mPAP >/35 mmHg) was identified in four patients (2.8%). Arterial partial oxygen pressure was the outcome most strongly associated with PH (r=-0.29, P<0.001). EIPH was observed in 60 patients (71%)and had a similar prevalence in both GOLD 2 and 3, and was present in all GOLD 4 patients. Patients with PH had lower cardiac index during exercise than patients without PH (5.0±1.2 versus 6.7±1.4 L/min/m2 ,respectively; P=0.001). Conclusion: PH has a similar prevalence in COPD patients with severe and very-severe airflow limitation, being associated with the presence of arterial hypoxemia. In contrast, EIPH is highly prevalent, even in moderate COPD, and might contribute to limiting exercise tolerance