epoc 11 guías y 11 mitos
DESCRIPTION
Conferencia Dr. Josep Morera PratTRANSCRIPT
Oviedo, 11 – 11 -11 , 11:11 h. Dr. Josep MoreraOviedo, 11 – 11 -11 , 11:11 h. Dr. Josep Morera
Memorial Dr. J.M. CosíoMemorial Dr. J.M. Cosío
EPOC: 11 Guías y 11 MitosEPOC: 11 Guías y 11 Mitos
Murray JL, et al. Lancet 1997; 349: 1498–1504
PROFECÍA
Murray JL, et al. Lancet 1997; 349: 1498–1504
PROFECÍA
ÍndiceÍndice
1) Las 11 Guías
2) Los 11 Mitos
3) Conclusiones
2. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease (COPD) and asthma. This official statement of the American Thoracic Society was adopted by the ATS Board of Directors, November 1986. Am Rev Respir Dis. 1987 Jul;136(1):225-44.
3. Siafakas NM, Vermeire P, Pride NB, Paoletti P, Gibson J, Howard P, Yernault JC, Decramer M, Higenbottam T, Postma DS, et al. Optimal assessment and management of chronic obstructive pulmonary disease (COPD). The European Respiratory Society Task Force. Eur Respir J. 1995 Aug;8(8):1398-420.
4. Montemayor T, Alfajeme I, Escudero C, Morera J, Sánchez Agudo L. [Guidelines on the diagnosis and treatment of chronic obstructive lung disease. The SEPAR
Working Group. The Spanish Society of Pneumology and Thoracic Surgery]. Arch Bronconeumol. 1996 Jun-Jul; 32 (6): 285-301.
5. BTS guidelines for the management of chronic obstructive pulmonary disease. The COPD Guidelines Group of the Standards of Care Committee of the BTS. Thorax. 1997 Dec;52 Suppl 5:S1-28.
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1. Terminology, Definitions, and Classification of Chronic Pulmonary Emphysema and Related Conditions: A Report of the Conclusions of a Ciba Guest Symposium Thorax 1959;14:286-299)
6. Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS; GOLD Scientific Committee. Global strategy for the diagnosis, management, and prevention of chronic
obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary. Am J Respir Crit Care Med. 2001 Apr;163(5):1256-76.
7. Barberà JA, Peces-Barba G, Agustí AG, Izquierdo JL, Monsó E, Montemayor T, Viejo JL; Sociedad Española de Neumología y Cirugía Torácica (SEPAR). [Clinical
guidelines for the diagnosis and treatment of chronic obstructive pulmonary disease]. Arch Bronconeumol. 2001 Jun;37(6):297-316.
8. Celli BR, MacNee W; ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J.
2004 Jun;23(6):932-46.
9. Halpin D. NICE guidance for COPD. Thorax. 2004 Mar;59(3):181-2.
10. Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P, Fukuchi Y, Jenkins C, Rodriguez-Roisin R, van Weel C, Zielinski J; Global Initiative for Chronic
Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007 Sep 15;176(6):532-55.
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11. Peces-Barba G, Barberà JA, Agustí A, Casanova C, Casas A, Izquierdo JL, Jardim J, López Varela V, Monsó E, Montemayor T, Viejo JL. [Diagnosis and management of chronic obstructive pulmonary disease: joint guidelines of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) and the Latin American Thoracic Society (ALAT)]. Arch Bronconeumol. 2008 May;44(5):271-81.
Grupo de Trabajo de GESEPOC. [Moving towards a new focus on COPD. The Spanish COPD Guidelines (GESEPOC)]. Arch Bronconeumol. 2011 Aug;47(8):379-81.
Qaseem A, Wilt TJ, Weinberger SE, Hanania NA, Criner G, van der Molen T, Marciniuk DD, Denberg T, Schünemann H, Wedzicha W, MacDonald R, Shekelle P; American College of
Physicians; American College of Chest Physicians; American Thoracic Society; European Respiratory Society. Diagnosis and management of stable chronic obstructive pulmonary
disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European
Respiratory Society. Ann Intern Med. 2011 Aug 2;155(3):179-91.
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Chronic obstructive pulmonary disease (COPD) is a slowly progressive disease involving the airways or pulmonary parenchyma (or both) that results in airflow obstruction. Manifestations of COPD range from dyspnea, poor exercise tolerance, chronic cough with or without sputum production, and wheezing to respiratory failure or cor pulmonale. Exacerbations of symptoms and concomitant chronic diseases may contribute to the severity of COPD in individual patients. A diagnosis of COPD is confirmed when a patient who has symptoms of COPD is found to have airflow obstruction (generally defined as a postbronchodilator FEV1–FVC ratio less than 0.70, but taking into account that age-associated decreases in FEV1–FVC ratio may lead to overdiagnosis in elderly persons) in the absence of an alternative explanation for the symptoms (for example, left ventricular failure or deconditioning) or the airflow obstruction (for example, asthma). Clinicians should be careful to avoid attributing symptoms to COPD when common comorbid conditions, such as heart failure, are associated with the same symptoms…
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Ann Intern Med. 2011;155:179-191.
Chronic obstructive pulmonary disease (COPD) is a slowly progressive disease involving the airways or pulmonary parenchyma (or both) that results in airflow obstruction. Manifestations of COPD range from dyspnea, poor exercise tolerance, chronic cough with or without sputum production, and wheezing to respiratory failure or cor pulmonale. Exacerbations of symptoms and concomitant chronic diseases may contribute to the severity of COPD in individual patients. A diagnosis of COPD is confirmed when a patient who has symptoms of COPD is found to have airflow obstruction (generally defined as a postbronchodilator FEV1–FVC ratio less than 0.70, but taking into account that age-associated decreases in FEV1–FVC ratio may lead to overdiagnosis in elderly persons) in the absence of an alternative explanation for the symptoms (for example, left ventricular failure or deconditioning) or the airflow obstruction (for example, asthma). Clinicians should be careful to avoid attributing symptoms to COPD when common comorbid conditions, such as heart failure, are associated with the same symptoms…
449 palabras antes de nombrar
tabaco
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Ann Intern Med. 2011;155:179-191.
No menciona tabaquismo en definición.
No menciona que el efecto del tabaco es dosis/efecto.
No se menciona la palabra “Smoke” hasta después de 688 palabras y 2 tablas, y 688 palabras más hasta repetirla.
No definen si en ensayos clínicos deben excluirse los no fumadores / ex.
Clasificación de severidad confusa / discutible
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GOLD’2001
• Host Factors– Genes– Airway Hyperresponsiveness– Lung Growth
• Exposures– Tobacco Smoke– Occupational Dust and Chemicals– Outdoor and Indoor Air Pollution– Infections– Socioeconomic Status
RISK FACTORS
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ÍndiceÍndice
1) Las 11 Guías
2) Los 11 Mitos
3) Conclusiones
Filosofía de la Ciencia: Método inductivo Vs método Refutacionista
Epidemiology: an introduction. Kenneth J. Rothman.KJ Rothman - Oxford University Press
What is Causation?. Cap. 2
EXCESIVA INFLUENCIA DE LA FILOSOFIA DE LA CIENCIA
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La navaja de Occam (navaja de Ockham o principio de economía o de parsimonia) hace referencia a un tipo de razonamiento basado en una premisa muy simple: en igualdad de condiciones la solución más sencilla es probablemente la correcta. El postulado es entia non sunt multiplicanda praeter necessitatem, o «no ha de presumirse la existencia de más cosas que las absolutamente necesarias».
VS POSITIVISTAS / NOMINALISTES
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1. Human experiments
2. Strength of association
3. Consistency of association
4. Temporal relationship
5. Dose-response gradient
6. Biological plausibility
7. Epidemiological plausibility
8. Specificity
9. Analogy
Coultas D.B & Samet J.M. Cigarrette Smoking. Ch 7 de Clinical epidemiology of COPD. M. Decker, N.Y. 1989, pp 109-138.
PRINCIPIS DE HILL
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Martin J. Tobin. Chest. 2008 May;
133(5):1071-4; discussion 1074-7.
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Basado en J. G. Scadding.Principles of definition in medicione. Lancet, 1959; 1: 323-325 .
Meaning of diagnostic terms in bronchopulmonary disease. BMJ, 1963; 2: 1425-1430.The semantics of medical diagnosis. Niomed. Comput, 1972; 3: 83-90.
Helath and disease: what can medicine do for philosophy?. J. Med. Ethics, 1988; 14: 118-124.Definition on asthma. In: Bronchial asthma, mechanisms and therapeutics, 3erd ed. Boston: Litle Brown; 1993. p.1-13.
Descripción Clínica1
Lesión AnatómicaCaracterística2
Desorden FuncionalCaracterístico3
Causa - Etiología4
SÍNDROME
ENFERMEDAD
DEFINICIÓN Y CATEGORIZACIÓN CLÍNICA
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1. Miravitlles M, Morera J. It's time for an aetiology-based definition of chronic obstructive pulmonary disease. Respirology. 2007 May;12(3):317-9.
2. Morera J, Miravitlles M. [Chronic obstructive pulmonary disease: disease or Zugzwang's syndrome?] Med Clin (Barc). 2008 May 10;130(17):655-6.
3. Snider GL. Nosology for our day: its application to chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2003 Mar 1;167(5):678-83.
EPOC: NOSOLOGÍA
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R. Pellegrino, V. Brusasco, G. Viegi, R.O. Crapo, F. Burgos, R. Casaburie, A. Coates, C.P.M. van der Grinten, P. Gustafsson, J. Hankinson, R. Jensen, D.C. Johnson, N. MacIntyreee, R. McKay***, M.R. Miller, D. Navajas, O.F. Pedersen
and J. Wanger.
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NECESIDAD ÚNICO CRITERIO
Can Global Initiative for Chronic Obstructive Lung Disease Stage 0 Provide Prognostic Information on Long-term Mortality in Men?
Stavem K, et al. Chest, 2006; 130: 318-25
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¿Y LOS SÍNTOMAS?
BODE: Celli BR, Cote CG, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med. 2004 Mar 4;350(10):1005-12.
ADO: Puhan MA, Garcia-Aymerich J, et al. Expansion of the prognostic assessment of patients with chronic obstructive
pulmonary disease: the updated BODE index and the ADO index. Lancet. 2009 Aug 29;374(9691):704-11.
DOSE: Jones RC, Donaldson GC, et al.. Derivation and Validation of a Composite Index of Severity in Chronic Obstructive Pulmonary Disease - The DOSE Index. Am J Respir Crit Care Med. 2009 Sep 24.
http://www.goldcopd.com.
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Asma Insuficiencia cardíaca Bronquiectasias Tuberculosis Bronquiolitis obliterante Panbronquiolitis difusa
GOLD – DIAGNÓSTICO DIFERENCIAL
Global Strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Update 2003 (GOLD). http://www.goldcopd.com.
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¿Y LOS SÍNTOMAS?
200-500 Causas ?!200-500 Causas ?!
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CAUSAS EPOC-SÍNDROME
Am J Respir Crit Care Med. 2009 Aug 1;180(3):257-64.
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Am J Respir Crit Care Med. 2009 Aug 1;180(3):257-64.
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Chest. 2004 Aug;126(2):622-9.
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Chest. 2004 Aug;126(2):622-9.
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Respiration 2005;72:221
Clinical Bronchiolitis Obliterans in Workers at a Microwave-Popcorn Plant
Kreiss K, et al. NEJM, 2002; 347: 330-338
100 Volatile Organic Compounds
Diacetyl (2,3-butanedione)
100 Volatile Organic Compounds
Diacetyl (2,3-butanedione)
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Does Distinction Between Asthma
and COPD Matter?
Does Distinction Between Asthma
and COPD Matter?
Kraft M. AJRCCM, 2006; 174: 238-244.
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… Potentially, the common mechanism by which major risk factors such as smoking, hyperlipidaemia, obesity, and
hypertension lead to chronic disease is systemic inflammation…
… Potentially, the common mechanism by which major risk factors such as smoking, hyperlipidaemia, obesity, and
hypertension lead to chronic disease is systemic inflammation…
CONFUSIÓN
Lancet. 2007 Sep 1;370(9589):797-9.
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Hernia inguinalHernia inguinal
Neuropatia S. vegetativo
Neuropatia S. vegetativo
Rinitis / SinusitisRinitis / SinusitisProzacProzac
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N Engl J Med. 2010 Jan 21;362(3):217-27.
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N Engl J Med. 2010 Jan 21;362(3):217-27.
Biochem. Soc. Trans. (2009) 37, 814–818;
Am J Respir Crit Care Med Vol 176. pp 1281–1288, 2007
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Am J Respir Crit Care Med. 2011 Aug 11.
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N Engl J Med. 2011 Sep 29;365(13):1184-92.
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N Engl J Med. 2011 Sep 29;365(13):1184-92.
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COPD: the dangerous underestimate of 15%. Rennard SI, Vestbo J.
Lancet. 2006 Apr 15;367(9518):1216-9.
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Decline in FEV1 and airfl ow limitation related to occupational exposures in men of an urban community.
Humerfelt S, Gulsvik A, Skjaerven R, et al. Eur Respir J 1993; 6: 1095–103.
COPD: the dangerous underestimate of 15%. Rennard SI, Vestbo J.
Lancet. 2006 Apr 15;367(9518):1216-9.
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COPD: the dangerous underestimate of 15%. Rennard SI, Vestbo J.
Lancet. 2006 Apr 15;367(9518):1216-9.
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Decline in FEV1 and airfl ow limitation related to occupational exposures in men of an urban community.
Humerfelt S, Gulsvik A, Skjaerven R, et al. Eur Respir J 1993; 6: 1095–103.
A homeopathic remedy for early COPD
Enright P. Respir Med. 2011 Nov;105(11):1573-5.
Proc Am Thorac Soc. 2006;3(1):58-65.
Enright P. Prim Care Respir J. 2011 Mar;20(1):6-8.
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Chest. 2009 Jan;135(1):173-80.
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Chest. 2009 Jan;135(1):173-80.
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Inspirados en: Dornhorst AC. Lancet. 1955 Jun 11;268(6876):1185-7.
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FENOTIPOS
Homes Homes DonesDones
Cortesía Dr. de Torres
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FENOTIPOS
El fenotipo está determinado fundamentalmente por el genotipo, o por la identidad de los alelos, los cuales, individualmente, cargan una o más posiciones en los cromosomas. Algunos fenotipos están determinados por los múltiples genes, y además influidos por factores del medio. De esta manera, la identidad de uno, o de unos pocos alelos conocidos, no siempre permite una predicción del fenotipo. En este sentido, la interacción entre el genotipo y el fenotipo ha sido descrita usando la simple ecuación que se expone a continuación:
Ambiente + Genotipo + Ambiente* Genotipo = Fenotipo
En conclusión, el fenotipo es cualquier característica detectable de un organismo (estructural, bioquímico, fisiológico o conductual) determinado por una interacción entre su genotipo y su medio.
El conjunto de la variabilidad fenotípica recibe el nombre de polifasia o polifenismo.
http://es.wikipedia.org/wiki/Fenotipo
FENOTIPOS
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Phenotype classically refers to any observable characteristic of an organism, and up until now, multiple disease characteristics have been termed COPD phenotypes. We, however, propose the following variation on this definition: ‘‘a single or combination of disease attributes that describe differences between individuals with COPD as they relate to clinically meaningful outcomes (symptoms, exacerbations, response to therapy, rate of disease progression, or death).’’
Am J Respir Crit Care Med 2010; 182: 589–604.
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Thorax. 2008 September ; 63(9): 761–767.
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Respirology (2011) 16, 264–268
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Thorax. 2009; 64(8): 728-35.
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Thorax. 2009; 64(8): 728-35.
Marin, et al. Am J Respir Crit Care Med Vol 182. pp 325–331, 2010
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Am J Respir Crit Care Med, 2004; 170: 400–407
Martínez-García MÁ , et al. Chest. 2011 Nov;140(5):1130-7.
¿Paciente sano? o ¿Paciente no sano?
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DIAGNÓSTICO Y PRONÓSTICO
Muy fumadores (hasta ahora predominio varón) 50 paquetes/año acumulados Disnea de esfuerzo “Velcro” basales Acropaquia >50% > 65 años DLCO Espirometría / volúmenes = desconcertantes Tx tórax = tórax sucio TAC = >enfisema paraseptal !! HAP Carcinoma Enfermedad coronaria +++
DIAGNÓSTICO Y PRONÓSTICO: CUADRO CLÍNICO
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DIAGNÓSTICO Y PRONÓSTICO
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Previamente catalogados de EPOC (leves / moderados)
Enfisema precede 5 años a fibrosis
Espirometría poco reveladora
Efecto “joven/vieja”
TAC (no siempre fácil de interpretar)
(No hacemos ni TAC ni difusión = guías)
No sabíamos que el humo del cigarrillo producía fibrosis pulmonar !!!???
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DIAGNÓSTICO Y PRONÓSTICO: CUADRO CLÍNICO (DIFICULTADES)
Combined pulmonary fibrosis and emphysema: a distinct underrecognised entity.
Cottin V, Nunes H, Brillet PY, Delaval P, Devouassoux G, Tillie-Leblond I, Israel-Biet D, Court-Fortune I, Valeyre D, Cordier JF; Groupe d'Etude et de Recherche sur les
Maladies Orphelines Pulmonaires (GERM O P).
Eur Respir J. 2005 Oct;26(4):586-93.
DIAGNÓSTICO Y PRONÓSTICO
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¿Coincidente o relación causal?¿Cita o encuentro?Humo de cigarrillo
¿Coincidente o relación causal?¿Cita o encuentro?Humo de cigarrillo
The spectrum of smoking-related interstitial lung disorders: the never-ending story of smoke and disease.
Selman M. Chest. 2003 Oct;124(4):1185-7.
Smoking: an injury with many lung manifestations. Flaherty KR, Hunninghake GG. Am J Respir Crit Care Med. 2005 Nov 1;172(9):1070-1.
LECCIONES PASADAS DE LA HISTORIA
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Relation of smoking and age to findings in lung parenchyma: a microscopic study. Auerbach O, Garfinkel L, Hammond EC. Chest. 1974 Jan;65(1):29-35.
Smoking Habits And Age In Relation To Pulmonary Changes. Rupture Of Alveolar Septums, Fibrosis And Thickening Of Walls Of Small Arteries And Arterioles.
Auerbach O, Stout Ap, Hammond Ec, Garfinkel L. N Engl J Med. 1963 Nov 14;269:1045-54.
J Occup Med. 1988 Jan;30(1):33-9).
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LECCIONES PASADAS DE LA HISTORIA: AVISOS
Relation of smoking and age to findings in lung parenchyma: a microscopic study. Auerbach O, Garfinkel L, Hammond EC. Chest. 1974 Jan;65(1):29-35.
Smoking Habits And Age In Relation To Pulmonary Changes. Rupture Of Alveolar Septums, Fibrosis And Thickening Of Walls Of Small Arteries And Arterioles.
Auerbach O, Stout Ap, Hammond Ec, Garfinkel L. N Engl J Med. 1963 Nov 14;269:1045-54.
J Occup Med. 1988 Jan;30(1):33-9).
Cigarettes – Packs/Day
No. In group0
20
40
60
80
100
0 <1 1 _ 2 2+
Age
36 52 32 87 87 38 205 200 43 83 96 15
Seve
re P
ulm
onar
y Fi
bros
is %
6,9
32,7
62,7
<60
1,9
39,1
82,590,660-69
50
90,7 93,370+
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LECCIONES PASADAS DE LA HISTORIA: AVISOS
Diagnosis of usual interstitial pneumonia and distinction from other fibrosing interstitial lung diseases.
Katzenstein AL, Mukhopadhyay S, Myers JL.
Hum Pathol. 2008 Sep;39(9):1275-94.
23 piezas lobectomía por tumor pulmonar
20 fumadores
Examen histológico: fibrosis >25% slides. En 12/20 (60%) fumadores 0 en no fumadores
Describe SRIF (Smoking-Related Fibrosis Disease)
ÚLTIMAS NOTICIAS
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Idiopathic pulmonary fibrosis and emphysema: decreased survival associated with severe pulmonary arterial hypertension.
Mejía M, Carrillo G, Rojas-Serrano J, Estrada A, Suárez T, Alonso D, Barrientos E, Gaxiola M, Navarro C, Selman M.
Chest. 2009 Jul;136(1):10-5. 30% !!!30% !!!
ÚLTIMAS NOTICIAS
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5% por año
5.000 nuevos casos por año (UK) =
[ 4.000 en España ?!]
5.000 +/a
>+ que por cáncer ovárico, linfoma, leucemia, hipernefroma o mesotelioma.
Thorax. 2011 Jun;66(6):462-7.
The rising incidence of idiopathic pulmonary fibrosis in the U.K.Navaratnam V, Fleming KM, West J, Smith CJ, Jenkins RG, Fogarty A, Hubbard RB.
The rising incidence of idiopathic pulmonary fibrosis in the U.K.Navaratnam V, Fleming KM, West J, Smith CJ, Jenkins RG, Fogarty A, Hubbard RB.
YA NO ES HUÉRFANA…YA NO ES HUÉRFANA…
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ÚLTIMAS NOTICIAS
N Engl J Med 2011;364:897-906.
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N Engl J Med 2011;364:897-906.
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Inspirados en: Dornhorst AC. Lancet. 1955 Jun 11;268(6876):1185-7.
“Blue Bloater / Blow-up”
ESPECULACIONES
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Thorax. 2011 Aug;66(8):643-5.
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N Engl J Med. 2011 May 12;364(19):1795-806.
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Petersen & Niklason
Thorax. 2011 Aug;66(8):645-6.
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Even more effective tobacco legislation, including prevention of passive smoking exposure for children in cars and at home. Legislation works17dor, if it does not, let us prorogue parliament at once!
Recognition that airborne pollution is a human rights issuedif you live in a Western city you cannot avoid air pollution.
The roots of much disease are in povertydand yet it is not only low and middle income countries that are affected. All major Western countries still have substantial poverty affecting children.
Finally, invest in research to understand early lung development, and devise interventions to operate before the lungs are shot to pieces.
ÍndiceÍndice
1) Las 11 Guías
2) Los 11 Mitos
3) Conclusiones
ConclusionesConclusiones
1) Factor de Riesgo o Causa
2) Cociente Fijo
3) Es Fácil de Diagnosticar
4) El Gran Síndrome Inflamatorio
5) La Irreversibilidad
6) La Comorbilidad
MITOS
ConclusionesConclusiones
MITOS
7) La Suscetibilidad
8) La Importancia de los Genes
9) Envejecimiento
10) Los Fenotipos
11) El Cigarrillo no Produce Fibrosis
Muchas GraciasMuchas Gracias