Direct costs associated with lupus nephritis management in the Private Healthcare System in Brazil: an expert panel perspective / Custos diretos associados ao manejo da nefrite lúpica no Sistema de Saúde Privado no Brasil: uma perspectiva segundo painel de especialistas

Objective: To estimate direct medical costs of lupus nephritis (LN) in the Brazilian private healthcare system. Methods: An expert panel of five specialists were convened to discuss health resource usage in LN patient management. The discussion included diagnosis, treatment, and disease monitoring, including dialysis and kidney transplantation. Unit costs (in BRL) were obtained from public sources, and an estimation of 1-year costs was conducted. Results: Approximately 76.0% of patients with LN undergo kidney biopsy, of which 48.1% present with LN classes III­IV and 21.4% have class V. Around 67.5% of patients with LN classes III­IV experience an average of four renal flares annually. Overall, 20.3% of patients present refractory LN, and 10.3% have end-stage kidney disease (ESKD), requiring dialysis and kidney transplantation. Estimated total weighted annual costs per patient were BRL 115,824.81 for LN classes III­IV, BRL 85,684.79 for LN class V, BRL 115,594.98 for refractory LN; and BRL 325,712.88 for ESKD. The main annual cost driver for LN classes III­IV was renal flares (BRL 60,240.41; 52.0%) and dialysis for LN class V (BRL 31,128.38; 36.3%). Conclusions: Total direct costs increase when LN progresses to ESKD. Although it is challenging to improve the diagnosis, identification of the disease at an early stage, together with rapid initiation of treatment, are fundamental elements to optimize results, potentially reducing costs to the system and the impact of disease burden and quality of life on patients.

Objetivo: Estimar os custos médicos diretos da nefrite lúpica (NL) no sistema suplementar de saúde brasileiro. Métodos: Um painel de cinco especialistas foi estruturado para discutir o uso de recursos em saúde no manejo de pacientes com NL. Nesta discussão, incluíram-se o diagnóstico, o tratamento e o monitoramento da doença, contemplando também diálise e transplante renal. Os custos unitários foram obtidos de fontes públicas e os resultados expressos em custo anual. Resultados: Aproximadamente 76,0% dos pacientes com NL são submetidos à biópsia renal, sendo 48,1% com NL de classes III-IV e 21,4% de classe V. Cerca de 67,5% dos pacientes com classes III-IV apresentam, aproximadamente, quatro flares renais anuais. No geral, 20,3% dos pacientes apresentam NL refratária e 10,3% desenvolvem doença renal terminal (DRT), necessitando de diálise e transplante renal. O custo ponderado anual estimado por paciente foi de R$ 115.824,81 para NL de classes III-IV, R$ 85.684,79 para classe V, R$ 115.594,98 para NL refratária e R$ 325.712,88 para DRT. O principal fator para incremento dos custos anuais para NL de classes III-IV foram os flares renais (R$ 60.240,41; 52,0%) e, na classe V, a diálise (R$ 31.128,38; 36,3%). Conclusões: Há um incremento dos custos diretos da NL na progressão para DRT. Embora seja desafiador melhorar o diagnóstico, a identificação da doença em uma fase precoce, aliada ao tratamento iniciado de forma célere, são elementos fundamentais para otimizar os resultados, potencialmente reduzindo os custos ao sistema e o impacto da carga da doença e qualidade de vida dos pacientes.

Perspective of Pulmonary Rehabilitation Centers in Latin America.

Pulmonary rehabilitation (PR) is a mandatory component of a comprehensive treatment of patients with chronic respiratory disease. However, there is no officially published data about PR Centers in Latin America.The objetive is to identify Latin American Pulmonary Rehabilitation Centers and evaluate their characteristics and organizational aspects.A cross-sectional study with the Pulmonary Rehabilitation Centers indicated by the Latin American Respiratory and Physiotherapy Societies and by our own personal survey among physicians and physiotherapists. An eletronic transmission questionnaire with 20 questions was sent to the Coordinator of each one of the Centers.217 Pulmonary Rehabilitation Centers were found throughout Latin America and a total of 160 (73.7%) Centers answered the questionnaire. Of these, 65.8% had private administration; 68.8% had an associated program for patients with heart disease; programs lasted an average of 24 sessions; the rehabilitation team consisted mainly of physiotherapists, physicians and dietitians; 90.6% of the centers evaluated the patients with different questionnaires; 91.9% used treadmill and 90.6% bicycle for exercises of lower limbs and 80.1% proprioceptive neuromuscular facilitation technique with weights to train the upper limbs of their patients; 55.6% had an educational program and 36.9% presented a home-based program.There has been a great increase in the number of Latin American Pulmonary Rehabilitation Centers, presenting diversity in organizational aspects.

The Glittre ADL-Test Differentiates COPD Patients with and without Self-Reported Functional Limitation.

The Glittre ADL-test is based on important and common activities of daily living (ADLs), and it is an useful test to objectively distinguish patients with and without self-reported functional limitations. This study aims to analyze if difficulty to perform ADLs, as self-reported by patients with COPD, would reflect a worse Glittre ADL-test performance. In the first visit, patients were evaluated for clinical and nutritional status, spirometry, maximal cardiopulmonary exercise test on a treadmill. One week later, the patients performed two Glittre ADL-tests. Maximal voluntary ventilation (MVV) and the VEGlittre/MVV, VO2Glittre/VO2peak, and HRGlittre/HRpeak ratios were calculated to analyze the ventilatory, metabolic, and cardiac reserves. The London Chest Activity of Daily Living (LCADL) scale was only answered after the two Glittre ADL-test were performed. Patients were splited into two subgroups based on the anchor question of the LCADL: those with and those without self-reported ADL limitation. Sixty-two COPD patients were included (65.3 ± 8.6 years, FEV1 62 ± 22%pred). Those with ADL limitation (39 patients) completed the Glittre ADL-test with a significantly longer time (p = 0.002), as well as higher VEGlittre/MVV (p = 0.005) and lower oxygen pulse (p = 0.021) than those without ADL limitation. The time spent to perform the Glittre ADL-test was significantly associated with total LCADL score (ρ = 0.327, p < 0.05). A cutoff of 253 s was able to distinguish those patients without and with ADL limitation. COPD patients who self-reported ADL limitation according to the LCADL scale took a longer time to perform the Glittre ADL-test with higher VEGlittre/MVV and lower oxygen pulse than those without ADL limitation.

Frequency of Osteoporosis and Vertebral Fractures in Chronic Obstructive Pulmonary Disease (COPD) Patients.

BACKGROUND: Osteoporosis is a systemic skeletal disease characterized by low bone mass and/or microarchitectural deterioration of bone. Osteoporosis is a risk factor for fractures specially in patients with advanced COPD. The aim of this cross-sectional study was to determine the frequency of osteoporosis and vertebral fracture in COPD patients. METHODS: We evaluated 91 COPD patients and compared to 82 healthy subjects (control group) matched for gender and age. We measured the bone mineral density by means of dual energy X-ray absorptiometry (DXA), evaluating the lumbar vertebra (L1-L4), proximal femur and total femur and evaluated vertebral fractures in thoracic and lumbar spine using X-ray. We questioned patients whether they had had any fall that resulted in any fracture in the past five years. RESULTS: Males comprised 60.4% of COPD group and 57.3% of the control group. Mean age was 66.2±9.2 years for COPD group and 64.2±8.8 for the control group. The frequency of osteoporosis in the COPD group was 29.7% and 18.3% in control group (p=0.007). The frequency of vertebral fractures was 18.6% in the COPD group and 9.0% in control group (p=0.06). The frequency of reported falls at resulting in any fracture was 36.3% in the COPD group and 7.3% in control group (p=0.001). CONCLUSIONS: Our data indicate that COPD patients present a high frequency of osteoporosis and falls seem to be an important factor for vertebral fracture.

Physiological Requirements to Perform the Glittre Activities of Daily Living Test by Subjects With Mild-to-Severe COPD.

BACKGROUND: The Glittre activities of daily living (ADL) test is supposed to evaluate the functional capacity of COPD patients. The physiological requirements of the test and the time taken to perform it by COPD patients in different disease stages are not well known. The objective of this work was to compare the metabolic, ventilatory, and cardiac requirements and the time taken to carry out the Glittre ADL test by COPD subjects with mild, moderate, and severe disease. METHODS: Spirometry, Medical Research Council questionnaire, cardiopulmonary exercise test, and 2 Glittre ADL tests were evaluated in 62 COPD subjects. Oxygen uptake (V̇O2 ), carbon dioxide production, pulmonary ventilation, breathing frequency, heart rate, SpO2 , and dyspnea were analyzed before and at the end of the tests. Maximum voluntary ventilation, Glittre peak V̇O2 /cardiopulmonary exercise test (CPET) peak V̇O2 , Glittre V̇E/maximum voluntary ventilation, and Glittre peak heart rate/CPET peak heart rate ratios were calculated to analyze their reserves. RESULTS: Subjects carried out the Glittre ADL test with similar absolute metabolic, ventilatory, and cardiac requirements. Ventilatory reserve decreased progressively from mild to severe COPD subjects (P < .001 for Global Initiative for Chronic Obstructive Lung Disease [GOLD] 1 vs GOLD 2, P < .001 for GOLD 1 vs GOLD 3, and P < .001 for GOLD 2 vs GOLD 3). Severe subjects with COPD presented a significantly lower metabolic reserve than the mild and moderate subjects (P = .006 and P = .043, respectively) and significantly lower Glittre peak heart rate/CPET peak heart rate than mild subjects (P = .01). Time taken to carry out the Glittre ADL test was similar among the groups (P = .82 for GOLD 1 vs GOLD 2, P = .19 for GOLD 1 vs GOLD 3, and P = .45 for GOLD 2 vs GOLD 3). CONCLUSIONS: As the degree of air-flow obstruction progresses, the COPD subjects present significant lower ventilatory reserve to perform the Glittre ADL test. In addition, metabolic and cardiac reserves may differentiate the severe subjects. These variables may be better measures to differentiate functional performance than Glittre ADL time.

Internet Use for Health-Care Information by Subjects With COPD.

BACKGROUND: Although the internet is an important tool for entertainment, work, learning, shopping, and communication, it is also a possible source for information on health and disease. The aim of this study was to evaluate the proportion of subjects with COPD in São Paulo, Brazil, who use the internet to obtain information about their disease. METHODS: Subjects (N = 382) with COPD answered a 17-question survey, including information regarding computer use, internet access, and searching for sites on COPD. Our sample was distributed according to the socioeconomic levels of the Brazilian population (low, 17.8%; medium, 66.5%; and high, 15.7%). RESULTS: Most of the subjects in the sample were male (62.6%), with a mean age of 67.0 ± 9.9 y. According to Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages, 74.3% of the subjects were in stage II or III. In addition, 51.6% of the subjects had a computer, 49.7% accessed the internet, and 13.9% used it to search for information about COPD. The internet was predominantly accessed by male (70.3%) and younger (64.6 ± 9.5 y of age) subjects compared with female (29.7%, P = .04) and older (67.5 ± 9.6 y of age, P < .007) subjects. Searching for information about COPD on the internet was associated with having a computer (5.9-fold), Medical Research Council dyspnea level 1 (5.3-fold), and high social class (8.4-fold). The search for information on COPD was not influenced by GOLD staging. CONCLUSIONS: A low percentage of subjects with COPD in São Paulo use the internet as a tool to obtain information about their disease. This search is associated with having a computer, low dyspnea score, and high socioeconomic level.

Dynamic hyperinflation during activities of daily living in COPD patients.

The objective of this study was to investigate whether some activities of daily living (ADLs) usually related to dyspnea sensation in patients with chronic obstructive pulmonary disease (COPD) are associated with dynamic lung hyperinflation (DH) and whether the use of simple energy conservation techniques (ECTs) might reduce this possible hyperinflation. Eighteen patients (mean age: 65.8 ± 9.8 years) with moderate-to-severe COPD performed six ADLs (walking on a treadmill, storing pots, walking 56 meters carrying a 5-kilogram weight, climbing stairs, simulating taking a shower, and putting on shoes) and had their inspiratory capacity (IC) measured before and after each task. The patients were moderately obstructed with forced expiratory volume in 1 second (FEV1): 1.4 ± 0.4 L (50% ± 12.4); FEV1/forced vital capacity: 0.4 ± 8.1; residual volume/total lung capacity: 52.7 ± 10.2, and a reduction in IC was seen after all six activities (p < 0.05): (1) going upstairs, 170 mL; (2) walking 56 meters carrying 5 kilogram weight, 150 mL; (3) walking on a treadmill without and with ECT, respectively, 230 mL and 235 mL; (4) storing pots without and with ECT, respectively, 170 mL and 128 mL; (5) taking a shower without and with ECT, respectively, 172 mL and 118 mL; and (6) putting on shoes without and with ECT, respectively, 210 mL and 78 mL). Patients with moderate to severe COPD develop DH after performing common ADLs involving the upper and lower limbs. Simple ECTs may avoid DH in some of these ADLs.

Home-Based Pulmonary Rehabilitation for Subjects With COPD: A Randomized Study.

BACKGROUND: The aim of this study was to develop an efficient, low-cost, home-based pulmonary rehabilitation program and to evaluate the impact of the program on exercise as measured by the 6-min walk test (6MWT) and treadmill endurance test. METHODS: Twenty-nine subjects with COPD (FEV1 = 62.4 ± 10.7% of predicted, 62.4 ± 10.7 y old) were included in a randomized and prospective pulmonary rehabilitation program, and they performed 24 sessions, 5 d/week. The control group included 15 subjects (FEV1 = 54 ± 26.2% of predicted, 65.3 ± 8 y old). They were evaluated pre-intervention and post-intervention by the 6MWT, St George Respiratory Questionnaire (SGRQ), treadmill endurance test, and spirometry. The home-based pulmonary rehabilitation program consisted of walking for 40 min along a corridor or a street, climbing stairs for 15 min, and exercising the arms with an oil can (1 kg) using diagonal movements for 15 min. Subjects were called once each week for encouragement and verification of adherence. Both groups received the usual pharmacologic treatment; in addition, the control group received a telephone call without guidance on exercise. RESULTS: The 2 groups were similar regarding age, FEV1, and FVC. The home-based pulmonary rehabilitation group increased by 65 m in the 6MWT (P < .05) and 316.6 ± 81.8 m in the endurance test (P < .05) and decreased by > 4 units in all SGRQ domains. The control group showed no difference in any variable. CONCLUSIONS: This study demonstrates that a simple, low-cost, home-based pulmonary rehabilitation program adapted to real-life situations leads to improvement in exercise capacity and quality of life.

Assessment of five different guideline indication criteria for spirometry, including modified GOLD criteria, in order to detect COPD: data from 5,315 subjects in the PLATINO study.

BACKGROUND: Spirometry is the gold standard for diagnosing chronic obstructive pulmonary disease (COPD). Although there are a number of different guideline criteria for deciding who should be selected for spirometric screening, to date it is not known which criteria are the best based on sensitivity and specificity. AIMS: Firstly, to evaluate the proportion of subjects in the PLATINO Study that would be recommended for spirometry testing according to Global initiative for Obstructive Lung Disease (GOLD)-modified, American College of Chest Physicians (ACCP), National Lung Health Education Program (NLHEP), GOLD and American Thoracic Society/European Respiratory Society (ATS/ERS) criteria. Secondly, we aimed to compare the sensitivity, specificity, and positive predictive and negative predictive values, of these five different criteria. METHODS: Data from the PLATINO study included information on respiratory symptoms, smoking and previous spirometry testing. The GOLD-modified spirometry indication criteria are based on three positive answers out of five questions: the presence of cough, phlegm in the morning, dyspnoea, age over 40 years and smoking status. RESULTS: Data from 5,315 subjects were reviewed. Fewer people had an indication for spirometry (41.3%) according to the GOLD-modified criteria, and more people had an indication for spirometry (80.4%) by the GOLD and ATS/ERS criteria. A low percentage had previously had spirometry performed: GOLD-modified (14.5%); ACCP (13.2%); NLHEP (12.6%); and GOLD and ATS/ERS (12.3%). The GOLD-modified criteria showed the least sensitivity (54.9) and the highest specificity (61.0) for detecting COPD, whereas GOLD and ATS/ERS criteria showed the highest sensitivity (87.9) and the least specificity (20.8). CONCLUSION: There is a considerable difference in the indication for spirometry according to the five different guideline criteria. The GOLD-modified criteria recruit less people with the greatest sum of sensitivity and specificity.

A survey of routine treatment of patients with intracranial hypertension (ICH) in specialized trauma centers in Sao Paulo, Brazil: a 11 million metropole!

OBJECTIVE: A survey of intensive care units (ICU) in São Paulo that care for patients with TBI and ICH using the hyperventilation technique. METHODS: A questionnaire was given to the physiotherapist coordinator at 57 hospitals in São Paulo, where 24-h neurosurgery service is provided. RESULTS: Fifty-one (89.5%) hospitals replied. From this total, thirty-four (66.7% perform the hyperventilation technique, 30 (85%) had the objective to reach values below 35 mmHg, four (11%) levels between 35 mmHg and 40 mmHg and one (3%) values over 40 mmHg. CONCLUSIONS: We concluded that most hospitals in São Paulo perform hyperventilation in patients with severe brain trauma although there are not any specific Brazilian guidelines on this topic. Widespread controversy on the use of the hyperventilation technique in patients with severe brain trauma highlights the need for a specific Global policy on this topic.

Evaluation of effects of shoulder girdle training on strength and performance of activities of daily living in patients with chronic obstructive pulmonary disease.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) have some limitations during activities of daily living that involve the arms. There is little information on the benefits of shoulder girdle training and its repercussions for activities of daily living in patients with COPD. The purpose of this study was to investigate whether shoulder girdle training with diagonal movements increases upper limb muscle strength and improves performance of activities of daily living in patients with COPD. METHODS: Thirty-five patients with moderate to severe COPD (forced expiratory volume in one second 1.22 ± 0.49 L) and aged 36-80 years were recruited. Endurance time, maximal sustained weight, oxygen saturation, heart rate, respiratory rate, dyspnea, and arm fatigue were evaluated during an incremental upper limb test and eight simulated activities of daily living before and after an 8-week exercise training program. RESULTS: A significant gain was observed for upper limb strength (P < 0.05). At the peak of the upper limb incremental test, the respiratory rate dropped from 33 to 27 breaths per minute, the Borg dyspnea score decreased from 2 to 0.5, and the upper limb fatigue score decreased from 3 to 2 (P < 0.05). No change was seen in any of these parameters during performance of activities of daily living. CONCLUSION: Although shoulder girdle training increased upper limb strength, no improvement was detected in performance of activities of daily living.

Quality of life and physical limitations in primary brain tumor patients.

OBJECTIVE: To correlate quality of life (QoL) and physical limitations in histological proven primary brain tumor patients using a battery of generic, disease-specific and symptom questionnaires. METHODS: Thirty patients with primary brain tumors were selected from a neuro-oncology outpatient clinic. The FACT-Br Functional Assessment of Cancer Therapy-Brain (specific quality of life questionnaire for patients with brain tumors), SF-36 (generic quality of life questionnaire), HADS (anxiety and depression), and Barthel Index (functionality scale) were answered by the patients at the same interview. RESULTS: The Barthel index did not demonstrate correlation with any subscale of the FACT-Br questionnaire. The HADS had a negative correlation with all FACT-Br subscales and its total score. The SF-36 had a significant weak to moderate correlation with the FACT-Br questionnaire. CONCLUSION: Considering that the FACT-Br is a quick specific questionnaire, it can be a valuable and simple option in evaluating QoL in brain tumor patients with good functional capacity.

Oscilação oral de frequência reduz a obstrução das vias aéreas em crianças com pneumonias? / Flutter can improve lung obstruction in children with pneumonia?

Introdução: A pneumonia pode determinar quadro respiratório obstrutivo e acúmulo de secreção, e técnicas de higiene brônquica favorecem a sua eliminação. As mudanças dela decorrentes podem ser avaliadas pela medição do Pico de Fluxo Expiratório (PFE). Objetivos: Analisar as variações do PFE em crianças com diagnóstico de pneumonia (clínico e radiológico) antes e após a realização das técnicas de oscilação oral de alta frequência (OOAF) e técnica de expiração forçada (TEF). Pacientes e Métodos: Foi realizado estudo randômico controlado com crianças hospitalizadas por diagnóstico clínico e radiológico de pneumonia, e idades entre seis e doze anos. Foram constituídos dois grupos: Controle (C, tosse) e outro submetido a OOAF+ TEF. Frequência cardíaca (FC), frequência respiratória (FR), PFE, a ausculta pulmonar (AP) foram avaliados antes e após a intervenção. Resultados: 17 crianças do grupo OOAF+ TEF e nove do C foram avaliadas (média de idade = nove anos). Houve aumento do PFE (% previsto) apenas no grupo tratamento (65,8%± 14,3% pré vs S0,7%±15,6% após intervenção, p=0,00l). Entre os C o aumento não foi significante (66,3%±12,3% pré vs 77,9%±14,5% após intervenção, p=0,146). Não houve alteração da FC e FR em ambos os grupos. Observou-se melhora qualitativa na ausculta pulmonar no grupo OOAF+ TEF após a intervenção. Conclusões: As técnicas OOAF e TEF associadas foram eficazes para a desobstrução das vias aéreas, aumentando o PFE e melhorando qualitativamente a AP em crianças hospitalizadas com diagnóstico de pneumonia.

Introduction: Pneumonia can cause airway obstruction and increase lung secretion. Chest physiotherapy aids pulmonary expectoration that can cause changes in the airway patency and can be measured by Peak Expiratory Flow rate (PEF). Objectives: To evaluate the PEF variation in children with pneumonia diagnosis (clinicai and radiologic) pre and post Flutter technique and forced expiratory technique (FET) associated was applied. Patients and Methods: Open and randomized study of 26 hospitalized children due to pneumonia, aged from 6 to 12 years was conducted. The children were divided into two groups according to the treatment they received: Flutter + FET (F+FFT) and Control (C, cough). Heart rate (HR), respiratory rate (RR), EPF and pulmonary auscultation were recorded before (pre) and post intervention. Results: 17 children were treated with F+FET and 9 with C (mean age was 9 years old). An increase in the EPF was observed only in the F+FET group (% of prediction) (65.8%±14.3% pre vs 50.7%±15.6% post intervention, p=0.00l). No changes were observed in the C group (66,3%±12,3% pre vs 77.9%± 14.5% post intervention, p=0.146). No significant changes regarding RR and HR were observed in both groups. However, there was a qualitative improvement in PA in the F+FET group. Conclusions: The associated treatment with Flutter and FET proved to be efficient improving PEF and PA in hospitalized children with pneumonia diagnosis.