Pulmonary hypertension as estimated by Doppler echocardiography in adolescent and adult patients with cystic fibrosis and their relationship with clinical, lung function and sleep findings.

BACKGROUND: In cystic fibrosis (CF) patients, end stage of pulmonary disease is characterized by pulmonary hypertension (PH), hypoxemia, decrease in exercise tolerance, and sleep quality. OBJECTIVE: To evaluate the association between clinical, lung function, sleep quality, and polysomnographic variables with PH in CF patients aged 16 years or older. METHODS: In a cross-sectional study, 51 clinically stable CF patients underwent a clinical evaluation, an overnight polysomnography and answered sleep questionnaires (Pittsburgh Sleep Quality Index and Epworth sleepiness scale). Also, CF patients had their pulmonary function, 6-minute walk test (6MWT) and echocardiography assessed. RESULTS: Fifty-one CF patients participated in the study; 47% were female. The mean age was 25.1 ± 8.8 years. Pulmonary artery systolic pressure (PASP) was greater than 35 mm Hg in 11 (27.5%) patients. Variables associated with PASP>35 mm Hg in univariate analysis were Shwachman-Kulczycki clinical score, forced expiratory volume in 1 second % of predicted, Pseudomonas aeruginosa in sputum culture, at-rest peripheral capillary oxygen saturation (SpO2 ), SpO2 at end of 6MWT and time of oxygen desaturation <90% during sleep. These variables were included in the binary logistic regression. The independent variable associated with the PASP > 35 mm Hg was at-rest SpO2 (OR = 10.8, CI 95% 1.7-67.3, P = .011). The cuttoff SpO2 < 94% had the sensitivity = 7/11 = 64%, specificity = 40/40 = 100%, positive predicted values = 7/7 = 100% and negative predicted values = 40/44 = 91% to the diagnosis of PH. CONCLUSION: the present study showed a high rate of PH in adolescent and adult CF patients. At-rest SpO2 was associated with PH.

Effects of positive expiratory pressure on pulmonary clearance of aerosolized technetium-99m-labeled diethylenetriaminepentaacetic acid in healthy individuals / Efeitos da pressão expiratória positiva na depuração pulmonar do ácido dietilenotriaminopentacético marcado com tecnécio-99m em aerossol em indivíduos saudáveis

ABSTRACT Objective: To evaluate the effects of positive expiratory pressure (PEP) on pulmonary epithelial membrane permeability in healthy subjects. Methods: We evaluated a cohort of 30 healthy subjects (15 males and 15 females) with a mean age of 28.3 ± 5.4 years, a mean FEV1/FVC ratio of 0.89 ± 0.14, and a mean FEV1 of 98.5 ± 13.1% of predicted. Subjects underwent technetium-99m-labeled diethylenetriaminepentaacetic acid (99mTc-DTPA) radioaerosol inhalation lung scintigraphy in two stages: during spontaneous breathing; and while breathing through a PEP mask at one of three PEP levels-10 cmH2O (n = 10), 15 cmH2O (n = 10), and 20 cmH2O (n = 10). The 99mTc-DTPA was nebulized for 3 min, and its clearance was recorded by scintigraphy over a 30-min period during spontaneous breathing and over a 30-min period during breathing through a PEP mask. Results: The pulmonary clearance of 99mTc-DTPA was significantly shorter when PEP was applied-at 10 cmH2O (p = 0.044), 15 cmH2O (p = 0.044), and 20 cmH2O (p = 0.004)-in comparison with that observed during spontaneous breathing. Conclusions: Our findings indicate that PEP, at the levels tested, is able to induce an increase in pulmonary epithelial membrane permeability and lung volume in healthy subjects.

RESUMO Objetivo: Avaliar os efeitos da pressão expiratória positiva (PEP) na permeabilidade da membrana epitelial pulmonar em indivíduos saudáveis. Métodos: Foi avaliada uma coorte de 30 indivíduos saudáveis (15 homens e 15 mulheres), com média de idade de 28,3 ± 5,4 anos, média da relação VEF1/CVF de 0,89 ± 0,14 e média de VEF1 de 98,5 ± 13,1% do previsto. Os indivíduos foram submetidos a cintilografia pulmonar por inalação de radioaerossol de ácido dietilenotriaminopentacético marcado com tecnécio-99m (99mTc-DTPA em inglês) em dois estágios: durante respiração espontânea e durante respiração com uma máscara de PEP de 10 cmH2O (n = 10), 15 cmH2O (n = 10) ou 20 cmH2O (n = 10). O 99mTc-DTPA foi nebulizado por 3 min, e sua depuração foi registrada por cintilografia por um período de 30 min durante respiração espontânea e por um período de 30 min durante a respiração com uma máscara de PEP. Resultados: A depuração pulmonar do 99mTc-DTPA foi significativamente menor quando PEP foi aplicada a 10 cmH2O (p = 0,044), 15 cmH2O (p = 0,044) e 20 cmH2O (p = 0,004), em comparação com a observada durante a respiração espontânea. Conclusões: Nossos achados indicam que o uso de PEP nos níveis testados pode induzir um aumento na permeabilidade da membrana epitelial pulmonar e no volume pulmonar em indivíduos saudáveis.

Effects of positive expiratory pressure on pulmonary clearance of aerosolized technetium-99m-labeled diethylenetriaminepentaacetic acid in healthy individuals.

OBJECTIVE:: To evaluate the effects of positive expiratory pressure (PEP) on pulmonary epithelial membrane permeability in healthy subjects. METHODS:: We evaluated a cohort of 30 healthy subjects (15 males and 15 females) with a mean age of 28.3 ± 5.4 years, a mean FEV1/FVC ratio of 0.89 ± 0.14, and a mean FEV1 of 98.5 ± 13.1% of predicted. Subjects underwent technetium-99m-labeled diethylenetriaminepentaacetic acid (99mTc-DTPA) radioaerosol inhalation lung scintigraphy in two stages: during spontaneous breathing; and while breathing through a PEP mask at one of three PEP levels-10 cmH2O (n = 10), 15 cmH2O (n = 10), and 20 cmH2O (n = 10). The 99mTc-DTPA was nebulized for 3 min, and its clearance was recorded by scintigraphy over a 30-min period during spontaneous breathing and over a 30-min period during breathing through a PEP mask. RESULTS:: The pulmonary clearance of 99mTc-DTPA was significantly shorter when PEP was applied-at 10 cmH2O (p = 0.044), 15 cmH2O (p = 0.044), and 20 cmH2O (p = 0.004)-in comparison with that observed during spontaneous breathing. CONCLUSIONS:: Our findings indicate that PEP, at the levels tested, is able to induce an increase in pulmonary epithelial membrane permeability and lung volume in healthy subjects. OBJETIVO:: Avaliar os efeitos da pressão expiratória positiva (PEP) na permeabilidade da membrana epitelial pulmonar em indivíduos saudáveis. MÉTODOS:: Foi avaliada uma coorte de 30 indivíduos saudáveis (15 homens e 15 mulheres), com média de idade de 28,3 ± 5,4 anos, média da relação VEF1/CVF de 0,89 ± 0,14 e média de VEF1 de 98,5 ± 13,1% do previsto. Os indivíduos foram submetidos a cintilografia pulmonar por inalação de radioaerossol de ácido dietilenotriaminopentacético marcado com tecnécio-99m (99mTc-DTPA em inglês) em dois estágios: durante respiração espontânea e durante respiração com uma máscara de PEP de 10 cmH2O (n = 10), 15 cmH2O (n = 10) ou 20 cmH2O (n = 10). O 99mTc-DTPA foi nebulizado por 3 min, e sua depuração foi registrada por cintilografia por um período de 30 min durante respiração espontânea e por um período de 30 min durante a respiração com uma máscara de PEP. RESULTADOS:: A depuração pulmonar do 99mTc-DTPA foi significativamente menor quando PEP foi aplicada a 10 cmH2O (p = 0,044), 15 cmH2O (p = 0,044) e 20 cmH2O (p = 0,004), em comparação com a observada durante a respiração espontânea. CONCLUSÕES:: Nossos achados indicam que o uso de PEP nos níveis testados pode induzir um aumento na permeabilidade da membrana epitelial pulmonar e no volume pulmonar em indivíduos saudáveis.

High frequency hearing thresholds and product distortion otoacoustic emissions in cystic fibrosis patients.

INTRODUCTION: The treatment of patients with cystic fibrosis involves the use of ototoxic drugs, mainly aminoglycoside antibiotics. Due to the use of these drugs, fibrocystic patients are at risk of developing hearing loss. OBJECTIVE: To evaluate the hearing of patients with cystic fibrosis by High Frequency Audiometry and Distortion Product Otoacoustic Emissions. METHODS: Cross-sectional study. The study group consisted of 39 patients (7-20 years of age) with cystic fibrosis and a control group of 36 individuals in the same age group without otologic complaints, with normal audiometric thresholds and type A tympanometric curves. High Frequency Audiometry and Distortion Product Otoacoustic Emissions tests were conducted. RESULTS: The study group had significantly higher thresholds at 250, 1000, 8000, 9000, 10,000, 12,500, and 16,000Hz (p=0.004) as well as higher prevalence of otoacoustic emission alterations at 1000 and 6000Hz (p=0.001), with significantly lower amplitudes at 1000, 1400, and 6000Hz. There was a significant association between alterations in hearing thresholds in High Frequency Audiometry with the number of courses of aminoglycosides administered (p=0.005). Eighty-three percent of patients who completed more than ten courses of aminoglycosides had hearing loss in High Frequency Audiometry. CONCLUSION: A significant number of patients with cystic fibrosis who received repeated courses of aminoglycosides showed alterations in High Frequency Audiometry and Distortion Product Otoacoustic Emissions. The implementation of ten or more aminoglycoside cycles was associated with alterations in High Frequency Audiometry.

Post-traumatic stress symptoms and exacerbations in COPD patients.

BACKGROUND: Post-Traumatic Stress Disorder (PTSD) is a common psychological consequence of exposure to traumatic stressful life events. During COPD exacerbations dyspnea can be considered a near-death experience that may induce post-traumatic stress symptoms. The aim of this study was to evaluate the relationship between COPD exacerbations and PTSD- related symptoms. METHOD: Thirty-three in-patients with COPD exacerbations were screened for the following: PTSS (Screen for Posttraumatic Stress Symptoms), anxiety (Beck Anxiety Inventory) and depression (Beck Depression Inventory). Patients had a median age of 72 years and 72.7% were female. RESULTS: Mean FEV1 and FVC were 0.8 ± 0.3 (37.7 ± 14.9% of predicted) and 1.7 ± 0.6 (60 ± 18.8% of predicted), respectively with a mean exacerbation of 2.9 episodes over the past year. Post-traumatic stress symptoms related to PTSD were found in 11 (33.3%) patients (SPTSS mean score 4.13 ± 2.54); moderate to severe depression in 16 (48.5%) (BDI mean score 21.2 ± 12.1) and moderate to severe anxiety in 23 (69.7%) (BAI mean score 23.5 ± 12.4). In a linear regression model, exacerbations significantly predicted post-traumatic stress symptoms scores: SPTSS scores increased 0.9 points with each exacerbation (p = 0.001). Significant correlations were detected between PTSD-related symptoms and anxiety (rs = 0.57; p = 0.001) and PTSD symptoms and depression (rs = 0.62; p = 0.0001). In a multivariable analysis model, two or more exacerbation episodes led to a near twofold increase in the prevalence ratio of post-traumatic stress symptoms related to PTSD(PR1.71; p = 0.015) specially those requiring hospitalization (PR 1.13; p = 0.030) CONCLUSION: PTSD symptoms increase as the patient's exacerbations increase. Two or more exacerbation episodes lead to a near twofold increase in the prevalence ratio of post-traumatic symptomatology. Overall, these findings suggest that psychological domains should be addressed along with respiratory function and exacerbations in COPD patients.

Activity level predicts 6-minute walk distance in healthy older females: an observational study.

BACKGROUND: The 6-minute walk test (6MWT) is widely used in clinical practice and research. Few studies have investigated activity level as a predictor of 6-minute walk distance (6MWD), and existing predictive models do not allow for activity level. OBJECTIVES: To evaluate if knowledge of the level of physical activity enhanced the ability to predict 6MWD, and if the inclusion of activity level added to the predictive accuracy of existing models for the 6MWT in healthy older women; and to validate existent predictive models for 6MWD in a new sample. DESIGN: Cross-sectional, observational study. SETTING: Four elderly communities. PARTICIPANTS: A convenience sample of healthy active and sedentary older non-smoking females with no musculoskeletal or lung disorders. MAIN OUTCOME MEASURES: Age, height, weight, spirometric values and 6MWD. RESULTS: Seventy-seven out of 154 females met the inclusion criteria [mean age 66 (standard deviation 6.5) years]: 46 were active and composed the active group and 31 were sedentary and composed the sedentary group. The active group had significantly greater 6MWD than the sedentary group (mean 44m; 95% confidence interval 14 to 73m; P<0.01). Previous published models that did not allow for activity level either over or underestimated the 6MWD in this sample. The activity level was shown to be an important independent predictor of 6MWD. CONCLUSION: This study demonstrates the importance of considering the level of physical activity when predicting 6MWD in older women.

D-dimer levels in stable COPD patients: a case-control study.

BACKGROUND: High D-dimer levels have been detected in patients with chronic obstructive pulmonary disease (COPD) exacerbation, irrespective of presence of venous thromboembolism. On the other hand, there is a continuing debate about the diagnostic efficiency of D-dimer tests in patients with stable COPD. OBJECTIVES: We aimed to investigate if basic laboratory investigations suggest hypercoagulability state in stable COPD patients, and if there is an association with D-dimer levels and pulmonary function tests. METHODS: We conducted a case-control study. COPD patients and controls were matched for sex and age in a 2:1 matching ratio. D-dimer levels and pulmonary function tests were performed in COPD patients and controls. RESULTS: A total of 58 COPD patients and 30 controls met the inclusion criteria and were included in the analysis. The median of D-dimers was 0.24 ng/mL (IQR: 0.21-0.36 ng/mL) in COPD group and 0.17 ng/mL (IQR: 0.12-0.24 ng/mL) in control group. This difference was not statistically significant (p = 0.102). Using bivariate correlations, we found significant positive correlations between BMI and D-dimers in COPD patients (r = 0.3, p = 0.024). CONCLUSIONS: We found that levels of D-dimers in stable COPD were not different as compared to control subjects. Our results also suggest that BMI could lead to disturbances in coagulation system.

Effects of expiratory positive airway pressure on dynamic hyperinflation during exercise in patients with COPD.

BACKGROUND: Expiratory positive airway pressure (EPAP) is a form of noninvasive positive-pressure ventilatory support that, in spite of not unloading respiratory muscles during inspiration, may reduce the inspiratory threshold load and attenuate expiratory dynamic airway compression, contributing to reduced expiratory air-flow limitation in patients with COPD. We sought to determine the effects of EPAP on operational lung volumes during exercise in COPD patients. METHODS: This was a nonrandomized, experimental comparison of 2 exercise conditions (with and without EPAP); subjects completed a treadmill exercise test and performed, before and immediately after exercise, lung volume measurements. Those who overtly developed dynamic hyperinflation (DH), as defined by at least a 15% reduction from pre-exercise inspiratory capacity (IC), were invited for an additional research visit to repeat the same exercise protocol while receiving EPAP through a spring loaded resistor face mask. The primary outcome was IC variance (pre-post exercise) comparison under the 2 exercise conditions. RESULTS: Forty-six subjects (32 males), a mean 65.0 ± 8.2 years of age, and with moderate to severe COPD (FEV(1) = 38 ± 16% predicted) were initially enrolled. From this initial sample, 17 (37%) presented overt DH, as previously defined. No significant difference was found between these subjects and the rest of the initial sample. Comparing before and after exercise, there was significantly less reduction in IC observed when EPAP was used (-0.18 ± 0.35 L vs -0.57 ± 0.45 L, P = .02), allowing greater IC final values (1.45 ± 0.50 L vs 1.13 ± 0.52 L, P = .02). CONCLUSIONS: The application of EPAP reduced DH, as shown by lower operational lung volumes after submaximal exercise in COPD patients who previously manifested exercise DH.

Sleep findings and predictors of sleep desaturation in adult cystic fibrosis patients.

PURPOSE: Questions remain about the polysomnographic findings and the predictors for sleep desaturation in cystic fibrosis (CF) patients. Our study aimed to evaluate sleep parameters in a sample of adult CF patients comparing them with healthy controls and to determine the best predictors of sleep desaturation in CF patients with awake resting peripheral oxygen saturation (SpO(2)) ≥90%. METHODS: In a cross-sectional study, with data collected prospectively, 51 clinically stable adult CF patients (mean age 25.1 ± 6.7 years) and 25 age-matched controls underwent an overnight polysomnography and answered sleep questionnaires. CF patients had their pulmonary function, 6-min walk test, and echocardiography assessed. RESULTS: CF patients and control subjects had similar sleep architecture. However, CF patients had impaired subjective sleep quality and a higher arousal index than controls. The apnea-hypopnea index was similar in both groups, and only two CF patients (3.9%) fulfilled the criteria for obstructive sleep apnea syndrome. Sleep desaturation was more common in CF patients (29.4% vs 0%; p < 0.001). In a logistic regression model, we observed that awake resting SpO(2) was the single best variable associated with sleep desaturation in CF population (p < 0.001). The awake SpO(2) <94% had a sensitivity, specificity, positive and negative predictive value for sleep desaturation of, respectively, 93.3%, 100%, 100%, and 97.3%. CONCLUSIONS: CF patients had a worse subjective sleep quality and small changes in sleep architecture. In nonhypoxic, adult CF patients, sleep desaturation is common, is not associated with obstructive sleep events, and can be accurately predicted by awake resting SpO(2) <94%.

Sleep abnormalities in untreated patients with mucopolysaccharidosis type VI.

Mucopolysaccharidosis type VI (MPS VI) is a lysosomal storage disease that affects an enzyme responsible for the degradation of glycosaminoglycans (GAGs). Partially degraded GAGs accumulate in several tissues, such as the upper airways (UA), which leads to the development of obstructive sleep apnea (OSA). Our objective was to determine the prevalence of OSA in a group of untreated patients with MPS VI and the association of OSA with clinical and echocardiographic findings. Patients aged 4 years or older with a biochemical diagnosis of MPS VI were included. Data about clinical history, physical examination, Doppler echocardiogram, and overnight polysomnography (PSG) were collected. Our results showed that of the 28 participants, 14 were boys; mean age was 98.5 months, and mean age at MPS VI diagnosis was 48.4 months. Snoring, witnessed apnea, pectus carinatum, and macroglossia were the main clinical findings. PSG results showed that 23:27 patients (85.1%) had OSA which was mild in 4, moderate in 5, and severe in 14 patients. Echocardiograms showed evidence of pulmonary hypertension (PH) in 14 patients. Lower (P = 0.037) and nadir SpO(2) (P = 0.007) were positively associated with PH. Clinical signs suggestive of respiratory abnormalities during sleep were not significantly correlated with the results of PSG. We conclude that the prevalence of OSA in patients with MPS VI was high, and the level of desaturation was positively correlated with PH. Symptoms during sleep were not associated with PSG findings, which suggests that this population should undergo routine PSG as earlier as possible. This study provides baseline data to estimate the potential impact of specific treatments in the sleep abnormalities presented by patients with MPS VI.

Perfused lung volume to thoracic gas volume ratio (perfused lung fraction) in patients with COPD and in controls.

BACKGROUND: The deterioration of the ventilation-to-perfusion distribution in patients with chronic obstructive pulmonary disease (COPD) reflects structural changes affecting both the airways and the blood vessels. These changes result in lung perfusion abnormalities that may be quantified by lung perfusion single photon emission computed tomography (SPECT). OBJECTIVE: To compare the perfused lung fraction (PLF) in patients with airflow obstruction and controls. METHODS: Fourteen patients with COPD and 21 controls underwent spirometry, whole-body plethysmography, and lung perfusion SPECT. PLF was derived from the ratio of perfused lung volume (measured by SPECT) to thoracic gas volume (measured by whole-body plethysmography). RESULTS: In the whole study sample, there were 18 (51%) women and 17 (49%) men, mean age was 46.2 (±20.3) years, range: 18-80 years). In the COPD group, PLF was 0.74 (±0.08), whereas in the control group PLF was 0.99 (±0.18) (P<0.001). PLF correlated directly with forced expiratory volume in 1 s to forced vital capacity (r=0.597, P<0.001). Perfused lung volume was 3.66 (±0.64) l in the COPD group compared with 2.71 (±0.70) l in the control group (P<0.001). CONCLUSION: The fraction of lung volume receiving blood from the pulmonary artery is reduced in patients with COPD. The degree of underperfusion seems to correlate with the degree of airflow limitation.

[Recommendations for the management of pulmonary thromboembolism, 2010]. / Recomendações para o manejo da tromboembolia pulmonar, 2010.

Pulmonary thromboembolism and deep vein thrombosis together constitute a condition designated venous thromboembolism. Despite the advances, the morbidity and the mortality attributed to this condition are still high, because the patients present with more complex diseases, are submitted to a greater number of invasive procedures and survive longer. Although there are various international guidelines available, we decided to write these recommendations for their application in medical practice in Brazil. These recommendations are based on the best evidence in the literature and the opinion of the advisory committee. This document is only a tool for use in the management of patients. Although the recommendations it contains can be applied to most situations, physicians should adapt its content depending on their local context and on a case-by-case basis. Pulmonary thromboembolism is diagnosed by evaluating pre-test clinical probability (scores) together with the results of imaging studies, the current method of choice being CT angiography. Stratification of the risk for an unfavorable outcome is fundamental. Hemodynamic instability is the most important predictor. Low-risk patients should be treated with heparin, commonly low-molecular-weight heparins. High-risk patients require intensive monitoring and, in some cases, thrombolytic therapy. In the long term, patients should receive anticoagulants for at least three months. The decision to prolong this treatment is made based on the presence of risk factors for the recurrence of the condition and the probability of bleeding. Prophylaxis is highly effective and should be widely used in clinical and surgical patients alike, according to their risk group. Finally, we include recommendations regarding the prevention, diagnosis and treatment of pulmonary thromboembolism.

Recomendações para o manejo da tromboembolia pulmonar, 2010 / Recommendations for the management of pulmonary thromboembolism, 2010

A tromboembolia pulmonar constitui, juntamente com a trombose venosa profunda, a condição denominada tromboembolismo venoso. Apesar dos avanços, a morbidade e a mortalidade atribuídas a essa doença ainda são elevadas, pois os pacientes apresentam doenças mais complexas, são submetidos a um maior número de procedimentos invasivos e sobrevivem por mais tempo. Embora existam inúmeras diretrizes internacionais disponíveis, optou-se por redigir estas recomendações para sua aplicação na prática médica nacional, embasadas nas melhores evidências na literatura e na opinião do grupo de consultores. Este documento é apenas uma ferramenta para o atendimento dos pacientes, e, embora possa ser aplicado na maioria das situações, o médico deve adaptar as informações a sua realidade local e ao caso específico. O diagnóstico de tromboembolia pulmonar é realizado através da combinação da probabilidade clínica pré-teste (escores) com o resultado dos exames de imagem, sendo atualmente o método de eleição a angiotomografia computadorizada. É fundamental a estratificação do risco de desfecho desfavorável, sendo a instabilidade hemodinâmica o preditor mais importante. Pacientes de baixo risco devem ser tratados com heparina, comumente as de baixo peso molecular. Pacientes de alto risco requerem vigilância intensiva e uso de trombolíticos em alguns casos. A longo prazo, os pacientes devem receber anticoagulantes por no mínimo três meses, sendo sua manutenção decidida pela presença de fatores de risco para a recorrência e a probabilidade de sangramento. A profilaxia é altamente eficaz e deve ser amplamente utilizada, tanto em pacientes clínicos como cirúrgicos, conforme os grupos de risco. Finalmente, são feitas recomendações relacionadas ao diagnóstico, tratamento e prevenção da tromboembolia pulmonar.

Pulmonary thromboembolism and deep vein thrombosis together constitute a condition designated venous thromboembolism. Despite the advances, the morbidity and the mortality attributed to this condition are still high, because the patients present with more complex diseases, are submitted to a greater number of invasive procedures and survive longer. Although there are various international guidelines available, we decided to write these recommendations for their application in medical practice in Brazil. These recommendations are based on the best evidence in the literature and the opinion of the advisory committee. This document is only a tool for use in the management of patients. Although the recommendations it contains can be applied to most situations, physicians should adapt its content depending on their local context and on a case-by-case basis. Pulmonary thromboembolism is diagnosed by evaluating pre-test clinical probability (scores) together with the results of imaging studies, the current method of choice being CT angiography. Stratification of the risk for an unfavorable outcome is fundamental. Hemodynamic instability is the most important predictor. Low-risk patients should be treated with heparin, commonly low-molecular-weight heparins. High-risk patients require intensive monitoring and, in some cases, thrombolytic therapy. In the long term, patients should receive anticoagulants for at least three months. The decision to prolong this treatment is made based on the presence of risk factors for the recurrence of the condition and the probability of bleeding. Prophylaxis is highly effective and should be widely used in clinical and surgical patients alike, according to their risk group. Finally, we include recommendations regarding the prevention, diagnosis and treatment of pulmonary thromboembolism.

Bacteriological analysis of induced sputum for the diagnosis of pulmonary tuberculosis in the clinical practice of a general tertiary hospital.

OBJECTIVE: To determine the diagnostic sensitivity of bacteriological analyses in induced sputum (IS) for the diagnosis of pulmonary tuberculosis (TB) and to identify the clinical characteristics associated with the confirmed diagnosis, as well as to determine the diagnostic yield of bronchoscopy carried out when IS tests negative for AFB in smear microscopy. METHODS: A retrospective, cross-sectional study of patients suspected of having active pulmonary TB and referred to our clinic for sputum induction. We consecutively reviewed the laboratory data of all patients submitted to sputum induction between June of 2003 and January of 2006, as well as their electronic medical records. In addition, the results of the bacteriological analysis of bronchoscopic specimens collected from the patients whose AFB tests were negative in IS were reviewed. RESULTS: Of the 417 patients included in the study, 83 (19.9%) presented IS samples that tested positive for TB (smear microscopy or culture). In the logistic regression analysis, radiological findings of cavitation (OR = 3.8; 95% CI: 1.9-7.6) and of miliary infiltrate (OR = 3.7; 95% CI: 1.6-8.6) showed the strongest association with the diagnosis of pulmonary TB. In 134 patients, bronchoscopy was carried out after negative AFB results in IS and added 25 (64.1%) confirmed diagnoses of pulmonary TB. CONCLUSIONS: In our clinical practice, the frequency of confirmed diagnosis of pulmonary TB using IS (19.9%) was lower than that previously reported in controlled trials. Cavitation and miliary infiltrate increase the diagnostic probability of pulmonary TB using IS. The use of bronchoscopy when IS tests negative for AFB significantly increases sensitivity in the diagnosis of pulmonary TB.

Association between nutritional status and dietary intake in patients with cystic fibrosis.

OBJECTIVE: To determine the relationship between nutritional status and dietary intake in patients with cystic fibrosis. METHODS: Cross-sectional study involving 85 cystic fibrosis patients between 6 and 18 years of age. Dietary intake was evaluated by the 3-day diet record (weighing the food consumed). The outcome measures were the following nutritional status indicators: weight/height (W/H%) percentage, body mass index (BMI) percentiles, Z score for weight/age (W/A), Z score for height/age (H/A) and percentage of dietary intake compared with the Recommended Dietary Allowance (RDA). RESULTS: The prevalence of well-nourished patients was 77.7%, using BMI above the 25th percentile as the cut-off value, and the W/H% was above 90% in 83.5%. The mean dietary intake, evaluated in 82 patients, was 124.5% of the RDA. In the univariate logistic regression analyses, we found a significant association between the independent variable calorie intake and the Z score for W/A. The multivariate analysis, based on the Z score for H/A and adjusted for FEV1, methicillin-resistant Staphylococcus aureus colonization and number of hospitalizations, demonstrated that a 1% increase in the calorie intake decreases the chance of having short stature by 2% (OR: 0.98; 95% CI: 0.96-1.00). Maternal level of education showed a borderline association (p = 0.054). CONCLUSIONS: The prevalence of malnutrition was low in this sample of patients. The study model demonstrated an association between dietary intake and nutritional status. Dietary intake was a predictive factor of statural growth in patients with cystic fibrosis.

Bacteriological analysis of induced sputum for the diagnosis of pulmonary tuberculosis in the clinical practice of a general tertiary hospital / Análise bacteriológica do escarro induzido para o diagnóstico de tuberculose pulmonar na prática clínica de um hospital geral terciário

OBJECTIVE: To determine the diagnostic sensitivity of bacteriological analyses in induced sputum (IS) for the diagnosis of pulmonary tuberculosis (TB) and to identify the clinical characteristics associated with the confirmed diagnosis, as well as to determine the diagnostic yield of bronchoscopy carried out when IS tests negative for AFB in smear microscopy. METHODS: A retrospective, cross-sectional study of patients suspected of having active pulmonary TB and referred to our clinic for sputum induction. We consecutively reviewed the laboratory data of all patients submitted to sputum induction between June of 2003 and January of 2006, as well as their electronic medical records. In addition, the results of the bacteriological analysis of bronchoscopic specimens collected from the patients whose AFB tests were negative in IS were reviewed. RESULTS: Of the 417 patients included in the study, 83 (19.9 percent) presented IS samples that tested positive for TB (smear microscopy or culture). In the logistic regression analysis, radiological findings of cavitation (OR = 3.8; 95 percent CI: 1.9-7.6) and of miliary infiltrate (OR = 3.7; 95 percent CI: 1.6-8.6) showed the strongest association with the diagnosis of pulmonary TB. In 134 patients, bronchoscopy was carried out after negative AFB results in IS and added 25 (64.1 percent) confirmed diagnoses of pulmonary TB. CONCLUSIONS: In our clinical practice, the frequency of confirmed diagnosis of pulmonary TB using IS (19.9 percent) was lower than that previously reported in controlled trials. Cavitation and miliary infiltrate increase the diagnostic probability of pulmonary TB using IS. The use of bronchoscopy when IS tests negative for AFB significantly increases sensitivity in the diagnosis of pulmonary TB.

OBJETIVO: Verificar a sensibilidade diagnóstica da análise bacteriológica do escarro induzido (EI) para o diagnóstico de tuberculose (TB) pulmonar e identificar as variáveis clínicas associadas com o diagnóstico confirmado. Além disso, avaliar o rendimento diagnóstico da broncoscopia realizada se a pesquisa de BAAR for negativa no EI. MÉTODOS: Estudo transversal e retrospectivo de pacientes com suspeita de TB pulmonar ativa, encaminhados ao serviço para a indução de escarro. Foram revisados consecutivamente os registros laboratoriais de todos os pacientes submetidos à indução de escarro entre junho de 2003 e janeiro de 2006, assim como o prontuário eletrônico de cada caso. Também foram revisados os resultados bacteriológicos das amostras broncoscópicas coletadas dos pacientes cujos resultados de BAAR em EI foram negativos. RESULTADOS: Dos 417 pacientes estudados, 83 (19,9 por cento) tiveram resultados positivos (BAAR e/ou cultura) no EI. Na análise de regressão logística, os achados radiológicos de cavitação pulmonar (OR = 3,8; IC95 por cento: 1,9-7,6) e de infiltrado de padrão miliar (OR = 3,7; IC95 por cento: 1,6-8,6) associaram-se mais significativamente com o diagnóstico de TB pulmonar. A broncoscopia foi realizada, após resultado de BAAR negativo no EI, em 134 pacientes e acrescentou 25 (64,1 por cento) diagnósticos confirmados de TB pulmonar. CONCLUSÕES: Na prática clínica, a frequência de diagnósticos confirmados de TB pulmonar por EI (19,9 por cento) foi menor do que aquela previamente relatada em ensaios controlados. Cavitação e infiltrado miliar aumentam a probabilidade diagnóstica de TB pulmonar no EI. O uso de broncoscopia quando EI é negativo para BAAR melhora significativamente a sensibilidade para o diagnóstico de TB.

Respiratory patterns in spirometric tests of adolescents and adults with cystic fibrosis.

OBJECTIVE: To evaluate spirometric patterns of respiratory disorders and their relationship with functional severity and maximal expiratory flows at low lung volumes in patients with cystic fibrosis (CF). METHODS: A retrospective cross-sectional study including adolescents and adults with CF. All of the patients were submitted to spirometry. Patients were classified as having preserved respiratory function, obstructive lung disease (OLD), OLD with reduced FVC, presumptive restrictive lung disease (RLD) or mixed obstructive and restrictive lung disease (MORLD). Maximal expiratory flows at low lung volumes were assessed using FEF(25-75%), FEF(75%) and FEF(75%)/FVC. We included 65 normal subjects, also submitted to spirometry, as a control group. RESULTS: The study group included 65 patients: 8 (12.3%) with preserved lung function; 18 (27.7%) with OLD; 24 (36.9%) with OLD and reduced FVC; 5 (7.7%) with presumptive RLD; and 10 (15.4%) with MORLD. The FEV1 was significantly lower in the OLD with reduced FVC group and the MORLD group than in the other groups (p < 0.001). In the patients with preserved respiratory function, FEF(25-75%) and FEF(75%) were significantly reduced in 1 patient, as was FEF(75%)/FVC in 2 patients. CONCLUSIONS: The respiratory pattern was impaired in 88% of the patients with CF. The most common pattern was OLD with reduced FVC. The degree of functional impairment was greater in the OLD with reduced FVC group and in the MORLD group than in the other groups. Maximal expiratory flows at low lung volumes were impaired in a low percentage of patients with preserved respiratory function.

Portuguese-language version of the Epworth sleepiness scale: validation for use in Brazil.

OBJECTIVE: The aim of this study was to develop a Portuguese-language version of the Epworth sleepiness scale (ESS) for use in Brazil. METHODS: The steps involved in creating the ESS in Brazilian Portuguese (ESS-BR) were as follows: translation; back-translation; comparison (by a committee) between the translation and the back-translation; and testing in bilingual individuals. The ESS-BR was applied to a group of patients who were submitted to overnight polysomnography in order to identify obstructive sleep apnea-hypopnea syndrome (OSAHS), insomnia and primary snoring. A control group was composed of subjects with a history of normal sleep habits, without reported snoring. RESULTS: A total of 114 patients and 21 controls were included. The 8-item scores of the ESS-BR had an overall reliability coefficient of 0.83. The study group was composed of 59 patients with OSAHS, 34 patients with primary snoring and 21 patients with insomnia. One-way ANOVA demonstrated significant differences in ESS-BR scores among the four diagnostic groups (p < 0.001). Post-hoc tests between groups showed that the ESS-BR scores of the patients with insomnia did not differ from those of the controls (p > 0.05). The ESS-BR scores were significantly higher for OSAHS patients and for primary snorers than for controls (p < 0.05). In addition, the scores for OSAHS patients were significantly higher than were those for primary snorers (p < 0.05). CONCLUSIONS: The results of the present study demonstrate that the ESS-BR is a valid and reliable instrument for the assessment of daytime sleepiness, equivalent to its original version when applied to individuals who speak Brazilian Portuguese.

Associação entre o estado nutricional e a ingestão dietética em pacientes com fibrose cística / Association between nutritional status and dietary intake in patients with cystic fibrosis

OBJETIVO: Determinar a relação entre o estado nutricional e a ingestão dietética de pacientes com fibrose cística. MÉTODOS: Estudo transversal com 85 pacientes com fibrose cística entre 6 e 18 anos de idade. A ingestão dietética foi avaliada pelo registro alimentar de 3 dias com a pesagem dos alimentos consumidos. Os desfechos avaliados foram os seguintes indicadores do estado nutricional: percentual da relação peso/estatura ( por centoP/E), percentil do índice de massa corpórea (IMC), escore Z para estatura/idade (E/I) e peso/idade (P/I), e percentual de ingestão dietética comparada a Recommended Dietary Allowances (RDAs). RESULTADOS: A prevalência de pacientes eutróficos foi de 77,7 por cento, considerando o IMC acima do percentil 25 como ponto de corte, e 83,5 por cento estavam acima de 90 por cento do por centoP/E. A média de ingestão, avaliada em 82 pacientes, foi de 124,5 por cento da RDA. Nas análises de regressão logística univariada, encontrou-se uma associação significativa entre a variável independente ingestão calórica e o desfecho escore Z E/I. O modelo de análise multivariado, elaborado a partir do desfecho escore Z E/I e ajustado para idade, VEF1, colonização por Staphylococcus aureus resistente à meticilina e número de internações hospitalares, demonstrou que um aumento de 1 por cento da ingestão calórica em relação à RDA diminui em 2 por cento a chance de ter déficit de estatura (OR = 0,98; IC95 por cento: 0,96-1,00). A escolaridade materna demonstrou uma associação limítrofe (p = 0,054). CONCLUSÕES: Houve baixa prevalência de desnutrição nesta amostra. O modelo de estudo demonstrou evidências da associação entre a ingestão dietética e o estado nutricional, sendo esta ingestão um fator preditor de crescimento nesses pacientes.

OBJECTIVE: To determine the relationship between nutritional status and dietary intake in patients with cystic fibrosis. METHODS: Cross-sectional study involving 85 cystic fibrosis patients between 6 and 18 years of age. Dietary intake was evaluated by the 3-day diet record (weighing the food consumed). The outcome measures were the following nutritional status indicators: weight/height (W/H percent) percentage, body mass index (BMI) percentiles, Z score for weight/age (W/A), Z score for height/age (H/A) and percentage of dietary intake compared with the Recommended Dietary Allowance (RDA). RESULTS: The prevalence of well-nourished patients was 77.7 percent, using BMI above the 25th percentile as the cut-off value, and the W/H percent was above 90 percent in 83.5 percent. The mean dietary intake, evaluated in 82 patients, was 124.5 percent of the RDA. In the univariate logistic regression analyses, we found a significant association between the independent variable calorie intake and the Z score for W/A. The multivariate analysis, based on the Z score for H/A and adjusted for FEV1, methicillin-resistant Staphylococcus aureus colonization and number of hospitalizations, demonstrated that a 1 percent increase in the calorie intake decreases the chance of having short stature by 2 percent (OR: 0.98; 95 percent CI: 0.96-1.00). Maternal level of education showed a borderline association (p = 0.054). CONCLUSIONS: The prevalence of malnutrition was low in this sample of patients. The study model demonstrated an association between dietary intake and nutritional status. Dietary intake was a predictive factor of statural growth in patients with cystic fibrosis.

Padrões ventilatórios na espirometria em pacientes adolescentes e adultos com fibrose cística / Respiratory patterns in spirometric tests of adolescents and adults with cystic fibrosis

OBJETIVO: Avaliar os padrões dos distúrbios ventilatórios observados na espirometria em pacientes com fibrose cística (FC) e suas relações com a gravidade funcional e com o comportamento dos fluxos máximos expiratórios a baixos volumes. MÉTODOS: Estudo transversal e retrospectivo, incluindo pacientes adolescentes e adultos com FC. Todos os pacientes foram submetidos à espirometria. Os pacientes foram classificados como tendo função ventilatória preservada, distúrbio ventilatório obstrutivo (DVO), DVO com CVF reduzida, sugestivo de distúrbio ventilatório restritivo (DVR) ou distúrbio ventilatório combinado (DVC). Os fluxos máximos expiratórios a baixos volumes foram avaliados utilizando-se FEF25-75 por cento, FEF75 por centoe FEF75 por cento/CVF. O grupo controle incluiu 65 indivíduos normais, também submetidos à espirometria. RESULTADOS: Foram incluídos 65 pacientes no grupo de estudo: 8 (12,3 por cento) com função pulmonar preservada, 18 (27,7 por cento) com DVO, 24 (36,9 por cento) com DVO com CVF reduzida, 5 (7,7 por cento) com padrão sugestivo de DVR e 10 (15,4 por cento) com DVC. O VEF1 foi significativamente menor nos grupos DVO com CVF reduzida e DVC, comparados com os outros grupos (p < 0,001). Nos pacientes com função ventilatória preservada, FEF25-75 por cento e FEF75 por cento foram significativamente reduzidos em 1 paciente, assim como FEF75 por cento/CVF em 2 pacientes. CONCLUSÕES: O padrão ventilatório estava alterado em 88 por cento dos pacientes com FC. O distúrbio mais frequente foi DVO com CVF reduzida. Houve maior prejuízo funcional nos pacientes com DVO e CVF reduzida e com DVC. Os fluxos expiratórios máximos a baixos volumes foram alterados em uma pequena percentagem de pacientes com função pulmonar preservada.

OBJECTIVE: To evaluate spirometric patterns of respiratory disorders and their relationship with functional severity and maximal expiratory flows at low lung volumes in patients with cystic fibrosis (CF). METHODS: A retrospective cross-sectional study including adolescents and adults with CF. All of the patients were submitted to spirometry. Patients were classified as having preserved respiratory function, obstructive lung disease (OLD), OLD with reduced FVC, presumptive restrictive lung disease (RLD) or mixed obstructive and restrictive lung disease (MORLD). Maximal expiratory flows at low lung volumes were assessed using FEF25-75 percent, FEF75 percent and FEF75 percent/FVC. We included 65 normal subjects, also submitted to spirometry, as a control group. RESULTS: The study group included 65 patients: 8 (12.3 percent) with preserved lung function; 18 (27.7 percent) with OLD; 24 (36.9 percent) with OLD and reduced FVC; 5 (7.7 percent) with presumptive RLD; and 10 (15.4 percent) with MORLD. The FEV1 was significantly lower in the OLD with reduced FVC group and the MORLD group than in the other groups (p < 0.001). In the patients with preserved respiratory function, FEF25-75 percent and FEF75 percent were significantly reduced in 1 patient, as was FEF75 percent/FVC in 2 patients. CONCLUSIONS: The respiratory pattern was impaired in 88 percent of the patients with CF. The most common pattern was OLD with reduced FVC. The degree of functional impairment was greater in the OLD with reduced FVC group and in the MORLD group than in the other groups. Maximal expiratory flows at low lung volumes were impaired in a low percentage of patients with preserved respiratory function.