Original Article
Treatment With Systemic Steroids in Severe Chronic Obstructive Pulmonary Disease Exacerbations: Use of Short Regimens in Routine Clinical Practice and Their Impact on Hospital Stay
Tratamiento con esteroides sistémicos en agudización grave de enfermedad pulmonar obstructiva crónica: empleo de pautas cortas en práctica clínica habitual y relación con la estancia hospitalaria
Pedro J. Marcosa,
, Irene Nieto-Codesidoa, Santiago de Jorge Dominguez-Pazosa, Arturo Huertab, Eduardo Márquezc, Alejandro Maisoa, Rodrigo Verdeald, Isabel Otero-Gonzáleza, Marina Blanco-Aparicioa, Carmen Montero-Martíneza
Corresponding author
a Servicio de Neumología, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña (CHUAC) Sergas Universidade da Coruña (UDC), As Xubias, A Coruña, Spain
b Servicio de Neumología, Institut Clínic del Tòrax Hospital Clínic-IDIBAPS CIBER de Respiratorio, Universidad de Barcelona, Barcelona, Spain
c Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, Spain
d Servicio de Medicina Interna, Instituto de Investigación Biomédica de A Coruña (INIBIC) Complejo Hospitalario Universitario de A Coruña (CHUAC) Sergas Universidade da Coruña (UDC), As Xubias, A Coruña, Spain
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(B) Cumulative steroid dose.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The natural history of chronic obstructive pulmonary disease (COPD) is characterized by intermittent episodes of exacerbation. Exacerbations are associated with an accelerated loss of lung function,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> poorer quality of life<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> and greater mortality,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a> associated mainly with more severe exacerbations requiring hospitalization.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a> Optimal management of severe exacerbations is essential if prognosis is to improve. Hospital treatment of COPD exacerbations (COPDE) includes the use of oxygen, antibiotics, bronchodilators, and systemic corticosteroids (SCS). SCS are useful for improving lung function and symptoms, improving the 30-day treatment failures rate, and reducing hospital stay.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">5</span></a> However, no benefit in terms of mortality has been demonstrated, and the use of SCS is associated with increased side effects, the most frequent being hyperglycemia.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">At present, almost all COPD clinical management guidelines recommend the use of SCS in severe exacerbations. However, the recommendations vary to some extent in terms of the appropriate dose and duration of treatment. Thus, while the GOLD 2013<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a> guidelines recommended 30–40<span class="elsevierStyleHsp" style=""></span>mg prednisone daily for 10–14 days, the NICE guidelines<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a> proposed a slightly shorter duration (7–14 days), and the 2012 edition of the Spanish COPD guidelines<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">8</span></a> recommended treatment with oral prednisone 0.5<span class="elsevierStyleHsp" style=""></span>mg/kg/day or equivalent until clinical improvement, with suspension of the treatment as soon as possible, preferably before 7–10 days. Following publication of the REDUCE study,<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">9</span></a> a randomized clinical trial which showed that a 5-day regimen produced similar rates of new exacerbations at 6 months, similar mortality and less exposure to corticosteroids as a 14-day regimen (37.2% versus 38.4%; <span class="elsevierStyleItalic">P</span>=NS), GOLD 2014<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a> included a recommendation for a 5-day course of 40<span class="elsevierStyleHsp" style=""></span>mg prednisone/day, and repeated the same recommendation in the recent update.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> The Spanish COPD guidelines updated in 2014<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">11</span></a> include the REDUCE data, and support the use of short 5-day courses, but only in exacerbations which do not require hospitalization, even though over 90% of the patients included in the REDUCE study were hospitalized.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Despite these recommendations, very little is known about the patterns of use of corticosteroids (dose and duration) in routine clinical practice. Our hypothesis is that, in the real world, practices vary widely, and the dose and duration of SCS are usually greater than those recommended in the clinical guidelines, and that this may impact on the duration of hospital stay.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study Design and Participants</span><p id="par0020" class="elsevierStylePara elsevierViewall">This was a prospective, observational cohort study in patients seen in a tertiary hospital (Hospital Universitario de A Coruña), with a catchment area of 540<span class="elsevierStyleHsp" style=""></span>000 inhabitants. The study was conducted between 1 July 2013 and 1 August 2015, and was approved by the Galician Clinical Research Ethics Committee (CREC).</p><p id="par0025" class="elsevierStylePara elsevierViewall">We included patients older than 40 years, with a history of smoking, COPD diagnosis prior to admission defined according to the GOLD criteria (FEV1/FVC<0.7 post-bronchodilator), and a diagnosis of COPDE. Patients who were taking chronic SCS were excluded, as were those who did not receive SCS during hospitalization, and those with no history of smoking. Only the first admission was analyzed among patients who were readmitted.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Objectives</span><p id="par0030" class="elsevierStylePara elsevierViewall">The primary study objective was to determine the percentage of patients receiving short course of SCS in the treatment of acute COPDE. A short course was defined as a cumulative dose 200–300<span class="elsevierStyleHsp" style=""></span>mg prednisone or equivalent over 5–6 days. Secondary variables were the percentage of patients with a SCS duration of 5–6 days, percentage of patients with a cumulative dose of 200–300<span class="elsevierStyleHsp" style=""></span>mg prednisone, dose given in the first 24<span class="elsevierStyleHsp" style=""></span>h, days of intravenous SCS, and duration of hospital stay.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data Collection</span><p id="par0035" class="elsevierStylePara elsevierViewall">Patients were seen by the usual medical team in each department, and data were collected by the investigators. Data were collected from patients admitted to the respiratory medicine hospital ward and to one of the internal medicine wards. Demographic (age, sex, smoking status, and immunizations), laboratory and clinical data were collected from the patients. Comorbidities were assessed and the Charlson index was calculated. Functional status was evaluated using the Barthel index. COPD severity was determined from spirometric values, baseline dyspnea scale (mMRC), COPD assessment test (CAT), and exacerbation history. The severity of the current episode was assessed by calculating dyspnea, eosinopenia, consolidation, acidosis, and atrial fibrillation. Treatments received by all patients were recorded. With regard to SCS, the type, dose, duration and route of administration were recorded. Prednisone doses were used as a reference for the calculation of equivalent doses of other SCS. Finally, data on hospitalization were recorded, including days of hospital stay, resources used (ICU admission and need for mechanical ventilation), and in-hospital mortality.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical Analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">Quantitative data are expressed as mean and standard deviation and qualitative data as frequencies. Quantitative data that did not follow a normal distribution are expressed as median and interquartile range. The association between hospital stay and duration of steroid treatment and cumulative dose were evaluated using the Spearman rank correlation. Simple linear regression with days of hospital stay as the dependent variable was used to study the degree of correlation. Multivariate linear regression was performed with factors associated with hospital stay: variables with a <span class="elsevierStyleItalic">P</span>-value of <.05 in the univariate analysis were incorporated into this model. All statistical analyses were performed using a digital statistical program (Stata for Mac O.S., version 13.0; Statacorp Inc., USA). Values were considered significant if <span class="elsevierStyleItalic">P</span><.05.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Patient Characteristics</span><p id="par0045" class="elsevierStylePara elsevierViewall">A total of 179 patients were analyzed, of whom 21 were withdrawn from the study (6 for chronic use of corticosteroids, 11 who did not receive corticosteroids, and 4 non-smokers). The final cohort consisted of 158 patients, 88.6% of whom were men. Mean age was 69.8 (standard deviation, 9.5) years. Patient characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Dose and Duration of Treatment with Systemic Corticosteroids</span><p id="par0050" class="elsevierStylePara elsevierViewall">Only 4.4% of the cohort (7 patients) received a short course of SCS; 8.7% (13) received an SCS dose of between 200 and 300<span class="elsevierStyleHsp" style=""></span>mg; and in 15.8% (24) the duration of administration was 5–6 days. Mean SCS dose was 602.5<span class="elsevierStyleHsp" style=""></span>mg (interquartile range [IQR]: 430–850), and the median duration of SCS was 14 days (IQR: 7–20) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Median duration of intravenous SCS was 4 days (IQR: 2–7) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Median length of hospital stay was 9 days (IQR: 7–12.5) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Relationship of Dose and Duration of Treatment With Systemic Steroids and Hospital Stay</span><p id="par0055" class="elsevierStylePara elsevierViewall">A positive association was observed between the dose of SCS and hospital stay (<span class="elsevierStyleItalic">P</span><.001) (rho=0.48) and days of SCS and hospital stay (<span class="elsevierStyleItalic">P</span><.001) (rho=0.49) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The multivariate analysis showed that a greater length of hospital stay was independently associated with a higher dose of SCS during admission after adjustment for other clinical variables, such as days of steroid treatment and PaFi (hazard ratio pO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span>) at admission (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">The dose and duration of treatment with SCS in COPD exacerbations in clinical practice are much higher than those recommended in clinical practice guidelines, and are associated with increased hospital stay. Treatment with SCS in patients admitted to hospital with severe exacerbation of COPD is a practice that is clearly widespread in hospitals. Indeed, the AUDIPOC study<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a> showed that more than 90% of the patients who had been admitted for COPDE received treatment with SCS.</p><p id="par0065" class="elsevierStylePara elsevierViewall">This unquestionable evidence on the use of these drugs prompts us to ask whether they might be less beneficial in some subgroups, such as patients with low eosinophil levels<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">14–16</span></a> and patients whose exacerbation is clearly caused by infection,<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">17</span></a> or if the efficacy of high doses administered by inhalation would be comparable to that of systemic administration.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">18</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In this study, we observed that instead of the recommended dose of 200<span class="elsevierStyleHsp" style=""></span>mg (40<span class="elsevierStyleHsp" style=""></span>mg/day for 5 days), patients in clinical practice were receiving 3 times this amount. This could be explained in several ways: (a) a delayed switch to oral treatment; (b) doses of corticosteroid used in asthma being transferred to COPD; and (c) the risk of adrenal crisis due to an abrupt withdrawal. It is interesting to note that more than 50% of the recommended dose is administered in the first 24<span class="elsevierStyleHsp" style=""></span>h, a period during which the patient is generally treated in the emergency department. In addition, we found that the recommended short duration of administration (5 days) is almost is tripled in clinical practice. Despite evidence that oral administration of steroids is not inferior to intravenous administration,<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a> and that this is the route of choice in some guidelines,<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">6,10</span></a> we found in this study that the average time to switch to oral administration was 5 days. Delays in the switch to oral administration, whether for corticosteroids or antibiotics, would require the patient to remain hospitalized for intravenous administration, thus extending hospital stay. It is important to remember that patients receiving corticosteroids are at risk of hyperglycemia. Excessive exposure to corticosteroids, whether from excessively high doses or prolonged duration of treatment, may cause hyperglycemia,<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a> and concomitant hyperglycemia can also prolong hospital stay. Accumulated doses of corticosteroid can also cause musculoskeletal effects which may become a problem as the frequency of exacerbations increases. The most worrying of these effects are fractures, infections and other metabolic changes.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">This study has a number of limitations that should be mentioned. The most obvious is that its single-center design prevents any generalization of our conclusions. However, we suspect that our observations hold true for other centers, or that the situation is even be worse than our findings suggest. In the AUDIPOC study, for example, 72% of patients who received corticosteroids during admission continued to receive them on discharge, compared to 52% in our series. A second limitation is that the study was conducted under conditions of routine clinical practice, and some of the study investigators were directly involved in the clinical management of these patients, a situation which may have generated some bias when deciding on the recommended dose and treatment duration. Moreover, the patients were not classified by phenotypes, so we cannot be sure, but merely suspect, that patients with asthma-COPD overlap behave differently. Finally, while we found an independent association between the duration of hospital stay and the dose and duration of steroids, many other factors which might have a direct effect on clinical practice were not analyzed, such as social considerations, hospital inefficiencies, continued care after discharge, etc.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In summary, this study shows that systemic corticosteroid regimens used in clinical practice in the treatment of severe exacerbations of COPD are administered for much longer periods and at higher doses than recommended, a practice that has a direct impact on hospital stay. More studies are needed to confirm how generalized this practice is in our setting and to determine the possible medium- and long-term consequences.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflict of Interests</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres941024" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec914248" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres941025" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec914247" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and Methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study Design and Participants" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Objectives" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Data Collection" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical Analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Patient Characteristics" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Dose and Duration of Treatment with Systemic Corticosteroids" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Relationship of Dose and Duration of Treatment With Systemic Steroids and Hospital Stay" ] ] ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflict of Interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-01-18" "fechaAceptado" => "2017-03-22" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec914248" "palabras" => array:5 [ 0 => "Chronic obstructive pulmonary disease" 1 => "Exacerbation" 2 => "Steroids" 3 => "Length of hospital stay" 4 => "Hospitalization" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec914247" "palabras" => array:5 [ 0 => "Enfermedad pulmonar obstructiva crónica" 1 => "Agudización" 2 => "Esteroides" 3 => "Estancia hospitalaria" 4 => "Hospitalización" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">It is not known whether clinical practice guidelines for the treatment of COPD exacerbations with short courses of systemic corticosteroids (SC-SCS) are followed in clinical practice.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Prospective, observational cohort study in patients admitted due to severe COPD exacerbation. The primary endpoint was the percentage of patients who received SC-SCS as treatment for severe exacerbation (doses of 200–300<span class="elsevierStyleHsp" style=""></span>mg for 5–6 days). Secondary variables were percentage of patients with duration or reduced dose, dose in the first 24<span class="elsevierStyleHsp" style=""></span>h, days of intravenous systemic corticosteroids (SCS), and duration of hospital length of stay (LOS). Simple linear regression was performed with LOS as a dependent variable and multivariate analysis with factors associated with LOS.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">158 patients were evaluated. 4.4% (7) patients received SC-SCS, 8.7% received a reduced dose and duration was reduced in 15.8%. The median dose and duration of SCS were 602.5<span class="elsevierStyleHsp" style=""></span>mg (200–1625) and 14 (4–36) days, respectively. We observed an association between days of SCS and LOS (<span class="elsevierStyleItalic">P</span><.001) and doses of intrahospital SCS and LOS (<span class="elsevierStyleItalic">P</span><.001). Factors associated with LOS were doses of intrahospital SCS received (0.01 [95% CI: 0.007–0.013]; <span class="elsevierStyleItalic">P</span><.001), days of steroid treatment (0.14 [95% CI: 0.03–0.25], <span class="elsevierStyleItalic">P</span>=.009) and PAFI (pO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> ratio) at admission (−0.012 [95% CI: −0.012 to -0.002], <span class="elsevierStyleItalic">P</span>=.015).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The SCS schedules used in routine clinical practice are longer and administered at a higher dose than recommended, leading to a longer hospital stay.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se desconoce si en la práctica clínica habitual se siguen las recomendaciones de las guías de práctica clínica con respecto al tratamiento de las exacerbaciones de la EPOC con pautas cortas (PC) de corticoesteroides sistémicos (CS).</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Método</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohortes, prospectivo y observacional en pacientes que ingresan por una agudización grave de su EPOC. La variable principal fue porcentaje de pacientes que recibían PC de CS como tratamiento en la exacerbación grave (dosis acumulada total de 200 a 300<span class="elsevierStyleHsp" style=""></span>mg y una duración de 5-6 días). Las variables secundarias fueron porcentaje de pacientes con duración o dosis corta, dosis en las primeras 24<span class="elsevierStyleHsp" style=""></span>horas, días de CS intravenosos y duración de la estancia hospitalaria (EH). Se realizó regresión lineal simple con días de estancia hospitalaria como variable dependiente y análisis multivariante con factores asociados a estancia hospitalaria.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se evaluaron 158 pacientes; 4,4% (7) pacientes recibieron una PC de CS. El 8,7% recibió un tratamiento corto y el 15,8% una duración reducida. La mediana de dosis y duración de CS fue 602,5<span class="elsevierStyleHsp" style=""></span>mg (rango intercuartílico: 430-850) y 14 (rango intercuartílico: 4-36) días respectivamente. Observamos asociación entre más días de CS y una mayor EH (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001) y una mayor dosis de CS intrahospitalaria e incremento de EH (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001). Los factores asociados con EH fueron dosis de CS intrahospitalaria recibida (0,01 [IC 95%: 0,007-0,013]; p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001), días de tratamiento esteroideo (0,14 [IC 95%: 0,03-0,25]; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,009) y PAFI (cociente pO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span>) al ingreso (–0,012 [IC 95%: –0,012 a –0,002]; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,015).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Las pautas de CS empleadas en la práctica clínica habitual son más prolongadas y a una mayor dosis que las recomendadas, asociando una mayor estancia hospitalaria.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Marcos PJ, Nieto-Codesido I, de Jorge Dominguez-Pazos S, Huerta A, Márquez E, Maiso A, et al. Tratamiento con esteroides sistémicos en agudización grave de enfermedad pulmonar obstructiva crónica: empleo de pautas cortas en práctica clínica habitual y relación con la estancia hospitalaria. Arch Bronconeumol. 2017;53:611–615.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1745 "Ancho" => 2483 "Tamanyo" => 117905 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">(A) Duration of steroid treatment. (B) Cumulative steroid dose.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1629 "Ancho" => 2598 "Tamanyo" => 182163 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">(A) Association between hospital stay and the cumulative dose of prednisone during admission. (B) Association between hospital stay and duration of treatment with systemic steroids.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">CI: inhaled corticosteroid; CRP: C-reactive protein; DECAF: DECAF score (Dyspnea, Eosinopenia, Consolidation, Acidemia and atrial Fibrillation); FEV1: forced expiratory volume in the first second; FVC: forced vital capacity; LABA: long-acting beta-2 agonist; LAMA: long-acting muscarinic agonist; PAFI: ratio of partial pressure arterial oxygen and fraction of inspired oxygen.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Demographic Data \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Male</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">140 (88.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age (years)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69.8 (9.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Active smoking</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64 (40.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Cumulative consumption (pack-years)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57 (SD=24.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Influenza vaccination</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96 (60.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Pneumococcal vaccination</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52 (32.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Barthel</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92.7 (SD=19.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Concomitant disease</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anxiety \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Depression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 (13.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Osteoporosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 (3.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Arterial hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75 (47.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Atrial fibrillation, atrial flutter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17 (10.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Thromboembolic disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 (3.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Abdominal aortic aneurysm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (2.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Acute myocardial infarction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 (7.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Peripheral artery disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 (12.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Heart failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 (8.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cerebral artery disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 (8.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hemiplegia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (1.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Venous ulcer disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 (4.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mild liver disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 (3.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Moderate-severe liver disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (1.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Moderate-severe renal disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37 (23.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diabetes with organ involvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (1.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tumor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 (12.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Metastatic tumor disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (1.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Charlson \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.5 (SD=2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">History of COPD</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Chronic bronchitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92 (58.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>History of asthma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No. of exacerbations in previous year<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (IQR: 0–15) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38 (24) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1–2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43 (27.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>≥2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">77 (48.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>mMRC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.6 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>FEV1/FVC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43.8 (12.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>FEV1 cc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1173 (530.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>FEV1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44.8 (19.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>FVC cc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2666 (827.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>FVC% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75.2 (21.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>BODEX \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.3 (1.29) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Home oxygen therapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56 (36.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LAMA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">122 (77.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LABA-ICS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">120 (75.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Current admission</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PAFI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">257.6 (83.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Eosinophils (no.) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 (10–560) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Eosinophils (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.5 (0.06–6.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>CRP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.97 (0.1–19.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>DECAF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.3 (0.96) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1592587.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Includes moderate and severe exacerbations.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Baseline Patient Characteristics.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">SCS: systemic corticosteroid.</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">SCS dose in milligrams of prednisone.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Median (Interquartile Range) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SCS dose in first 24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">125 (100–150) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SCS dose during hospitalization \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">510 (370–695) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SCS dose on discharge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45 (0–175) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total SCS dose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">602.5 (430–850) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intravenous steroid dose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (2–7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total days of steroid administration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 (7–20) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Days of hospital stay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (7–12.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1592589.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">SCS Dose and Duration.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">PAFI: ratio of partial pressure arterial oxygen and fraction of inspired oxygen; SCS: systemic corticosteroid.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Coefficient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intrahospital dose of SCS (mg prednisone) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total days of SCS administration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.009 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PAFI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.015 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1592588.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Multivariate Analysis of the Association of Hospital Stay and Intrahospital Dose of Corticosteroids.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0110" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G.C. 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Zdanowicz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2146/ajhp090293" "Revista" => array:6 [ "tituloSerie" => "Am J Health Syst Pharm" "fecha" => "2010" "volumen" => "67" "paginaInicial" => "1061" "paginaFinal" => "1069" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20554591" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005300000011/v2_201711201359/S1579212917303099/v2_201711201359/en/main.assets" "Apartado" => array:4 [ "identificador" => "9374" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original Articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005300000011/v2_201711201359/S1579212917303099/v2_201711201359/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212917303099?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 0 | 3 |
| 2024 October | 42 | 6174 | 6216 |
| 2024 September | 64 | 27 | 91 |
| 2024 August | 105 | 48 | 153 |
| 2024 July | 111 | 37 | 148 |
| 2024 June | 87 | 33 | 120 |
| 2024 May | 117 | 36 | 153 |
| 2024 April | 45 | 40 | 85 |
| 2024 March | 51 | 29 | 80 |
| 2024 February | 35 | 23 | 58 |
| 2023 March | 19 | 10 | 29 |
| 2023 February | 77 | 22 | 99 |
| 2023 January | 60 | 46 | 106 |
| 2022 December | 79 | 33 | 112 |
| 2022 November | 75 | 31 | 106 |
| 2022 October | 59 | 52 | 111 |
| 2022 September | 35 | 27 | 62 |
| 2022 August | 38 | 45 | 83 |
| 2022 July | 27 | 54 | 81 |
| 2022 June | 40 | 27 | 67 |
| 2022 May | 38 | 44 | 82 |
| 2022 April | 34 | 30 | 64 |
| 2022 March | 71 | 58 | 129 |
| 2022 February | 58 | 25 | 83 |
| 2022 January | 68 | 35 | 103 |
| 2021 December | 59 | 42 | 101 |
| 2021 November | 50 | 48 | 98 |
| 2021 October | 60 | 51 | 111 |
| 2021 September | 57 | 50 | 107 |
| 2021 August | 62 | 42 | 104 |
| 2021 July | 42 | 30 | 72 |
| 2021 June | 63 | 37 | 100 |
| 2021 May | 58 | 40 | 98 |
| 2021 April | 152 | 80 | 232 |
| 2021 March | 116 | 42 | 158 |
| 2021 February | 75 | 22 | 97 |
| 2021 January | 57 | 12 | 69 |
| 2020 December | 53 | 33 | 86 |
| 2020 November | 56 | 16 | 72 |
| 2020 October | 48 | 15 | 63 |
| 2020 September | 41 | 14 | 55 |
| 2020 August | 30 | 15 | 45 |
| 2020 July | 40 | 22 | 62 |
| 2020 June | 35 | 9 | 44 |
| 2020 May | 37 | 23 | 60 |
| 2020 April | 38 | 24 | 62 |
| 2020 March | 40 | 10 | 50 |
| 2020 February | 38 | 22 | 60 |
| 2020 January | 48 | 38 | 86 |
| 2019 December | 56 | 22 | 78 |
| 2019 November | 47 | 23 | 70 |
| 2019 October | 56 | 18 | 74 |
| 2019 September | 29 | 22 | 51 |
| 2019 August | 25 | 16 | 41 |
| 2019 July | 32 | 20 | 52 |
| 2019 June | 60 | 21 | 81 |
| 2019 May | 81 | 25 | 106 |
| 2019 April | 37 | 22 | 59 |
| 2019 March | 42 | 24 | 66 |
| 2019 February | 36 | 29 | 65 |
| 2019 January | 43 | 27 | 70 |
| 2018 December | 44 | 18 | 62 |
| 2018 November | 205 | 26 | 231 |
| 2018 October | 281 | 26 | 307 |
| 2018 September | 115 | 11 | 126 |
| 2018 May | 34 | 2 | 36 |
| 2018 April | 30 | 9 | 39 |
| 2018 March | 42 | 14 | 56 |
| 2018 February | 62 | 4 | 66 |
| 2018 January | 1 | 0 | 1 |
| 2017 November | 2 | 0 | 2 |
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