Showing papers in "Jornal Brasileiro De Pneumologia in 2016"

The role of physical exercise in obstructive sleep apnea.

Abstract: Obstructive sleep apnea (OSA) is a common clinical condition, with a variable and underestimated prevalence. OSA is the main condition associated with secondary systemic arterial hypertension, as well as with atrial fibrillation, stroke, and coronary artery disease, greatly increasing cardiovascular morbidity and mortality. Treatment with continuous positive airway pressure is not tolerated by all OSA patients and is often not suitable in cases of mild OSA. Hence, alternative methods to treat OSA and its cardiovascular consequences are needed. In OSA patients, regular physical exercise has beneficial effects other than weight loss, although the mechanisms of those effects remain unclear. In this population, physiological adaptations due to physical exercise include increases in upper airway dilator muscle tone and in slow-wave sleep time; and decreases in fluid accumulation in the neck, systemic inflammatory response, and body weight. The major benefits of exercise programs for OSA patients include reducing the severity of the condition and daytime sleepiness, as well as increasing sleep efficiency and maximum oxygen consumption. There are few studies that evaluated the role of physical exercise alone for OSA treatment, and their protocols are quite diverse. However, aerobic exercise, alone or combined with resistance training, is a common point among the studies. In this review, the major studies and mechanisms involved in OSA treatment by means of physical exercise are presented. In addition to systemic clinical benefits provided by physical exercise, OSA patients involved in a regular, predominantly aerobic, exercise program have shown a reduction in disease severity and in daytime sleepiness, as well as an increase in sleep efficiency and in peak oxygen consumption, regardless of weight loss. RESUMO A apneia obstrutiva do sono (AOS) e uma condicao clinica comum, possuindo prevalencia variavel e subestimada. Principal condicao associada a hipertensao arterial sistemica secundaria, associa-se ainda a fibrilacao atrial, acidente vascular encefalico e doenca arterial coronariana, aumentando a morbidade e mortalidade cardiovascular. O tratamento da AOS com pressao positiva continua em vias aereas nao e tolerado por todos os pacientes e, muitas vezes, nao e indicado para formas leves. Dai, metodos alternativos de tratamento da AOS e de suas consequencias cardiovasculares sao necessarios. A pratica usual de exercicios fisicos promove beneficios adicionais a reducao do peso em pacientes com AOS; contudo, os mecanismos ainda sao incertos. Entre as adaptacoes fisiologicas proporcionadas pelo exercicio fisico nessa populacao destacam-se o aumento do tonus da musculatura dilatadora das vias aereas superiores e do tempo do estagio do sono de ondas lentas e a reducao do acumulo cervical de liquido, da resposta inflamatoria sistemica e do peso corporeo. Os principais beneficios de programas de exercicio fisico para essa populacao incluem a reducao da gravidade da AOS e da sonolencia diurna e o aumento da eficiencia do sono e consumo maximo de oxigenio. Poucos estudos avaliaram o papel do exercicio fisico realizado de forma isolada no tratamento da AOS, alem de existirem muitas diferencas relacionadas aos protocolos de exercicio utilizados. Entretanto, o emprego de exercicios aerobios isolados ou combinados aos exercicios resistidos e um ponto comum entre os estudos. Nessa revisao, os principais estudos e mecanismos envolvidos no tratamento da AOS por meio da realizacao de exercicios fisicos sao apresentados. Alem dos beneficios clinicos sistemicos proporcionados pelo exercicio fisico, pacientes com AOS submetidos a um programa regular de exercicios predominantemente aerobicos, apresentam reducao da gravidade da doenca e da sonolencia diurna, aumento da eficiencia do sono e do pico de consumo de oxigenio, independentemente da perda de peso.

Is there a rationale for pulmonary rehabilitation following successful chemotherapy for tuberculosis

Abstract: The role of tuberculosis as a public health care priority and the availability of diagnostic tools to evaluate functional status (spirometry, plethysmography, and DLCO determination), arterial blood gases, capacity to perform exercise, lesions (chest X-ray and CT), and quality of life justify the effort to consider what needs to be done when patients have completed their treatment To our knowledge, no review has ever evaluated this topic in a comprehensive manner Our objective was to review the available evidence on this topic and draw conclusions regarding the future role of the "post-tuberculosis treatment" phase, which will potentially affect several million cases every year We carried out a non-systematic literature review based on a PubMed search using specific keywords (various combinations of the terms "tuberculosis", "rehabilitation", "multidrug-resistant tuberculosis", "pulmonary disease", "obstructive lung disease", and "lung volume measurements") The reference lists of the most important studies were retrieved in order to improve the sensitivity of the search Manuscripts written in English, Spanish, and Russian were selected The main areas of interest were tuberculosis sequelae following tuberculosis diagnosis and treatment; "destroyed lung"; functional evaluation of sequelae; pulmonary rehabilitation interventions (physiotherapy, long-term oxygen therapy, and ventilation); and multidrug-resistant tuberculosisThe evidence found suggests that tuberculosis is definitively responsible for functional sequelae, primarily causing an obstructive pattern on spirometry (but also restrictive and mixed patterns), and that there is a rationale for pulmonary rehabilitation We also provide a list of variables that should be discussed in future studies on pulmonary rehabilitation in patients with post-tuberculosis sequelae RESUMO O papel da tuberculose como uma prioridade de saude publica e a disponibilidade de ferramentas diagnosticas para avaliar o estado funcional (espirometria, pletismografia e DLCO), a gasometria arterial, a capacidade de realizar exercicios, as lesoes (radiografia de torax e TC) e a qualidade de vida justificam o esforco de se considerar o que deve ser feito quando os pacientes completam seu tratamento Ate onde sabemos, nenhuma revisao avaliou esse topico de forma abrangente Nosso objetivo foi revisar as evidencias disponiveis e obter algumas conclusoes sobre o futuro papel da fase de "tratamento pos-tuberculose", que ira potencialmente impactar milhoes de casos todos os anos Realizou-se uma revisao nao sistematica da literatura tendo como base uma pesquisa no PubMed usando palavras-chave especificas (varias combinacoes dos termos "tuberculose", "reabilitacao", "tuberculose multirresistente", "doenca pulmonar", "doenca pulmonar obstrutiva", e "medidas de volume pulmonar") As listas de referencias dos artigos principais foram recuperadas para melhorar a sensibilidade da busca Foram selecionados manuscritos escritos em ingles, espanhol e russo As principais areas de interesse foram sequelas de tuberculose apos diagnostico e tratamento; "pulmao destruido"; avaliacao funcional das sequelas; intervencoes de reabilitacao pulmonar (fisioterapia, oxigenoterapia de longo prazo e ventilacao); e tuberculose multirresistente As evidencias encontradas sugerem que a tuberculose e definitivamente responsavel por sequelas funcionais, principalmente causando um padrao obstrutivo na espirometria (mas tambem padroes restritivos e mistos) e que ha razao para a reabilitacao pulmonar Fornecemos tambem uma lista de variaveis a serem discutidas em futuros estudos sobre reabilitacao pulmonar em pacientes com sequelas pos-tuberculose

Identifying decreased diaphragmatic mobility and diaphragm thickening in interstitial lung disease: the utility of ultrasound imaging

Abstract: Objective: To investigate the applicability of ultrasound imaging of the diaphragm in interstitial lung disease (ILD). Methods: Using ultrasound, we compared ILD patients and healthy volunteers (controls) in terms of diaphragmatic mobility during quiet and deep breathing; diaphragm thickness at functional residual capacity (FRC) and at total lung capacity (TLC); and the thickening fraction (TF, proportional diaphragm thickening from FRC to TLC). We also evaluated correlations between diaphragmatic dysfunction and lung function variables. Results: Between the ILD patients (n = 40) and the controls (n = 16), mean diaphragmatic mobility was comparable during quiet breathing, although it was significantly lower in the patients during deep breathing (4.5 ± 1.7 cm vs. 7.6 ± 1.4 cm; p < 0.01). The patients showed greater diaphragm thickness at FRC (p = 0.05), although, due to lower diaphragm thickness at TLC, they also showed a lower TF (p < 0.01). The FVC as a percentage of the predicted value (FVC%) correlated with diaphragmatic mobility (r = 0.73; p < 0.01), and an FVC% cut-off value of < 60% presented high sensitivity (92%) and specificity (81%) for indentifying decreased diaphragmatic mobility. Conclusions: Using ultrasound, we were able to show that diaphragmatic mobility and the TF were lower in ILD patients than in healthy controls, despite the greater diaphragm thickness at FRC in the former. Diaphragmatic mobility correlated with ILD functional severity, and an FVC% cut-off value of < 60% was found to be highly accurate for indentifying diaphragmatic dysfunction on ultrasound.

Perme Intensive Care Unit Mobility Score and ICU Mobility Scale: translation into Portuguese and cross-cultural adaptation for use in Brazil.

Abstract: Objective: To translate the Perme Intensive Care Unit Mobility Score and the ICU Mobility Scale (IMS) into Portuguese, creating versions that are cross-culturally adapted for use in Brazil, and to determine the interobserver agreement and reliability for both versions. Methods: The processes of translation and cross-cultural validation consisted in the following: preparation, translation, reconciliation, synthesis, back-translation, review, approval, and pre-test. The Portuguese-language versions of both instruments were then used by two researchers to evaluate critically ill ICU patients. Weighted kappa statistics and Bland-Altman plots were used in order to verify interobserver agreement for the two instruments. In each of the domains of the instruments, interobserver reliability was evaluated with Cronbach's alpha coefficient. The correlation between the instruments was assessed by Spearman's correlation test. Results: The study sample comprised 103 patients-56 (54%) of whom were male-with a mean age of 52 ± 18 years. The main reason for ICU admission (in 44%) was respiratory failure. Both instruments showed excellent interobserver agreement ( > 0.90) and reliability ( > 0.90) in all domains. Interobserver bias was low for the IMS and the Perme Score (−0.048 ± 0.350 and −0.06 ± 0.73, respectively). The 95% CIs for the same instruments ranged from −0.73 to 0.64 and −1.50 to 1.36, respectively. There was also a strong positive correlation between the two instruments (r = 0.941; p < 0.001). Conclusions: In their versions adapted for use in Brazil, both instruments showed high interobserver agreement and reliability.

STOP-Bang questionnaire: translation to Portuguese and cross-cultural adaptation for use in Brazil.

Abstract: Objective: To translate and perform a cross-cultural adaptation of the Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, and Gender (STOP-Bang) questionnaire so that it can be used as a screening tool for the diagnosis of obstructive sleep apnea in Brazil. Methods: Based on the principles of good practice for the translation and cross-cultural adaptation of such instruments, the protocol included the following steps: acquisition of authorization from the lead author of the original questionnaire; translation of the instrument to Brazilian Portuguese, carried out by two translators; reconciliation; back-translation to English, carried out by two English teachers who are fluent in Portuguese; review of the back-translation; harmonization; review and approval of the questionnaire by the original author; cognitive debriefing involving 14 patients who completed the questionnaire; analysis of the results; and review and preparation of the final version of the instrument approved by the review committee. Results: The final version of the STOP-Bang questionnaire for use in Brazil showed a clarity score > 9 (on a scale of 1-10) for all of the questions. The Cronbach's alpha coefficient was 0.62, demonstrating the internal consistency of the instrument. The means and standard deviations of the age, body mass index, and neck circumference of the patients studied were 46.8 ± 11.2 years, 43.7 ± 8.5 kg/m2, and 41.3 ± 3.6 cm, respectively. Conclusions: The STOP-Bang questionnaire proved to be understandable, clear, and applicable. The original instrument and the translated version, cross-culturally adapted for use in Brazil, were consistently equivalent. Therefore, it can become a widely used screening tool for patients with suspected obstructive sleep apnea.

Effects of N-acetylcysteine and pentoxifylline on remote lung injury in a rat model of hind-limb ischemia/reperfusion injury

Abstract: Objective : To investigate the effects of N-acetylcysteine (NAC) and pentoxifylline in a model of remote organ injury after hind-limb ischemia/reperfusion (I/R) in rats, the lungs being the remote organ system. Methods : Thirty-five male Wistar rats were assigned to one of five conditions (n = 7/group), as follows: sham operation (control group); hind-limb ischemia, induced by clamping the left femoral artery, for 2 h, followed by 24 h of reperfusion (I/R group); and hind-limb ischemia, as above, followed by intraperitoneal injection (prior to reperfusion) of 150 mg/kg of NAC (I/R+NAC group), 40 mg/kg of pentoxifylline (I/R+PTX group), or both (I/R+NAC+PTX group). At the end of the trial, lung tissues were removed for histological analysis and assessment of oxidative stress. Results : In comparison with the rats in the other groups, those in the I/R group showed lower superoxide dismutase activity and glutathione levels, together with higher malondialdehyde levels and lung injury scores (p 0.05 for all). Conclusions : Our results suggest that NAC and pentoxifylline both protect lung tissue from the effects of skeletal muscle I/R. However, their combined use does not appear to increase the level of that protection.

New anticoagulants for the treatment of venous thromboembolism

Abstract: Worldwide, venous thromboembolism (VTE) is among the leading causes of death from cardiovascular disease, surpassed only by acute myocardial infarction and stroke. The spectrum of VTE presentations ranges, by degree of severity, from deep vein thrombosis to acute pulmonary thromboembolism. Treatment is based on full anticoagulation of the patients. For many decades, it has been known that anticoagulation directly affects the mortality associated with VTE. Until the beginning of this century, anticoagulant therapy was based on the use of unfractionated or low-molecular-weight heparin and vitamin K antagonists, warfarin in particular. Over the past decades, new classes of anticoagulants have been developed, such as factor Xa inhibitors and direct thrombin inhibitors, which significantly changed the therapeutic arsenal against VTE, due to their efficacy and safety when compared with the conventional treatment. The focus of this review was on evaluating the role of these new anticoagulants in this clinical context.

Hard metal lung disease: a case series

Abstract: Objective: To describe diagnostic and treatment aspects of hard metal lung disease (HMLD) and to review the current literature on the topic. Methods: This was a retrospective study based on the medical records of patients treated at the Occupational Respiratory Diseases Clinic of the Instituto do Coracao, in the city of Sao Paulo, Brazil, between 2010 and 2013. Results: Of 320 patients treated during the study period, 5 (1.56%) were diagnosed with HMLD. All of those 5 patients were male (mean age, 42.0 ± 13.6 years; mean duration of exposure to hard metals, 11.4 ± 8.0 years). Occupational histories were taken, after which the patients underwent clinical evaluation, chest HRCT, pulmonary function tests, bronchoscopy, BAL, and lung biopsy. Restrictive lung disease was found in all subjects. The most common chest HRCT finding was ground glass opacities (in 80%). In 4 patients, BALF revealed multinucleated giant cells. In 3 patients, lung biopsy revealed giant cell interstitial pneumonia. One patient was diagnosed with desquamative interstitial pneumonia associated with cellular bronchiolitis, and another was diagnosed with a hypersensitivity pneumonitis pattern. All patients were withdrawn from exposure and treated with corticosteroid. Clinical improvement occurred in 2 patients, whereas the disease progressed in 3. Conclusions: Although HMLD is a rare entity, it should always be included in the differential diagnosis of respiratory dysfunction in workers with a high occupational risk of exposure to hard metal particles. A relevant history (clinical and occupational) accompanied by chest HRCT and BAL findings suggestive of the disease might be sufficient for the diagnosis.

Influence of age and gender on the profile of exhaled volatile organic compounds analyzed by an electronic nose

Abstract: We aimed to investigate the effects of age and gender on the profile of exhaled volatile organic compounds. We evaluated 68 healthy adult never-smokers, comparing them by age and by gender. Exhaled breath samples were analyzed by an electronic nose (e-nose), resulting in "breathprints". Principal component analysis and canonical discriminant analysis showed that older subjects (≥ 50 years of age) could not be distinguished from younger subjects on the basis of their breathprints, as well as that the breathprints of males could not distinguished from those of females (cross-validated accuracy, 60.3% and 57.4%, respectively).Therefore, age and gender do not seem to affect the overall profile of exhaled volatile organic compounds measured by an e-nose.

The halo sign: HRCT findings in 85 patients.

Abstract: Objective: The halo sign consists of an area of ground-glass opacity surrounding pulmonary lesions on chest CT scans. We compared immunocompetent and immunosuppressed patients in terms of halo sign features and sought to identify those of greatest diagnostic value. Methods: This was a retrospective study of CT scans performed at any of seven centers between January of 2011 and May of 2015. Patients were classified according to their immune status. Two thoracic radiologists reviewed the scans in order to determine the number of lesions, as well as their distribution, size, and contour, together with halo thickness and any other associated findings. Results: Of the 85 patients evaluated, 53 were immunocompetent and 32 were immunosuppressed. Of the 53 immunocompetent patients, 34 (64%) were diagnosed with primary neoplasm. Of the 32 immunosuppressed patients, 25 (78%) were diagnosed with aspergillosis. Multiple and randomly distributed lesions were more common in the immunosuppressed patients than in the immunocompetent patients (p < 0.001 for both). Halo thickness was found to be greater in the immunosuppressed patients (p < 0.05). Conclusions: Etiologies of the halo sign differ markedly between immunocompetent and immunosuppressed patients. Although thicker halos are more likely to occur in patients with infectious diseases, the number and distribution of lesions should also be taken into account when evaluating patients presenting with the halo sign.

Smoking control: challenges and achievements.

Abstract: Smoking is the most preventable and controllable health risk. Therefore, all health care professionals should give their utmost attention to and be more focused on the problem of smoking. Tobacco is a highly profitable product, because of its large-scale production and great number of consumers. Smoking control policies and treatment resources for smoking cessation have advanced in recent years, showing highly satisfactory results, particularly in Brazil. However, there is yet a long way to go before smoking can be considered a controlled disease from a public health standpoint. We can already perceive that the behavior of our society regarding smoking is changing, albeit slowly. Therefore, pulmonologists have a very promising area in which to work with their patients and the general population. We must act with greater impetus in support of health care policies and social living standards that directly contribute to improving health and quality of life. In this respect, pulmonologists can play a greater role as they get more involved in treating smokers, strengthening anti-smoking laws, and demanding health care policies related to lung diseases. RESUMO O tabagismo e o fator de risco mais prevenivel e controlavel em saude e, por isso, precisa ter a maxima atencao e ser muito mais enfocado por todos os profissionais da saude. O tabaco e um produto de alta rentabilidade pela sua grande producao e pelo elevado numero de consumidores. As politicas de controle e os recursos terapeuticos para o tabagismo avancaram muito nos ultimos anos e tem mostrado resultados altamente satisfatorios, particularmente no Brasil. Entretanto, ainda resta um longo caminho a ser percorrido para que se possa considerar o tabagismo como uma doenca controlada sob o ponto de vista da saude publica. Ja se observam modificacoes do comportamento da sociedade com relacao ao tabagismo, mas ainda em escala muito lenta, de modo que os pneumologistas tem nesse setor um campo muito promissor para atuar junto a seus pacientes e a populacao em geral. E preciso atuar com maior impeto em prol das politicas de saude e das normas de convivio social que contribuem diretamente para melhorar a saude e a vida. Nesse aspecto, os pneumologistas podem ter um papel de maior destaque na medida em que se envolvam com o tratamento dos fumantes, a aplicacao da lei antifumo e as politicas de saude relacionadas as doencas respiratorias.

Viability of gait speed test in hospitalized elderly patients

Abstract: Objective: The gait speed test (GST) is a physical test that can predict falls and aid in the diagnosis of sarcopenia in the elderly. However, to our knowledge, there have been no studies evaluating its reproducibility in hospitalized elderly patients. The objective of this study was to evaluate the safety and reproducibility of the six-meter GST (6GST) in hospitalized elderly patients. Methods: This repeated measures study involved hospitalized elderly patients (≥ 60 years of age) who underwent the 6GST by the fifth day of hospitalization, were able to walk without assistance, and presented no signs of dyspnea or pain that would prevent them from performing the test. The 6GST was performed three times in sequence, with a rest period between each test, in a level corridor. Gait speed was measured in meters/second. Reproducibility was assessed by comparing the means, intraclass correlation coefficients (ICCs) and Bland-Altman plots. Results: We evaluated 110 elderly patients in a total of 330 tests. All participants completed all of the tests. The comparisons between the speeds obtained during the three tests showed high ICCs and a low mean bias (Bland-Altman plots). The correlation and accuracy were greatest when the mean maximum speed was compared with that obtained in the third test (1.26 ± 0.44 m/s vs. 1.22 ± 0.44 m/s; ICC = 0.99; p = 0.001; mean bias = 0.04; and limits of agreement = −0.27 to 0.15). Conclusions: The 6GST was proven to be safe and to have good reproducibility in this sample of hospitalized elderly patients. The third measurement seems to correspond to the maximum speed, since the first two measurements underestimated the actual performance.

Temporal analysis of reported cases of tuberculosis and of tuberculosis-HIV co-infection in Brazil between 2002 and 2012

Abstract: Objective: To investigate the reported cases of tuberculosis and of tuberculosis-HIV co-infection in Brazil between 2002 and 2012. Methods: This was an observational study based on secondary time series data collected from the Brazilian Case Registry Database for the 2002-2012 period. The incidence of tuberculosis was stratified by gender, age group, geographical region, and outcome, as was that of tuberculosis-HIV co-infection. Results: Nationally, the incidence of tuberculosis declined by 18%, whereas that of tuberculosis-HIV co-infection increased by 3.8%. There was an overall decrease in the incidence of tuberculosis, despite a significant increase in that of tuberculosis-HIV co-infection in women. The incidence of tuberculosis decreased only in the 0- to 9-year age bracket, remaining stable or increasing in the other age groups. The incidence of tuberculosis-HIV co-infection increased by 209% in the ≥ 60-year age bracket. The incidence of tuberculosis decreased in all geographical regions except the south, whereas that of tuberculosis-HIV co-infection increased by over 150% in the north and northeast. Regarding the outcomes, patients with tuberculosis-HIV co-infection, in comparison with patients infected with tuberculosis only, had a 48% lower chance of cure, a 50% greater risk of treatment nonadherence, and a 94% greater risk of death from tuberculosis. Conclusions: Our study shows that tuberculosis continues to be a relevant public health issue in Brazil, because the goals for the control and cure of the disease have yet to be achieved. In addition, the sharp increase in the incidence of tuberculosis-HIV co-infection in women, in the elderly, and in the northern/northeastern region reveals that the population of HIV-infected individuals is rapidly becoming more female, older, and more impoverished. Objetivo: Investigar os casos notificados de tuberculose e de sua coinfeccao com o HIV na populacao brasileira no periodo entre 2002 e 2012. Metodos: Realizou-se um estudo observacional de serie temporal, no qual foram analisados dados secundarios coletados do Sistema de Informacao de Agravos de Notificacao, no periodo entre 2002 e 2012. As incidencias de tuberculose e tuberculose-HIV foram estratificadas por sexo, faixa etaria, macrorregiao e situacao de encerramento. Resultados: A incidencia de tuberculose decaiu 18%, enquanto a de coinfeccao tuberculose-HIV aumentou 3,8% no pais. Houve uma reducao geral da incidencia de tuberculose apesar do aumento expressivo de tuberculose-HIV em mulheres. A taxa de incidencia de tuberculose diminuiu apenas na faixa etaria de 0-9 anos, permanecendo estavel ou com variacao positiva nas outras faixas etarias. A incidencia da coinfeccao tuberculose-HIV cresceu 209% na faixa etaria ≥ 60 anos. A incidencia de tuberculose diminuiu em todas as macrorregioes, exceto no Sul, enquanto a de tuberculose-HIV aumentou mais de 150% no Norte e Nordeste. Quanto a situacao de encerramento, revelou-se que pacientes com tuberculose-HIV tem 48% menos chance de cura, 50% mais chance de abandonar o tratamento e 94% mais chance de obito por tuberculose em relacao aqueles sem a coinfeccao. Conclusoes: O presente estudo evidencia a tuberculose como um importante problema de saude publica no Brasil, uma vez que as metas estabelecidas de cura e controle da doenca ainda nao foram alcancadas. Ademais, o aumento vertiginoso na incidencia de tuberculose-HIV em mulheres, idosos e nas regioes Norte e Nordeste evidencia a feminizacao, a transicao etaria e a pauperizacao pelo HIV.

Test for trend: evaluating dose-response effects in association studies

Abstract: 1. Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. 2. Methods in Epidemiologic, Clinical and Operations Research–MECOR–program, American Thoracic Society/Asociación Latinoamericana del Tórax. 3. Divisão de Pneumologia, Instituto do Coração – InCor – Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil. PRACTICAL SCENARIO

Randomization: beyond tossing a coin.

Abstract: 1. Methods in Epidemiologic, Clinical and Operations Research–MECOR–program, American Thoracic Society/Asociación Latinoamericana del Tórax. Montevídeo, Uruguay. 2. Divisão de Pneumologia, Instituto do Coração – InCor – Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil. 3. Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. INTRODUCTION

Robotic pulmonary lobectomy for lung cancer treatment: program implementation and initial experience.

Abstract: Objective: To describe the implementation of a robotic thoracic surgery program at a public tertiary teaching hospital and to analyze its initial results. Methods: This was a planned interim analysis of a randomized clinical trial aimed at comparing video-assisted thoracoscopic surgery and robotic surgery in terms of the results obtained after pulmonary lobectomy. The robotic surgery program developed at the Instituto do Câncer do Estado de Sao Paulo, in the city of Sao Paulo, Brazil, is a multidisciplinary initiative involving various surgical specialties, as well as anesthesiology, nursing, and clinical engineering teams. In this analysis, we evaluated the patients included in the robotic lobectomy arm of the trial during its first three months (from April to June of 2015). Results: Ten patients were included in this analysis. There were eight women and two men. The mean age was 65.1 years. All of the patients presented with peripheral tumors. We performed right upper lobectomy in four patients, right lower lobectomy in four, and left upper lobectomy in two. Surgical time varied considerably (range, 135-435 min). Conversion to open surgery or video-assisted thoracoscopic surgery was not necessary in any of the cases. Intraoperative complications were not found. Only the first patient required postoperative transfer to the ICU. There were no deaths or readmissions within the first 30 days after discharge. The only postoperative complication was chest pain (grade 3), in two patients. Pathological examination revealed complete tumor resection in all cases. Conclusions: When there is integration and proper training of all of the teams involved, the implementation of a robotic thoracic surgery program is feasible and can reduce morbidity and mortality.

What is survival analysis, and when should I use it?

Abstract: 1. Divisao de Pneumologia, Instituto do Coracao – InCor – Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil. 2. Methods in Epidemiologic, Clinical and Operations Research–MECOR–program, American Thoracic Society/Asociacion Latinoamericana del Torax. 3. Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. INTRODUCTION

Prevalence of latent Mycobacterium tuberculosis infection in prisoners.

Abstract: Objective: To determine the prevalence of and the factors associated with latent Mycobacterium tuberculosis infection (LTBI) in prisoners in the state of Minas Gerais, Brazil Methods: This was a cross-sectional cohort study conducted in two prisons in Minas Gerais Tuberculin skin tests were performed in the individuals who agreed to participate in the study Results: A total of 1,120 individuals were selected for inclusion in this study The prevalence of LTBI was 252% In the multivariate analysis, LTBI was associated with self-reported contact with active tuberculosis patients within prisons (adjusted OR = 151; 95% CI: 105-218) and use of inhaled drugs (adjusted OR = 148; 95% CI: 103-213) Respiratory symptoms were identified in 131 (117%) of the participants Serological testing for HIV was performed in 940 (839%) of the participants, and the result was positive in 5 (05%) Two cases of active tuberculosis were identified during the study period Conclusions: Within the prisons under study, the prevalence of LTBI was high In addition, LTBI was associated with self-reported contact with active tuberculosis patients and with the use of inhaled drugs Our findings demonstrate that it is necessary to improve the conditions in prisons, as well as to introduce strategies, such as chest X-ray screening, in order to detect tuberculosis cases and, consequently, reduce M tuberculosis infection within the prison system

Asthma treatment in children and adolescents in an urban area in southern Brazil: popular myths and features.

Abstract: Objective: To describe the frequency of popular myths about and features of asthma treatment in children and adolescents in an urban area in southern Brazil. Methods: The parents or legal guardians of public school students (8-16 years of age) completed a specific questionnaire regarding their understanding of asthma, asthma control, and treatment characteristics. The sample included parents or legal guardians of students with asthma (n = 127) and healthy controls (n = 124). Results: The study involved 251 parents or legal guardians, of whom 127 (68.5%) were the mothers and 130 (51.8%) were White. The mean age of these participants was 38.47 ± 12.07 years. Of the participants in the asthma and control groups, 37 (29.1%) and 26 (21.0%), respectively, reported being afraid of using asthma medications, whereas 61 (48%) and 56 (45.2%), respectively, believed that using a metered dose inhaler can lead to drug dependence. However, only 17 (13.4%) and 17 (13.7%) of the participants in the asthma and control groups, respectively, reported being afraid of using oral corticosteroids. In the asthma group, 55 students (43.3%) were diagnosed with uncontrolled asthma, only 41 (32.3%) had a prescription or written treatment plan, and 38 (29.9%) used asthma medications regularly. Conclusions: Popular myths about asthma treatment were common in our sample, as were uncontrolled asthma and inappropriate asthma management. Further studies in this field should be conducted in other developing countries, as should evaluations of pediatric asthma treatment programs in public health systems.

Cervical computed tomography in patients with obstructive sleep apnea: influence of head elevation on the assessment of upper airway volume

Abstract: Objective : Obstructive sleep apnea syndrome (OSAS) has a high prevalence and carries significant cardiovascular risks. It is important to study new therapeutic approaches to this disease. Positional therapy might be beneficial in reducing the apnea-hypopnea index (AHI). Imaging methods have been employed in order to facilitate the evaluation of the airways of OSAS patients and can be used in order to determine the effectiveness of certain treatments. This study was aimed at determining the influence that upper airway volume, as measured by cervical CT, has in patients diagnosed with OSAS. Methods : This was a quantitative, observational, cross-sectional study. We evaluated 10 patients who had been diagnosed with OSAS by polysomnography and on the basis of the clinical evaluation. All of the patients underwent conventional cervical CT in the supine position. Scans were obtained with the head of the patient in two positions (neutral and at a 44° upward inclination), and the upper airway volume was compared between the two. Results : The mean age, BMI, and neck circumference were 48.9 ± 14.4 years, 30.5 ± 3.5 kg/m2, and 40.3 ± 3.4 cm, respectively. The mean AHI was 13.7 ± 10.6 events/h (range, 6.0-41.6 events/h). The OSAS was classified as mild, moderate, and severe in 70%, 20%, and 10% of the patients, respectively. The mean upper airway volume was 7.9 cm3 greater when the head was at a 44° upward inclination than when it was in the neutral position, and that difference (17.5 ± 11.0%) was statistically significant (p = 0.002). Conclusions : Elevating the head appears to result in a significant increase in the caliber of the upper airways in OSAS patients.

Exercise performance and differences in physiological response to pulmonary rehabilitation in severe chronic obstructive pulmonary disease with hyperinflation

Abstract: Objective: Pulmonary rehabilitation (PR) improves exercise capacity in most but not all COPD patients. The factors associated with treatment success and the role of chest wall mechanics remain unclear. We investigated the impact of PR on exercise performance in COPD with severe hyperinflation. Methods: We evaluated 22 COPD patients (age, 66 ± 7 years; FEV1 = 37.1 ± 11.8% of predicted) who underwent eight weeks of aerobic exercise and strength training. Before and after PR, each patient also performed a six-minute walk test and an incremental cycle ergometer test. During the latter, we measured chest wall volumes (total and compartmental, by optoelectronic plethysmography) and determined maximal workloads. Results: We observed significant differences between the pre- and post-PR means for six-minute walk distance (305 ± 78 vs. 330 ± 96 m, p < 0.001) and maximal workload (33 ± 21 vs. 39 ± 20 W; p = 0.02). At equivalent workload settings, PR led to lower oxygen consumption, carbon dioxide production (VCO2), and minute ventilation. The inspiratory (operating) rib cage volume decreased significantly after PR. There were 6 patients in whom PR did not increase the maximal workload. After PR, those patients showed no significant decrease in VCO2 during exercise, had higher end-expiratory chest wall volumes with a more rapid shallow breathing pattern, and continued to experience symptomatic leg fatigue. Conclusions: In severe COPD, PR appears to improve oxygen consumption and reduce VCO2, with a commensurate decrease in respiratory drive, changes reflected in the operating chest wall volumes. Patients with severe post-exercise hyperinflation and leg fatigue might be unable to improve their maximal performance despite completing a PR program.

Etiology of primary spontaneous pneumothorax

Abstract: With the advent of HRCT, primary spontaneous pneumothorax has come to be better understood and managed, because its etiology can now be identified in most cases. Primary spontaneous pneumothorax is mainly caused by the rupture of a small subpleural emphysematous vesicle (designated a bleb) or of a subpleural paraseptal emphysematous lesion (designated a bulla). The aim of this pictorial essay was to improve the understanding of primary spontaneous pneumothorax and to propose a description of the major anatomical lesions found during surgery. RESUMO Com o advento da TCAR, o pneumotorax espontâneo primario passou a ser mais bem entendido e conduzido, pois sua etiologia pode ser atualmente identificada na maioria dos casos. O pneumotorax espontâneo primario tem como principal causa a rotura de uma pequena vesicula enfisematosa subpleural, denominada bleb ou de uma lesao enfisematosa parasseptal subpleural, denominada bulla. O objetivo deste ensaio pictorico foi melhorar o entendimento do pneumotorax espontâneo primario e propor uma descricao das principais lesoes anatomicas encontradas durante a cirurgia.

Alternative diagnoses based on CT angiography of the chest in patients with suspected pulmonary thromboembolism.

Abstract: Objective : To determine the prevalence of alternative diagnoses based on chest CT angiography (CTA) in patients with suspected pulmonary thromboembolism (PTE) who tested negative for PTE, as well as whether those alternative diagnoses had been considered prior to the CTA. Methods : This was a cross-sectional, retrospective study involving 191 adult patients undergoing CTA for suspected PTE between September of 2009 and May of 2012. Chest X-rays and CTAs were reviewed to determine whether the findings suggested an alternative diagnosis in the cases not diagnosed as PTE. Data on symptoms, risk factors, comorbidities, length of hospital stay, and mortality were collected. Results : On the basis of the CTA findings, PTE was diagnosed in 47 cases (24.6%). Among the 144 patients not diagnosed with PTE via CTA, the findings were abnormal in 120 (83.3%). Such findings were consistent with an alternative diagnosis that explained the symptoms in 75 patients (39.3%). Among those 75 cases, there were only 39 (20.4%) in which the same alterations had not been previously detected on chest X-rays. The most common alternative diagnosis, made solely on the basis of the CTA findings, was pneumonia (identified in 20 cases). Symptoms, risk factors, comorbidities, and the in-hospital mortality rate did not differ significantly between the patients with and without PTE. However, the median hospital stay was significantly longer in the patients with PTE than in those without (18.0 and 9.5 days, respectively; p = 0.001). Conclusions : Our results indicate that chest CTA is useful in cases of suspected PTE, because it can confirm the diagnosis and reveal findings consistent with an alternative diagnosis in a significant number of patients.

Obstructive sleep apnea related to rapid-eye- movement or non-rapid-eye-movement sleep: comparison of demographic, anthropometric, and polysomnographic features

Abstract: Objective : To determine whether there are significant differences between rapid-eye-movement (REM)-related obstructive sleep apnea (OSA) and non-REM (NREM)-related OSA, in terms of the demographic, anthropometric, and polysomnographic characteristics of the subjects. Methods : This was a retrospective study of 110 patients (75 males) with either REM-related OSA (n = 58) or NREM-related OSA (n = 52). To define REM-related and NREM-related OSA, we used a previously established criterion, based on the apnea-hypopnea index (AHI): AHI-REM/AHI-NREM ratio > 2 and ≤ 2, respectively. Results : The mean age of the patients with REM-related OSA was 49.5 ± 11.9 years, whereas that of the patients with NREM-related OSA was 49.2 ± 12.6 years. The overall mean AHI (all sleep stages combined) was significantly higher in the NREM-related OSA group than in the REM-related OSA group (38.6 ± 28.2 vs. 14.8 ± 9.2; p < 0.05). The mean AHI in the supine position (s-AHI) was also significantly higher in the NREM-related OSA group than in the REM-related OSA group (49.0 ± 34.3 vs. 18.8 ± 14.9; p < 0.0001). In the NREM-related OSA group, the s-AHI was higher among the men. In both groups, oxygen desaturation was more severe among the women. We found that REM-related OSA was more common among the patients with mild-to-moderate OSA, whereas NREM-related OSA was more common among those with severe OSA. Conclusions : We found that the severity of NREM-related OSA was associated mainly with s-AHI. Our findings suggest that the s-AHI has a more significant effect on the severity of OSA than does the AHI-REM. When interpreting OSA severity and choosing among treatment modalities, physicians should take into consideration the sleep stage and the sleep posture.

Restrictive pattern on spirometry: association with cardiovascular risk and level of physical activity in asymptomatic adults

Abstract: Objective : To determine whether a restrictive pattern on spirometry is associated with the level of physical activity in daily life (PADL), as well as with cardiovascular disease (CVD) risk factors, in asymptomatic adults. Methods : A total of 374 participants (mean age, 41 ± 14 years) underwent spirometry, which included the determination of FVC and FEV1. A restrictive pattern on spirometry was defined as an FEV1/FVC ratio > 0.7 and an FVC < 80% of the predicted value. After conducting demographic, anthropometric, and CVD risk assessments, we evaluated body composition, muscle function, and postural balance, as well as performing cardiopulmonary exercise testing and administering the six-minute walk test. The PADL was quantified with a triaxial accelerometer. Results : A restrictive pattern on spirometry was found in 10% of the subjects. After multivariate logistic regression, adjusted for confounders (PADL and cardiorespiratory fitness), the following variables retained significance (OR; 95% CI) as predictors of a restrictive pattern: systemic arterial hypertension (17.5; 1.65-184.8), smoking (11.6; 1.56-87.5), physical inactivity (8.1; 1.43-46.4), larger center-of-pressure area while standing on a force platform (1.34; 1.05-1.71); and dyslipidemia (1.89; 1.12-1.98). Conclusions : A restrictive pattern on spirometry appears to be common in asymptomatic adults. We found that CVD risk factors, especially systemic arterial hypertension, smoking, and physical inactivity, were directly associated with a restrictive pattern, even when the analysis was adjusted for PADL and cardiorespiratory fitness. Longitudinal studies are needed in order to improve understanding of the etiology of a restrictive pattern as well as to aid in the design of preventive strategies.

Educational interventions to improve inhaler techniques and their impact on asthma and COPD control: a pilot effectiveness-implementation trial.

Abstract: To assess the impact that educational interventions to improve inhaler techniques have on the clinical and functional control of asthma and COPD, we evaluated 44 participants before and after such an intervention. There was a significant decrease in the number of errors, and 20 patients (46%) significantly improved their technique regarding prior exhalation and breath hold. In the asthma group, there were significant improvements in the mean FEV1, FVC, and PEF (of 6.4%, 8.6%, and 8.3% respectively). Those improvements were accompanied by improvements in Control of Allergic Rhinitis and Asthma Test scores but not in Asthma Control Test scores. In the COPD group, there were no significant variations. In asthma patients, educational interventions appear to improve inhaler technique, clinical control, and functional control. RESUMO Para avaliar o impacto do ensino da tecnica inalatoria no controle clinico e funcional de pacientes com asma ou DPOC, incluiram-se 44 participantes antes e apos essa intervencao. Houve uma diminuicao significativa no numero de erros cometidos, sendo que 20 pacientes (46%) melhoraram significativamente sua tecnica na expiracao previa e apneia final. No grupo asma, houve significativa melhora nas medias de FEV1 (6,4%), CVF (8,6%) e PFE (8,3%), e essa melhora correlacionou-se com os resultados no Control of Allergic Rhinitis and Asthma Test, mas nao com os do Asthma Control Test. No grupo DPOC, nao houve variacoes significativas. O ensino da tecnica inalatoria parece melhorar seu desempenho e os controles clinico e funcional em pacientes com asma.

Lack of association between viral load and severity of acute bronchiolitis in infants.

Abstract: Objetivo: Investigar a correlacao entre a carga viral do virus sincicial respiratorio e o tempo de internacao hospitalar em lactentes com episodios de sibilância aguda. Metodos: Este foi um estudo transversal de dois anos envolvendo lactentes de ate 12 meses de idade com bronquiolite no momento da internacao em um hospital terciario. Para a identificacao dos virus respiratorios foram coletadas secrecoes nasofaringeas. As amostras foram analisadas (por todo o periodo do estudo) por imunofluorescencia direta e (no segundo ano do estudo) por PCR quantitativa em tempo real para tres virus humanos (rinovirus, virus sincicial respiratorio e metapneumovirus). Resultados: Das 110 amostras avaliadas por imunofluorescencia direta, 56 (50,9%) foram positivas para um unico virus, e 16 (14,5%) foram positivas para dois ou mais virus. Nessas 72 amostras, o virus mais prevalente foi o virus sincicial respiratorio, seguido por influenza. Das 56 amostras avaliadas por PCR quantitativa em tempo real, 24 (42,8%) foram positivas para um unico virus, e 1 (1,7%) foi positiva para dois virus. Nessas 25 amostras, o virus mais prevalente foi o virus sincicial respiratorio, seguido por rinovirus humano. A coinfeccao nao influenciou o tempo de internacao ou outros desfechos. Alem disso, nao houve associacao entre a carga viral de virus sincicial respiratorio e o tempo de internacao. Conclusoes: A coinfeccao e a carga viral do virus sincicial respiratorio nao parecem influenciar os desfechos em lactentes com bronquiolite aguda.

Risk factors for cardiovascular disease in patients with COPD: mild-to-moderate COPD versus severe-to-very severe COPD

Abstract: Objective: To assess and compare the prevalence of comorbidities and risk factors for cardiovascular disease (CVD) in COPD patients according to disease severity. Methods: The study included 25 patients with mild-to-moderate COPD (68% male; mean age, 65 ± 8 years; mean FEV1, 73 ± 15% of predicted) and 25 with severe-to-very severe COPD (males, 56%; mean age, 69 ± 9 years; mean FEV1, 40 ± 18% of predicted). Comorbidities were recorded on the basis of data obtained from medical charts and clinical evaluations. Comorbidities were registered on the basis of data obtained from medical charts and clinical evaluations. The Charlson comorbidity index was calculated, and the Hospital Anxiety and Depression Scale (HADS) score was determined. Results: Of the 50 patients evaluated, 38 (76%) had been diagnosed with at least one comorbidity, 21 (42%) having been diagnosed with at least one CVD. Twenty-four patients (48%) had more than one CVD. Eighteen (36%) of the patients were current smokers, 10 (20%) had depression, 7 (14%) had dyslipidemia, and 7 (14%) had diabetes mellitus. Current smoking, depression, and dyslipidemia were more prevalent among the patients with mild-to-moderate COPD than among those with severe-to-very severe COPD (p < 0.001, p = 0.008, and p = 0.02, respectively). The prevalence of high blood pressure, diabetes mellitus, alcoholism, ischemic heart disease, and chronic heart failure was comparable between the two groups. The Charlson comorbidity index and HADS scores did not differ between the groups. Conclusions: Comorbidities are highly prevalent in COPD, regardless of its severity. Certain risk factors for CVD, themselves classified as diseases (including smoking, dyslipidemia, and depression), appear to be more prevalent in patients with mild-to-moderate COPD.

Analysis of the stability of housekeeping gene expression in the left cardiac ventricle of rats submitted to chronic intermittent hypoxia

Abstract: Obstructive sleep apnea (OSA) has been associated with oxidative stress and various cardiovascular consequences, such as increased cardiovascular disease risk. Quantitative real-time PCR is frequently employed to assess changes in gene expression in experimental models. In this study, we analyzed the effects of chronic intermittent hypoxia (an experimental model of OSA) on housekeeping gene expression in the left cardiac ventricle of rats. Analyses via four different approaches-use of the geNorm, BestKeeper, and NormFinder algorithms; and 2-ΔCt (threshold cycle) data analysis-produced similar results: all genes were found to be suitable for use, glyceraldehyde-3-phosphate dehydrogenase and 18S being classified as the most and the least stable, respectively. The use of more than one housekeeping gene is strongly advised. RESUMO A apneia obstrutiva do sono (AOS) tem sido associada ao estresse oxidativo e a varias consequencias cardiovasculares, tais como risco aumentado de doenca cardiovascular. A PCR quantitativa em tempo real e frequentemente empregada para avaliar alteracoes na expressao genica em modelos experimentais. Neste estudo, analisamos os efeitos da hipoxia intermitente cronica (um modelo experimental de AOS) na expressao de genes de referencia no ventriculo cardiaco esquerdo de ratos. Analises a partir de quatro abordagens - uso dos algoritmos geNorm, BestKeeper e NormFinder e analise de dados 2-ΔCt (ciclo limiar) - produziram resultados semelhantes: todos os genes mostraram-se adequados para uso, sendo que gliceraldeido-3-fosfato desidrogenase e 18S foram classificados como o mais e o menos estavel, respectivamente. A utilizacao de mais de um gene de referencia e altamente recomendada.

Recent transmission of drug-resistant Mycobacterium tuberculosis in a prison population in southern Brazil

Abstract: We conducted a cross-sectional, retrospective study, characterized by classical and molecular epidemiology, involving M. tuberculosis isolates from a regional prison in southern Brazil. Between January of 2011 and August of 2014, 379 prisoners underwent sputum smear microscopy and culture; 53 (13.9%) were diagnosed with active tuberculosis. Of those, 8 (22.9%) presented with isoniazid-resistant tuberculosis. Strain genotyping was carried out by 15-locus mycobacterial interspersed repetitive unit-variable-number tandem-repeat analysis; 68.6% of the patients were distributed into five clusters, and 87.5% of the resistant cases were in the same cluster. The frequency of drug-resistant tuberculosis cases and the rate of recent transmission were high. Our data suggest the need to implement an effective tuberculosis control program within the prison system. RESUMO Estudo transversal, retrospectivo, com isolados de M. tuberculosis de pacientes de um presidio regional no sul do Brasil, caracterizado atraves de epidemiologia classica e molecular. Entre janeiro de 2011 e agosto de 2014, 379 detentos foram submetidos a baciloscopia e cultura, sendo 53 (13,9%) diagnosticados com tuberculose ativa. Desses, 8 (22,9%) apresentavam tuberculose resistente a isoniazida. A genotipagem das cepas foi realizada por 15-locus mycobacterial interspersed repetitive units-variable number of tandem repeat analysis; 68,6% dos pacientes estavam distribuidos em cinco clusters, e 87,5% dos casos resistentes estavam em um mesmo cluster. Verificou-se uma frequencia elevada de casos de resistencia e alta taxa de transmissao recente. Estes dados sugerem a necessidade da implantacao de um programa efetivo de controle da tuberculose no sistema prisional.