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1.
Rev. bras. educ. méd ; 47(3): e110, 2023.
Artigo em Português | LILACS-Express | LILACS | ID: biblio-1514986

RESUMO

Resumo: Introdução: A literatura sobre educação médica vem mostrando que os alunos de Medicina vivenciam dificuldades quanto à sobrecarga de atividades e tarefas, culminando com estresse e depressão, muitas vezes associados aos desafios trazidos pelo modelo pedagógico da Aprendizagem Baseada em Problemas. Objetivo: Este estudo teve como objetivo relatar os resultados de duas intervenções terapêuticas desenvolvidas com estudantes, tendo como foco situações-problema enfrentadas no curso de Medicina e como finalidade a promoção do bem-estar. Método: Trata-se de pesquisa de natureza qualitativa e exploratória. Criou-se um cenário para vivências psicodramáticas com cavalos. A amostra foi composta por duas discentes de Medicina, que atenderam ao critério de inclusão "participar do Centro Acadêmico". As alunas atuaram como protagonistas-pacientes-participantes. As intervenções com cada participante foram individuais e agiram nos níveis intrapsíquico e sistêmico, considerando aqui o sistema educação médica. Além da dramatização em si no palco-arena, ocorreram entrevistas semidirigidas abertas, à guisa de aquecimento e compartilhamento dos resultados, no dia da intervenção e seis meses após. Resultado: As protagonistas-pacientes-participantes, provenientes de dois cursos diferentes, ambos com currículo organizado em Aprendizagem Baseada em Problemas, cursavam o sexto e oitavo semestres do curso. Os "dramas-sofrimento em relação ao curso" escolhidos para serem trabalhados foram "competição na tutoria" e "sobrecarga". A dramatização trouxe à tona tomada de consciência do seu protagonismo em relação ao problema e da possibilidade de aquisição de novas respostas espontâneo-criativas, o que foi verificado seis meses após, por meio do relato das protagonistas-pacientes-participantes. O trabalho terapêutico realizado proporcionou às discentes melhora no bem-estar e melhor desempenho nas atividades estudantis, pessoais e sociais, de modo a prepará-las a ser as profissionais mais humanizadas que o SUS busca. Conclusão: Os resultados sugerem que o uso das "intervenções terapêuticas com cavalos" pode auxiliar as escolas médicas no cumprimento das DCN, pela via da promoção da saúde dos discentes de Medicina.


Abstract: Introduction: The literature on medical education has been revealing that medical students experience difficulties with the overload of activities and tasks, culminating in stress and depression, often associated with the challenges brought by the Problem-Based Learning pedagogical model. Objective: to report the results of two therapeutic interventions developed with students, focusing on problem situations faced in the medical course and with the purpose of promoting well-being. Method: Qualitative and exploratory research. A scenario was created for psychodramatic experiences with horses. The convenience sample consisted of two medical students, who met the inclusion criterion 'participate in the Academic Center' of the course. They acted as protagonist-patient-participants. The interventions with each participant were individual, and acted at the intrapsychic and systemic levels, considering here the medical education system. Besides the dramatization itself on the stage-arena, there were open semi-structured interviews, as a warm-up and sharing of results, on the day of the intervention and six months later. Results: The protagonist-patient-participants are female, from two different universities which both offer a curriculum centered on Problem-Based Learning, and were in the 6th and 8th semesters of the course. The 'suffering-dramas in relation to the course' chosen by each protagonist-patient-participant were 'tutoring competition' and 'overload'. The dramatization was effective in promoting awareness of its protagonism in relation to the problem and the possibility of acquiring new spontaneous-creative responses, which was verified six months later, in the protagonist-patient-participants' report. The therapeutic work promoted improved student well-being and performance in academic, personal and social activities, preparing the students to be the most humanized professionals, as sought by the SUS. Conclusion: The results suggest that the use of "Therapeutic Intervention with Horses" can help medical schools to comply with National Curriculum Guidelines, through health promotion among medicine students.

2.
J Heart Lung Transplant ; 41(12): 1700-1711, 2022 12.
Artigo em Inglês | MEDLINE | ID: mdl-36229329

RESUMO

BACKGROUND: In the US, only 23% of lungs offered for transplantation are transplanted. Ex vivo lung perfusion (EVLP) allows for evaluation of additional donor lungs; its adoption has been limited by resources and expertise. Dedicated facilities with a centralized lung evaluation system (CLES) could expand access to EVLP. METHODS: In this unblinded, nonrandomized, traditional feasibility study, 7 US transplant centers referred lungs declined for standard transplantation to a dedicated EVLP facility, which utilized a CLES. EVLP was remotely monitored by the transplant teams. CLES lungs were matched with contemporaneous conventional static cold-preserved controls at each center. RESULTS: A total of 115 recipients were enrolled, and 66 received allografts from 63 donors after EVLP at the dedicated CLES facility. Forty-nine contemporaneous patients served as controls. Primary graft dysfunction grade 3 at 72 hours (PGD3-72 hours) was higher in the CLES group with 16 (24%) vs 2 (4%) in the control (common RD 95% CI, 0.07-0.32; p = 0.0009). All recipients survived to 30 days and 1-year survival was similar for both groups (92% controls vs 89% CLES; common RD 95% CI, -0.14-0.08; p = 0.58). Total preservation time, hospital and ICU lengths of stay, and time to first extubation were longer in the CLES group. CONCLUSIONS: Remote ex vivo perfusion of lung allografts declined for conventional transplantation at a dedicated CLES facility is feasible and resulted in additional transplants. Recipients of allografts assessed with a CLES had a higher rate of PGD3-72 hours, but similar 30-day and 1-year outcomes compared to conventional lung recipients. (NCT02234128).


Assuntos
Transplante de Pulmão , Humanos , Circulação Extracorpórea , Pulmão , Transplante de Pulmão/métodos , Preservação de Órgãos/métodos , Perfusão/métodos , Doadores de Tecidos , Estudos de Viabilidade
3.
JACC Case Rep ; 4(12): 699-703, 2022 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-35734534

RESUMO

A patient diagnosed with expanded Goldenhar complex with oculoauriculovertebral spectrum complicated with complex pulmonary and congenital heart disease, underwent successful heart-lung transplantation 21 years ago, with excellent functional outcome and good quality of life. Heart-lung transplantation can be an option of care for patients with expanded Goldenhar complex. (Level of Difficulty: Advanced.).

5.
Transplantation ; 103(3): 638-646, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-29697575

RESUMO

BACKGROUND: Lungs are allocated in the United States using the lung allocation score (LAS). We investigated the effect of LAS trends on lung transplant-related costs, healthcare utilization, and mortality. METHODS: Utilization data from Mayo Clinic (Florida and Minnesota) from 2005 to 2015 were obtained from the electronic health records (N = 465). Costs were categorized as 1-year posttransplant or transplant episode and standardized using 2015 Medicare reimbursement and cost-to-charge ratios. Regression analysis was used to assess the relationship of LAS to length of stay (LOS), mortality, and cost of transplant. RESULTS: The mean LAS at transplant increased from 45.7 to 58.3 during the study period, whereas the 1-year survival improved from 88.1% to 92.5% (P < 0.0001). The proportion of patients transplanted with LAS of 60 or greater increased from 16.9% to 33.3%. Posttransplant, overall, and intensive care unit LOS increased with increasing LAS. Patients with higher LAS had substantially higher transplant episode costs. An increase of LAS at transplant by 10 points increased inflation-adjusted costs by 12.0% (95% confidence interval, 9.3%-14.5%). CONCLUSIONS: The mean LAS at transplant has significantly increased over time associated with increases in LOS, resource utilization and cost. Lung allocation score has not jeopardized overall survival, but a high LAS (>60) at transplant is associated with increased mortality.


Assuntos
Pneumopatias/economia , Pneumopatias/cirurgia , Transplante de Pulmão/economia , Transplante de Pulmão/estatística & dados numéricos , Escores de Disfunção Orgânica , Idoso , Registros Eletrônicos de Saúde , Feminino , Florida , Custos de Cuidados de Saúde , Alocação de Recursos para a Atenção à Saúde , Humanos , Tempo de Internação , Pneumopatias/mortalidade , Masculino , Medicare , Pessoa de Meia-Idade , Minnesota , Seleção de Pacientes , Doadores de Tecidos , Obtenção de Tecidos e Órgãos , Resultado do Tratamento , Estados Unidos , Listas de Espera
6.
J Clin Gastroenterol ; 53(4): 284-289, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-29505550

RESUMO

GOALS: To assess the effect of unilateral versus bilateral lung transplantation (LTx) on esophageal motility and gastroesophageal reflux, and the association with the development of obstructive chronic lung allograft dysfunction (o-CLAD). BACKGROUND: We have shown that esophagogastric junction outflow obstruction, incomplete bolus transit, and proximal reflux are all independent risk factors for the development of chronic allograft failure. However, it remains unclear whether these factors are influenced by the type of surgery and how this relates to allograft failure. STUDY: Patients post-LTx (n=48, 24 female; aged 20 to 73 y) completed high-resolution impedance manometry and 24-hour pH/impedance. RESULTS: Patients who had undergone unilateral LTx were more likely to exhibit esophagogastric junction outflow obstruction (47% vs. 18%; P=0.046) and less likely to exhibit hypocontractility (0% vs. 21%; P=0.058) than those who had undergone bilateral LTx. Although the proportion of patients exhibiting gastroesophageal reflux was no different between groups (33% vs. 39%; P=0.505), those undergoing bilateral LTx were more likely to exhibit proximal reflux (8% vs. 37%; P=0.067). Univariate Cox proportion hazards regression analysis did not show a difference between unilateral versus bilateral LTx in the development of o-CLAD (hazard ratio=1.17; 95% confidence interval, 0.48-2.85; P=0.723). CONCLUSION: The type of LTx performed seems to lead to different risk factors for the development of o-CLAD. Physicians should be aware of these differences, as they may need to be taken into account when managing patient's post-LTx.


Assuntos
Transtornos da Motilidade Esofágica/epidemiologia , Refluxo Gastroesofágico/epidemiologia , Rejeição de Enxerto/epidemiologia , Transplante de Pulmão/efeitos adversos , Adulto , Idoso , Transtornos da Motilidade Esofágica/fisiopatologia , Junção Esofagogástrica/fisiopatologia , Feminino , Refluxo Gastroesofágico/fisiopatologia , Rejeição de Enxerto/etiologia , Humanos , Masculino , Manometria , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
7.
Transplantation ; 103(2): 428-434, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-29847505

RESUMO

BACKGROUND: Acute cellular rejection (ACR) in lung transplant recipients requires demonstration of perivascular lymphocytic infiltration in alveolar tissue samples from transbronchial biopsies (TBBs). Probe-based confocal laser endomicroscopy (pCLE) allows in vivo observation of alveolar, vascular, and cellular microstructures in the lung with potential to identify ACR. The objective of our prospective, blinded, multicenter observational study was to identify pCLE findings in patients with ACR diagnosed histopathologically by TBB. METHODS: Lung transplant recipients undergoing diagnostic bronchoscopies within 1 year posttransplant for suspected ACR had pCLE video imaging obtained immediately prior to tissue sampling via TBB. Findings of 2 pCLE criteria, abundant alveolar cellularity and perivascular cellularity (PVC), were assessed by 4 investigators familiar with pCLE and compared with histopathologic criteria of ACR to derive sensitivity, specificity, area under the receiver operating characteristic curve, and accuracy. Interobserver agreement was assessed by calculating intraclass coefficient and Fleiss κ. Findings were analyzed before and after a consensus meeting of investigators on interpreting images. RESULTS: Thirty pCLE procedures were performed on 24 patients, 8 showing ACR in TBB. Diagnostic performance and interobserver agreement using pCLE to identify PVC were significantly higher than those of abundant alveolar cellularity (P < 0.01). The number of blood vessels identified with PVC on pCLE was significantly correlated with histopathologic activity grading of ACR (P < 0.01). Perivascular cellularity agreement among investigators significantly improved after consensus meeting (P < 0.01). CONCLUSIONS: When found on pCLE, PVC is a feasible and reproducible criterion for assessment of ACR in vivo, but there is a learning curve for image interpretation.


Assuntos
Rejeição de Enxerto/diagnóstico , Transplante de Pulmão/efeitos adversos , Doença Aguda , Adulto , Idoso , Feminino , Humanos , Masculino , Microscopia Confocal , Pessoa de Meia-Idade , Estudos Prospectivos
8.
Hum Pathol ; 79: 199-207, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29885404

RESUMO

Lymphangioleiomyomatosis (LAM) is a rare progressive cystic lung disease with features of a low-grade neoplasm. It is primarily caused by mutations in TSC1 or TSC2 genes. Sirolimus, an inhibitor of mTOR complex 1 (mTORC1), slows down disease progression in some, but not all patients. Hitherto, other potential therapeutic targets such as mTOR complex 2 (mTORC2) and various metabolic pathways have not been investigated in human LAM tissues. The aim of this study was to assess activities of mTORC1, mTORC2 and various metabolic pathways in human LAM tissues through analysis of protein expression. Immunohistochemical analysis of p-S6 (mTORC1 downstream protein), Rictor (mTORC2 scaffold protein) as well as GLUT1, GAPDH, ATPB, GLS, MCT1, ACSS2 and CPT1A (metabolic pathway markers) were performed on lung tissue from 11 patients with sporadic LAM. Immunoreactivity was assessed in LAM cells with bronchial smooth muscle cells as controls. Expression of p-S6, Rictor, GAPDH, GLS, MCT1, ACSS2 and CPT1A was significantly higher in LAM cells than in bronchial smooth muscle cells (P<.01). No significant differences were found between LAM cells and normal bronchial smooth muscle cells in GLUT1 and ATPB expression. The results are uniquely derived from human tissue and indicate that, in addition to mTORC1, mTORC2 may also play an important role in the pathobiology of LAM. Furthermore, glutaminolysis, acetate utilization and fatty acid ß-oxidation appear to be the preferred bioenergetic pathways in LAM cells. mTORC2 and these preferred bioenergetic pathways appear worthy of further study as they may represent possible therapeutic targets in the treatment of LAM.


Assuntos
Biomarcadores Tumorais/análise , Metabolismo Energético , Neoplasias Pulmonares/química , Linfangioleiomiomatose/metabolismo , Alvo Mecanístico do Complexo 1 de Rapamicina/análise , Alvo Mecanístico do Complexo 2 de Rapamicina/análise , Adulto , Humanos , Imuno-Histoquímica , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/terapia , Linfangioleiomiomatose/patologia , Linfangioleiomiomatose/terapia , Pessoa de Meia-Idade
9.
Stem Cells Transl Med ; 7(2): 161-167, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29322685

RESUMO

Feasibility, tolerance, and safety of intravenous infusions of allogeneic mesenchymal stem cell (MSC) therapy in lung transplant recipients with bronchiolitis obliterans syndrome (BOS) are not well established. MSCs were manufactured, cryopreserved, transported to our facility, thawed, and infused into nine recipients with moderate BOS (average drop in forced expiratory volume in 1 second was 56.8% ± 3.2% from post-transplant peak) who were refractory to standard therapy and not candidates for retransplant. Cells were viable and sterile prior to infusion. Patients received a single infusion of either 1 (n = 3), 2 (n = 3), or 4 (n = 3) million MSCs per kg. Patients were medically evaluated before; during; and at 24 hours, 1 week, and 1 month after infusion for evidence of infusion-related adverse events and tolerance of therapy. Vital signs, pulmonary function test results, Borg Dyspnea Index, and routine laboratory data were recorded. Vital signs and O2 saturation did not significantly change during or up to 2 hours after MSC infusion. There were no significant changes in gas exchange variables, pulmonary function test results, or laboratory values at 1, 7, and 30 days postinfusion compared with preinfusion values. Infusion of MSCs in patients with BOS was feasible, safe, and well tolerated and did not produce any significant adverse changes in clinical, functional, or laboratory variables during or up to 30 days after infusion. Manufacturing, transport, and administration of intravenous, allogeneic bone marrow-derived MSCs in doses from 1 to 4 million MSCs per kg is safe in lung transplant recipients with BOS. Stem Cells Translational Medicine 2018;7:161-167.


Assuntos
Aloenxertos/citologia , Bronquiolite Obliterante/terapia , Tolerância Imunológica/imunologia , Pulmão/citologia , Células-Tronco Mesenquimais/citologia , Idoso , Estudos de Viabilidade , Feminino , Humanos , Terapia de Imunossupressão/métodos , Transplante de Pulmão/métodos , Masculino , Transplante de Células-Tronco Mesenquimais/métodos , Pessoa de Meia-Idade
10.
Clin Transl Gastroenterol ; 8(6): e102, 2017 Jun 29.
Artigo em Inglês | MEDLINE | ID: mdl-28662022

RESUMO

OBJECTIVES: Gastroesophageal reflux is common in patients post-lung transplantation (LTx) and thus considered a risk factor for aspiration and consequently allograft rejection and the development of chronic allograft failure. However, evidence supporting this remains unclear and often contradictory. Our aim was to examine the role played by esophageal motility on gastroesophageal reflux exposure, along with its clearance and that of boluses swallowed, and the relationship to development of obstructive chronic lung allograft dysfunction (o-CLAD). METHODS: Patients post-LTx (n=50, 26 female; mean age 55 years (range, 20-73 years)) completed high-resolution impedance manometry and 24-h pH/impedance. Esophageal motility abnormalities were classified based upon the Chicago Classification version 3.0. RESULTS: Esophagogastric junction outflow obstruction alone (EGJOOa) (P=0.01), incomplete bolus transit (IBT) (P=0.006) and proximal reflux (P=0.042) increased the risk for o-CLAD. Patients with EGJOOa were most likely to present with o-CLAD (77%); despite being less likely to exhibit abnormal numbers of reflux events (10%) compared with those with normal motility (o-CLAD: 29%, P<0.05; abnormal reflux events: 64%, P<0.05). Patients with EGJOOa had lower total reflux bolus exposure time than those with normal motility (0.6 vs. 1.5%; P<0.05). In addition, poor esophageal clearance documented by abnormal post-reflux swallow-induced peristaltic wave index associated with o-CLAD; inversely correlating with the proportion of reflux events reaching the proximal esophagus (r=-0.251; P=0.052). CONCLUSIONS: These observations support esophageal dysmotility, especially EGJOOa, and impaired clearance of swallowed bolus or refluxed contents, more so than just the presence of gastroesophageal reflux alone, as important risk factors in the development of o-CLAD.

11.
Hum Pathol ; 50: 176-82, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26997453

RESUMO

Giant cell interstitial pneumonia is a rare lung disease and is considered pathognomonic for hard metal lung disease, although some cases with no apparent hard metal (tungsten carbide cobalt) exposure have been reported. We aimed to explore the association between giant cell interstitial pneumonia and hard metal exposure. Surgical pathology files from 2001 to 2004 were searched for explanted lungs with the histopathologic diagnosis of giant cell interstitial pneumonia, and we reviewed the associated clinical histories. Mass spectrometry, energy-dispersive x-ray analysis, and human leukocyte antigen typing data were evaluated. Of the 455 lung transplants, 3 met the histologic criteria for giant cell interstitial pneumonia. Patient 1 was a 36-year-old firefighter, patient 2 was a 58-year-old welder, and patient 3 was a 45-year-old environmental inspector. None reported exposure to hard metal or cobalt dust. Patients 1 and 2 received double lung transplants; patient 3 received a left single-lung transplant. Histologically, giant cell interstitial pneumonia presented as chronic interstitial pneumonia with fibrosis, alveolar macrophage accumulation, and multinucleated giant cells of both alveolar macrophage and type 2 cell origin. Energy-dispersive x-ray analysis revealed no cobalt or tungsten particles in samples from the explanted lungs. None of the samples had detectable tungsten levels, and only patient 2 had elevated cobalt levels. The lack of appropriate inhalation history and negative analytical findings in the tissue from 2 of the 3 patients suggests that giant cell interstitial pneumonia is not limited to individuals with hard metal exposure, and other environmental factors may elicit the same histologic reaction.


Assuntos
Células Gigantes/patologia , Doenças Pulmonares Intersticiais/patologia , Pulmão/patologia , Fibrose Pulmonar/patologia , Adulto , Ligas/efeitos adversos , Biópsia , Cobalto/efeitos adversos , Células Gigantes/imunologia , Antígenos HLA/imunologia , Humanos , Imuno-Histoquímica , Exposição por Inalação/efeitos adversos , Pulmão/imunologia , Pulmão/cirurgia , Doenças Pulmonares Intersticiais/etiologia , Doenças Pulmonares Intersticiais/cirurgia , Transplante de Pulmão , Masculino , Espectrometria de Massas , Pessoa de Meia-Idade , Exposição Ocupacional/efeitos adversos , Fibrose Pulmonar/etiologia , Fibrose Pulmonar/cirurgia , Fatores de Risco , Espectrometria por Raios X , Resultado do Tratamento , Tungstênio/efeitos adversos
12.
Respir Med ; 109(10): 1354-9, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26321137

RESUMO

OBJECTIVES: Lymphangioleiomyomatosis (LAM) is a rare, cystic lung disease that generally results in progressive decline in lung function. Despite advancement of pharmacological therapy for LAM, lung transplantation remains an important option for women with end-stage LAM. METHODS: Patients with LAM undergoing lung transplantation at the Mayo Clinic campuses in Rochester, Minnesota and Jacksonville, Florida since 1995 were retrospectively reviewed. RESULTS: Overall, 12 women underwent lung transplantation. Nine of 12 (75%) underwent double lung transplant. The mean age was 42 ± 8 years at the time of transplant. One patient (8%) had a chylothorax and 7 (58%) had recurrent pneumothoraces, 4 (33%) of which required pleurodesis. All had diffuse, cystic lung disease on chest CT consistent with LAM which was confirmed in the explant of all patients. The average length of ICU and hospital stays were 5 ± 4 and 19 ± 19 days, respectively. Mild to moderate anastomotic ischemia was evident in all patients but resolved with time. No patient was treated with sirolimus pre-transplant. Seven patients received sirolimus post-transplant; however, clinical benefit was documented in only 2 patients, 1 of which was treated for large retroperitoneal cysts with ureteral obstruction and another with persistent chylothorax and retroperitoneal lymphangioleimyomas. Five patients are deceased. The median survival by Kaplan-Meier analysis was 119 months with a median follow-up of 68 months (range 2-225 months). CONCLUSIONS: Lung transplant remains a viable treatment for patients with end-stage LAM. The role of sirolimus peri-transplantation remains ill-defined.


Assuntos
Neoplasias Pulmonares/cirurgia , Transplante de Pulmão/métodos , Linfangioleiomiomatose/cirurgia , Adulto , Ecocardiografia/métodos , Feminino , Humanos , Imunossupressores/uso terapêutico , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/patologia , Transplante de Pulmão/efeitos adversos , Linfangioleiomiomatose/diagnóstico por imagem , Linfangioleiomiomatose/patologia , Pessoa de Meia-Idade , Pleurodese/métodos , Estudos Retrospectivos , Índice de Gravidade de Doença , Sirolimo/uso terapêutico , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento
13.
Am J Manag Care ; 21(1 Suppl): s12-23, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25734416

RESUMO

Significant advancements in solid organ transplantation immunosuppressive medications and regimens have resulted in improved outcomes over the years. A multidrug approach involving medications with different mechanisms of action is commonly used. Induction therapy can involve the use of antibody agents or higher doses of medications used for maintenance therapy. A calcineurin inhibitor, an antiproliferative agent, and a corticosteroid commonly serve as the initial triple medication regimen. Due to the potential for nephrotoxicity with the use of calcineurin inhibitors and chronic conditions with the prolonged use of corticosteroids, various withdrawal strategies are used in practice. Antimicrobial agents are prescribed to provide prophylaxis against certain viral, fungal, and bacterial infections. Other concomitant medications in the regimens for patients who have undergone transplantation vary depending on patient-specific factors and conditions.


Assuntos
Transplante de Órgãos , Antibioticoprofilaxia , Inibidores de Calcineurina/uso terapêutico , Glucocorticoides/uso terapêutico , Rejeição de Enxerto/prevenção & controle , Humanos , Imunossupressores/uso terapêutico , Infecções Oportunistas/prevenção & controle
14.
J Heart Lung Transplant ; 34(5): 651-7, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25578626

RESUMO

BACKGROUND: Obesity is associated with increased mortality after lung transplantation and is a relative contraindication to transplant. It is unknown whether weight reduction prior to transplantation ameliorates this risk. Our objective was to determine whether weight loss prior to lung transplantation improves survival. METHODS: Our investigation was a two-center, retrospective cohort study of lung transplant recipients between January 1, 2000 and November 5, 2010. Change in weight, demographics, transplant details, lung allocation score, length of intensive care and mechanical ventilator days and graft and patient survival were abstracted. Wilcoxon's signed-rank test and the Cox proportional hazard model were used for analysis where appropriate. RESULTS: Three hundred fifty-five patients (55% male, median age 59 years) satisfied inclusion and exclusion criteria. After adjusting for standard demographic and clinical measures, a 1-unit reduction in BMI pre-transplant was associated with a reduced risk of death with a hazard ratio 0.89 (95% confidence interval 0.82 to 0.96; p = 0.004). This survival benefit persisted in the group with baseline BMI ≥ 25 kg/m(2) (overweight and obese) and hazard ratio 0.85 (95% CI 0.77 to 0.95; p = 0.003), but not in those with a BMI ≤ 24.9 kg/m(2). The 1-unit reduction in BMI was also associated with a 6.1% decrease in median mechanical ventilator days (p = 0.02) and a trend toward decreased intensive care unit length of stay (p = 0.06). CONCLUSIONS: A reduction in BMI prior to lung transplantation was associated with a reduction in the risk of death and mechanical ventilator days. A greater reduction in BMI was associated with a greater survival benefit.


Assuntos
Rejeição de Enxerto/mortalidade , Transplante de Pulmão/mortalidade , Redução de Peso , Idoso , Índice de Massa Corporal , Feminino , Seguimentos , Sobrevivência de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Período Pré-Operatório , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
16.
Clin Transplant ; 28(8): 911-5, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24931421

RESUMO

BACKGROUND: Concomitant administration of the triazole antifungals, voriconazole or itraconazole, with tacrolimus can result in significant drug interaction in the transplant recipient. Limited published information exists regarding tacrolimus dosing when transitioning from voriconazole to itraconazole. The objective of this study was to evaluate the extent of the drug interaction with antifungal prophylaxis using voriconazole followed by a change to itraconazole in lung transplant recipients receiving tacrolimus. METHODS: This prospective study included lung transplant recipients receiving antifungal prophylaxis with voriconazole followed by a switch to itraconazole. Patients were followed from the time of transplant until two months after converting to itraconazole. All patients received standard immunosuppression with tacrolimus, mycophenolate mofetil, and a corticosteroid. Tacrolimus dose normalized concentrations using concentration/dose ratio were compared while receiving voriconazole versus itraconazole. RESULTS: Twenty lung transplant recipients were included in the final analysis. No difference was found with the tacrolimus dose normalized concentrations on voriconazole 254 ± 28 (ng/mL)/(mg/kg) compared with itraconazole 234 ± 34 (ng/mL)/(mg/kg), p = 0.65. CONCLUSION: Tacrolimus dosage adjustments were not necessary when converting from voriconazole to itraconazole. Validation in a larger population is needed to confirm these findings.


Assuntos
Antibioticoprofilaxia , Antifúngicos/uso terapêutico , Itraconazol/uso terapêutico , Transplante de Pulmão , Tacrolimo/administração & dosagem , Voriconazol/uso terapêutico , Adulto , Idoso , Relação Dose-Resposta a Droga , Interações Medicamentosas , Quimioterapia Combinada , Feminino , Seguimentos , Humanos , Imunossupressores/administração & dosagem , Masculino , Pessoa de Meia-Idade , Micoses/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Prognóstico , Estudos Prospectivos
17.
South Med J ; 106(2): 141-6, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23380750

RESUMO

OBJECTIVES: Noninvasive assessment of right heart function and hemodynamics in patients with pulmonary arterial hypertension (PAH) is most often performed at rest, whereas the symptoms, in general, present with exertion. Assessment during exertion is limited to symptom assessment and the 6-minute walk distance. We investigated the feasibility of obtaining echocardiographic data that could accurately reflect pulmonary artery pressures (PAP), particularly mean PAP and right ventricular function during exercise in patients with PAH. METHODS: We investigated right ventricular function and hemodynamics using echocardiography during symptom-limited exercise in 10 consecutive patients undergoing right heart catheterization (RHC) as part of their clinical evaluation for PAH. We further assessed these measurements for correlation with known predictors of outcome in PAH in an exploratory analysis. RESULTS: We were able to successfully obtain complete right heart measurements by echocardiography, including mean PAP, in the majority (9 of 10) of the subjects. One patient had an incomplete tricuspid regurgitation jet at rest and with exercise. Echocardiographic pulmonary vascular resistance correlated with RHC cardiac output and brain natriuretic peptide level, whereas tricuspid annular plane systolic excursion during exercise correlated with right atrial pressure on RHC, brain natriuretic peptide, and 6-minute walk distance. Tricuspid regurgitation velocity and mean PAP with exercise correlated moderately with mean PAP and cardiac output by RHC. CONCLUSIONS: Exercise echocardiography can provide meaningful data in patients with PAH, including measuring mean PAP. The presence of correlations in this small number of patients indicates promising targets for future investigation.


Assuntos
Ecocardiografia sob Estresse , Ventrículos do Coração/diagnóstico por imagem , Hipertensão Pulmonar/fisiopatologia , Função Ventricular Direita/fisiologia , Adulto , Idoso , Pressão Sanguínea/fisiologia , Débito Cardíaco/fisiologia , Tolerância ao Exercício/fisiologia , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico/sangue , Artéria Pulmonar/fisiologia , Insuficiência da Valva Tricúspide/fisiopatologia , Resistência Vascular/fisiologia
18.
Ann Thorac Surg ; 93(2): 662-4, 2012 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-22269739

RESUMO

A patient with blunt trauma and traumatic bronchial rupture and lung collapse had prominent symptoms of platypnea-orthodeoxia syndrome. These symptoms were relieved by bronchial repair. The syndrome is rarely seen and is usually associated with a patent foramen ovale or atrial septal defect. The syndrome has not been described previously in association with traumatic bronchial rupture.


Assuntos
Brônquios/lesões , Dispneia/etiologia , Hipóxia/etiologia , Postura , Atelectasia Pulmonar/etiologia , Ferimentos não Penetrantes/complicações , Acidentes de Trânsito , Adulto , Brônquios/cirurgia , Broncoscopia , Constrição Patológica/etiologia , Constrição Patológica/cirurgia , Dispneia/diagnóstico por imagem , Dispneia/cirurgia , Dispneia/terapia , Humanos , Hipóxia/diagnóstico por imagem , Hipóxia/cirurgia , Hipóxia/terapia , Masculino , Traumatismo Múltiplo/reabilitação , Traumatismo Múltiplo/cirurgia , Oxigenoterapia , Atelectasia Pulmonar/diagnóstico por imagem , Atelectasia Pulmonar/cirurgia , Atelectasia Pulmonar/terapia , Ruptura/etiologia , Ruptura/cirurgia , Decúbito Dorsal/fisiologia , Técnicas de Sutura , Tomografia Computadorizada por Raios X , Relação Ventilação-Perfusão
19.
Respir Med ; 106(1): 109-19, 2012 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-21843930

RESUMO

BACKGROUND: In COPD patients, hyperinflation impairs cardiac function. We examined whether lung deflation improves oxygen pulse, a surrogate marker of stroke volume. METHODS: In 129 NETT patients with cardiopulmonary exercise testing (CPET) and arterial blood gases (ABG substudy), hyperinflation was assessed with residual volume to total lung capacity ratio (RV/TLC), and cardiac function with oxygen pulse (O(2) pulse=VO(2)/HR) at baseline and 6 months. Medical and surgical patients were divided into "deflators" and "non-deflators" based on change in RV/TLC from baseline (∆RV/TLC). We defined deflation as the ∆RV/TLC experienced by 75% of surgical patients. We examined changes in O(2) pulse at peak and similar (iso-work) exercise. Findings were validated in 718 patients who underwent CPET without ABGs. RESULTS: In the ABG substudy, surgical and medical deflators improved their RV/TLC and peak O(2) pulse (median ∆RV/TLC -18.0% vs. -9.3%, p=0.0003; median ∆O(2) pulse 13.6% vs. 1.8%, p=0.12). Surgical deflators also improved iso-work O(2) pulse (0.53 mL/beat, p=0.04 at 20 W). In the validation cohort, surgical deflators experienced a greater improvement in peak O(2) pulse than medical deflators (mean 18.9% vs. 1.1%). In surgical deflators improvements in O(2) pulse at rest and during unloaded pedaling (0.32 mL/beat, p<0.0001 and 0.47 mL/beat, p<0.0001, respectively) corresponded with significant reductions in HR and improvements in VO(2). On multivariate analysis, deflators were 88% more likely than non-deflators to have an improvement in O(2) pulse (OR 1.88, 95% CI 1.30-2.72, p=0.0008). CONCLUSION: In COPD, decreased hyperinflation through lung volume reduction is associated with improved O(2) pulse.


Assuntos
Pulmão/fisiopatologia , Consumo de Oxigênio , Pneumonectomia , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Idoso , Gasometria , Estudos de Coortes , Teste de Esforço , Feminino , Volume Expiratório Forçado , Humanos , Pulmão/metabolismo , Pulmão/patologia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Doença Pulmonar Obstrutiva Crônica/metabolismo , Doença Pulmonar Obstrutiva Crônica/patologia , Volume Sistólico , Capacidade Pulmonar Total
20.
Prog Transplant ; 19(3): 267-71, 2009 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-19813490

RESUMO

OBJECTIVE: To observe the effect of naloxone on the lung function of potential lung transplant donors with neurogenic pulmonary edema. DESIGN AND INTERVENTIONS: Donors aged 16 to 55 years without any factors to contraindicate lung donation (pneumonia, pulmonary contusion, etc) were included. Ventilator settings were standardized to a tidal volume of 10 to 12 mL/kg, an FIO2 of 0.40, and a respiratory rate that kept PCO2 between 35 and 45 mm Hg. Chest physiotherapy, nebulizer treatments, and frequent suctioning were undertaken. Baseline arterial blood gas analysis and an oxygen challenge were performed. The patients were then given 8 to 10 mg of naloxone. Oxygen challenges and arterial blood gas analyses were repeated every 4 to 6 hours. The data were analyzed by using a paired t test, and each patient served as his or her own control. SETTING: These interventions were performed on the 19 LifeQuest donors who met the set criteria from July 2002 to July 2004. RESULTS: The PaO2 on the oxygen challenge immediately after administration of naloxone increased from 329 (SD 177) to 363 (SD 191) mm Hg, although the increase from baseline was not significant. The PaO2 from the second oxygen challenge (median time, 7 hours after administration of naloxone) increased to 413 (SD 177) mm Hg (P<.01).


Assuntos
Morte Encefálica , Transplante de Pulmão , Naloxona/administração & dosagem , Antagonistas de Entorpecentes/administração & dosagem , Troca Gasosa Pulmonar/efeitos dos fármacos , Doadores de Tecidos , Adolescente , Adulto , Gasometria , Morte Encefálica/metabolismo , Morte Encefálica/fisiopatologia , Seleção do Doador , Humanos , Infusões Intravenosas , Transplante de Pulmão/estatística & dados numéricos , Pessoa de Meia-Idade , Naloxona/farmacologia , Antagonistas de Entorpecentes/farmacologia , Oxigênio/sangue , Respiração com Pressão Positiva/métodos , Taxa Respiratória , Terapia Respiratória , Estudos Retrospectivos , Volume de Ventilação Pulmonar , Obtenção de Tecidos e Órgãos/métodos
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