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Moreno G, Ruiz-Botella M, Martín-Loeches I, Gómez Álvarez J, Jiménez Herrera M, Bodí M, Armestar F, Marques Parra A, Estella Á, Trefler S, Jorge García R, Murcia Paya J, Vidal Cortes P, Díaz E, Ferrer R, Albaya-Moreno A, Socias-Crespi L, Bonell Goytisolo J, Sancho Chinesta S, Loza A, Forcelledo Espina L, Pozo Laderas J, deAlba-Aparicio M, Sánchez Montori L, Vallverdú Perapoch I, Hidalgo V, Fraile Gutiérrez V, Casamitjana Ortega A, Martín Serrano F, Nieto M, Blasco Cortes M, Marín-Corral J, Solé-Violán J, Rodríguez A. A differential therapeutic consideration for use of corticosteroids according to established COVID-19 clinical phenotypes in critically ill patients. Med Intensiva 2023; 47:23-33. [PMID: 36272908 PMCID: PMC9579897 DOI: 10.1016/j.medine.2021.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 10/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine if the use of corticosteroids was associated with Intensive Care Unit (ICU) mortality among whole population and pre-specified clinical phenotypes. DESIGN A secondary analysis derived from multicenter, observational study. SETTING Critical Care Units. PATIENTS Adult critically ill patients with confirmed COVID-19 disease admitted to 63 ICUs in Spain. INTERVENTIONS Corticosteroids vs. no corticosteroids. MAIN VARIABLES OF INTEREST Three phenotypes were derived by non-supervised clustering analysis from whole population and classified as (A: severe, B: critical and C: life-threatening). We performed a multivariate analysis after propensity optimal full matching (PS) for whole population and weighted Cox regression (HR) and Fine-Gray analysis (sHR) to assess the impact of corticosteroids on ICU mortality according to the whole population and distinctive patient clinical phenotypes. RESULTS A total of 2017 patients were analyzed, 1171 (58%) with corticosteroids. After PS, corticosteroids were shown not to be associated with ICU mortality (OR: 1.0; 95% CI: 0.98-1.15). Corticosteroids were administered in 298/537 (55.5%) patients of "A" phenotype and their use was not associated with ICU mortality (HR=0.85 [0.55-1.33]). A total of 338/623 (54.2%) patients in "B" phenotype received corticosteroids. No effect of corticosteroids on ICU mortality was observed when HR was performed (0.72 [0.49-1.05]). Finally, 535/857 (62.4%) patients in "C" phenotype received corticosteroids. In this phenotype HR (0.75 [0.58-0.98]) and sHR (0.79 [0.63-0.98]) suggest a protective effect of corticosteroids on ICU mortality. CONCLUSION Our finding warns against the widespread use of corticosteroids in all critically ill patients with COVID-19 at moderate dose. Only patients with the highest inflammatory levels could benefit from steroid treatment.
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Affiliation(s)
- G. Moreno
- ICU, Hospital Universitario Joan XXIII/URV/IISPV, Tarragona, Spain
| | - M. Ruiz-Botella
- Tarragona Health Data Research Working Group (THeDaR) – ICU Hospital Universitario Joan XXIII, Tarragona, Spain
| | - I. Martín-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | - J. Gómez Álvarez
- Tarragona Health Data Research Working Group (THeDaR) – ICU Hospital Universitario Joan XXIII, Tarragona, Spain
| | | | - M. Bodí
- ICU, Hospital Universitario Joan XXIII/URV/IISPV, Tarragona, Spain,CIBERES/CIBERESUCICOVID
| | - F. Armestar
- ICU, Hospital Universitario German Trias i Pujol, Badalona, Spain
| | | | - Á. Estella
- ICU, Hospital Universitario de Jerez, Jerez de la Frontera, Spain
| | - S. Trefler
- ICU, Hospital Universitario Joan XXIII/URV/IISPV, Tarragona, Spain
| | | | | | - P. Vidal Cortes
- UCI, Complejo Hospitalario Universitario de Ourense, Orense, Spain
| | - E. Díaz
- UCI, Hospital Parc Taulí/UAB/CIBERES, Barcelona, Spain
| | - R. Ferrer
- UCI, Hospital Universitario Vall d’Hebron, Barcelona, Spain
| | | | - L. Socias-Crespi
- UCI, Hospital Universitario Son Llátzer, Palma de Mallorca, Spain
| | | | | | - A. Loza
- ICU, Hospital Universitario Nuestra Señora de Valme, Sevilla, Spain
| | - L. Forcelledo Espina
- ICU, Hospital Central de Asturias, Grupo de Investigación de Microbiología Traslacional del ISPA, Oviedo, Spain
| | | | | | | | | | - V. Hidalgo
- ICU, Hospital Complejo Asistencial de Segovia, Segovia, Spain
| | | | - A.M. Casamitjana Ortega
- UCI, Complejo Hospitalario Universitario Insular – Materno Infantil, Las Palmas de Gran Canaria, Spain
| | | | - M. Nieto
- UCI, Hospital Clínico San Carlos, Madrid, Spain
| | | | - J. Marín-Corral
- ICU, Hospital del Mar/GREPAC – IMIM, Barcelona, Spain,Division of Pulmonary Diseases & Critical Care Medicine, UTH San Antonio, San Antonio, TX, USA
| | - J. Solé-Violán
- ICU, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - A. Rodríguez
- ICU, Hospital Universitario Joan XXIII/URV/IISPV, Tarragona, Spain,CIBERES/CIBERESUCICOVID,Corresponding author
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Carrasco Hernández L, Caballero Eraso C, Ruiz-Duque B, Abad Arranz M, Márquez Martín E, Calero Acuña C, Lopez-Campos JL. Deconstructing Phenotypes in COPD: an Analysis of the TRACE Cohort. Arch Bronconeumol 2021; 58:30-34. [PMID: 33546927 DOI: 10.1016/j.arbres.2020.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/22/2020] [Accepted: 12/03/2020] [Indexed: 11/02/2022]
Abstract
OBJECTIVES In a clinical phenotype-based management strategy for COPD, it would be preferable to at least assign all patients to a phenotype, but to a single phenotype only. The aim of this study was to evaluate whether all patients are assigned to one and only one phenotype using the Spanish COPD guidelines (GesEPOC) and to evaluate the criteria that define these categories. METHOD The Time-based Register and Analysis of COPD Endpoints study (TRACE; clinicaltrials.gov NCT03485690) is a prospective cohort of COPD patients attending annual visits since 2012, which collects GesEPOC phenotypes. Although the GesEPOC recommends that patients considered to be at low risk are not phenotyped, an analysis of the criteria for identifying high- and low-risk phenotypes was performed, comparing the distribution of phenotypes and the criteria applied between these 2 groups. RESULTS The cohort included 970 patients with a confirmed diagnosis of COPD, divided into 427 (44.02%) low-risk and 543 (55.9%) high-risk patients. The most frequent phenotype was the non-exacerbator (44.9% of high-risk patients). Overall, 20.6% of low-risk patients met criteria for asthma-COPD overlap syndrome, while 9.2% of the cohort did not meet the diagnostic criteria for any phenotype, and 19.1% met the criteria for 2 phenotypes, with no differences between risk groups. CONCLUSIONS Our data highlight some of the weaknesses of the current clinical phenotype strategy, revealing overlapping categories in some cases, and patients to whom no phenotype was assigned.
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Affiliation(s)
- Laura Carrasco Hernández
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias. Instituto de Biomedicina de Sevilla (IBiS). Hospital Universitario Virgen del Rocio/ Universidad de Sevilla, Sevilla, España; CIBER de Enfermedades Respiratorias (CIBERES). Instituto de Salud Carlos III, Madrid, España
| | - Candela Caballero Eraso
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias. Instituto de Biomedicina de Sevilla (IBiS). Hospital Universitario Virgen del Rocio/ Universidad de Sevilla, Sevilla, España; CIBER de Enfermedades Respiratorias (CIBERES). Instituto de Salud Carlos III, Madrid, España
| | - Borja Ruiz-Duque
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias. Instituto de Biomedicina de Sevilla (IBiS). Hospital Universitario Virgen del Rocio/ Universidad de Sevilla, Sevilla, España
| | - María Abad Arranz
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias. Instituto de Biomedicina de Sevilla (IBiS). Hospital Universitario Virgen del Rocio/ Universidad de Sevilla, Sevilla, España; CIBER de Enfermedades Respiratorias (CIBERES). Instituto de Salud Carlos III, Madrid, España
| | - Eduardo Márquez Martín
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias. Instituto de Biomedicina de Sevilla (IBiS). Hospital Universitario Virgen del Rocio/ Universidad de Sevilla, Sevilla, España; CIBER de Enfermedades Respiratorias (CIBERES). Instituto de Salud Carlos III, Madrid, España
| | - Carmen Calero Acuña
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias. Instituto de Biomedicina de Sevilla (IBiS). Hospital Universitario Virgen del Rocio/ Universidad de Sevilla, Sevilla, España; CIBER de Enfermedades Respiratorias (CIBERES). Instituto de Salud Carlos III, Madrid, España
| | - Jose Luis Lopez-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias. Instituto de Biomedicina de Sevilla (IBiS). Hospital Universitario Virgen del Rocio/ Universidad de Sevilla, Sevilla, España; CIBER de Enfermedades Respiratorias (CIBERES). Instituto de Salud Carlos III, Madrid, España.
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Martínez-García MA, Olveira C, Máiz L, Girón RMª, Prados C, de la Rosa D, Blanco M, Agustí A. Bronchiectasis: A Complex, Heterogeneous Disease. Arch Bronconeumol 2019; 55:427-433. [PMID: 31005356 DOI: 10.1016/j.arbres.2019.02.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 02/22/2019] [Accepted: 02/22/2019] [Indexed: 12/30/2022]
Abstract
Most areas of respiratory medicine continue to use an Oslerian approach, based on signs and symptoms, in which the disease is the center of all activity. However, this paradigm is changing. Now that lung diseases have been recognized as heterogeneous and complex, we are moving towards more personalized, precise, patient-oriented medicine. The aim of this review was to define the current state of the knowledge on bronchiectasis, or, more accurately, the bronchiectasis syndrome, as a multidimensional, systemic, heterogeneous, complex disease. We explore the advances that have already been made, and above all the many steps that are still to be taken. We also propose some tools which might facilitate the application of these concepts in clinical practice, and help us continue our journey towards a more holistic view of this disease.
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Affiliation(s)
| | - Casilda Olveira
- Servicio de Neumología, Hospital Regional Universitario de Málaga, Málaga, España
| | - Luis Máiz
- Servicio de Neumología, Hospital Ramón y Cajal, Madrid, España
| | - Rosa M ª Girón
- Hospital Universitario e Instituto de Investigación La Princesa, Madrid, España
| | - Concepción Prados
- Servicio de Neumología, Hospital Universitario La Paz, Madrid, España
| | | | - Marina Blanco
- Servicio de Neumología, Hospital Universitario A Coruña, A Coruña, España
| | - Alvar Agustí
- Institut Respiratori, Hospital Clínic, Universidad de Barcelona, IDIBAPS, CIBERES, Barcelona, España
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