Quality indicators in the rational management of severe asthma: A Spanish multidisciplinary consensus

AIM

Severe asthma is a complex, heterogeneous condition that can be difficult to control despite currently available treatments. Multidisciplinary severe asthma units (SAU) improve control in these patients and are cost-effective in our setting; however, their implementation and development can represent an organizational challenge. The aim of this study was to validate a set of quality care indicators in severe asthma for SAU in Spain.

METHODS

The Carabela initiative, sponsored by SEPAR, SEAIC, SECA and SEDISA and implemented by leading specialists, analyzed the care processes followed in 6 pilot centers in Spain to describe the ideal care pathway for severe asthma. This analysis, together with clinical guidelines and SEPAR and SEAIC accreditation criteria for asthma units, were used to draw up a set of 11 quality of care indicators, which were validated by a panel of 60 experts (pulmonologists, allergologists, and health-policy decision-makers) using a modified Delphi method.

RESULTS

All 11 indicators achieved a high level of consensus after just one Delphi round.

CONCLUSIONS

Experts in severe asthma agree on a series of minimum requirements for the future optimization, standardization, and excellence of current SAUs in Spain. This proposal is well grounded on evidence and professional experience, but the validity of these consensus indicators must be evaluated in clinical practice.

Endothelin Receptor Antagonists in Kidney Disease

Endothelin (ET) is found to be increased in kidney disease secondary to hyperglycaemia, hypertension, acidosis, and the presence of insulin or proinflammatory cytokines. In this context, ET, via the endothelin receptor type A (ET_A) activation, causes sustained vasoconstriction of the afferent arterioles that produces deleterious effects such as hyperfiltration, podocyte damage, proteinuria and, eventually, GFR decline. Therefore, endothelin receptor antagonists (ERAs) have been proposed as a therapeutic strategy to reduce proteinuria and slow the progression of kidney disease. Preclinical and clinical evidence has revealed that the administration of ERAs reduces kidney fibrosis, inflammation and proteinuria. Currently, the efficacy of many ERAs to treat kidney disease is being tested in randomized controlled trials; however, some of these, such as avosentan and atrasentan, were not commercialized due to the adverse events related to their use. Therefore, to take advantage of the protective properties of the ERAs, the use of ET_A receptor-specific antagonists and/or combining them with sodium-glucose cotransporter 2 inhibitors (SGLT2i) has been proposed to prevent oedemas, the main ERAs-related deleterious effect. The use of a dual angiotensin-II type 1/endothelin receptor blocker (sparsentan) is also being evaluated to treat kidney disease. Here, we reviewed the main ERAs developed and the preclinical and clinical evidence of their kidney-protective effects. Additionally, we provided an overview of new strategies that have been proposed to integrate ERAs in kidney disease treatment.

Trend in the use of topical ocular anti-infectives in a region of Spain between 2015 and 2019: a population-based registry study

OBJECTIVE

This study presents the use and trends of use of topical ocular anti-infectives into a European population in the current decade (2015 to 2019) with an analysis of concomitant use with other ocular drugs, considering distribution by age and gender.

METHODS

A population-based registry study was carried out to assess the ocular anti-infectives use from 2015 to 2019. All dispensations of these medicines at pharmacies in the largest region of Spain, Castile and León, was accessed. The number of packages dispensed, the percentage of the population under treatment, diagnosis, and the concomitant use with other ocular medicines was observed. For all analyses, the population distribution by age and gender was considered.

RESULTS

An average of 198,000 packages of topical ocular anti-infectives were dispensed annually to 5.38% of the population, and more commonly for women than for men (5.83% vs. 4.91%). Children and the elderly used more these medicines. Tobramycin, alone or in combination, accounted for more than 68% of the total consumption (135,000 packages per year), and was the most widely used anti-infective in almost all identified diagnoses. Conjunctivitis (50.12%), and stye (11.51%) were the most frequent diagnoses. The consumption of ocular anti-infectives increased by 8.23% from 2015 to 2019, and more among men than in women.

CONCLUSIONS

Our findings show that the most used topical ocular anti-infective was tobramycin, in accordance with the clinical practice guidelines recommendations. However, ocular infections are sometimes treated empirically, especially conjunctivitis.

The Synthetic Cannabinoid URB447 Reduces Brain Injury and the Associated White Matter Demyelination after Hypoxia-Ischemia in Neonatal Rats

The number of functions controlled by the endocannabinoid system in health and disease continues growing over the years. In the brain, these include the modulation of harmful events such as glutamate excitotoxicity, oxidative stress, and inflammation, mainly regulated by activation/blockade of CB₁/CB₂ cannabinoid receptors. In the present work, we evaluated the capacity of the CB₁ antagonist/CB₂ agonist synthetic cannabinoid URB447 on reducing neurodegeneration after brain injury. By using a model of hypoxia-ischemia (HI) in neonatal rats, we found that URB447 strongly reduced brain injury when administered before HI. A comparable effect was observed with the CB₁ antagonist SR141716A, whereas the CB₁ agonist WIN-55,212-2 reduced the effect of URB447. When administered 3 h after HI, which is considered a clinically feasible therapeutic window to treat perinatal brain injury in humans, URB447 reduced neurodegeneration and white matter damage. Markers of astrogliosis and microglial activation also appeared reduced. These results confirm the important role played by the endocannabinoid system in the neurodegenerative process and strongly encourage further research into the mechanisms of URB447-induced neuroprotection.

Evaluation of Gene Variants in TGFB1, SERPINF1 and MEPE in a Spanish Family Affected by Otosclerosis and Tinnitus

Otosclerosis (OTSC) is a common type of deafness affecting up to 0.4 % of Caucasians. Its familial form is inherited in an autosomal dominant fashion, although to this date, no definitive cause for OTSC has been found. In the development of OTSC, three recent genetic association studies have suggested the participation of particular point mutations and small indels in the TGFB1, SERPINF1, and MEPE genes. Consequently, replicative studies are needed to confirm the role of the proposed mutations in OTSC patients. The goal of this study was to test the presence of the candidate variants described in the genes TGFB1, SERPINF1, and MEPE in a new case of familial OTSC with seven affected individuals. DNA was extracted from saliva samples of a Spanish family with several members affected by OTSC. PCR amplified target regions of some candidate genes, and the products were purified, Sanger-sequenced, and analyzed in silico. The family subject of the study did not carry the candidate variants for OTSC described in the genes TGFB1, SERPINF1, and MEPE, although it cannot be ruled out the involvement of other mutations in genes related to their same signaling pathways. This result highlights the importance of performing replicative studies for complex diseases, such as OTCS, in families of diverse origins. Additionally, a significant association of subjective tinnitus with OTSC has been found in this family, although the link between the two pathologies should be studied further.

Optimisation of imaging protocols in interventional cardiology: impact on patient doses

The purpose of this work is to evaluate the impact of the imaging protocol as part of the optimisation of patient doses in interventional cardiology. This paper reports the results of an initial study to refine the existing fluoroscopy and cine settings, evaluates a new imaging protocol by measuring the image quality and phantom entrance air kerma values, and tests the clinical implementation of the new protocol in terms of the reduction in patient doses and the impact on clinical images. The initial study developed a new fluoroscopy mode using 7.5 frames s^-1 (instead of the previous 15 frames s^-1) with a similar dose/frame and a reduction of approximately 26% in dose/frame for the existing standard cine mode. For the new imaging protocol, the reduction in entrance air kerma was characterised for water depths of 16, 20, and 24 cm and the image quality was evaluated using a Leeds test object. A reduction in dose of around 50% was observed for the low fluoroscopy mode and an 18%-38% reduction was measured for cine. The image quality was unchanged in fluoroscopy mode and did not suffer noticeable alterations in cine mode. In the clinical implementation, cardiologists evaluated the new imaging protocol in clinical practice and cooperated with medical physicists to ensure full optimisation. The image quality criteria evaluated the ability to visualise the standard coronary arteries and small vessels (<2 mm), and the proper visualisation of the heart and diaphragm. A total of 1635 interventional cardiac procedures were assessed. The median kerma-area product exhibited a reduction of 37% for CA and 43% for PTCA examinations, and the quality of the clinical images was considered sufficient for standard clinical practice.

Procalcitonin cannot be used as a biomarker of infection in heart surgery patients with acute kidney injury

PURPOSE

We intended to assess how acute kidney injuy impacts on procalcitonin levels in cardiac surgery patients, with or without infection, and whether procalcitonin might be used as a biomarker of infection in acute kidney injuy.

MATERIAL AND METHODS

A case-control study was designed which included patients that had had cardiac surgery between January 2011 and January 2015. Every patient developing severe sepsis or septic shock (n = 122; 5.5%) was enrolled. In addition, consecutive cardiac surgery patients during 2013 developing systemic inflammatory response syndrome (n = 318) were enrolled. Those recruited 440 patients were divided into 2 groups, according to renal function.

RESULTS

Median procalcitonin levels were significantly higher during the 10 postoperative days in the acute kidney injury patients. Regression analysis showed that postoperatory day, creatinine, white blood cells and infection were significantly (P < .0001) associated to serum procalcitonin level. In patients with creatinine ≥2, median procalcitonin levels were similar in infected and non-infected patients. Only when creatinine was less than 2 mg/L, the median procalcitonin levels were significantly higher in patients with infection, as compared to those with no infection.

CONCLUSIONS

In acute kidney injuy patients, high procalcitonin levels are a marker of acute kidney injuy but will not be able to differentiate infected from non-infected patients.

Reduction of occupational radiation dose in staff at the cardiac catheterisation laboratory by protective material placed on the patient

Reducing occupational radiation dose in cardiac catheterisation laboratories is one of the objectives of the radiation protection system because the procedures performed involve high levels of radiation compared with others in health care. Recommendations on protection methods used are referred to different structural types and personal protection tools. In this work, the effectiveness of a shielding drape above the patient in different geometric shapes for a standard procedure in interventional cardiology was evaluated. Values of personal dose equivalent Hp(10) obtained simultaneously with three active electronic semiconductor dosemeters located at the usual position of staff and at the C-arm have been used to show the usefulness of the shielding drape.

Effects of omalizumab in non-atopic asthma: results from a Spanish multicenter registry

Aim. To evaluate the effectiveness of omalizumab in non-atopic asthma. Methods. Using data from a multicenter registry of severe asthma, we evaluated and compared the clinical outcome of 29 omalizumab-treated severe non-atopic asthmatics with 266 omalizumab-treated severe allergic asthmatics. Effectiveness was assessed by considering severe exacerbations, pulmonary function, the Global Evaluation of Treatment Effectiveness (GETE) scale, and Asthma Control Test (ACT). Results. Omalizumab demonstrated significant improvement in the clinical status of non-atopic asthmatics as measured by GETE, which rose from 1.6 ± 1.1 to 2.8 ± 0.9 [corrected] at 4 months (p = .0215) to 2.9 ± 0.9 at 1 year (p = .0093) and to 3.4 ± 0.6 at 2 years (p = .0078), and by the ACT, which increased from 13.3 ± 5.5 [corrected] to 17.5 ± 5.4 at 4 months (p = .0236) to 17.9 ± 4.8 at 1 year (p = .0136) and to 20.6 ± 3.9 at 2 years (p = .0024). Forced expiratory volume in 1 second (FEV1) improved from 61.0 ± 19.4% to 65.1 ± 17.2 at 4 months to 64.1 ± 24.7 at 1 year and to 67.3 ± 23.0% [corrected] at 2 years, but without significant differences between initial and follow-up measurements (p = .52, .91, and .45, respectively) and exacerbations decreased from 3.1 ± 3.5 to 1.9 ± 2.8 at 1 year (p = .1709) to 1.8 ± 4.4 at 2 years (p = .2344). The results were not significantly different from those obtained in atopic asthmatics. Conclusion. Anti-IgE therapy can be effective in non-atopic severe asthma.