Medicinas tradicionales andinas y su despenalización: entrevista con Walter Álvarez Quispe / Decriminalizing traditional Andean medicine: an interview with Walter Álvarez Quispe

Walter Álvarez Quispe, terapeuta kallawaya y biomédico especializado en cirugía general y ginecología, presenta la lucha de los terapeutas tradicionales y alternativos por la depenalización de estos sistemas médicos andinos realizada entre 1960 y 1990. Bolivia se torna el primer país en América Latina y el Caribe en despenalizar la medicina tradicional antes de los planteamientos de la Conferencia Internacional sobre Atención Primaria de Salud (Alma-Ata, 1978). Los datos aportados por el entrevistado aseguran que los logros alcanzados, principalmente por los kallawayas, responden a un proyecto propio y autónomo. Estas conquistas no se deben a las políticas oficiales de interculturalidad en salud, aunque busquen atribuirse para sí los logros alcanzados.

Walter Álvarez Quispe, a Kallawaya healer and biomedical practitioner specializing in general surgery and gynecology, presents the struggle of traditional and alternative healers to get their Andean medical systems depenalized between 1960 and 1990. Bolivia was the first country in Latin America and the Caribbean to decriminalize traditional medicine before the proposals of the International Conference on Primary Health Care (Alma-Ata, 1978). The data provided by the interviewee show that the successes achieved, mainly by the Kallawayas, stem from their own independent initiative. These victories are not the result of official policies of interculturality in healthcare, although the successes achieved tend to be ascribed to them.

Utilização da técnica de resistência do interruptor na avaliação da resistência das vias aéreas em pacientes com fibrose cística / Using the interrupter technique to evaluate airway resistance in cystic fibrosis patients

OBJETIVO: Medir a resistência de vias aéreas utilizando a técnica de resistência do interruptor (Rint) em pacientes com fibrose cística (FC) e correlacioná-la com parâmetros espirométricos, assim como avaliar a acurácia de Rint para determinar a resposta das vias aéreas a um broncodilatador. MÉTODOS: Estudo transversal com 38 crianças e adolescentes com FC acompanhados no Ambulatório de FC do Hospital São Lucas, em Porto Alegre (RS). Após a determinação de Rint, os pacientes foram submetidos à espirometria. Para a avaliação da resposta ao broncodilatador, as medições foram repetidas após o uso de salbutamol inalatório. RESULTADOS: Houve uma forte correlação entre o inverso de Rint e VEF1 (r = 0,8; p < 0,001) e moderadas correlações entre o inverso de Rint e FEF25-75% (r = 0,74; p < 0,001) e entre o inverso de Rint e índice de massa corpórea (r = 0,62; p < 0,001). A curva ROC foi utilizada na comparação da resposta ao broncodilatador determinada por Rint com aquela determinada por valores espirométricos. Para um ponto de corte de -28% para Rint, a área sob a curva foi de 0,75, com uma sensibilidade de 66% e uma especificidade de 82%. CONCLUSÕES: Nossos achados indicam que Rint apresenta uma boa correlação com parâmetros espirométricos, embora a técnica Rint não tenha sido suficientemente acurada para substituir a espirometria na avaliação da resposta ao broncodilatador.

OBJECTIVE: To measure airway resistance with the interrupter resistance (Rint) technique in patients with cystic fibrosis (CF) and to determine whether Rint values correlate with spirometric parameters, as well as to evaluate the accuracy of the Rint technique in determining the airway response to a bronchodilator. METHODS: This was a cross-sectional study involving 38 children and adolescents with CF followed at the Cystic Fibrosis Outpatient Clinic of the São Lucas Hospital, located in the city of Porto Alegre, Brazil. After Rint had been measured, the subjects underwent spirometry. To evaluate bronchodilator response, we repeated the measurements after the use of inhaled albuterol. RESULTS: There was a strong correlation between inverse Rint and FEV1 (r = 0.8; p < 0.001), and there was a moderate correlation between inverse Rint and FEF25-75% (r = 0.74; p < 0.001), as well as between inverse Rint and body mass index (r = 0.62; p < 0.001). We used a ROC curve to compare the bronchodilator response, as determined by Rint, with spirometric values. For a Rint cut-off point of -28%, the area under the curve was 0.75, with a sensitivity of 66% and a specificity of 82%. CONCLUSIONS: Our findings suggest that Rint correlates well with spirometric parameters, although the Rint technique was not sufficiently accurate to replace spirometry in the evaluation of bronchodilator responses.

Oral contraceptive pills decrease pulmonary airway resistance in healthy north Indian women.

Objectives: Oral contraceptive pills (OCPs) are hormonal pills used by females to prevent conception; they are a combination of estrogen and progestin. There is, however, compelling evidence that throughout the reproductive life of a woman, her airways are subject to the influence of the cyclical variations in sex hormones which occur in relation to circadian rhythms. The present study has been designed to investigate the effects of OCPs on airway resistance in terms of spirometric parameters in OCP users and nonusers. Materials and Methods: A total of 100 women (age: 20-40 years) ware selected for the present study. The subjects were provided with a one-month supply of OCPs. The constituents per tablet of MALA-N used were levonorgestrel 0.15 mg and ethinylestradiol 0.03 mg. Peak expiratory flow rate (PEFR), forced expiratory flow in expiring 25-75% air (FEF 25-75), forced expiratory volume percentage in one second (FEV1% or FEV1/FVC), forced vital capacity (FVC), and forced expiratory volume in one second (FEV1) were recorded. Results: In our study, the FEF 25-75and PEFR increased significantly in OCP users, showing that these hormone pills decrease the resistance offered by small bronchioles.

Efeito da obstrução de vias aéreas nas variações das propriedades resistivas e elásticas do sistema respiratório de asmáticos, mediadas pelo uso de salbutamol / Effects of airway obstruction on albuterol-mediated variations in the resistive and elastic properties of the respiratory system of patients with asthma

OBJETIVO: Investigar os efeitos da obstrução de vias aéreas nas variações das propriedades resistivas e elásticas do sistema respiratório de asmáticos adultos mediadas pelo uso de salbutamol. MÉTODOS: Foram analisados 24 indivíduos controles e 69 asmáticos, todos não tabagistas, divididos em três grupos segundo o nível de obstrução de vias aéreas (leve, moderada e acentuada). Cada grupo foi dividido em dois subgrupos de acordo com a resposta broncodilatadora: resposta broncodilatadora positiva (RB+) ou negativa (RB-). A espirometria foi utilizada para a avaliação da obstrução, e a técnica de oscilações forçadas, para a análise das propriedades resistivas e elásticas, sendo realizadas antes e após a utilização de 300 µg de salbutamol. RESULTADOS: A resistência no intercepto (R0) apresentou maior redução nos grupos com maior obstrução. Essa redução foi mais evidente nos subgrupos RB+ do que nos RB- (p < 0,02 e p < 0,03, respectivamente). Houve diferença significativa entre o grupo controle e a o subgrupo com obstrução acentuada RB+ (p < 0,002). As reduções na elastância dinâmica (Edyn) se acentuaram significativamente com a obstrução, tanto para os subgrupos RB- (p < 0,03), quanto para os RB+ (p < 0,003). As reduções da Edyn foram significativamente maiores nos subgrupos com obstrução moderada RB- (p < 0,008) e com obstrução acentuada RB+ (p < 0,0005) do que no grupo controle. CONCLUSÕES: Em asmáticos, o aumento da obstrução de vias aéreas resulta na elevação das variações em R0 e Edyn com o uso de salbutamol. Pacientes com RB+ apresentam variações mais elevadas que indivíduos com RB-.

OBJECTIVE: To investigate the effects of airway obstruction on albuterol-mediated variations in the resistive and elastic properties of the respiratory system of adult patients with asthma. METHODS: This study comprised 24 healthy controls and 69 patients with asthma, all of whom were nonsmokers. The patients were divided into three groups according to the severity of airway obstruction (mild, moderate or severe). Each of the three groups was divided into two subgroups according to the bronchodilator response (BR): positive (BR+) or negative (BR-). Airway obstruction was determined by means of spirometry, and the resistive and elastic properties were determined by means of the forced oscillation technique. These measurements were conducted before and after albuterol use (300 µg). RESULTS: The resistance at the intercept (R0) presented greater reductions in the groups with higher obstruction. This reduction was more evident in the BR+ subgroups than in the BR- subgroups (p < 0.02 and p < 0.03, respectively). There was a significant difference between the control group and the BR+ subgroup with severe obstruction (p < 0.002). The reductions in dynamic elastance (Edyn) were significantly greater in proportion to the degree of obstruction, in the BR- subgroups (p < 0.03), and in the BR+ subgroups (p < 0.003). The reductions in Edyn were significantly greater in the BR- subgroup with moderate obstruction (p < 0.008) and in the BR+ subgroup with severe obstruction (p < 0.0005) than in the control group. CONCLUSIONS: In patients with asthma, increased airway obstruction results in greater reductions in R0 and Edyn after albuterol use. These reductions are greater among BR+ patients than among BR- patients.

Broncodilatação na DPOC: muito além do VEF1-efeito do salbutamol nas propriedades resistivas e reativas do sistema respiratório / Bronchodilation in COPD: beyond FEV1-the effect of albuterol on resistive and reactive properties of the respiratory system

OBJETIVO: Atualmente existem importantes debates na literatura sobre a resposta broncodilatadora em pacientes com DPOC e se a variação do VEF1 pode ser considerada uma indicação completa de reversibilidade neste caso particular. O objetivo deste estudo foi investigar o efeito do salbutamol nas propriedades resistivas e elásticas do sistema respiratório de portadores de DPOC. MÉTODOS: Foram avaliados 70 indivíduos com DPOC, classificados através da espirometria em dois grupos: broncodilatador (BD)-negativo (n = 39); e BD-positivo (n = 31). Utilizou-se a técnica de oscilações forçadas (TOF) para avaliar os seguintes parâmetros: a resistência no intercepto (R0), associada à resistência total do sistema respiratório; a resistência média (Rm), relacionada à resistência de vias aéreas centrais; e a complacência dinâmica (Cdyn); assim como o coeficiente angular da resistência (S) e a reatância média (Xm), relacionados com a homogeneidade do sistema respiratório. RESULTADOS: O uso do salbutamol resultou em reduções significativas de R0 (p < 0,00002) e Rm (p < 0,0002). Foram também observadas elevações significativas em S (p < 0,0001), Cdyn (p < 0,0001) e Xm (p < 0,00004). Estas alterações ocorreram tanto nos dois grupos, tendo sido observadas maiores modificações nos parâmetros da TOF do que nos parâmetros da espirometria. CONCLUSÕES: O uso de salbutamol melhorou o comportamento dos componentes resistivos e reativos do sistema respiratório dos pacientes com DPOC estudados. Estas mudanças ocorreram independentemente da classificação do exame empregando o VEF1, o que indica que a utilização deste parâmetro isoladamente pode não ser suficiente para identificar completamente os efeitos fisiológicos envolvidos.

OBJECTIVE: Current debates on the bronchodilator response in COPD patients and whether the variation in FEV1 can be considered as an indicator of complete reversibility in such patients motivated us to conduct this study. The objective of the study was to determine the effect of albuterol on the resistive and reactive properties of the respiratory system in COPD patients. METHODS: We evaluated 70 patients with COPD, divided into two groups based on spirometry findings: bronchodilator (BD)-negative (n = 39); and BD-positive (n = 31). We used the forced oscillation technique (FOT) to evaluate the following parameters: resistance at the intercept (R0), associated with the total resistance of the respiratory system; mean resistance (Rm), associated with central airway resistance; dynamic compliance (Cdyn); and the slope of resistance (S) and mean reactance (Xm), both of which are associated with the homogeneity of the respiratory system. RESULTS: The use of albuterol resulted in significant reductions in (p < 0.00002) and Rm (p < 0.0002). There were also significant increases in S (p < 0.0001), Cdyn (p < 0.0001) R0 and Xm (p < 0.00004).These modifications occurred in both groups, the changes in FOT parameters being greater than those observed for spirometric parameters. CONCLUSIONS: The use of albuterol improved the resistive and reactive properties of the respiratory system of the COPD patients under study. These changes occurred regardless of the FEV1-based classification, thereby indicating that the use of this parameter in isolation might not suffice to identify the physiological effects involved.

Angiopoietin-1 variant, COMP-Ang1 attenuates hydrogen peroxide-induced acute lung injury

Reactive oxygen species (ROS) play a crucial role in acute lung injury. Tissue inflammation, the increased vascular permeability, and plasma exudation are cardinal features of acute lung injury. Angiopoietin-1 (Ang1) has potential therapeutic applications in preventing vascular leakage and also has beneficial effects in several inflammatory disorders. Recently developed COMP-Ang1 is more potent than native Ang1 in phosphorylating tyrosine kinase with immunoglobulin and EGF homology domain 2 receptor in endothelial cells. However, there are no data on effects and related molecular mechanisms of COMP- Ang1 on ROS-induced acute lung injury. We used hydrogen peroxide (H2O2)-inhaled mice to evaluate the effect of COMP-Ang1 on pulmonary inflammation, bronchial hyper-responsiveness, and vascular leakage in acute lung injury. The results have revealed that VEGF expression, the levels of IL-4, TNF-alpha, IL-1 beta, intercellular adhesion molecule-1, and vascular cell adhesion molecule-1 in lungs, the levels of hypoxia-inducible factor-1alpha (HIF-1 alpha) and NF-kappa B in nuclear protein extracts, phosphorylation of Akt, and vascular permeability were increased after inhalation of H2O2 and that the administration of COMP-Ang1 markedly reduced airway hyper-responsiveness, pulmonary inflammation, plasma extravasation, and the increases of cytokines, adhesion molecules, and VEGF in lungs treated with H2O2. We have also found that the activation of HIF-1a and NF-kappa B and the increase of phosphoinositide 3-kinase activity in lung tissues after H2O2 inhalation were decreased by the administration of COMP-Ang1. These results suggest that COMP-Ang1 ameliorates ROS-induced acute lung injury through attenuating vascular leakage and modulating inflammatory mediators.

Thoracic sympathetic block reduces respiratory system compliance

CONTEXT AND OBJECTIVE: Thoracic epidural anesthesia (TEA) following thoracic surgery presents known analgesic and respiratory benefits. However, intraoperative thoracic sympathetic block may trigger airway hyperreactivity. This study weighed up these beneficial and undesirable effects on intraoperative respiratory mechanics. DESIGN AND SETTING: Randomized, double-blind clinical study at a tertiary public hospital. METHODS: Nineteen patients scheduled for partial lung resection were distributed using a random number table into groups receiving active TEA (15 ml 0.5 percent bupivacaine, n = 9) or placebo (15 ml 0.9 percent saline, n = 10) solutions that also contained 1:200,000 epinephrine and 2 mg morphine. Under general anesthesia, flows and airway and esophageal pressures were recorded. Pressure-volume curves, lower inflection points (LIP), resistance and compliance at 10 ml/kg tidal volume were established for respiratory system, chest wall and lungs. StudentÆs t test was performed, including confidence intervals (CI). RESULTS: Bupivacaine rose 5 ± 1 dermatomes upwards and 6 ± 1 downwards. LIP was higher in the bupivacaine group (6.2 ± 2.3 versus 3.6 ± 0.6 cmH2O, p = 0.016, CI = -3.4 to -1.8). Respiratory system and lung compliance were higher in the placebo group (respectively 73.3 ± 10.6 versus 51.9 ± 15.5, p = 0.003, CI = 19.1 to 23.7; 127.2 ± 31.7 versus 70.2 ± 23.1 ml/cmH2O, p < 0.001, CI = 61 to 53). Resistance and chest wall compliance showed no difference. CONCLUSION: TEA decreased respiratory system compliance by reducing its lung component. Resistance was unaffected. Under TEA, positive end-expiratory pressure and recruitment maneuvers are advisable.

CONTEXTO E OBJETIVO: Os benefícios pós-operatórios da anestesia peridural torácica (APT) na analgesia e respiração após toracotomias são conhecidos. Contudo, bloqueio simpático torácico pode desencadear hiperreatividade das vias aéreas. Este estudo pesou tais efeitos benéficos e indesejáveis na mecânica respiratória intra-operatória. TIPO DE ESTUDO E LOCAL: Estudo clínico, randomizado, duplo-cego realizado em hospital público terciário. MÉTODOS: Uma tabela de números aleatórios dividiu 19 pacientes submetidos a ressecção pulmonar parcial entre duas soluções administradas na APT: ativa (15 ml 0,5 por cento bupivacaína, n = 9) ou placebo (15 ml 0,9 por cento NaCl, n = 10). Ambas continham epinefrina 1:200,000 e morfina 2 mg. Sob anestesia geral, pressões esofágicas e de vias aéreas foram registradas. Curvas de pressão versus volume, pontos de inflexão inferior (PII), resistências e complacências sob volume corrente de 10 ml.kg-1 foram aferidos para sistema respiratório, parede torácica e pulmões. O teste t de Student foi realizado (p < 0,005), incluindo intervalos de confiança (IC). RESULTADOS: A dispersão cefálica e caudal da bupivacaína foi, respectivamente, de 5 ± 1 e de 6 ± 1 dermátomos. A curva PII foi maior no Grupo Bupivacaína (6,2 ± 2,3 versus 3,6 ± 0,6 cm H2O, p = 0,016, IC = -3,4 a -1,8). Complacências do sistema respiratório e pulmões foram maiores no Grupo Placebo (respectivamente 73.3 ± 10.6 versus 51.9 ± 15.5, p = 0,003, IC = 19,1 a 23,7, e 127,2 ± 31,7 versus 70,2 ± 23,1 ml.cm H2O-1, p < 0,001, IC = 61 a 53). Resistências e complacências da parede torácica não mostraram diferenças. CONCLUSÃO: APT diminui a complacência do sistema respiratório por reduzir seu componente pulmonar. Resistências não são afetadas. Sob APT, pressão positiva expiratória final e manobras de recrutamento são recomendáveis.

Effect of household exposure to environmental tobacco smoke on airflow mechanics in asymptomatic healthy women.

BACKGROUND & OBJECTIVES: Exposure to environmental tobacco smoke (ETS) can lead to airflow limitation, similar to that seen in smokers. However, the effects have not been conclusively proven. In the present study an attempt was made to characterize the effect of ETS exposure at home on airflow mechanics in asymptomatic healthy women. METHODS: Fifty women volunteers with no apparent health related problem, exposed to household ETS (group I), and 50 age-matched women not exposed (group II) were studied. Vital capacity (VC), forced expiratory flow in first second (FEV1), FEV1/VC ratio, peak expiratory flow (PEF), maximal midexpiratory flow (FEF(25-75%)), airway resistance (R(aw)) and specific airway conductance (sG(aw)) were measured, and compared between the two groups. Conditional logistic and linear regression analysis were done to assess contribution of household ETS exposure to decreased lung function. RESULTS: FEV1 and PEF values were marginally lower among women in group I (mean difference 0.13 l and 0.20 l/sec respectively). FEF(25-75%), R(aw) and sG(aw) were significantly impaired in this group. Ten (20.0%) women in group I and five (10.0%) in group II had abnormal R(aw) (adjusted odds ratio 6.72, 95% confidence limits 1.15-39.42), while eight (16.0%) women in group I and one (2.0%) in group II had abnormal sG(aw) (adjusted odds ratio 21.08, 95% confidence limits 1.30-341.05). Cumulative life time ETS exposure was, not significantly related to a reduction in FEV1, VC, PEF, FEF(25-75%), R(aw) or sG(aw) after adjustments for potential confounders. INTERPRETATION & CONCLUSION: Exposure to household ETS resulted in subtle impairment of airflow mechanics in asymptomatic women, possibly attributed to small airway narrowing. Further investigations are required to study the progression of this impairment with time.

Respiratory and systemic effects of inhaled dexamethasone on ventilator dependant preterm infants at risk for bronchopulmonary dysplasia.

Short-term inhaled dexamethasone therapy was evaluated in a double blind placebo controlled trial in 36 ventilator dependent preterm neonates (BW < 1500 gm, postnatal age > 7 days) who were at risk for bronchopulmonary dysplasia. Pulmonary and systemic effects were compared at early (day 3), late (7-10 days) and post (14 days after initiation) phases of therapy. Airflow mechanics improved as demonstrated by a net 101% improvement in pulmonary resistance (a decrease from 139 to 101 cm H2O/L/s in the dexamethasone treated infants as compared to an increase from 153 to 267 cmH2O/L/s in the placebo treated infants during the early phase of therapy); this was associated with a 45% increase in inspiratory airflow (1.29 +/- 0.43 to 1.87 +/- 0.978 L/min; p < 0.01), and 37% increase in expiratory airflow. These changes resulted in a significant reduction in the work of breathing such that the mean tidal driving pressure significantly decreased from 13.6 cmH2O to 9.4 cm H2O with inhaled steroid administration. Though the brief duration of therapy did not result in cessation of ventilatory support, the level of support was significantly reduced (decreased values of oxygen supplementation, mean airway pressure and oxygenation index and increased ventilatory efficiency index). The inhaled dexamethasone therapy was also associated with systemic absorption of the drug as evidenced by transient but apparently reversible reduction in serum cortisol levels. No systemic side effects of hypertension, hyperglycemia or nosocomial sepsis were observed. These data demonstrate beneficial effects of short-term inhaled dexamethasone on the resistive airflow properties of preterm infants at risk for BPD and may provide adjunctive means to facilitate weaning in the ventilator dependent neonates.

Emergency room assessment and adrenaline treatment of patients with acute asthma of different severity.

The adequacy of emergency room assessment and treatment of patients with acute severe asthmatic attacks was evaluated by analyzing the course of 451 visits of 348 patients to Chulalongkorn hospital's Emergency Room. Eighty-five per cent of the patients had an initial index score of greater than or equal to 4 and an average peak expiratory flow rate of 92.16 +/- 46.3 L/min. The discharge index score was 85 per cent with a score of less than or equal to 3 and an average peak expiratory flow rate of 192 +/- 40.3 L/min. Our study indicated that the predictive index proposed by Fischl et al correlated with the severity of airway obstruction; however, the initial index did not help with emergency room decision-making in predicting which patients might be hospitalized, have a relapse or be discharged. In fact, in our emergency room department, the index score to determine airway obstruction and the pattern of response to treatment were better predictors of the outcome, which was classified into three categories: non-responsive or minimally responsive, responsive, and partially responsive. By using conventional clinical criteria (i.e. recumbent position with elimination of laboured breathing, disappearance of dyspnea and reduction of wheezing), there was a 93 per cent accurate determination in the episodes of patients who responded sufficiently to the emergency room treatment to allow their discharge. The remaining 7 per cent of those seeking emergency treatment were hospitalized, which is a lower incidence than that of others series.(ABSTRACT TRUNCATED AT 250 WORDS)

Efeitos respiratórios e cardiovasculares agudos de mascagnea rigida (tingui) no cäo / Acute respiratory and cardiovascular effects of Mascagnea regida (tingui) in dogs

Estudaram-se os efeitos cardiovasculares, respiratórios e peristálticos intestinais de princípio tóxicos de Mascagnea rigida, em cäes e ratos. Foi observado intensa e permanente queda da pressäo arterial média, broncoconstriçäo e exacerbaçäo da propulsäo peristáltica intestinal com reduçäo na freqüência cardíaca. Esses efeitos näo säo revertidos por agentes anticolinérgicos, nem säo bloqueados pelo propranolol, nem por agentes antihistamínicos, sugerindo um efeito por princípio ativo de natureza desconhecida