Adaptation of the Medical Research Council Dyspnea Scale and the Oxygen Cost Diagram for its use in Puerto Rico

INTRODUCTION: Dyspnea is a common and disabling symptom for patients with chronic lung diseases. The Medical Research Council Dyspnea Scale (MRC) and the Oxygen Cost Diagram (OCD) are widely used instruments validated in English to measure breathlessness. OBJECTIVE: To translate and culturally adapt the MRC and the OCD for its use in Puerto Rico. METHOD: The scales were translated to Spanish and back translated. They were tested in patients attending a pulmonary clinic to assess its relevance and comprehension. Subjects answered the instruments, had a structured clinical interview and provided feedback. A multidisciplinary committee analyzed the source of misunderstanding using the input of the subjects, the clinical physicians, and the evaluators; made adjustments, and retested the instruments until inconsistencies were not observed. RESULTS: Placing emphasis on time spent walking instead of distance traveled improved the discrimination between grade two and three in the MRC. In the OCD, placing the activities to the right side eased the interpretation of the scale. Numerical symbols were eliminated to minimize discomfort in the severely impaired subjects reluctant to mark the line near zero. Reversing the order of both scales encouraged a thorough reading of the activities from minimal to high energy demanding eliciting a more fitting response compared to structured clinical interview especially in the severely ill patient. CONCLUSION: Using cross-cultural research methodologies to translate the MRC and OCD allowed the identification of differences in conceptualization when assessing the severity of dyspnea in Puerto Rico. Further testing is needed to confirm psychometric properties.

Respiratory pathogens in bronchoalveolar lavage in a Puerto Rican population infected with the human immunodeficiency virus

OBJECTIVE: To describe the respiratory pathogens found in the bronchoalveolar lavage of a Puerto Rican population infected with the human immunodeficiency virus (HIV). BACKGROUND: Empirical treatment is an accepted strategy for management of HIV-related pneumonia, but it is usually recommended for countries that have knowledge of the prevalent organisms in their population. In Puerto Rico, we have relied on data from the United States, but ethnic and geographical differences have been reported. DESIGN: Case series of a HIV-infected population admitted to an academic hospital in Puerto Rico because of respiratory symptoms and who underwent diagnostic standard bronchoalveolar lavage. RESULTS: From August 1998 to March 2000, 32 bronchoalveolar lavages (BAL) were performed in 31 Puerto Rican HIV patients. Nine (31) were female. Mean age was 37 years old. Predominant mode of infection of the virus was intravenous drug use in men and heterosexual contact in women. BAL was diagnostic in 17/32 (53) of the cases. Identified respiratory pathogens were Pneumocystis carinii (5), Mycobacterium tuberculosis (4), Staphylococcus aureus (2), Pseudomonas aeuruginosa (1), Bordetella bronchiseptica (1), viridans streptococcus (1), Histoplasma capsulatum (1), Cytomegalovirus (1), and, Mycobacterium kansassi (1). Retrospective review of medical records of non bronchoscoped patients for the period added six culture confirmed tuberculosis cases increasing tuberculosis rate to 18(10/56). CONCLUSIONS: Tuberculosis appears to be a more frequent pathogen in Puerto Rico than is reported in the United States. A larger study is needed to confirm this finding and thus to clarify whether an initial presumption of tuberculosis should be assumed in the Puerto Rican HIV population.