epoc: perspectivas de futuro (y una mirada al pasado)

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EPOC:PERSPECTIVAS DE FUTURO

(Y UNA MIRADA AL PASADO)

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“Nunca hago predicciones y nunca las haré”

Paul Gascoigne

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1. ¡Que es la demografía!

2. Tabaquismo: malas perspectivas

3. Las “noncommunicable”

4. Peligro: camino equivocado

5. Fenotipos o formas clínicas

6. 1,2,3,4......?

7. Nuevas tecnologías

8. Conclusiones

ÍNDICE

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Manila (Filipinas) 31 octubre 2011

Nace Danica May Manila Camacho

Es la ciudadana número 7mil millones del planeta

2011

¡Que es la demografía!

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Sarajevo(Bosnia) 13 octubre, 1999

Nace Adnan Nevic, el ciudadano número 6 millones

¡Que es la demografía!

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El mundo en 2050.Todas las tendencias que canviaran el planeta

(The Economist).ed Franklin D. y Andrews J. 2012

¡Que es la demografía!

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Eriksen M. Judith Mackay Hana Ross EL ATLAS

DEL TABACO cuarta edición.

http://www.tobaccoatlas.org/uploads/Images/PDFs/

TA4Spanish.pdf

Tabaquismo: malas perspectivas

8N Engl J Med. 2013 Jan 24;368(4):341-50

Tabaquismo: malas perspectivas

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N Engl J Med. 2013 Jan 24;368(4):351-64

Tabaquismo: malas perspectivas

…More women die of lung cancer than of breast cancer. But there is no “race for the cure” for lung cancer, no brown ribbon, and no group analogous to the Susan G. Komen Breast Cancer Foundation…

10Thorax. 2011 Aug;66(8):645-6

Tabaquismo: malas perspectivas

11Noncommunicable Diseases David J. Hunter, M.B., B.S., M.P.H., Sc.D., and K. Srinath Reddy, M.D., D.M.N

New Engl J Med 2013; 369:1336-1343 October 3, 2013

Las “noncommunicable”

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PLoS Med. 2006 Nov;3(11):e442.

Projections of global mortality and burden of disease from 2002 to 2030.

Mathers CD, Loncar D.

Las “noncommunicable”

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PLoS Med. 2006 Nov;3(11):e442.

Projections of global mortality and burden of disease from 2002 to 2030 Mathers CD, Loncar D.

Las “noncommunicable”

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Las “noncommunicable”

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- Mathers CD, Loncar D. PLoS Med. 2006 Nov;3(11):e442.

Projections of global mortality and burden of disease from 2002 to 2030

- Stockley RA. Am J Respir Crit Care Med. 2013 Apr 15;187(8):786-8

Las “noncommunicable”

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Las “noncommunicable”

17Thorax. 2011 Aug;66(8):643-5

Peligro: camino equivocado

Even more effective tobacco legislation, including prevention of passive smokingexposure 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 aWestern city you cannot avoid air pollution.

The roots of much disease are in povertydand yet it is not only low and middleincome countries that are affected. All major Western countries still havesubstantial poverty affecting children.

Finally, invest in research to understand early lung development, and deviseinterventions to operate before the lungs are shot to pieces.

18Thorax. 2011 Aug;66(8):645-6

Peligro: camino equivocado

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Peligro: camino equivocado

20Am J Respir Crit Care Med. 2012 Nov 15;186(10):975-81

Peligro: camino equivocado

1) No menciona que el efecto del tabaco es dosis/efecto. !!!!!

2) No menciona la palabra “Smoke” hasta después de 688 palabras y 2 tablas, y688 palabras hasta repetirla. !!!!!

• Host Factors– Genes

– Airway Hyperresponsiveness

– Lung Growth

• Exposures– Tobacco Smoke

– Occupational Dust and Chemicals

– Outdoor and Indoor Air Pollution

– Infections

– Socioeconomic Status

Am J Respir Crit Care Med Vol 163. pp 1256–1276, 200121

Peligro: camino equivocado

…The adjusted differences in FEV1 between individuals who did not consume cured meats and those who consumed cured meats 1

to 2,3 to 4, 5 to 13, and 14 or more times per month were 37.6, 11.5, 42.0, and 110 ml, respectively (p for trend 0.001).Corresponding

differences for FEV1/FVC were 0.91,0.54, 1.13, and 2.13% (p for trend 0.001). These associations were not modified by smoking

status. The multivariate odds ratio for COPD (FEV1/FVC 0.7 and FEV1 80% predicted) was 1.78 (95% confidence interval, 1.29–2.47)

comparing the highest with the lowest category of cured meat consumption. The corresponding odds ratios for mild, moderate, and

severe COPD were 1.11, 1.46, and 2.41, respectively….

…High dietary nitrite intake warrants further evaluation in prospective, longitudinal studies as a novel risk factor for COPD.

22Am J Respir Crit Care Med. 2007 Apr 15;175(8):798-804

Peligro: camino equivocado

Biochem. Soc. Trans. (2009) 37, 814–818;

Am J Respir Crit Care Med Vol 176. pp 1281–1288, 2007

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Peligro: camino equivocado

Necesidad de criterio único

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Peligro: camino equivocado

…This is clearly apparent if one keeps in mind that

two patients with FEV1 of 20 and 100% pred may

have the same FEV1/FVC ,0.70 or even, LLN,

depending on the associated reduction of FVC…

25Eur Respir J. 2008 Mar;31(3):681-2

Peligro: camino equivocado

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Thorax. 2009 Oct;64(10):894-900

Peligro: camino equivocado

27Chest. 2006 Aug;130(2):318-25

Peligro: camino equivocado

Basat 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: Weiss EB, Stein M. Editors. Bronchial asthma, mechanisms and therapeutics, 3erd ed. Boston: Litle Brown;

1993. p.1-13.

Descripción Clínica1

Lesión AnatómicaCaracterística

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Desorden FuncionalCaracterístico

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Causa - Etiología4

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ENFERMEDAD

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Peligro: camino equivocado

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-

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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.

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Peligro: camino equivocado

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Peligro: camino equivocado

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P.G. Gibson, J.L. Simpson.Thorax 2009;64:728-735

The overlap syndrome of asthma and COPD: what are its features and how important

is it?

Fenotipos o formas clínicas

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Miguel-Angel Martínez-García, et al.Prognostic Value of Bronchiectasis in

Patients with Moderate-to-Severe Chronic Obstructive Pulmonary Disease

American Journal of Respiratory and Critical Care Medicine 2013 187: 823-831

Fenotipos o formas clínicas

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Jose M. Marin, et al. "Outcomes in Patients with Chronic Obstructive Pulmonary

Disease and Obstructive Sleep Apnea", American Journal of Respiratory and

Critical Care Medicine, Vol. 182, No. 3 (2010), pp. 325-331.

Fenotipos o formas clínicas

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John R. Hurst, Evaluation of COPD Longitudinally to Identify Predictive Surrogate

Endpoints (ECLIPSE)

Susceptibility to Exacerbation in Chronic Obstructive Pulmonary Disease

New engl j med 363;12 september 16, 2010

Fenotipos o formas clínicas

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Camp PG, et al.

COPD phenotypes in biomass smoke- versus tobacco smoke-exposed Mexican

females. Eur Respir J. 2013 Oct 10.

Fenotipos o formas clínicas

¿Paciente sano? o ¿Paciente no sano?36

Fenotipos o formas clínicas

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Fenotipos o formas clínicas

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Fenotipos o formas clínicas

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Fenotipos o formas clínicas

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Fenotipos o formas clínicas

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Almagro P, et al.

Comorbidities in patients hospitalized due to chronic obstructive

pulmonary disease. A comparative analysis of the ECCO and ESMI.

Rev Clin Esp. 2012 Jun;212(6):281-6

Morera Prat J, Martinez –Ortiz ML

Chronic obstructive pulmonary disease in the elderly: next phenotype

Med Clin (Barc)2012 Apr 28;138(11):478-9.

Fenotipos o formas clínicas

42Am J Respir Crit Care Med. 2012 Jan 1;185(1):44-52

Fenotipos o formas clínicas

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Guerra S, et al.Combined effects of parental and active smoking on early lung

function deficits: a prospective study from birth to age 26 years.

Thorax. 2013 Nov;68(11):1021-8.

Fenotipos o formas clínicas

Han MK, et al.

Chronic Obstructive Pulmonary Disease Exacerbations in the COPDGene Study:

Associated Phenotypes. Radiology. 2011 Oct;261(1):274-82

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Fenotipos o formas clínicas

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Fenotipos o formas clínicas

Inspirado en: Dornhorst AC. Lancet. 1955 Jun 11;268(6876):1185-7.

“Blue Bloater / Blow-up”46

Fenotipos o formas clínicas

47N Engl J Med. 2007 Feb 22;356(8):775-89

1, 2, 3, 4…?

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1, 2, 3, 4…?

49N Engl J Med. 2011 Aug 25;365(8):689-98

1, 2, 3, 4…?

50Am J Respir Crit Care Med. 2012 Jan 15;185(2):152-9

1, 2, 3, 4…?

51N Engl J Med. 2010 Sep 23;363(13):1233-44

1, 2, 3, 4…?

52Thorax. 2010 Apr;65(4):298-302

1, 2, 3, 4…?

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1, 2, 3, 4…?

54The Lancet Respiratory Medicine, Early Online Publication, 6 December 2012

1, 2, 3, 4…?

55Chest. 2012 Nov;142(5):1300-7.

1, 2, 3, 4…?

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Estépar RS, et al. Computed tomographic measures of pulmonary vascular

morphology in smokers and their clinical implications.

Am J Respir Crit Care Med. 2013 Jul 15;188(2):231-9

Nuevas tecnologías

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Carlos H Martinez,et al. Relationship between quantitative CT metrics and health

status nd BODE in chronic obstructive pulmonary disease.

Thorax,2012,67,399-406

Nuevas tecnologías

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Nuevas tecnologías

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1. Debemos maximizar nuestros esfuerzos en la batalla del tabaquismo

y el diagnóstico precoz.

2. En un futuro, la comunidad científica deberá homogeneizar más los

conceptos de la EPOC.

3. Esperanzados con la medicina regenerativa, no sabemos cuando

será una realidad.

4. El fenotipo de la EPOC del futuro será el fenotipo de la EPOC del

anciano.

5. A nivel clínico es intrigante la comorbilidad con la obesidad.

Conclusiones

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MUCHAS GRACIAS