Enfermedades pulmonares intersticiales difusas asociadas al tabaquismo / Diffuse interstitial lung diseases associated with smoking

El interrogatorio sobre hábito tabáquico no debe obviarse jamás, pues el abanico de posibilidades diagnósticas inherentes es amplio. Es un gesto clínico fundamental frente a individuos que consultan por síntomas y/o hallazgos radiológicos casuales. Presentamos tres casos clínicos: síndrome de combinación de fibrosis pulmonar y enfisema, neumonitis intersticial descamativa e histiocitosis de células de Langerhans, como parte del abanico de las enfermedades pulmonares intersticiales difusas asociadas a tabaco (EPIDAT), donde la tomografía de alta resolución de tórax tiene un rol destacado. Palabras clave: tabaquismo; enfisema; enfermedades pulmonares intersticiales; histiocitosis de células de Langerhans

Questioning about smoking habits should never be ignored, since the range of inherent diagnostic possibilities is wide. It is a fundamental clinical step facing individuals who consult for symptoms and/or casual radiological findings. We present three clinical cases: the combined syndrome of pulmonary fibrosis and emphysema, desquamative interstitial pneumonitis, and Langerhans cell histiocytosis, as part of the range of tobacco-associated diffuse interstitial lung diseases (EPIDAT), where high-resolution chest tomography has a prominent role. Key words: smoking; emphysema; interstitial lung diseases; Langerhans cell histiocytosis

Abordaje paliativo en enfermedades respiratorias avanzadas / Palliative Approach in Advanced Respiratory Diseases

Las enfermedades respiratorias crónicas avanzadas son prevalentes y producen deterioro de la calidad de vida, en particular la enfermedad pulmonar obstructiva crónica (EPOC), las enfermedades pulmonares intersticiales difusas (EPID) y las enfermedades neuromusculares progresivas con compromiso diafragmático (ENM). Quienes las padecen presentan síntomas persistentes que no son siempre adecuada-mente controlados por los tratamientos recomendados por las guías clínicas de mane-jo. El tratamiento paliativo de los síntomas persistentes es un punto relevante y suelen presentarse barreras para su implementación.Este artículo ofrece una revisión narrativa sobre una perspectiva latinoamericana acerca del rol de los cuidados paliativos en enfermedades respiratorias avanzadas.

Advanced chronic respiratory diseases are prevalent and cause deterioration in qual-ity of life, particularly chronic obstructive pulmonary disease (COPD), diffuse intersti-tial lung diseases (ILD) and progressive neuromuscular diseases with diaphragmatic involvement (NMD). Those who suffer from them usually present persistent symptoms that are not always adequately controlled by the treatments recommended by the clinical management guidelines. Palliative treatment of persistent symptoms is a relevant point, but the pal-liative approach usually presents barriers to its implementation.This article offers a narrative review over Latin American perspective on the role of pal-liative care in advanced respiratory diseases.

Ecografía pulmonar en la evaluación del paciente crítico / Lung ultrasound in the evaluation of critically ill patients

Introducción: La ecografía es una técnica de imagen no invasiva que permite explorar diferentes órganos de manera inmediata, constituye un instrumento de alto valor diagnóstico al alcance del profesional de la salud, y es utilizada en todas las especialidades médicas. En los últimos años, la evolución tecnológica ha permitido que los aparatos de ecografía sean más pequeños, portátiles, y con una alta resolución, tal es el caso de la ecografía clínica o ecografía a pie de cama. La ecografía del paciente crítico ha cambiado la práctica médica; específicamente la ecografía pulmonar se debe realizar en todos los pacientes con enfermedad pulmonar aguda. Objetivo: Aportar el conocimiento teórico necesario para promover el uso de la ecografía pulmonar en la evaluación del paciente crítico, y contribuir, mediante su aplicación, a la disminución del riesgo de exposición a las radiografías. Métodos: Se efectuó una revisión de la literatura médica actualizada sobre el papel de la ecografía pulmonar en la evaluación del paciente crítico, en el período de julio a diciembre de 2021. Se utilizaron los siguientes motores de búsqueda: SciELO, Medigraphic y Google Académico. Conclusiones: En el contexto actual, la ecografía pulmonar ha adquirido un papel protagónico, pues su uso facilita una evaluación frecuente y no invasiva del paciente crítico con afección pleuropulmonar. Su aplicación garantiza la disminución del riesgo de exposición a las radiografías.

Introduction: ultrasound is a non-invasive imaging technique that allows us to explore different organs immediately; it constitutes an instrument of high diagnostic value within the reach of health professionals and used in all medical specialties. In recent years, technological evolution has allowed ultrasound devices to be smaller, portable and with high resolution, such is the case of clinical ultrasound or bedside ultrasound. Bedside ultrasound in critically ill patients has changed medical practice; specifically, lung ultrasound should be performed in all patients with acute lung disease. Objective: to provide the necessary theoretical knowledge in order to promote the use of lung ultrasound in the evaluation of critically ill patients, as well as to contribute, through its application, to reduce the risk of exposure to radiographs. Methods: a review of the updated medical literature on the role of lung ultrasound in the evaluation of the critically ill patients was performed from July to December 2021. SciELO, Medigraphic and Google Scholar were the search engines used. Conclusions: lung ultrasound has acquired a leading role in the current context, since its use facilitates a non-invasive and common evaluation of the criticall ill patients with pleuropulmonary disease. Its application guarantees the reduction of the risk of exposure to X-rays.

Neumonitis por hipersensibilidad fibrótica: reporte de casos y propuesta de fuentes de exposición en nuestro medio / Fibrotic hypersensitivity pneumonitis: case report and proposal of sources of exposure in our environment

Una excesiva respuesta inmune a antígenos inhalados en algunos individuos susceptibles puede causar neumonitis por hipersensibilidad, considerada una entidad prevalente entre las enfermedades pulmonares intersticiales difusas. Recientemente, se ha propuesto un cambio radical en la clasificación de esta infravalorada entidad. En este reporte describimos las características clínicas y radiológicas de tres casos de neumonitis por hipersensibilidad fibrótica: pulmón de cuidador de aves, pulmón de almohada de plumas y alveolitis química. Se muestra una tabla con las probables ocupaciones o exposiciones de riesgo en nuestro medio y se realiza una revisión actualizada del tema. Palabras clave:neumonía; enfermedadespulmonaresintersticiales; alveolitis alérgica extrínseca

An excessive immune response to inhaled antigens in some susceptible individuals can cause hypersensitivity pneumonitis, considered a prevalent entity among diffuse interstitial lung diseases. A radical change in the classification of this undervalued entity has recently been proposed. In this report we describe the clinical and radiological characteristics of three cases of fibrotic hypersensitivity pneumonitis: bird keeper's lung, feather pillow lung, and chemical alveolitis. A table is shown with the probable occupations or risk exposures in our environment and an updated review of the subject is carried out.Key Words:pneumonia; interstitial lung diseases; extrinsic allergic alveolitis

Fisiología respiratoria: fisiología de las enfermedades pulmonares restrictivas / Pathophysiology of pulmonary restrictive diseases

Las enfermedades restrictivas comprenden un grupo heterogéneo de trastornos que se caracterizan por una alteración en la distensibilidad pulmonar, generada por enfermedades del parénquima o intersticio pulmonar o por problemas extrapulmonares (alteraciones de la caja torácica o enfermedades neuromusculares). Presentan un patrón característico en las pruebas de función pulmonar, relación VEF1/ FVC normal o aumentada con CVF disminuida, VEF1 disminuido leve o normal y capacidad pulmonar total disminuida (CPT). Su manejo es complejo debido a la dificultad para establecer el diagnóstico diferencial, por lo que se recomienda una derivación precoz a un especialista en enfermedades respiratorias y el enfrentamiento por un equipo multidisciplinario.

Restrictive diseases comprise a heterogeneous group of disorders characterized by an alteration in lung compliance, generated by diseases of the lung parenchyma or interstitium, as well as by extrapulmonary problems (abnormalities of the rib cage or neuromuscular diseases). They present a characteristic pattern in pulmonary function tests, with decreased FVC (forced vital capacity), slightly decreased or normal FEV1 (forced expiratory volume in 1 second), normal or increased FEV1/FVC ratio, and decreased total lung capacity. Its management is complex due to the difficulty in establishing the differential diagnosis, so early referral to a specialist in respiratory diseases and confrontation by a multidisciplinary team is recommended.

Taquipnea persistente como manifestación inicial de hiperplasia de células neuroendocrinas: reporte de un caso clínico / Persistent tachypnea as initial manifestation of hyperplasia of neuroendocrine cells: case report

Se realiza revisión de la literatura y presentación de un caso clínico de Hiperplasia de Células Neuroendocrinas en paciente lactante masculino que inicia su padecimiento a los 3 meses de vida con dificultad respiratoria caracterizada por retracciones subcostales y taquipnea persistente, posterior-mente a los 8 meses de edad se agrega hipoxemia respirando aire ambiente que requiere uso de oxígeno suplementario continuo. Tiene antecedente de tres hospitalizaciones, con diagnóstico de Bronquiolitis y Neumonía atípica, realizándose panel viral respiratorio con reporte negativo. El paciente persiste con sintomatología respiratoria a pesar de tratamientos médicos, por lo que se deriva a neumología pediátrica, unidad de enfermedad pulmonar intersticial del lactante, iniciando protocolo de estudio, se realiza tomografía tórax de alta resolución, que evidencia imágenes en vidrio despulido en lóbulo medio y región lingular, además de atrapamiento aéreo. Se concluye el diagnóstico de Hiperplasia de Células neuroendocrinas con base a la clínica y hallazgos tomográficos. La Hiperplasia de Células Neuroendocrinas es una patología pulmonar intersticial poco frecuente, cuyo diagnóstico es clínico y radiológico, en la minoría de los casos se requiere biopsia pulmonar para confirmación. Puede ser fácilmente confundida con otras enfermedades respiratorias comunes, por lo que es importante sospecharla para realizar un diagnóstico precoz. La mayor parte de los casos evolucionan con declinación de los síntomas, mejorando espontáneamente en los primeros años de vida.

A review of the literature and presentation of a clinical case of Neuroendocrine Cell Hyperplasia in a male infant patient who begins his condition at 3 months of age with respiratory distress characterized by subcostal retractions and persistent tachypnea is presented. After 8 months of age hypoxemia is added requiring continuous oxygen therapy. He has a history of three hospitalizations, with a diagnosis of bronchiolitis and atypical pneumonia, respiratory viral panel has a negative report. The patient persists with respiratory symptoms despite medical treatments, so it is referred to pediatric pulmonology, initiating study protocol for interstitial lung disease of the infant. A high resolution chest tomography is performed, which evidences images in polished glass in the middle lobe and lingular region, in addition to air entrapment. The diagnosis of neuroendocrine cell hyperplasia is concluded based on clinical and tomographic findings. Neuroendocrine Cell Hyperplasia is a rare interstitial pulmonary pathology, whose diagnosis is clinical and radiological. Lung biopsy is required only in the minority of cases for confirming diagnosis. It can be easily confused with other common respiratory diseases, so it is important to suspect it to make an early diagnosis. Most cases evolve with decline in symptoms, improving spontaneously in the first years of life.

Caracterización clínico-radiológica de pacientes con enfermedad pulmonar intersticial y panel de miositis positivo en hospital Santiago Oriente / Clinical-radiological characterization of patients with interstitial lung disease and positive myositis panel at hospital Santiago Oriente

Introducción: Las Enfermedades Pulmonares Intersticiales (EPI) afectan principalmente al intersticio pulmonar, con importante morbimortalidad asociada. Tienen un espectro de posibles etiologías que es cada vez más amplio. Hay una importante causalidad a partir de Enfermedades del Tejido Conectivo (ETC), describiéndose cada vez más casos asociados a Síndrome Antisintetasa, y con diversos patrones radiológicos según serología obtenida, agrupada en "Panel de Miositis" (PaM). El presente estudio de cohorte retrospectiva reúne PaMs realizados en el Hospital Santiago Oriente, correlacionando resultados con manifestaciones clínicas e imagenológicas. Material y Métodos: Se recuperaron 33 PaMs realizados entre 2017 y 2022, y a través de revisión de fichas de los pacientes de quienes provenían las PaMs se consignaron las principales manifestaciones clínicas, imagenológicas y de la serología reumatológica complementaria, estableciendo correlaciones entre múltiples variables. Resultados: Hubo 15 pacientes PaM positivos (45,4%), 8 de ellos (53%) ya contaban con alguna miopatía inflamatoria diagnosticada. Los principales hallazgos clínicos consignados fueron pápulas de Gottron, artritis, eritema heliotropo, Fenómeno de Raynaud y fiebre. El anticuerpo positivo más frecuente fue Ro-52. Se pudo objetivar ANA positivo en 10 casos (66,7%). Se identificó EPI en 66,7% de aquellos con PaM positivo, siendo la Neumonía Intersticial no específica fibrótica con Neumonía en Organización la manifestación más frecuente. No hubo asociación significativa entre manifestaciones imagenológicas y anticuerpos específicos. Se encontró ANA 1/80 en 66,7% de los casos, lo cual no se asoció a mayor riesgo de EPI. Conclusiones: Existe asociación entre varias ETC y las EPI. Destaca la importancia de los hallazgos clínicos para establecer un adecuado índice de sospecha, para dirigir oportunamente el estudio complementario (ej: PaM), y la eventual terapia específica.

Introduction: Interstitial Lung Diseases (ILD) mainly affect the pulmonary interstitium, with significant associated morbidity and mortality. They have a spectrum of possible etiologies that is increasingly broad. There is an important causality from Connective Tissue Diseases (CTD), describing more and more cases associated with Antisynthetase Syndrome, and with different radiological patterns according to the serology obtained, enclosed into "Panel of Myositis" (PaM). This retrospective cohort study gathers PaMs performed at Hospital Santiago Oriente, PaM results are correlated with clinical and imaging manifestations. Material and Methods: 33 PaMs performed between 2017 and 2022 were saved up and by reviewing the clinical records of the patients from whom the PaMs came, their clinical and radiological manifestations and the results of their complementary rheumatological serology were recorded to establish correlations between multiple variables. Results: There were 15 positive PaMs (45.4%), 8 (53%) of them already had some diagnosed inflammatory myopathy. The main clinical findings reported were Gottron's papules, arthritis, heliotrope erythema, Raynaud's phenomenon, and fever. The most frequent positive antibody detected was Ro-52. Positive ANA could be found in 10 cases (66.7%). PID was identified in 66.7% of those with a positive PaM, being non-specific fibrotic Interstitial Pneumonia with Organizing Pneumonia being the most frequent manifestation. There was no significant association between imaging manifestations and specific antibodies. ANA 1/80 was found in 6.7% of the cases, which was not associated with an increased risk of PID. Conclusions: There is association between several CTEs and EPIs. It is necessary to highlight the importance of the clinical findings to establish an adequate index of suspicion, in order to timely direct the complementary study (eg: PaM), and the eventual specific therapy.

Openreuma consensus on the role of nursing in the care of patients with rheumatoid arthritis and diffuse interstitial lung disease / Consenso de Openreuma sobre el papel de la enfermería en el cuidado de pacientes con artritis reumatoide y enfermedad pulmonar intersticial difusa / Consenso Openreuma sobre o papel da enfermagem no cuidado de pacientes com artrite reumatoide e doença pulmonar intersticial difusa

Objective.To develop practical recommendations, based on the best available evidence and experience, on the nursing management of patients with rheumatoid arthritis (RA) and interstitial lung disease (ILD). Methods. The usual consensus methodology was used, with a nominal group, systematic reviews (SRs), and Delphi survey. The expert panel, consisting of rheumatology nurses, rheumatologists, a psychologist, a physiotherapist, and a patient, defined the scope, the users, the topics on which to explore the evidence and on which to issue recommendations. Results.Three PICO questions evaluated the efficacy and safety of pulmonary rehabilitation and non-pharmacological measures for the treatment of chronic cough and gastroesophageal reflux by means of SR of the literature. With the results of the reviews, 15 recommendations were established for which the degree of agreement was obtained with a Delphi survey. Three recommendations were rejected in the second round. The 12 recommendations were in patient assessment (n=4); patient education (n=4); and risk management (n=4). Only one recommendation was based on available evidence, while the remaining were based on expert opinion. The degree of agreement ranged from 77% to 100%. Conclusion.This document presents a series of recommendations with the aim of improving the prognosis and quality of life of patients with RA-ILD. Nursing knowledge and implementation of these recommendations can improve the follow-up and prognosis of patients with RA who present with ILD.

Objetivo.Desarrollar recomendaciones prácticas, basadas en la mejor evidencia y experiencia disponible, sobre el manejo de enfermería de los pacientes con artritis reumatoide (AR) y enfermedad pulmonar intersticial (EPI). Métodos. Se utilizó la metodología de consenso en la que un panel de expertos (formado por enfermeras de reumatología, reumatólogos, una psicóloga, una fisioterapeuta y una paciente) definió el ámbito, los usuarios, los temas sobre los que explorar la evidencia y sobre los que emitir recomendaciones. Tres preguntas PICO evaluaron la eficacia y seguridad de la rehabilitación pulmonar y las medidas no farmacológicas para el tratamiento de la tos crónica y el reflujo gastroesofágico mediante la búsqueda de revisiones sistemáticas, excluyendo aquellas cuya calidad era baja, muy baja o críticamente baja, según la herramienta AMSTAR-2. Posteriormente, se hizo una reunión para la formulación de recomendaciones que se presentaron con un resumen de la evidencia a la encuesta Delphi. Resultados.Con los resultados de las revisiones se establecieron 15 recomendaciones cuyo grado de acuerdo osciló entre el 77% y el 100% en la una encuesta Delphi. Tres recomendaciones fueron rechazadas en la segunda ronda: una por la evidencia disponible y los dos restantes se basaron en la opinión de expertos. Las 12 recomendaciones restantes aprobadas se referían a la evaluación del paciente (n=4), a la educación del paciente (n=4) y a la gestión del riesgo (n=4). Conclusión. El conocimiento del consenso Openreumapor parte de enfermería y la aplicación sus 12 recomendaciones basadas en la mejor evidencia y experiencia puede mejorar el seguimiento y el pronóstico de los pacientes con AR que presentan EPI.

Objetivo.Desenvolver recomendações práticas, baseadas na melhor evidência e experiência disponíveis, sobre o manejo de enfermagem de pacientes com artrite reumatoide (AR) e doença pulmonar intersticial (DPI). Métodos.Foi utilizada a metodologia de consenso, com grupo nominal, revisões sistemáticas e levantamento Delphi. O painel de especialistas, formado por enfermeiros reumatologistas, reumatologistas, psicólogo, fisioterapeuta e paciente, definiu o escopo, os usuários, os tópicos sobre os quais explorar as evidências e sobre os quais emitir recomendações. Três questões do PICO avaliaram a eficácia e segurança da reabilitação pulmonar e medidas não farmacológicas para o tratamento da tosse crônica e refluxo gastroesofágico por meio de RS. Aqueles cuja qualidade era baixa, muito baixa ou criticamente baixa, de acordo com a ferramenta AMSTAR-2, foram excluídos. Posteriormente, realizou-se uma reunião para formular recomendações que foram apresentadas com um resumo das evidências ao inquérito Delphi. Resultados. Com os resultados das revisões, foram estabelecidas 15 recomendações cujo grau de concordância entre 77% e 100% foi obtido com uma pesquisa Delphi. Três recomendações foram rejeitadas na segunda rodada. As 12 recomendações referiam-se à avaliação do paciente (n=4); à educação do paciente (n=4); e ao gerenciamento de risco (n=4). Apenas uma recomendação foi baseada nas evidências disponíveis, enquanto as demais foram baseadas na opinião de especialistas. Conclusão. Este documento apresenta uma série de recomendações com o objetivo de melhorar o prognóstico e a qualidade de vida dos pacientes com AR-ILD. O conhecimento da enfermagem e a aplicação dessas recomendações podem melhorar o acompanhamento e o prognóstico de pacientes com AR com DPI.

Comportamiento clínico radiológico de la enfermedad intersticial difusa sintomática en pacientes con afecciones reumatológicas / Clinical radiological behavior of symptomatic diffuse interstitial disease in patients with rheumatological conditions

Introducción: Las enfermedades pulmonares intersticiales difusas constituyen un grupo amplio de afecciones, con manifestaciones clínicas, expresión radiológica y alteraciones funcionales del intersticio pulmonar. Objetivo: Describir el comportamiento clínico y radiológico de la enfermedad intersticial difusa sintomática en pacientes diagnosticados con enfermedades reumáticas. Métodos: Se realizó un estudio observacional, descriptivo transversal, con una población compuesta por 33 pacientes con manifestaciones respiratorias secundarias a enfermedades reumáticas entre enero de 2020 a enero de 2021 en el Hospital Universitario Clínico Quirúrgico Arnaldo Milián Castro. La muestra estuvo conformada por la totalidad de los pacientes. El análisis estadístico se llevó a cabo por medio de estadística descriptiva de cada variable. Resultados: Existió un mayor número de mujeres afectadas (75,8 por ciento) por esclerosis sistémica (31 por ciento), artritis reumatoide (27 por ciento) y lupus eritematoso sistémico (21 por ciento). La afectación respiratoria predominante fue de 81,8 por ciento con compromiso intersticial asociada a un patrón radiológico de neumonitis intersticial usual con 5 casos (21,4 por ciento), todos ligados a artritis reumatoide. Para 25 casos (75,8 por ciento) hubo un retraso diagnóstico menor de 1 año; la enfermedad reumática antecedió a la manifestación respiratoria en 21 casos (63,6 por ciento). Conclusiones: El compromiso intersticial fue la manifestación respiratoria más frecuente; los patrones de neumonitis intersticial usual y la neumonía intersticial no específica predominaron como hallazgos imagenológicos. La secuencia diagnóstica apuntó hacia las enfermedades reumáticas como el debut del proceso(AU)

Introduction: Diffuse interstitial lung diseases constitute a wide group of conditions, with clinical manifestations, radiological expression and functional alterations of the pulmonary interstitium. Objective: To describe the clinical and radiological behavior of symptomatic diffuse interstitial disease in patients diagnosed with collagenosis. Methods: An observational, descriptive, cross-sectional study was carried out. The population consisted of 33 patients with respiratory manifestations secondary to rheumatic diseases. The sample consisted of all the patients. Statistical analysis was carried out by means of descriptive statistics for each variable. Results: There was a greater number of women affected (75.8 percent) by systemic sclerosis (31percent), rheumatoid arthritis (27 percent) and systemic lupus erythematosus (21 percent). The predominant respiratory involvement was 81.8 percent with interstitial involvement associated with a radiological pattern of usual interstitial pneumonitis with 5 cases (21.4 percent), all linked to rheumatoid arthritis. For 25 cases (75.8 percent) there was a diagnostic delay of less than 1-year, rheumatic diseases preceded the respiratory manifestation in 21 cases (63.6 percent). Conclusions: Interstitial involvement was the most frequent respiratory manifestation; the patterns of usual interstitial pneumonitis and nonspecific interstitial pneumonia as predominated imaging findings. The diagnostic sequence pointed towards rheumatic diseases were the debut of the process(AU)

Carboxyhemoglobinemia as a laboratory finding in an outpatient

Resumen El monóxido de carbono (CO) es un gas producido principalmente por combustión incompleta de hidrocarburos. La intoxicación por exposición ambiental puede presentarse con síntomas inespecíficos y constituye la causa más importante de aumento de carboxihemoglobina (COHb). Su nivel en sangre depende de la duración de la exposición, la ventilación minuto y las concentraciones de CO y oxígeno en el ambiente. La elevada toxicidad radica en la hipoxia tisular que se genera. Se presenta el caso de un paciente masculino, 73 años, en seguimiento en el hospital por neumonía intersticial no específica como patología de base. En un control de laboratorio se encontró 11,9% de COHb, sin exposición a tabaco. No utilizaba calefacción a gas sino un panel cerámico eléctrico, recientemente pintado con esmalte sintético. La suspensión del uso del panel normalizó la COHb. El CO, producto de descomposición térmica del esmalte sintético, explica la causa de la intoxicación.

Abstract Carbon monoxide (CO) is a gas produced mainly by incomplete combustion of hydrocarbons. Poisoning from environmental exposure can present with nonspecific symptoms and is the most important cause of increased carboxyhemoglobin (COHb). Its blood level depends on the duration of exposure, minute ventilation, and the concentrations of CO and oxygen in the environment. The high toxicity lies in the tissue hypoxia that is generated. The case of a male patient, 73 years old, under follow-up in the hospital for non-specific interstitial pneumonia as the underlying pathology was presented. In a laboratory control, COHb 11,9% was found. There was no exposure to tobacco and there was no use of gas heating but of an electric ceramic panel, recently painted with synthetic enamel type paint. The suspension of the use of the panel normalised the COHb. The CO product of thermal decomposition of synthetic enamel explains the cause of poisoning.

Resumo O monóxido de carbono (CO) é um gás produzido principalmente pela combustão incompleta de hidrocarbonetos. A intoxicação por exposição ambiental pode se apresentar com sintomas inespecíficos e é a causa mais importante de aumento da carboxihemoglobina (COHb). Seu nível em sangue depende do tempo de exposição, da ventilação minuto e das concentrações de CO e oxigênio no ambiente. A alta toxicidade está na hipóxia tecidual gerada. Apresentamos o caso de um paciente do sexo masculino, 73 anos, em acompanhamento hospitalar por pneumonia intersticial inespecífica como patologia de bas. Em um controle laboratorial, achou-se 11,9% de COHb, sem exposição ao tabaco. Não utilizava aquecimento a gás e sim um painel elétrico cerâmico, recentemente pintado com esmalte sintético. A suspensão do uso do painel normalizou o COHb. O CO produto da decomposição térmica do esmalte sintético explica a causa da intoxicação.

Recomendaciones para la rehabilitación pulmonar en pacientes con COVID-19 / Recommendations for pulmonary rehabilitation in patients with COVID-19

Introducción: La COVID-19 es una enfermedad que desencadena infecciones respiratorias graves como el síndrome respiratorio agudo severo, que puede requerir atención prolongada intra y extrahospitalaria. Objetivo: Brindar recomendaciones y pautas para una correcta evaluación y tratamiento del paciente con COVID-19 mediante la rehabilitación pulmonar. Materiales y métodos: Revisión de la literatura en las bases de datos MEDLINE, PEDRO, Scielo y en Google Scholar, a partir de las palabras clave: COVID-19, Síndrome de Dificultad Respiratoria del Adulto, Enfermedades pulmonares, Rehabilitación, pruebas de función respiratoria, Unidad de cuidado intensivo; seleccionando, aquellos artículos que presentaran información sobre rehabilitación en pacientes con COVID-19 y otras alteraciones con compromiso similar como el Síndrome Respiratorio Agudo y las Enfermedades Pulmonares Intersticiales Difusas. Resultados: Para realizar una intervención en paciente con COVID-19 u otra alteración respiratoria como Síndrome de Dificultad Respiratoria del Adulto y Enfermedad Pulmonar Intersticial Difusa, es necesario realizar un adecuado diagnóstico de la enfermedad, una minuciosa evaluación integral y una intervención basada en las necesidades de cada individuo. Conclusiones: El paciente intrahospitalario puede recibir intervención enfocada a evitar el deterioro funcional y una vez son dados de alta la rehabilitación pulmonar extrahospitalaria podría ser una alternativa eficaz en el tratamiento para los pacientes.

Introduction: COVID-19 is a disease that triggers serious respiratory infections such as severe acute respiratory syndrome, which requires treatment on an inpatient and outpatient basis. Objective: To provide recommendations and guidelines for the appropriate assessment and treatment of COVID-19 patients through pulmonary rehabilitation. Materials and methods: A literature review using MEDLINE, PEDRO, Scielo and Google Scholar databases and the keywords: COVID-19, Adult Respiratory Distress Syndrome, Pulmonary diseases, Rehabilitation, Respiratory function tests, Intensive Care Unit. Articles that described information regarding rehabilitation in COVID-19 patients and other similar dysfunctions such as Acute Respiratory Syndrome and Diffuse Interstitial Lung Diseases. Results: It is necessary to carry out an appropriate disease diagnosis, a detailed integral assessment, and an intervention based on the needs of each patient in order to intervene with either COVID-19 patients or cases with other respiratory dysfunctions such as Adult Respiratory Distress Syndrome and Diffuse Interstitial Lung Disease. Conclusions: Inpatients can be subjected to an intervention focused on avoiding functional failure. Once they are discharged, outpatient pulmonary rehabilitation could be an effective treatment alternative for these patients.

Síndrome antisintetasa: reporte de un caso / Antisynthetase syndrome: a case repor

El síndrome antisintetasa es una miopatía inflamatoria idiopática (MII) de origen autoinmune, poco frecuente, que se caracteriza por la presencia de autoanticuerpos antisintetasa ARNt (generalmente anti-Jo1), asociado frecuentemente a miositis, enfermedad pulmonar intersticial, poliartritis, manos de mecánico y fenómeno de Raynaud. Se reporta el caso de una mujer de 45 años de edad que presenta este síndrome con características fenotípicas de dermatomiositis y responde de forma favorable luego de la administración del tratamiento con glucocorticoides asociado a metotrexato.

Anti-synthetase syndrome is a rare autoimmune inflammatory myopathy characterized by autoantibodies against tRNA synthetases (most commonly anti-Jo1) with clinical features that include myositis, interstitial lung disease, polyarthritis, mechanic's hands and Raynaud's phenomenon. We report a 45-year-old woman who presented with dermatomyositis phenotypical features and a significant improvement with corticosteroids and metotrexate treatment.

Manifestaciones pulmonares al diagnóstico de 170 pacientes con vasculitis asociadas a anticuerpos anticitoplasma de neutrófilos: cohorte retrospectiva de un centro universitario / Pulmonary manifestations at the diagnosis of 170 patients with vasculitis associated with anticytoplasmic neutrophil antibodies: retrospective cohort of a university center

INTRODUCCIÓN: Las Vasculitis Asociadas a Anticuerpos Anticitoplasma de Neutrófilos (VAA) son infrecuentes, pero de amplio espectro de presentación. Si bien el consenso de clasificación de Chapel Hill del año 2012, sigue vigente, la tendencia actual es clasificarlas de acuerdo al marcador inmunológico: anti-Proteinasa 3 (PR3) o anti-mieloperoxidasa (MPO). Las manifestaciones pulmonares clásicas son la hemorragia alveolar y los nódulos pulmonares. En los últimos 10 años se ha descrito la enfermedad pulmonar difusa (EPD). Los estudios epidemiológicos son escasos, y suelen representar en su mayoría poblaciones norteamericanas o europeas. El objetivo es describir las características del compromiso pulmonar al debut en VAA en un centro universitario. PACIENTES Y MÉTODO: De un total de 190 pacientes con diagnóstico de VAA se incluyeron 170 en seguimiento en nuestro centro. Se revisaron aspectos clínicos, demográficos, laboratorio e imagenológicos de los pacientes incluidos. RESULTADOS: De los 170 pacientes, 112 (65,88%) presentaron compromiso pulmonar. 106 (94,64%) de los pacientes fueron anticuerpos anti citoplasma de neutrófilos (ANCA) positivos; de estos, 56 (53,27%) MPO (+) y 39 (36,45%) PR-3 (+). Un tercio de los pacientes de ambos grupos presentó hemorragia alveolar. En los pacientes MPO (+) predomina la EPD (53,5%) y en PR-3 (+) los nódulos pulmonares (69,23%). Destaca la baja frecuencia de patología obstructiva asociada. CONCLUSIONES: El compromiso pulmonar en las VAA es prevalente y heterogéneo. En nuestra serie, destaca la frecuencia de EPD en VAA MPO (+), lo que releva la importancia del estudio con ANCA en paciente con diagnóstico y seguimiento por EPD.

INTRODUCTION: Antineutrophil Cytoplasmic Antibodies (ANCA) associated vasculitis (AAV) are uncommon, but of broad spectrum of presentation. Although the 2012 Chapel Hill classification consensus remains valid, the current trend is to classify them according to the immunological marker: anti-Proteinase 3 antibody (PR-3) or anti-Myeloperoxidase antibody (MPO). The classic pulmonary manifestations are alveolar hemorrhage and pulmonary nodules. Interstitial lung disease (ILD) has been described in the last 10 years. Epidemiological studies are scarce, and they usually represent mostly North American or European populations. The objective is to describe the characteristics of lung involvement upon debut in AAV in a university center. PATIENTS AND METHODS: Of a total of 190 patients diagnosed with AAV, 170 were included in follow-up at our center. Clinical, demographic, laboratory and imaging aspects of the included patients were reviewed. RESULTS: Of the 170 patients, 112 (65.88%) had lung involvement. 106 (94.64%) of the patients were ANCA (+); of these, 56 (53.27%) MPO (+) and 39 (36.45%) PR-3 (+). One third of the patients in both groups had alveolar hemorrhage. In MPO (+) patients, ILD predominates (53.5%) and in PR-3 (+) pulmonary nodules (69.23%). The low frequency of associated obstructive pathology stands out. CONCLUSIONS: Pulmonary manifestations in AAVs are frequent and heterogeneous. Locally, the association of ILD and AAV MPO (+) stands out, which highlights the importance of ANCA study in patients with diagnosis and follow-up by ILD.

Impacto del ejercicio aeróbico en enfermedades pulmonares intersticiales / Impact of aerobic exercise on patients with interstitial lung diseases

Resumen Introducción: El tratamiento integral para pacientes con enfermedades pulmonares intersticiales incluye entrenamiento físico, dados los efectos fisiológicos que se generan. El objetivo de este estudio es analizar el impacto del ejercicio aeróbico en el tratamiento para los pacientes con enfermedades pulmonares intersticiales. Métodos: Se realizaron búsquedas de ensayos clínicos (enero 2015- junio 2020) en bases de datos indexadas tales como: Ebsco, Scopus, Medline, Medscape, PubMed Central, EMBASE, Redalyc, DOAJ y OVID. Se utilizó la estrategia PICO, Cochrane y escala de PEDro en cada estudio seleccionado. Resultados: Se incluyeron 11 ensayos clínicos para esta revisión y la calidad de los estudios fue media-alta. Todos los estudios incluyeron el componente de entrenamiento con ejercicio aeróbico combinado con otras estrategias como el desarrollo de fuerza, resistencia y flexibilidad. Se demostraron cambios significativos en más del 50% de los estudios para el componente de la capacidad aeróbica, consumo máximo de oxígeno, función cardiovascular y calidad de vida. Sin embargo, otros estudios, no demostraron diferencias significativas en pruebas de función pulmonar, cambios en variables ventilatorias, de intercambio gaseoso o cardiovasculares tal como señalan algunos autores en los estudios realizados. Conclusiones: El ejercicio aeróbico demostró ser un componente que mejoró resultados en la capacidad aeróbica, evidenciados en la distancia y metros recorridos post caminata de 6 minutos, así como en la calidad de vida, consumo máximo de oxígeno, fuerza y resistencia, mas no en variables ventilatorias e intercambio gaseoso.

Abstract Introduction: Comprehensive treatment for patients with interstitial lung diseases includes physical training, given the physiological effects that are generated. The objective of this study is to analyze the impact of aerobic exercise in the treatment for patients with interstitial lung diseases. Methods: Clinical trials (January 2015- June 2020) were searched in indexed databases such as Ebsco, Scopus, Medline, Medscape, PubMed Central, EMBASE, Redalyc, DOAJ and OVID. PICO, Cochrane and PEDro scale were used in each selected study. Results: Eleven clinical trials were included for this review and the quality of the studies was medium to high. All studies included the training component of aerobic exercise combined with other strategies such as strength development, endurance, flexibility. Significant changes were demonstrated in over 50% of the studies for the aerobic capacity component, maximum oxygen consumption, cardiovascular function and quality of life. Other studies, however, did not demonstrate significant differences in lung function tests, changes in ventilatory, gas exchange or cardiovascular variables as indicated by some authors in the studies conducted. Conclusions: Aerobic exercise proved to be a component that improved results in aerobic capacity evidenced in distance and meters traveled after a 6-minute walk, as well as in quality of life, maximum oxygen consumption, strength and resistance, but not in ventilatory variables and exchange gaseous.

Prevalencia y letalidad de enfermedades pulmonares intersticiales en la Región de Los Ríos, Chile / Prevalence and lethality of interstitial pulmonary diseases in the Region of Los Ríos, Chile

BACKGROUND: Idiopathic Pulmonary Fibrosis (IPF) is a subtype of interstitial lung disease (ILD) that significantly affects people's quality of life, whose prevalence and mortality has increased. AIM: To determine the prevalence and lethality of ILD in the Los Ríos Region between the years 2018 and 2019. MATERIAL AND METHODS: Review of a database of all patients attended at an outpatient clinic of the regional hospital. Those patients with the diagnosis of ILD and seen between 2018 and 2019 were selected. Mortality and its causes were verified with death certificates. RESULTS: In the study period, 339 cases with ILD, aged 71 ± 10 years (64% women) were identified. The calculated ILD prevalence was 84 cases per 100,000 inhabitants, with a higher predominancy in Futrono and Paillaco communes. IPF and Connective Tissue Diseases were the predominant subtypes. Overall lethality was 18%, with more deaths among patients with IPF (n = 31). CONCLUSIONS: In the Los Ríos Region, ILDs have a relevant prevalence and lethality.

Prevalence of latent tuberculosis infection among patients with interstitial lung disease requiring immunosuppression / Prevalência de infecção latente por tuberculose em pacientes com doença pulmonar intersticial com necessidade de imunossupressão

ABSTRACT Objective To characterize the prevalence of latent tuberculosis infection (LTBI) in patients with interstitial lung diseases (ILDs) requiring immunosuppression. Only 5 to 10% of individuals infected with Mycobacterium tuberculosis develop tuberculosis, and certain groups of patients have an increased risk of illness, such as the immunocompromised. Patients with ILDs are frequently treated with immunosuppressants and, therefore, might have a higher risk of developing the disease. Methods Prospective study conducted at the ILD reference center of the Federal University of Paraná from January 2019 to December 2020. The screening of LTBI was performed with the use of the tuberculin skin test (TST). Results The sample consisted of 88 patients, of whom 64.8% were women, with a mean age of 61.4 years. The most frequent diagnoses were autoimmune rheumatic disease ILD (38.6%) and hypersensitivity pneumonitis (35.2%). The most common immunosuppressant in use at the time of the TST was prednisone, either in combination with mycophenolate (19.3%) or alone (17.1%). The majority of participants had fibrotic lung disease, characterized by a reticular interstitial pattern on chest computed tomography (79.5%) and moderate to severe functional impairment (mean FVC 69.2%). A prevalence of LTBI of 9.1% (CI 95%, 2.1%-15.1%) was found, with a TST median of 13. Conclusion Patients with ILD who are treated with immunosuppressants are not commonly screened for LTBI, despite being under a greater risk of progression to active disease. This study suggests the need for a more cautious approach to these patients.

RESUMO Objetivo Caracterizar a prevalência de Infecção Latente por Tuberculose (ILTB) em pacientes com Doenças Pulmonares Intersticiais (DPIs) que necessitam de imunossupressão. Apenas 5 a 10% dos indivíduos infectados pelo Mycobacterium tuberculosis desenvolvem tuberculose, sendo que certos grupos de pacientes apresentam maior risco de doença, tais como os imunocomprometidos. Pacientes com DPIs são frequentemente tratados com imunossupressores, portanto, podem apresentar maior risco de desenvolver a doença. Métodos Estudo prospectivo conduzido no Centro de Referência para DPI da Universidade Federal do Paraná (UFPR), entre Janeiro de 2019 e Dezembro de 2020. O rastreio de ILTB foi realizado por meio da Prova Tuberculínica (PT). Resultados A amostra foi composta por 88 pacientes, dos quais 64,8% eram mulheres, com, em média, 61,4 anos de idade. Os diagnósticos mais frequentes foram DPI associada a doença reumática autoimune (DRAI) (38,6%) e pneumonite de hipersensibilidade (35,2%). Prednisona foi o imunossupressor mais comumente utilizado à época da PT, em combinação com micofenolato (19,3%) ou isoladamente (17,1%). A maioria dos participantes tinha doença pulmonar fibrótica, caracterizada por infiltrado reticular em tomografia computadorizada de tórax (79,5%), bem como comprometimento funcional moderado a grave (Capacidade Vital Forçada (CVF) média de 69,2%). Observou-se uma prevalência de ILTB de 9,1% (Intervalo de Confiança (IC) 95%, 2,1%-15,1%), com mediana da PT de 13. Conclusão Não é comum que pacientes com DPI tratados com imunossupressores sejam avaliados quanto à presença de ILTB, apesar de estarem sob um maior risco de progressão para doença ativa. Este estudo sugeriu a necessidade de uma abordagem mais cuidadosa em relação a esses pacientes.

Taquipnea persistente de la infancia: hiperplasia de células neuroendocrinas, una revisión / Persistent tachypnea of infancy: neuroendocrine cell hyperplasia, a review

La hiperplasia de células neuroendocrinas de la infancia (HCNEI) constituye una de las enfermedades intersticiales más frecuentes en pediatría. Tanto su etiología como los mecanismos fisiopatológicos involucrados son inciertos. Suele presentarse en pacientes por lo demás sanos, durante los primeros meses de vida con taquipnea, retracciones costales, rales e hipoxemia. En la tomografía axial computada de tórax de alta resolución (TACAR) presenta imágenes características en vidrio esmerilado de distribución central y zonas de atrapamiento aéreo. Para el diagnóstico, además de la clínica y la TACAR, podemos recurrir a la biopsia en casos atípicos. Los hallazgos histológicos reflejan una arquitectura pulmonar normal y un aumento en el número de células neuroendocrinas. El manejo global es con medidas de sostén, ya que no se cuenta con un tratamiento específico. La sintomatología suele mejorar con la edad y el pronóstico es favorable.

Neuroendocrine cell hyperplasia of infancy (NEHI) is one of the most common interstitial lung diseases of childhood. The etiology and pathophysiological mechanisms involved are uncertain. It usually presents in otherwise healthy patients during the first months of life with tachypnea, rib retractions, crackles, and hypoxemia. High-resolution chest computed tomography (HRCT) shows ground-glass opacities of central distribution and areas of air trapping. For diagnosis purposes, in addition to clinical and HRCT features, a lung biopsy is indicated for atypical cases. Histological findings reflect normal architecture and an increased number of neuroendocrine cells. The management consists of supportive and preventive care, since there is no specific treatment. Symptoms usually improve with age and the prognosis is favorable.

Oxigenoterapia domiciliaria y capacidad aeróbica en pacientes con enfermedad pulmonar intersticial difusa. Estudio transversal / Home Oxygen Therapy And Aerobic Capacity In Patients With Diffuse Interstitial Lung Disease. Cross-Sectional Study

Introducción: La enfermedad pulmonar intersticial difusa es un grupo de enfermedades que causan un trastorno de la capacidad aeróbica y calidad de vida, además, ocasionan una gran tasa de morbimortalidad para esta población. El uso de oxigenoterapia domiciliaria mayor a 15 horas diarias tiene beneficios en pacientes hipoxémicos crónicos, sin embargo, poco se ha comparado su uso con pacientes que no lo reciben. Objetivo: Describir las características clínicas, capacidad aeróbica funcional y calidad de vida relacionada con la salud de dos grupos de pacientes con enfermedad pulmonar intersticial difusa, uno con indicación de oxigenoterapia domiciliaria y otro grupo sin indicación. Métodos: Estudio descriptivo transversal, que incluyó 41 pacientes con enfermedad pulmonar intersticial difusa que firmaron consentimiento informado. En ambos grupos, características demográficas y clínicas, ansiedad/depresión, calidad de vida relacionada con la salud con el cuestionario Saint George y la capacidad aeróbica funcional con la prueba de marcha de seis minutos fueron medidas. Se compararon los grupos con la prueba t de student para muestras independientes. Resultados: El grupo enfermedad pulmonar intersticial difusa con oxigenoterapia domiciliaria presentó mayor porcentaje de antecedente de tabaquismo (p = 0,041), menor distancia caminada en la prueba de marcha de seis minutos (304,1 ± 108,7 vs. 390,3 ± 95,6 p = 0,01), y menor porcentaje de la distancia predicha (58,37 ± 20,45 vs. 73,34 ± 22,90, p = 0,034) frente al grupo enfermedad pulmonar intersticial difusa sin oxigenoterapia domiciliaria. Conclusiones: Los pacientes con enfermedad pulmonar intersticial difusa con indicación de oxigenoterapia domiciliaria presentan menor capacidad aeróbica funcional comparada con pacientes sin indicación(AU)

Introduction: Diffuse interstitial lung disease is a group of diseases that cause a disorder of aerobic capacity and quality of life; in addition, they cause a high rate of morbidity and mortality for this population. The use of home oxygen therapy greater than 15 hours a day has benefits in chronic hypoxemic patients, however, little has been compared to patients who do not receive it. Objective: Describe the clinical characteristics, functional aerobic capacity and health-related quality of life of two groups of patients with diffuse interstitial lung disease, one with indication for home oxygen therapy and another group without indication. Methods: A cross-sectional descriptive study included 41 patients with diffuse interstitial lung disease who signed informed consent. In both groups, demographic and clinical characteristics, anxiety/depression, health quality of life related with the Saint George questionnaire, and functional aerobic capacity with the six-minute gait test were measured. The groups were compared with the student's t-test for independent samples. Results: The diffuse interstitial lung disease group with home oxygen therapy presented a higher percentage of smoking history (p = 0.041), a shorter distance walked in the six-minute gait test (304.1 ± 108.7 vs. 390.3 ± 95.6 p = 0.01), and a lower percentage of the predicted distance (58.37 ± 20.45 vs. 73.34 ± 22.90, p = 0.034) compared to the diffuse interstitial lung disease group without home oxygen therapy. Conclusions: Patients with diffuse interstitial lung disease with indication of home oxygen therapy have lower functional aerobic capacity compared to patients without indication(AU)

Acometimento da função ventricular direita em pacientes com esclerose sistêmica e doença pulmonar intersticial: avaliação pelo doppler tecidual / Impairment of right ventricular function in patients with systemic sclerosis and interstitial lung disease: tissue doppler evaluation

Introdução: A esclerose sistêmica (ES) é uma doença autoimune do tecido conjuntivo que cursa com fibrose e disfunção microvascular. O envolvimento dos órgãos viscerais, incluindo os pulmões e o coração, é a principal causa de óbito na ES. Nesse contexto, analisamos a relação entre os parâmetros ventriculares direitos (VD) pela ecocardiografia com Doppler tecidual e o acometimento pulmonar em pacientes com ES. Métodos: Os pacientes que preencheram os Critérios de Classificação da ES de 2013 foram submetidos à ecocardiografia com Doppler tecidual para avaliação da função sistólica (fração de ejeção) ventricular esquerda (VE), enquanto a função sistólica do VD foi avaliada por meio da fração de variação de área do VD (fractional area change ­ FAC), velocidade (sistólica) do Doppler tecidual, índice de desempenho miocárdico (IDM) e excursão sistólica do plano anular tricúspide (TAPSE). A pressão sistólica pulmonar foi estimada por insuficiência tricúspide. A tomografia computadorizada de alta resolução (TCAR) de tórax avaliou a presença de fibrose pulmonar. De acordo com os resultados da TCAR, os pacientes foram divididos em 2 subgrupos: Grupo I, incluindo pacientes com fibrose pulmonar (n=26), e Grupo II sem fibrose (n=17). Resultados: Entre os 43 pacientes com ES, a maioria era do sexo feminino (86%) com idade de 51±12 anos. Todos os pacientes apresentavam função ventricular sistólica normal, avaliada pela FEVE>55% e FAC VD>35%. Não houve diferença significativa em termos de idade ou duração da doença para os grupos. Exceto pela diminuição das velocidades do Doppler tecidual em pacientes com fibrose pulmonar, todos os índices de desempenho do VD foram semelhantes. Conclusão: Em pacientes com ES e fibrose pulmonar, o Doppler tecidual identifica acometimento miocárdico longitudinal precoce do VD, apesar do desempenho sistólico radial preservado do VD.(AU)

Introduction: Systemic sclerosis (SSc) is an autoimmune tissue connective disease that courses with fibrosis and microvascular dysfunction. Involvement of the visceral organs, including the lungs and heart, is the main cause of death among patients with SSc. In this context, here we analyzed the relationship between right ventricle (RV) parameters assessed by tissue Doppler echocardiography and lung involvement in patients with SSc. Methods: Patients fulfilling the 2013 SSc Classification Criteria underwent tissue Doppler echocardiography for the assessment of left ventricular (LV) systolic function (ejection fraction) and RV fractional area change (FAC), tissue Doppler s' (systolic) velocity, myocardial performance index, and tricuspid annular plane systolic excursion for the assessment of RV systolic function. Pulmonary systolic pressure was estimated using tricuspid regurgitation. Chest high-resolution computed tomography was used to evaluate the presence of pulmonary fibrosis. The patients were divided into two subgroups accordingly: Group I, patients with pulmonary fibrosis (n=26); and Group II, those without fibrosis (n=17). Results: Among the 43 patients with SSc, most were female (86%), and the mean age was 51 ± 12 years. All patients had normal systolic ventricular function as evidenced by an LV ejection fraction > 55% and an RV FAC > 35%. No significant intergroup difference was noted in age or disease duration. Except for a decreased tissue Doppler s' velocity in patients with lung fibrosis, all indexes of RV performance were similar. Conclusion: In patients with SSc and pulmonary fibrosis, tissue Doppler identified early RV longitudinal myocardial involvement despite preserved RV radial systolic performance.(AU)