O uso de métodos contraceptivos hormonais em pacientes com asma: repercussões clínicas / The use of hormonal contraceptives methods in patients with asthma: clinical repercussions

Objetivo: Analisar o uso dos contraceptivos hormonais em mulheres com asma e a escolha desses métodos contraceptivos para essa população, com avaliação de eventuais repercussões sobre novos episódios de asma e sibilos. Métodos: Foram selecionados estudos longitudinais, ensaios clínicos, revisões sistemáticas e metanálises. As plataformas consultadas foram PubMed, Embase, Cochrane e SciELO, com a utilização dos descritores: "contracepção", "contracepção hormonal", "sistema intrauterino liberador de levonorgestrel" e "asma". Resultados: Dois grandes estudos demonstraram que o uso de contraceptivos hormonais esteve associado à redução do risco de novos episódios de asma. Uma revisão sistemática concluiu que os resultados para o uso de contraceptivos hormonais para mulheres com asma foram mistos, com aumento ou redução dos seguintes riscos: novo episódio de asma e aumento da frequência das crises e dos sibilos. O uso da contracepção hormonal em pacientes obesas portadoras de asma é controverso. Conclusão: Os resultados para o uso de contraceptivos hormonais em mulheres com asma são inconsistentes, com relatos de aumento ou de redução do risco de novos episódios. O uso do método contraceptivo deve ser discutido individualmente, levando-se em consideração outros fatores de risco associados e o desejo da mulher. A paciente deverá ser orientada se houver piora dos sintomas clínicos de asma na vigência do uso de qualquer método contraceptivo hormonal.

Objective: To analyze the use of hormonal contraceptives in women with asthma and the choice of this contraceptive method for this population, evaluating possible repercussions on new episodes of asthma and wheezing. Methods: Longitudinal studies, clinical trials, systematic reviews and meta-analyses were selected. Platforms consulted: PubMed, Embase, Cochrane, SciELO, using the descriptors: "contraception", "hormonal contraception", "levonorgestrel-releasing intrauterine system" and "asthma". Results: Two large studies demonstrated that the use of hormonal contraceptives was associated with a reduced risk of new episodes of asthma. A systematic review concluded that the results for the use of hormonal contraceptives for women with asthma were mixed, with increased or decrease in the following risks: new asthma episodes, increased frequency and wheezing. The use of hormonal contraception in obese patients with asthma is controversial. Conclusion: The results for the use of hormonal contraceptives in women with asthma are inconsistent, with reports of increased or reduced risk of new episodes. The use of the contraceptive method should be discussed individually, taking into account other associated risk factors and the woman's desire. The patient will be advised if there is a worsening of the clinical symptoms of asthma while using any hormonal contraceptive method.

Impacto de las exacerbaciones en la enfermedad pulmonar obstructiva crónica / Impact of Exacerbations on Chronic Obstructive Pulmonary Disease

La enfermedad pulmonar obstructiva crónica (EPOC) es la tercera causa de muerte en todo el mundo. Sin embargo, ante la falta de herramientas diagnósticas precisas en el primer nivel de atención médica, como la espirometría, es difícil determinar la prevalen-cia real de la EPOC.Por otro lado, la falta de una definición clara y precisa de las exacerbaciones de la EPOC hace que se subestime su impacto en la salud pública; habitualmente, los pacien-tes con EPOC que cursan una exacerbación retrasan la búsqueda de atención médica inmediata porque se acostumbran al deterioro asociado a la enfermedad o lo confun-den con cambios por la edad avanzada. Esto puede provocar un aumento de la mor-bilidad y la mortalidad, asimismo, mayor utilización de los recursos sanitarios y mayor carga económica. Por lo tanto, es importante sensibilizar sobre la importancia del diagnóstico temprano y el tratamiento adecuado de las exacerbaciones de la EPOC, del mismo modo que el mayor conocimiento público de los síntomas, las causas y los factores de riesgo de la EPOC. Con ello, se podrán aplicar estrategias de prevención, diagnóstico y tratamiento más eficaces que mejoren la calidad de vida de los pacientes y disminuyan la carga de la enfermedad para la sociedad.Esta revisión ofrece un análisis crítico de la definición más reciente y esboza las impli-caciones del comportamiento de las exacerbaciones, su impacto en los distintos ám-bitos del sistema sanitario, así como en las diferentes esferas de la vida de los pacien-tes con EPOC. (AU)

Chronic Obstructive Pulmonary Disease (COPD) is a common disease and the third leading cause of death worldwide. However, due to the lack of accurate diagnostic tools at the first level of care, such as spirometry, the true prevalence of COPD is difficult to determine.In addition, the lack of a clear definition of COPD exacerbations means that its pub-lic health impact is underestimated. Patients with COPD often do not seek immediate medical attention because they become used to the deterioration associated with the disease. This can lead to increased patient morbidity and mortality, as well as increased utilization of healthcare resources and higher economic costs. Therefore, it is important to promote greater awareness of the importance of early di-agnosis and proper management of COPD exacerbations, as well as increased public awareness of COPD symptoms, etiologic agents, and risk factors.By better understanding COPD exacerbations, more effective prevention, diagnosis and treatment strategies can be implemented to improve the quality of life of patients and reduce the burden of the disease on society.This review aims to provide a critical analysis of the most recent definition and to out-line the implications of the behavior of COPD exacerbations and their impact on the dif-ferent settings of the health care system, as well as on the different spheres of patients' lives. (AU)

Dyspnea and COVID-19: A Review of Confounding Diagnoses during the Postpartum Period / Dispneia e COVID-19: uma revisão de diagnósticos confundidores no período pós-parto

Abstract The puerperium is a complex period that begins with placental delivery and lasts for 6 weeks, during which readaptation of the female organism and redistribution of blood volume occur. This period is conducive to the occurrence of thromboembolic events. In the context of the SARS-CoV-2 pandemic, the virus responsible for COVID-19, the attention of the scientific community and health professionals has been focused on obtaining insights on different aspects of this disease, including etiology, transmission, diagnosis, and treatment. Regarding the pregnancy-postpartum cycle, it is opportune to review the clinical conditions that can occur during this period and to investigate dyspnea as a postpartum symptom in order to avoid its immediate association with COVID-19 without further investigation, which can lead to overlooking the diagnosis of other important and occasionally fatal conditions.

Resumo O puerpério é um período complexo que se inicia com a dequitação placentária e dura por 6 semanas, no qual a readaptação do organismo materno e a redistribuição do volume sanguíneo ocorrem, além de ser também um cenário propício para eventos pró-trombóticos. No contexto da pandemia de SARS-CoV-2, vírus responsável pela COVID-19, a atenção da comunidade científica e dos profissionais da saúde está voltada a elucidar os aspectos da doença, como a etiologia, a transmissão, o diagnóstico e o tratamento. Considerando o ciclo gravídico-puerperal, é oportuna a revisão de condições clínicas que ocorrem durante este período e que apresentam a dispneia como sintoma, a fimde evitar que ela seja automaticamente associada à COVID-19 sem investigações aprofundadas, o que pode levar à negligência do diagnóstico de outras condições importantes e que podem ser, por vezes, fatais.

Pulmonology approach in the investigation of chronic unexplained dyspnea / Abordagem pneumológica na investigação de dispneia crônica inexplicada

ABSTRACT Chronic unexplained dyspnea and exercise intolerance represent common, distressing symptoms in outpatients. Clinical history taking and physical examination are the mainstays for diagnostic evaluation. However, the cause of dyspnea may remain elusive even after comprehensive diagnostic evaluation-basic laboratory analyses; chest imaging; pulmonary function testing; and cardiac testing. At that point (and frequently before), patients are usually referred to a pulmonologist, who is expected to be the main physician to solve this conundrum. In this context, cardiopulmonary exercise testing (CPET), to assess physiological and sensory responses from rest to peak exercise, provides a unique opportunity to unmask the mechanisms of the underlying dyspnea and their interactions with a broad spectrum of disorders. However, CPET is underused in clinical practice, possibly due to operational issues (equipment costs, limited availability, and poor remuneration) and limited medical education regarding the method. To counter the latter shortcoming, we aspire to provide a pragmatic strategy for interpreting CPET results. Clustering findings of exercise response allows the characterization of patterns that permit the clinician to narrow the list of possible diagnoses rather than pinpointing a specific etiology. We present a proposal for a diagnostic workup and some illustrative cases assessed by CPET. Given that airway hyperresponsiveness and pulmonary vascular disorders, which are within the purview of pulmonology, are common causes of chronic unexplained dyspnea, we also aim to describe the role of bronchial challenge tests and the diagnostic reasoning for investigating the pulmonary circulation in this context.

RESUMO A dispneia crônica inexplicada e a intolerância ao exercício representam sintomas comuns e angustiantes em pacientes ambulatoriais. O histórico clínico e o exame físico são as bases da avaliação diagnóstica. No entanto, a causa da dispneia pode permanecer inexplicada mesmo após uma avaliação diagnóstica abrangente - análises laboratoriais básicas, exames de imagem do tórax, testes de função pulmonar e testes cardíacos. Nesse momento (e frequentemente antes), os pacientes geralmente são encaminhados a um pneumologista, o qual se espera que seja o principal médico para a resolução desse enigma. Nesse contexto, o teste de exercício cardiopulmonar (TECP), para avaliação de respostas fisiológicas e sensoriais do repouso ao pico do exercício, proporciona uma oportunidade única de desvendar os mecanismos subjacentes à dispneia e as interações desses mecanismos com um amplo espectro de distúrbios. No entanto, o TECP é subutilizado na prática clínica, possivelmente por questões operacionais (custos dos equipamentos, disponibilidade limitada e baixa remuneração) e limitação da formação médica em relação ao método. Para enfrentar esta última deficiência, almejamos fornecer uma estratégia pragmática para a interpretação dos resultados do TECP. O agrupamento dos achados da resposta ao exercício permite a caracterização de padrões que possibilitam ao clínico restringir a lista de possíveis diagnósticos, em vez de apontar uma etiologia específica. Apresentamos uma proposta de avaliação diagnóstica e alguns casos ilustrativos avaliados por TECP. Como a hiper-responsividade das vias aéreas e os distúrbios vasculares pulmonares, que são da competência da pneumologia, são causas comuns de dispneia crônica inexplicada, também objetivamos descrever o papel dos testes de broncoprovocação e o raciocínio diagnóstico para a investigação da circulação pulmonar nesse contexto.

Respiratory symptoms (COPD Assessment Test and modified Medical Research Council dyspnea scores) and GOLD-ABCD COPD classification: the LASSYC study / Sintomas respiratórios (Teste de Avaliação da DPOC e pontuação modificada de dispneia do Conselho de Pesquisa Médica) e classificação GOLD-ABCD COPD: o estudo LASSYC

ABSTRACT Objective To assess the frequency and severity of 24-hour respiratory symptoms according to COPD GOLD-ABCD classification (2017-version), the distribution of the patients with COPD into GOLD categories using mMRC (≥2) or CAT (≥10) scores, and agreement between these cut-off points. Methods In this cross-sectional study (LASSYC study), 24-hour day respiratory symptoms were assessed by the Evaluating Respiratory Symptoms in COPD (E-RS) questionnaire, Nighttime Symptoms of COPD Instrument (NiSCI), Early Morning Symptoms of COPD Instrument (EMSCI), CAT and mMRC scores. Results Among the 734 patients with COPD, 61% were male, age 69.6±8.7 years, FEV1% post-BD 49.1±17.5%, mMRC 1.8±1.0 and CAT 15.3±.8.1. By mMRC 33.7% were group-A, 29.2% group-B, 10.2% group-C and 26.9% group-D. By CAT 22.3% were group-A, 41% group-B, 4.8% group-C and 31.9% group-D. Using the mMRC the severity of E-RS, NiSCI and EMSCI scores increased from group A to D. Using the CAT, the groups B and D had the higher scores. Agreement between mMRC and CAT was 89.5% (Kappa statistics=75.7%). For mMRC score of 2, CAT score of ≥11 showed the maximum Youden's index (1.34). For mMRC score of 1, CAT score of ≥9 and ≥10 showed the maximum Youden's index (1.48). Conclusion GOLD COPD classification by CAT seems to better discriminate 24-hour symptoms. Results do not support the equivalent use of CAT≥10 and mMRC≥2 for assessing symptoms.

RESUMO Objetivo Avaliar a frequência e gravidade dos sintomas respiratórios de 24 horas de acordo com a classificação COPD GOLD-ABCD (versão 2017), a distribuição dos pacientes com DPOC nas categorias GOLD usando escores mMRC (≥2) ou CAT (≥10) e concordância entre esses pontos de corte. Métodos Neste estudo transversal (estudo LASSYC), os sintomas respiratórios diários de 24 horas foram avaliados pelo questionário Avaliando os Sintomas Respiratórios em DPOC (Evaluating Respiratory Symptoms - E-RS), Instrumento de Sintomas Noturnos de DPOC (Nighttime Symptoms of COPD Instrument -NiSCI), Instrumento de Sintomas Matinais de DPOC (Early Morning Symptoms of COPD Instrument - EMSCI), pontuações CAT e mMRC. Resultados Entre os 734 pacientes com DPOC, 61% eram do sexo masculino, idade 69,6 ± 8,7 anos, VEF1% pós-BD 49,1 ± 17,5%, mMRC 1,8 ± 1,0 e CAT 15,3 ± 0,8,1. Por mMRC 33,7% eram do grupo A, 29,2% do grupo B, 10,2% do grupo C e 26,9% do grupo D. Por CAT, 22,3% eram do grupo A, 41% do grupo B, 4,8% do grupo C e 31,9% do grupo D. Usando o mMRC, a gravidade dos escores E-RS, NiSCI e EMSCI aumentou do grupo A para D. Usando o CAT, os grupos B e D tiveram os escores mais altos. A concordância entre mMRC e CAT foi de 89,5% (estatística Kappa = 75,7%). Para a pontuação mMRC de 2, a pontuação CAT ≥11 mostrou o índice de Youden máximo (1,34). Para a pontuação mMRC de 1, a pontuação CAT ≥9 e ≥10 mostrou o índice de Youden máximo (1,48). Conclusão A classificação GOLD COPD por CAT parece discriminar melhor os sintomas de 24 horas. Os resultados não suportam o uso equivalente de CAT≥10 e mMRC≥2 para avaliação dos sintomas.

Body mass index, asthma, and respiratory symptoms: a population-based study / Índice de massa corpórea, asma e sintomas respiratórios: um estudo de base populacional

ABSTRACT Objective: To estimate the prevalence of respiratory symptoms and asthma, according to body mass index (BMI), as well as to evaluate factors associated with physician-diagnosed asthma, in individuals ≥ 40 years of age. Methods: This was a population-based cross-sectional study conducted in Florianópolis, Brazil, with probability sampling. Data were collected during home visits. Demographic data were collected, as were reports of physician-diagnosed asthma, respiratory symptoms, medications in use, and comorbidities. Anthropometric measurements were taken. Individuals also underwent spirometry before and after bronchodilator administration. Individuals were categorized as being of normal weight (BMI < 25 kg/m2), overweight (25 kg/m2 ≥ BMI < 30 kg/m2), or obese (BMI ≥ 30 kg/m2). Results: A total of 1,026 individuals were evaluated, 274 (26.7%) were of normal weight, 436 (42.5%) were overweight, and 316 (30.8%) were obese. The prevalence of physician-diagnosed asthma was 11.0%. The prevalence of obesity was higher in women (p = 0.03), as it was in respondents with ≤ 4 years of schooling (p < 0.001) or a family income of 3-10 times the national minimum wage. Physician-diagnosed asthma was more common among obese individuals than among those who were overweight and those of normal weight (16.1%, 9.9%, and 8.0%, respectively; p = 0.04), as were dyspnea (35.5%, 22.5%, and 17.9%, respectively; p < 0.001) and wheezing in the last year (25.6%, 11.9%, and 14.6%, respectively; p < 0.001). These results were independent of patient smoking status. In addition, obese individuals were three times more likely to report physician-diagnosed asthma than were those of normal weight (p = 0.005). Conclusions: A report of physician-diagnosed asthma showed a significant association with being ≥ 40 years of age and with having a BMI ≥ 30 kg/m2. Being obese tripled the chance of physician-diagnosed asthma.

RESUMO Objetivo: Estimar a prevalência de sintomas respiratórios e asma de acordo com o índice de massa corpórea (IMC) em indivíduos com idade ≥ 40 anos e avaliar os fatores associados ao relato de diagnóstico médico de asma. Métodos: Estudo transversal de base populacional realizado no município de Florianópolis (SC), com coleta domiciliar de dados e processo de amostragem probabilístico. Foram coletadas informações demográficas, assim como sobre relato de diagnóstico médico de asma, sintomas respiratórios, medicações em uso e comorbidades. Também foram realizadas medidas antropométricas e espirometria pré- e pós-broncodilatador. O IMC foi categorizado em normal (IMC < 25 kg/m2), sobrepeso (25 kg/m2 ≥ IMC < 30 kg/m2) e obesidade (IMC ≥ 30 kg/m2). Resultados: Foram avaliados 1.026 indivíduos, 274 (26,7%) com IMC normal, 436 (42,5%) com sobrepeso e 316 (30,8%) obesos. A prevalência de diagnóstico médico de asma foi de 11,0%. A prevalência de obesidade foi maior em mulheres (p = 0,03) e em entrevistados com escolaridade < 4 anos (p < 0,001) ou com renda familiar entre 3-10 salários mínimos. Obesos, quando comparados com aqueles com sobrepeso e peso normal, relataram mais frequentemente diagnóstico médico de asma (16,1%, 9,9% e 8,0%, respectivamente; p = 0,04), dispneia (35,5%, 22,5% e 17,9%, respectivamente; p < 0,001) e sibilos no último ano (25,6%, 11,9% e 14,6%, respectivamente; p < 0,001). Esses resultados foram independentes do status tabágico. Além disso, obesos tinham uma chance três vezes maior de relato de diagnóstico médico de asma do que não obesos (p = 0,005). Conclusões: Houve associação significativa entre o relato de diagnóstico médico de asma em indivíduos com idade ≥ 40 anos e IMC ≥ 30 kg/m2. Ser obeso triplicou a chance de diagnóstico médico de asma.

COVID-19: presentación clínica en adultos / COVID-19: clinical features in adult patients

Este artículo resume las diferentes formas de presentación clínica de la enfermedad COVID-19 causada por el virus SARS-Co-2 documentadas fundamentalmente en las tres principales revisiones sistemáticas disponibles. Entre las manifestaciones clínicas de frecuente aparición se destacan la fiebre (83 %), la tos (60 %) y la fatiga (38 %), seguidas por las mialgias (29 %), el aumento de la producción del esputo (27 %) y la disnea (25 %). Entre los hallazgos de laboratorio,predominan el aumento de los valores de proteína C reactiva (69 %), la linfopenia (57 %) y el aumento de los niveles de lactato-deshidrogenasa (52 %). Respecto de las manifestaciones radiológicas, tienen especial importancia las opacificaciones en vidrio esmerilado (80 %), la neumonía bilateral (73 %) y la afectación de tres lóbulos pulmonares o más (57 %).Si bien la evidencia sintetizada tiene limitaciones, permite una aproximación actualizada a los conocimientos disponibles sobre la clínica de esta nueva enfermedad en la población adulta. (AU)

This article summarizes the different forms of clinical presentation of COVID-19, caused by the SARS-Co-2 virus, synthesizing the information collected mainly by three published systematic reviews. Frequent clinical manifestations include fever(83 %), cough (60 %), and fatigue (38 %), followed by myalgia (29 %), increased sputum production (27 %) and dyspnea(25 %). Among the laboratory findings, the most common are the increase in C-reactive protein values (69 %), lymphopenia (57 %) and the increase in lactate dehydrogenase levels (52 %).. Most remarkable radiological features include ground glass opacifications (80 %), bilateral pneumonia (73 %) and the involvement of three or more lung lobes (57 %). Although the synthesized evidence has limitations, it allows an updated approach to the available knowledge about the clinical symptoms of this new disease in the adult population. (AU)

¿Cómo se sospecha una fibrosis pulmonar idiopática en la atención primaria de salud? / How is idiopathic pulmonary fibrosis suspected in primary health care?

La fibrosis pulmonar idiopática (FPI) es una enfermedad pulmonar de sintomatología inespecífica. La tos crónica y disnea progresivas en adultos mayores fumadores o exfumadores son los síntomas y características clínicas más frecuentes. Por lo tanto, es usual que el diagnóstico sea tardío. La atención primaria constituye el primer contacto del paciente con el sistema de salud. Por esto es necesaria la entrega de toda la información posible a los médicos, enfermeras y kinesiólogos que atienden adultos con problemas respiratorios, ya que sólo se diagnosticará FPI si se piensa en FPI.

Idiopathic pulmonary fibrosis (IPF) is a lung disease of nonspecific symptomatology. Progressive chronic cough and dyspnea in older smokers or ex-smokers are the most frequent symptoms and clinical features. Therefore, it is usual for the diagnosis to be late. Primary care constitutes the patient's first contact with the health system. Therefore, it is necessary to deliver all possible information to physicians, nurses and physical therapists who care for adults with respiratory problems, since IPF will only be diagnosed if FPI is considered.

Modified medical research council (mMRC) e a sua relação com variáveis respiratórias e o tempo de internação em pacientes hospitalizados com doença pulmonar obstrutiva crônica / Modified medical research council (mMRC) and their relation with respiratory variables and the time of intermission in hospitalized patients with chronic obstructive pulmonary disease

Objetivo: Correlacionar a sensação de dispneia obtida pela escala Medical Research Council modificada (mMRC) com as variáveis respiratórias e o tempo de internação em portadores de doença pulmonar obstrutiva crônica (DPOC) hospitalizados. Material e Métodos: Estudo transversal de caráter observacional e descritivo; no qual participaram do estudo pacientes interna-dos na Santa Casa de Misericórdia (SCM) de Goiânia-GO e Hospital Geral de Goiânia Dr. Alberto Rassi (HGG), com diag-nóstico de DPOC. Foram coletados sinais vitais, dados antro-pométricos e aplicada a escala de mMRC. Resultados: Foram avaliados 28 participantes, com média de idade de 74,10±12,46 anos; a média de mMRC foi de 3,10±1,19, comprometimento moderado, não ocorrendo diferença de mMRC entre homens e mulheres (p=0,503), além de não ter sido encontrada cor-relação entre o mMRC com a FR (r= -0,035 p=0,864), SpO2 (r=-0,228 p=0,222) e o tempo de internação (r=0,140 p=0,486). No entanto, em relação a necessidade de internação em uni-dade de terapia intensiva e o tempo de internação na unidade houve correlação significativa (r-0,457 p<0,01 e r 0,388 p<0,04, respectivamente). Conclusão: Não se encontrou relação da sensação de dispneia com as variáveis respiratórias e o tempo de internação total, porém foi possível verificar uma correlação entre o mMRC e a necessidade de internação e o tempo de internação em unidade de terapia intensiva. (AU)

Objetive:To correlate the dyspnea syndrome with the modified Medical Research Council scale (mMRC) with the respiratory and temporal variables of hospitalization in patients with hospitalized chronic obstructive pulmonary disease (COPD). Method: Cross-sectional observational and descriptive studyin which participated patients from the Santa Casa de Misericórdia (SCM) of Goiânia-GO and the General Hospital of Goiânia Dr. Alberto Rassi (HGG), with the diagnosis of COPD. Vital signs and anthropometric data were collected and the mMRC scale was applied. Results: Twenty-eight participants were evaluated, with a mean age of 74.10 ± 12.46 years; the mean mMRC was 3.10 ± 1.19, there was moderate impairment, no difference of mMRC between men and women (p = 0.503), nor was it found among mMRC with FR (r = -0.035 p = 0.864), SpO2 (r = -0.228 p = 0.222) and length of stay (r = 0.140 p = 0.486), which means that intensive care unit stay and length of stay in the domestic unit are important (r-0,457 p<0,01 e r 0,388 p<0,04 respectively). Conclusion: No differences between dyspnea syndrome and respiratory variables and total hospitalization time were found, but it was possible that they occurred between the MRC and the need for hospitalization and length of stay in intensive care therapy. There is a moderate influence of the dyspnea syndrome to direct the attention to the individuals under hospitalization, in order to minimize the progression of the disorder and greater impairment in the general state of health. (AU)

Fístula arteriovenosa pós-cateterismo radial com repercussões cardiopulmonares / Arteriovenous fistula after radial catheterization with cardiopulmonary repercussions

O presente artigo relata o caso de um paciente coronariopata de 86 anos submetido a cateterismo cardíaco via acesso radial à esquerda. Cerca de 16 meses após o procedimento, manifestou dispneia sem relação com esforço, associada a hipóxia noturna. Apresentava frêmito à palpação do punho esquerdo e foi diagnosticado com fístula arteriovenosa radiocefálica no punho esquerdo. Ao duplex scan apresentava alteração de padrão de onda e aumento da velocidade diastólica compatível com fístula arteriovenosa. Foi submetido a correção cirúrgica da fístula, apresentando melhora clínica e laboratorial após o procedimento. O acesso radial para cateterismo cardíaco tem sido cada vez mais utilizado, principalmente por causar complicações menos frequentes e menos deletérias em comparação ao acesso femoral. Entretanto, complicações como fístula arteriovenosa ocorrem e podem ser especialmente prejudiciais em pacientes octogenários

This article describes the case of an 86-year-old coronary disease patient who underwent cardiac catheterization via a left radial access. Around 16 months after the procedure, he presented with dyspnea, unrelated to effort, but associated with nocturnal hypoxia. There was a palpable thrill in the left wrist and he was diagnosed with a radiocephalic arteriovenous fistula in the left wrist. A duplex scan revealed an abnormal wave pattern and increased diastolic velocity compatible with arteriovenous fistula. The fistula was repaired surgically and the patient exhibited improvement in clinical and laboratory parameters after the procedure. Radial access is increasingly being used for cardiac catheterization, primarily because it is associated with fewer and less harmful complications than femoral access. However, complications such as arteriovenous fistula occur and can be particularly harmful in octogenarian patients

Influence of pulmonary rehabilitation on clinical characteristics in patients with chronic heart failure and chronic obstructive pulmonary disease / Influência da reabilitação pulmonar nas características clínicas em pacientes com insuficiência cardíaca crônica e doença pulmonar obstrutiva crônica

Background: The improvement of treatment strategies in patients with chronic obstructive pulmonary disease (COPD) and especially with comorbid pathology should provide rational conversion of standard schemes of therapy and rehabilitation in accordance with their clinical, pathogenic, functional and economic feasibility. Objective: To assess the influence of pulmonary rehabilitation on clinical characteristics in patients with chronic heart failure (CHF) and concomitant COPD. Methods: The study included 102 patients with CHF and concomitant COPD (males, 62%; mean age, 68.2 ± 4.5 years). All patients were divided into two groups: control group (CG) (n = 54), received only standard therapy of CHF and COPD; and intervention group (IG) (n = 48) were additionally taught the full yogic breathing as a program of pulmonary rehabilitation. Calculation of points by clinical evaluation scale (CES), assessment of CHF functional class (FC) (NYHA) and 6-minute walk test (6MWT - with the evaluation of dyspnea by the Borg scale) were performed in all patients on admission to the department and at discharge. Significant association was defined by p value < 0.05. Results: At baseline, there were no significant differences in clinical characteristics of the patients and studied parameters between the groups. At discharge both groups showed significant reduction of dyspnea by the Borg scale (in CG: from 7.2 ± 0.8 points to 5.2 ± 0.3; in IG: from 7.4 ± 0.6 points to 3.2 ± 0.4), the number of points by CES (in CG: from 10.8 ± 0.3 points to 7.2 ± 0.4; in IG: from 10.7 ± 0.6 points to 5.9 ± 0.6). Increase in exercise tolerance (by the distance of 6MWT) was observed in both groups (in CG: from 215 ± 24 m to 275 ± 22 m; in IG: from 219 ± 21 m to 308 ± 24 m). The changes were more significant in IG compared to CG. We observed the prominent decrease in CHF FC and length of hospital stay in IG. Conclusions: Application of full yogic breathing as the program of pulmonary rehabilitation in addition to standard therapy of the patients with CHF and COPD is associated with a significant decrease in CHF FC, an increase in exercise tolerance and a reduced length of hospital stay

Associação entre dispneia e o grau de disfunção diastólica ao ecocardiograma / Association among dyspnea and the degrees of diastolic dysfunction at echocardiography

ntrodução: A disfunção diastólica do ventrículo esquerdo (DDVE) pode levar a insuficiência cardíaca com fração de ejeção preservada. O ecocardiograma, em especial o Doppler tecidual, é o principal exame utilizado. A clínica geralmente cursa com dispneia, avaliada pela escala modified Medical Research Council (mMRC). Entretanto, existem poucos estudos que investiguem qual é a associação entre o sintoma e a disfunção. Objetivo: Avaliar se a queixa de dispneia se associa com a progressão da DDVE e se há relação entre mMRC e os graus de DDVE. Métodos: Estudo caso-controle e transversal, com 60 participantes, com avaliação clínica (mMRC) e ecocardiográfica (parâmetros bidimensionais, Doppler espectral e tecidual). Dentre os participantes avaliados, 49 configuraram o grupo caso (DDVE com dispneia) e 11 o grupo controle (DDVE sem dispneia). Foram excluídos participantes com comorbidades ou outras alterações ecocardiográficas relacionadas à dispneia. Resultados: A média de idade foi de 61,7 anos (± 7,9), sendo 72% mulheres. Do total, 82% dos participantes apresentaram dispneia. Destes, 82% apresentaram DDVE grau I. Todos apresentaram função ventricular sistólica preservada. A presença de dispneia se associou com o grau de DDVE (p = 0,04), relação que não se observou com a intensidade do sintoma (p = 0,72). Conclusão: Houve associação entre a presença de dispneia e grau de DDVE, porém não houve relação entre a progressão da dispneia e a evolução da DDVE. O aumento do átrio esquerdo e a presença de doença arterial coronariana foram associadas com graus mais avançados de DDVE

Introduction: The left ventricle diastolic dysfuntion (LVDD) can lead to heart failure with preserved ejection fraction. Echocardiography, especially the tissue Doppler, is the main exam. The clinic has dyspnea as a typical symptom, which is evaluated by modified Medical Research Council (mMRC). However, there are few studies that investigate what is the association between the symptom and LVDD. Objective: Evaluate if dyspnea is associated with the advancement of LVDD and if there is a linkage between mMRC and the degrees of LVDD. Method: Case-control transversal study, with 60 participants, with clinical (mMRC) and echocardiographic (bidimensional parameters, spectral and tissue Doppler) evaluation. Among the participants, 49 constituted the case group (LVDD with dyspnea) and 11 the control group (LVDD without dyspnea). Participants with co-morbidity or other echocardiographic abnormalities related to dyspnea were excluded. Results: The average age was 61,7 (± 7,9) years and 72% were women. In overwall, 82% of the participants had dyspnea. Among them, 82% had LVDD degree I. All of the study population had preserved ventricular systolic function. The presence of dyspnea was associated with the degree of LVDD (p = 0,04), however, the symptom severity was not (p = 0,72). Conclusion: Dyspnea was associated with the degree of LVDD, but there was no association between the symptom severity and the evolution of LVDD. The aging, the increase of left atrium and coronary artery disease were associated with the advanced grades of LVDD

Evaluación de la disnea asociada al ejercicio / Exercise-induced dyspnea evaluation

Exercise-induced dyspnea is a common pediatric question but difficult to address since usually symptoms are described ambiguously by the child or parents. Most of times dyspnea is secondary to poor training but sometimes may be due to an underlying condition like exercise-induced bronchoconstriction or vocal cord dysfunction. To provide clinicians with a practical approach about exercise-induced dyspnea we have review pathogenesis and clinical characteristics of respiratory diseases and proposed an algorithm for study.

Frecuentemente nos vemos enfrentados a evaluar un niño con síntomas vagos asociados al ejercicio que el mismo paciente o sus padres describen como ahogo o sensación de pecho apretado. La mayoría de las veces se trata de cansancio atribuible al ejercicio normal que solo refleja pobre condicionamiento físico del individuo; sin embargo, este cansancio puede ser desproporcionado al esfuerzo, lo que obliga a considerar enfermedades comunes como asma o poco comunes como disfunción de cuerdas vocales. El objetivo de esta revisión es actualizar el conocimiento aquellas enfermedades respiratorias que forman parte del diagnóstico diferencial de la disnea asociada al ejercicio y proponer un algoritmo de estudio que permita un acercamiento práctico según causas de origen.

Age and mini-mental state examination score can predict poor-quality spirometry in the elderly: a cross-sectional study

OBJECTIVES: The goal was to identify predictors of poor-quality spirometry in community-dwelling older adults and their respective cutoffs. METHODS: This was a cross-sectional population-based study involving 245 elderly subjects (age≥60 years). The spirometric data were categorized as good or poor quality, and cognitive status was assessed using an adapted version (scaled to have a maximum of 19 points) of the Mini-Mental State Examination. Multivariate analysis was used to assess the association between poor-quality spirometry and sociodemographic, behavioral and health characteristics. The best cutoff points for predicting poor-quality spirometry were evaluated by the receiver operating characteristic curve. RESULTS: In this population, 61 (24.9%) subjects with poor-quality spirometry were identified. After multiple logistic regression analysis, only age and Mini-Mental State Examination score were still associated with poor-quality spirometry (p≤0.05). The cutoff for the Mini-Mental State Examination score was 15 points, with an area under the receiver operating characteristic curve of 0.628 (p=0.0017), sensitivity of 74.5% and specificity of 49.5%; for age, the cutoff was 78 years, with an area under the receiver operating characteristic curve of 0.718 (p=0.0001), sensitivity of 57.4% and specificity of 79.9%. CONCLUSION: Age and Mini-Mental State Examination score together are good predictors of poor-quality spirometry and can contribute to the screening of community-dwelling older adults unable to meet the minimum quality criteria for a spirometric test.

Associações entre discriminadores do Sistema de Triagem de Manchester e diagnósticos de enfermagem / Asociación entre el Sistema de Triage Manchester y el diagnóstico de enfermería / Association between Manchester Triage System discriminators and nursing diagnoses

Resumo OBJETIVO Analisar associações entre discriminadores do Sistema de Triagem de Manchester e Diagnósticos de Enfermagem em pacientes adultos, classificados com prioridade clínica I (emergência) e II (muito urgente). MÉTODO Estudo transversal realizado na unidade de emergência do sul do Brasil, entre abril e agosto de 2014. Amostra de 219 pacientes. Os dados foram coletados no prontuário online e analisados estatisticamente, com teste exato de Fisher ou qui-quadrado. RESULTADOS Encontrou-se 16 discriminadores e 14 diagnósticos de enfermagem. Houve associação entre sete discriminadores e cinco diagnósticos de enfermagem do tipo foco no problema, dentre Dor precordial ou cardíaca com o diagnóstico Dor aguda. Também houve associação entre três discriminadores com quatro diagnósticos de enfermagem de risco, dentre Déficit neurológico agudo com o diagnóstico Risco de perfusão tissular cerebral ineficaz. CONCLUSÃO Existem associações significativas entre discriminadores do Sistema de Triagem de Manchester e diagnósticos de enfermagem mais frequentemente estabelecidos na Unidade de Emergência.

Resumen OBJETIVO Analizar asociaciones entre los discernidores del Sistema Triaje de Manchester y los Diagnósticos de Enfermería en pacientes adultos con prioridad clínica I (emergencia) y II (muy urgente). MÉTODO Estudio transversal realizado en la unidad de emergencia del sur de Brasil, entre abril y agosto de 2014, con la muestra de 219 pacientes. La colecta de datos fue realizada en el prontuario online de los pacientes. El análisis estadístico fue realizado con el uso del Test Exacto de Fisher o chi-cuadrado. RESULTADOS Fue identificado el uso de 16 discernidores y 14 diagnósticos de enfermería. Hubo una asociación entre siete discernidores y cinco diagnósticos de enfermería del tipo foco en el problema, entre estos Dolor precordial o cardíaca y Dolor agudo. También hubo asociación entre tres discernidores y cuatro diagnósticos de enfermería de riesgo, entre estos Déficit neurológico agudo con el diagnóstico Riesgo de perfusión tisular cerebral ineficaz. CONCLUSIÓN Existen asociaciones significativas entre los discernidores del Sistema Triaje de Manchester y los diagnósticos de enfermería más frecuente establecidos en la Unidad de Emergencia.

Abstract OBJECTIVE To analyze the association between Manchester Triage System flowchart discriminators and nursing diagnoses in adult patients classified as clinical priority I (emergency) and II (very urgent). METHOD Cross-sectional study conducted in an emergency department in southern Brazil between April and August 2014. The sample included 219 patients. Data were collected from online patient medical records and data analysis was performed using Fisher's exact test or the chi-square test. RESULTS 16 discriminators and 14 nursing diagnoses were identified. Associations were found between seven discriminators and five problem-focused nursing diagnoses, including the discriminator Cardiac pain and the diagnosis Acute pain. Three discriminators were associated with four risk nursing diagnoses, among these Acute neurological deficit with the diagnosis Risk of ineffective cerebral tissue perfusion. CONCLUSION Significant associations were found between Manchester Triage System discriminators and the nursing diagnoses most frequently established in the emergency department.

Valoración mediante espirometría de mineros del carbón de Paipa, Colombia / Spirometry in a population of coal miners in Paipa, Colombia

RESUMEN Introducción: Las enfermedades respiratorias derivadas de la exposición a material en partículas, como sucede en la minería del carbón, continúa siendo un reto investigativo en el país y un problema de salud pública. La espirometría es una prueba de la función respiratoria, fundamental para el diagnóstico y la vigilancia de este tipo de enfermedades pulmonares crónicas. Objetivo. Determinar los valores de la espirometría en la población minera de carbón del municipio de Paipa, y su asociación con la edad y el tiempo de exposición laboral. Materiales y métodos. Se hizo un estudio descriptivo de corte transversal. Se diligenció el cuestionario de enfermedad respiratoria ocupacional de la American Thoracic Society (ATS), se registraron las mediciones de la espirometría y se interpretaron siguiendo las recomendaciones internacionales. Resultados. La muestra incluyó 226 trabajadores de minas de carbón de Paipa; en 12,3 % (n=28) de ellos se registraron alteraciones leves, de tipo obstructivo o restrictivo. En 35 % (n=80) hubo disminución de la relación entre la capacidad vital forzada y el volumen espirado en el primer segundo (CVF/VEF1 ). Se encontró una asociación estadísticamente significativa entre el rango de edad (p=0,002) y los años de trabajo minero (p=0,34), además de trastornos restrictivos y obstructivos. Asimismo, hubo una asociación estadísticamente significativa entre el rango de edad (p<0,01) y los años de trabajo minero (p<0,01), de diferente seriedad en el patrón de las mediciones de la espirometría. Conclusiones. La espirometría es una prueba útil para detectar la presencia de trastornos respiratorios en la población minera del carbón. La enfermedad respiratoria en estos mineros estuvo significativamente asociada con el tiempo de exposición.

ABSTRACT Introduction: Respiratory diseases resulting from exposure to particulate matter such as in coal mining remains a research challenge in this country and a public health issue. Spirometry is a basic test of fundamental respiratory function for the diagnosis and monitoring of these types of chronic lung diseases. Objective: To determine spirometric values in the coal mining municipality of Paipa and their association with age and occupational exposure times. Materials and methods: We conducted a descriptive cross-sectional study. The occupational respiratory disease questionnaire of the American Thoracic Society (ATS) was completed while spirometric measurements were performed and interpreted in accordance with international recommendations for conducting the test. Results: The sample consisted of 226 coal mining workers of the municipality of Paipa. Twenty-eight subjects (12.3%) of the sample showed patterns of obstructive and restrictive respiratory disease with mild degrees of severity. Eighty subjects (35%) showed a decrease in the forced vital capacity ratio/expiratory volume in one second (FVC/FEV1 ). A statistically significant association between age range (p=0.002) and years of mining work (p=0.34) with the development of restrictive and obstructive disorders was found. Also, there was a statistically significant association between age range (p<0.01) and years of mining work (p<0.01) with various degrees of severity of the spirometric pattern. Conclusions: Spirometry is a useful test for detecting the presence of respiratory disorders in the population of coal miners. The time of exposure was significantly associated with the respiratory disease exhibited by these miners.

Native-valve endocarditis caused by Achromobacter xylosoxidans: a case report and review of literature

Achromobacter xylosoxidans is a Gram-negative aerobic bacterium first described by Yabuuchi and Ohyama in 1971. A. xylosoxidans is frequently found in aquatic environments. Abdominal, urinary tract, ocular, pneumonia, meningitis, and osteomyelitis are the most common infections. Infective endocarditis is rare. As far as we know, until now, only 19 cases have been described, including this current report. We report the case of community-acquired native valve endocarditis caused by A. xylosoxidans in an elderly patient without a concomitant diagnosis of a malignancy or any known immunodeficiency. The patient presented with a 2-month history of fever, weight loss, and progressive dyspnea. On physical examination, mitral and aortic murmurs were present, along with Janeway's lesions, and a positive blood culture for A. xylosoxidans. The transesophageal echocardiogram showed vegetation in the aortic valve, which was consistent with the diagnosis of infective endocarditis

Edema de Reinke obstructivo / Obstructive Reinke edema

Introducción: el edema de Reinke es la acumulación de fluidos en la capa externa de la lámina propia de las cuerdas vocales. Produce disfonía y raras veces obstrucción respiratoria. Las etiologías más frecuentes son el tabaquismo, el reflujo gastroesofágico y el mal uso y abuso vocal. Objetivos: determinar, mediante tratamiento quirúrgico, la tasa de resolución de la disnea inspiratoria severa provocada por edema de Reinke bilateral de cuerdas vocales. Diseño: estudio descriptivo y retrospectivo. Material y métodos: revisión de las historias clínicas electrónicas de todos los pacientes que consultaron y fueron tratados por disnea inspiratoria severa provocada por edema de Reinke bilateral de las cuerdas vocales, en el servicio de Otorrinolaringología del Hospital Italiano de Buenos Aires, entre febrero de 2007 y abril de 2015. Resultados: fueron tratados 4 pacientes de sexo femenino que consultaron por disnea inspiratoria severa. Fumaban más de 30 cigarrillos por día. La técnica quirúrgica consistió en resecar todo el edema polipoideo en forma bilateral, preservando el borde libre de las cuerdas vocales. Conclusiones: el edema de Reinke obstructivo es una patología infrecuente. La tasa de resolución de la disnea inspiratoria severa en las cuatro enfermas tratadas fue del100%. La resección total del edema y de la mucosa excedente, preservando un pequeño sector para que recubra el borde libre de la cuerda vocal (cordectomía vs. cordotomía), fue la técnica quirúrgica preferida. (AU)

Introduction: the Reinke edema is an accumulation of fluid in the outer layer of the lamina propria of the vocal cords. Causes dysphonia and rarely produces respiratory obstruction. Objectives: to determine the rate of resolution of the severe inspiratory dyspnea caused by bilateral Reinke edema of vocal cords with surgical treatment. Design: descriptive and retrospective study. Material and methods: review of the electronic medical records of all patients who consulted and were treated for severe inspiratory dyspnea caused by bilateral Reinke edema of the vocal chords in the Hospital Italiano de Buenos Aires between February 2007 and April 2015. Results: four women were treated, consulted for severe inspiratory dyspnea. Smoked more than 30 cigarettes per day. The surgical technique consisted in to resect all the bilateral polypoid edema, while preserving the free edge of the vocal cords. Conclusions: the obstructive Reinke edema is an infrequent pathology. The rate of resolution of the severe inspiratory dyspnea in the four patients treated was 100%. The total resection of the edema and mucosa excess, preserving a small sector to cover the free edge of the vocal cord (cordectomy vs cordotomy) was the preferred surgical technique. (AU)