Editorial
Exacerbation syndrome in COPD: A paradigm shift
Hacia el síndrome de agudización en la EPOC: un cambio de paradigma
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La presencia de un factor desencadenante sobre un paciente con EPOC (con sus condicionantes sociales y su comorbilidad) provoca la aparición de un síndrome de un SAE, donde el empeoramiento de la disnea es el exponente final de diversos mecanismos biológicos y fisiopatológicos. Consecuencia de la heterogeneidad del cuadro se pueden expresar distintos endotipos biológicos y varias presentaciones fenotípicas susceptibles de recibir tratamientos específicos.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Juan José Soler-Cataluña, Cristina Miralles" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Juan José" "apellidos" => "Soler-Cataluña" ] 1 => array:2 [ "nombre" => "Cristina" "apellidos" => "Miralles" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1579212921000380" "doi" => "10.1016/j.arbr.2020.07.021" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212921000380?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289620302337?idApp=UINPBA00003Z" "url" => "/03002896/0000005700000004/v1_202104020827/S0300289620302337/v1_202104020827/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S1579212921000392" "issn" => "15792129" "doi" => "10.1016/j.arbr.2020.08.013" "estado" => "S300" "fechaPublicacion" => "2021-04-01" "aid" => "2601" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "edi" "cita" => "Arch Bronconeumol. 2021;57:249-50" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "The long road to biologic therapies for asthma in pediatric patients" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "249" "paginaFinal" => "250" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El largo camino al tratamiento con biológicos del asma en pediatría" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jaime Lozano, Begonya Nafria, Laia Alsina" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Jaime" "apellidos" => "Lozano" ] 1 => array:2 [ "nombre" => "Begonya" "apellidos" => "Nafria" ] 2 => array:2 [ "nombre" => "Laia" "apellidos" => "Alsina" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0300289620302829" "doi" => "10.1016/j.arbres.2020.08.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289620302829?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212921000392?idApp=UINPBA00003Z" "url" => "/15792129/0000005700000004/v1_202104020819/S1579212921000392/v1_202104020819/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1579212921000343" "issn" => "15792129" "doi" => "10.1016/j.arbr.2020.04.013" "estado" => "S300" "fechaPublicacion" => "2021-04-01" "aid" => "2485" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "edi" "cita" => "Arch Bronconeumol. 2021;57:243-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Treatment of moderate-severe asthma: an alternative strategy to the guideline recommendations" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "243" "paginaFinal" => "245" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estrategia para el tratamiento del asma moderada-grave: una alternativa a la recomendada por las guías" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2969 "Ancho" => 2508 "Tamanyo" => 246148 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Therapeutic algorithm for the treatment of uncontrolled asthma with high doses of inhaled corticosteroids.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">BHR: bronchial hyperresponsiveness; FP: fluticasone propionate; ICS: inhaled corticosteroids; LABA: long-action β-adrenergic agonists; LTRA: leukotriene receptor antagonists (*: especially indicated in patients with predominantly inflammatory changes rather than functional impairment with upper airway involvement, clinically significant allergy, or acetylsalicylic acid-exacerbated respiratory disease); OCS: oral corticosteroids; T2: inflammation mediated by T helper type 2 (Th2) cells or innate lymphoid cells type 2 (ILC2s).</p>" ] ] ] "autores" => array:3 [ 0 => array:2 [ "autoresLista" => "Luis Pérez de Llano" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Luis" "apellidos" => "Pérez de Llano" ] ] ] 1 => array:2 [ "autoresLista" => "Santiago Quirce Gancedo" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Santiago" "apellidos" => "Quirce Gancedo" ] ] ] 2 => array:2 [ "autoresLista" => "Vicente Plaza Moral" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Vicente" "apellidos" => "Plaza Moral" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0300289620301368" "doi" => "10.1016/j.arbres.2020.04.017" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289620301368?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212921000343?idApp=UINPBA00003Z" "url" => "/15792129/0000005700000004/v1_202104020819/S1579212921000343/v1_202104020819/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Exacerbation syndrome in COPD: A paradigm shift" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "246" "paginaFinal" => "248" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Juan José Soler-Cataluña, Cristina Miralles" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Juan José" "apellidos" => "Soler-Cataluña" "email" => array:1 [ 0 => "jjsoler@telefonica.net" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Cristina" "apellidos" => "Miralles" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Arnau de Vilanova, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hacia el síndrome de agudización en la EPOC: un cambio de paradigma" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1416 "Ancho" => 3204 "Tamanyo" => 176531 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The diagram shows the concept of CES. The presence of a triggering factor in a COPD patient (with its social determinants and comorbidity) leads to the appearance of a CES syndrome, where worsening dyspnea is the final manifestation of various biological and pathophysiological mechanisms. Because of the heterogeneity of symptoms, different biological endotypes and various phenotypic presentations susceptible to specific treatments can be expressed.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In a position paper published in 1995, the American Thoracic Society (ATS) officially recognized that the exacerbation of chronic obstructive pulmonary disease (COPD) was difficult to define, and that its pathogenesis was still unclear. At the time, the society already mooted the need for a standardized definition that could be universally accepted and useful for clinicians, researchers, and other health providers.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Five years later, responding to that challenge, a group of experts led by Dr. Rodríguez-Roisin<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> defined exacerbation as <span class="elsevierStyleItalic">“a sustained worsening of the patient's condition, from the s</span>table s<span class="elsevierStyleItalic">tate and beyond normal day-to-day variations, that is acute in onset and necessitates a change in regular medication in a patient with underlying COPD”.</span> It has been 20 years since that initial proposal, and significant advances have been made in the knowledge of COPD, which is now understood as a complex and heterogeneous syndrome requiring an increasingly personalized approach.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However, the concept, diagnosis, and management of exacerbations have hardly changed. We continue to indiscriminately use short-acting bronchodilators, systemic steroids, and antibiotics with poor outcomes. Therapeutic failures are common, the 30-day readmission rate is 20%, and in-hospital mortality is 5%, increasing to 11% at 3 months. Furthermore, a considerable proportion of patients have persistent exacerbations, we do not have a good classification system, we do not use generalized predictive risk models, admission criteria are not standardized, and clinical trials still define exacerbation or severity based on resource use.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–7</span></a> As a result, scientific results are very heterogeneous and progress is inconsistent.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The origin of this confusion lies in the construction of the definition itself, which fails to identify the underlying biological mechanism, does not recognize the heterogeneity of the clinical picture and, being symptom-based, is very unspecific. Many other concomitant diseases (comorbidities) can also cause the same worsening of symptoms in COPD patients. Heart failure, arrhythmias, ischemic heart disease, anxiety, pulmonary embolism, and pneumonia are diseases that often occur in COPD and present with increased respiratory symptoms. However, by consensus, they are not considered COPD exacerbations. A comprehensive differential diagnosis is needed to rule out these other diseases, but this is not always easy. Pneumonia, for example, is an entity that is typically distinct from exacerbation due to the presence of infiltrates in the pulmonary parenchyma. However, the difference between the two entities is very subtle. Up to one third of COPD patients have infiltrates on computed tomography that are not visible on simple chest X-ray.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> These patients are classified and categorized as COPD exacerbations when they are actually pneumonia. Are they different entities or phases of the same disease? The pulmonary microbiome is practically identical, causative factors are very similar, and clinical expression, prognostic impact, and treatment are also similar.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> A similar situation occurs with heart failure, ischemic heart disease, and pulmonary embolism, which often overlap with the exacerbation itself.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10–12</span></a> The direct consequence of all this is confusion, heterogeneous clinical outcomes, scant progress in understanding the underlying mechanisms, and barriers to accessing personalized treatment. A change of strategy is therefore urgent. We need a new definition derived from more objective and specific criteria that, even at the risk of losing some sensitivity, also takes into account the variety of presentations, helps identify biological endotypes, and offers a direct pathway to precision medicine.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A good reference model is acute coronary disease, the current definition of which is based on 3 essential parameters: 1) a syndrome-based approach (acute coronary syndrome); 2) a guiding symptom (chest pain); and 3) objective variables with underlying biological mechanisms (electrocardiographic alterations and biomarkers).<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Using a syndrome-based approach to what we might call COPD exacerbation syndrome (CES) would allow us to take into account all other diseases that can produce similar symptoms that are very hard to differentiate. The advantage of this approach is that differentiated and/or combined clinical endotypes or phenotypes that may potentially have different outcomes and specific therapeutic approaches are taken into account (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Worsening dyspnea emerges as the guiding symptom of CES. Expiratory airflow limitation and dynamic hyperinflation have been described as the main pathophysiological mechanisms, although cardiovascular, muscle, and psychosocial disorders may also be involved.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Changes in respiratory rate, heart rate and/or gas exchange are also an objective manifestation of underlying pathophysiological changes, so analysis of these parameters may be helpful.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Finally, we need to incorporate biomarkers associated with the underlying biological alteration that help identify and categorize exacerbations and guide treatment. Various, largely unsuccessful, attempts have been made to identify a reference biomarker for diagnosis.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> However, the simultaneous use of different biomarkers may open new avenues. In a multilevel analysis, Noell et al.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> found that the best biomarker panel to define exacerbation was the combination of circulating neutrophils, C-reactive protein, and dyspnea (area under the curve = 0.97). Peripheral eosinophilia, procalcitonin, D-dimer or cardiovascular biomarkers such as troponin or N-terminal pro-brain natriuretic peptide (NT-pro-BNP) are some examples of other biomarkers that may be helpful in identifying traits that guide personalization of treatment,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> although none of them has been shown to be sufficiently specific to the disease. In contrast, some alveolar mediators, such as surfactant protein D, may be useful during COPD exacerbations.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In short, a quarter of a century after the ATS recommendation, we need to change the paradigm and redefine exacerbation by incorporating elements that help improve the specificity of the clinical picture, without losing sensitivity. A syndrome-based approach may better address the heterogeneity of the process. Dyspnea emerges as the guiding symptom. However, given its subjective nature, it would be desirable to include some objective parameters associated with the pathophysiology of the episode, along with biomarkers that help to profile the underlying endotype. Only if we can improve the specificity of the picture will we be able to deepen our understanding of its biological mechanisms, customize treatments, and ultimately mitigate the negative consequences that these episodes generate.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0035" class="elsevierStylePara elsevierViewall">Juan José Soler-Cataluña has received speaker fees from AstraZeneca, Boehringer Ingelheim, Bial, Ferrer, Laboratorio Esteve, Menarini, Mundipharma, Novartis, Rovi, and TEVA; consultancy fees from AirLiquide, AstraZeneca, Boehringer Ingelheim, Chiesi, Ferrer, GlaxoSmithKline, Laboratorios Esteve, Mundipharma and Novartis, and research assistance from GlaxoSmithKline, Chesi, and Boehringer Ingelheim.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Cristina Miralles Saavedra states that she has no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Soler-Cataluña JJ, Miralles C. Hacia el síndrome de agudización en la EPOC: un cambio de paradigma. Arch Bronconeumol. 2021;57:246–248.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1416 "Ancho" => 3204 "Tamanyo" => 176531 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The diagram shows the concept of CES. The presence of a triggering factor in a COPD patient (with its social determinants and comorbidity) leads to the appearance of a CES syndrome, where worsening dyspnea is the final manifestation of various biological and pathophysiological mechanisms. Because of the heterogeneity of symptoms, different biological endotypes and various phenotypic presentations susceptible to specific treatments can be expressed.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "American Thoracic Society" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "1995" "volumen" => "152" "paginaInicial" => "S77" "paginaFinal" => "S120" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7582322" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Toward a consensus definition for COPD exacerbations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R. Rodriguez-Roisin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.117.5_suppl_2.398s" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2000" "volumen" => "117" "paginaInicial" => "398S" "paginaFinal" => "401S" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10843984" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "COPD: time to improve its taxonomy?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "B.R. Celli" 1 => "A. Agustí" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/23120541.00132-2018" "Revista" => array:6 [ "tituloSerie" => "ERJ Open Res" "fecha" => "2018" "volumen" => "4" "paginaInicial" => "00132" "paginaFinal" => "02017" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30364344" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Early hospital readmissions after an acute exacerbation of chronic obstructive pulmonary disease in the nationwide readmission database" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.M. Jacobs" 1 => "K. Noyes" 2 => "J. Zhao" 3 => "W. Gibson" 4 => "T.F. Murphy" 5 => "S. Sethi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1513/AnnalsATS.201712-913OC" "Revista" => array:6 [ "tituloSerie" => "Ann Am Thorac Soc" "fecha" => "2018" "volumen" => "15" "paginaInicial" => "837" "paginaFinal" => "845" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29611719" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk of death and readmission of hospital-admitted COPD exacerbation European COPD audit" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Hartl" 1 => "J.L. López-Campos" 2 => "F. Pozo-Rodríguez" 3 => "A. Castro-Acosta" 4 => "M. Studnicka" 5 => "B. Kaiser" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/13993003.01391-2014" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2016" "volumen" => "47" "paginaInicial" => "113" "paginaFinal" => "121" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26493806" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Susceptibility to exacerbation in chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.R. Hurst" 1 => "J. Vestbo" 2 => "A. Anzueto" 3 => "N. Locantore" 4 => "H. Müllerova" 5 => "R. Tal-Singer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "N Engl J Med" "fecha" => "2010" "volumen" => "363" "paginaInicial" => "1128" "paginaFinal" => "1138" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prediction models for exacerbation in patients with COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B. Guerra" 1 => "V. Gaveikate" 2 => "C. Bianch" 3 => "M.A. Puhan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/16000617.0061-2016" "Revista" => array:5 [ "tituloSerie" => "Eur Respir Rev" "fecha" => "2017" "volumen" => "26" "paginaInicial" => "160061" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28096287" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Early chest computed tomography scan to assist diagnosis and guide treatment decision for suspected community-acquired pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y.-E. Claessens" 1 => "M.-P. Debray" 2 => "F. Tubach" 3 => "A.-L. Brun" 4 => "B. Rammaert" 5 => "P. Hausfater" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2015" "volumen" => "192" "paginaInicial" => "974" "paginaFinal" => "982" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impact of radiologically stratified exacerbations: insights into pneumonia aetiology in COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N.P. Williams" 1 => "K. Ostrigde" 2 => "J.M. Devaster" 3 => "V. Kim" 4 => "N.A. Coombs" 5 => "S. Bourne" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s12931-018-0842-8" "Revista" => array:5 [ "tituloSerie" => "Respir Res" "fecha" => "2018" "volumen" => "19" "paginaInicial" => "143" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30055608" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Biochemical markers of cardiac dysfunction predict mortality in acute exacerbations of COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.L. Chang" 1 => "S.C. Robinson" 2 => "G.D. Mills" 3 => "G.D. Sullivan" 4 => "N.C. Karalus" 5 => "J.D. McLachlan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2010.155333" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2011" "volumen" => "66" "paginaInicial" => "764" "paginaFinal" => "768" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21474497" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Association of left-heart dysfunction with severe exacerbation of chronic obstructive pulmonary disease. Diagnostic performance of cardiac biomarkers" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Abroug" 1 => "L. Quanes-Besbes" 2 => "N. Nciri" 3 => "N. Sellami" 4 => "F. Addad" 5 => "K. Ben Hamda" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.200603-380OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2006" "volumen" => "174" "paginaInicial" => "990" "paginaFinal" => "996" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16840745" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence and localization of pulmonary embolism in unexplained acute exacerbations of COPD: a systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "F.E. Aleva" 1 => "L.W. Voets" 2 => "S.O. Simons" 3 => "Q. de Mast" 4 => "A.J. van der Ven" 5 => "Y.F. Heijdra" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.chest.2016.07.034" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2017" "volumen" => "151" "paginaInicial" => "544" "paginaFinal" => "554" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27522956" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dissecting COPD exacerbations: time to rethink our definition" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "B.R. Celli" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/13993003.01432-2017" "Revista" => array:5 [ "tituloSerie" => "Eur Respir J" "fecha" => "2017" "volumen" => "50" "paginaInicial" => "1701432" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28954777" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Physiologic changes during symptom recovery from moderate exacerbation of COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C.M. Parker" 1 => "N. Voduc" 2 => "S.D. Aaron" 3 => "K.A. Webb" 4 => "D.E. O’Donnell" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.05.00136304" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2005" "volumen" => "26" "paginaInicial" => "420" "paginaFinal" => "428" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16135722" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of plasma biomarkers at exacerbation of chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.R. Hurst" 1 => "G.C. Donaldson" 2 => "W.R. Perera" 3 => "T.M.A. Wilkinson" 4 => "J.A. Bilello" 5 => "G.W. Hagan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.200604-506OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2006" "volumen" => "174" "paginaInicial" => "867" "paginaFinal" => "874" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16799074" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multi-level differential network analysis of COPD exacerbations" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Noell" 1 => "B.G. Cosío" 2 => "R. Faner" 3 => "E. Monsó" 4 => "G. Peces-Barba" 5 => "A. de Diego" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Eur Respir J" "fecha" => "2017" "volumen" => "50" ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A systematic review of diagnostic biomarkers of COPD exacerbation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Y.W.R. Chen" 1 => "J.M. Leung" 2 => "D. Sin" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "PLoS One" "fecha" => "2017" "volumen" => "11" ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Serum surfactant protein D during acute exacerbations of chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "T.A. Shakoori" 1 => "D.D. Sin" 2 => "F. Ghafoor" 3 => "S. Bashir" 4 => "S.N. Bokhari" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3233/DMA-2009-0674" "Revista" => array:7 [ "tituloSerie" => "Dis Markers" "fecha" => "2014" "volumen" => "27" "paginaInicial" => "287" "paginaFinal" => "294" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20075511" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0302283812004022" "estado" => "S300" "issn" => "03022838" ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005700000004/v1_202104020819/S1579212921000380/v1_202104020819/en/main.assets" "Apartado" => array:4 [ "identificador" => "45360" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorials" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005700000004/v1_202104020819/S1579212921000380/v1_202104020819/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212921000380?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 2 | 8 |
| 2024 October | 77 | 10 | 87 |
| 2024 September | 61 | 18 | 79 |
| 2024 August | 82 | 33 | 115 |
| 2024 July | 57 | 18 | 75 |
| 2024 June | 74 | 29 | 103 |
| 2024 May | 85 | 36 | 121 |
| 2024 April | 45 | 17 | 62 |
| 2024 March | 76 | 16 | 92 |
| 2024 February | 45 | 29 | 74 |
| 2024 January | 44 | 23 | 67 |
| 2023 December | 42 | 25 | 67 |
| 2023 November | 67 | 15 | 82 |
| 2023 October | 61 | 31 | 92 |
| 2023 September | 49 | 27 | 76 |
| 2023 August | 60 | 43 | 103 |
| 2023 July | 44 | 24 | 68 |
| 2023 June | 50 | 15 | 65 |
| 2023 May | 58 | 18 | 76 |
| 2023 April | 53 | 29 | 82 |
| 2023 March | 77 | 25 | 102 |
| 2023 February | 60 | 25 | 85 |
| 2023 January | 46 | 61 | 107 |
| 2022 December | 63 | 28 | 91 |
| 2022 November | 70 | 30 | 100 |
| 2022 October | 71 | 39 | 110 |
| 2022 September | 68 | 30 | 98 |
| 2022 August | 44 | 39 | 83 |
| 2022 July | 44 | 40 | 84 |
| 2022 June | 46 | 40 | 86 |
| 2022 May | 76 | 32 | 108 |
| 2022 April | 75 | 29 | 104 |
| 2022 March | 75 | 47 | 122 |
| 2022 February | 30 | 26 | 56 |
| 2022 January | 1 | 0 | 1 |
| 2021 November | 1 | 0 | 1 |
| 2021 June | 0 | 1 | 1 |
| 2021 April | 7 | 2 | 9 |
| 2021 March | 2 | 4 | 6 |
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