Prediction models for physical function in COVID-19 survivors.

BACKGROUND: The burden of caring for patients who have survived COVID-19 will be enormous in the coming years, especially with respect to physical function. Physical function has been routinely assessed using the Post-COVID-19 Functional Status (PCFS) scale. AIM: This study built prediction models for the PCFS scale using sociodemographic data, clinical findings, lung function, and muscle strength. METHOD: Two hundred and one patients with post-COVID-19 syndrome (PCS) completed the PCFS scale to assess physical function. Their levels of general fatigue were also assessed using the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) scale, handgrip strength (HGS), and spirometry. RESULTS: The number of participants who scored 0 (none), 1 (negligible), 2 (slight), 3 (moderate), and 4 (severe) on the PCFS scale was 25 (12%), 40 (20%), 39 (19%), 49 (24%), and 48 (24%), respectively. The PCFS scale was significantly correlated with the following variables: FACIT-F score (r = -0.424, P < 0.001), HGS (r = -0.339, P < 0.001), previous hospitalization (r = 0.226, P = 0.001), body mass index (r = 0.163, P = 0.021), and sex (r = -0.153, P = 0.030). The regression model with the highest coefficient of regression (R = 0.559) included the following variables: age, sex, body mass index, FACIT-F, HGS, and previous hospitalization. CONCLUSIONS: Worse general fatigue and HGS are associated with more severe physical function impairments in PCS patients. Furthermore, a history of prior hospitalization results in worse physical function. Thus, prediction models for the PCFS scale that incorporate objective measures enable a better assessment of the physical function of these patients, thus helping in the selection of candidates for a program of physical reconditioning.

Ventilation dynamics using a portable device coupled to the six-minute walk test in people with long-COVID syndrome: a preliminary study.

OBJECTIVE: To investigated the dynamic ventilatory responses and their influence on functional exercise capacity in patients with long-COVID-19 syndrome (LCS). RESULTS: Sixteen LCS patients were subjected to resting lung function (spirometry and respiratory oscillometry-RO) and cardiopulmonary performance to exercise (Spiropalm®-equipped six-minute walk test-6MWT and cardiopulmonary exercise test-CPX). At rest, spirometry showed a normal, restrictive and obstructive pattern in 87.5%, 6.25% and 6.25% of participants, respectively. At rest, RO showed increased resonance frequency, increased integrated low-frequency reactance and increased difference between resistance at 4-20 Hz (R4-R20) in 43.7%, 50%, and 31.2% of participants, respectively. The median of six-minute walking distance (DTC6) was 434 (386-478) m, which corresponds to a value of 83% (78-97%) of predicted. Dynamic hyperinflation (DH) and reduced breathing reserve (BR) were detected in 62.5% and 12.5% of participants, respectively. At CPX, the median peak oxygen uptake (VO2peak) was 19 (14-37) ml/kg/min. There was a significant correlation of 6MWD with both R4-R20 (rs=-0.499, P = 0.039) and VO2peak (rs=0.628, P = 0.009). Our results indicate that DH and low BR are contributors to poor exercise performance, which is associated with peripheral airway disease. These are promising results considering that they were achieved with simple, portable ventilatory and metabolic systems.

Chocolate-Colored Pseudochylothorax in a Woman with a History of Pleuropulmonary Tuberculosis.

BACKGROUND Pseudochylothorax is a rare entity, with only a few hundred case reports worldwide. It presents as a pleural effusion rich in lipids, typically with a cloudy, milky appearance. The diagnosis is made based on the levels of cholesterol and triglycerides in the pleural fluid. CASE REPORT This is the case report of a 55-year-old woman with a history of pleuropulmonary tuberculosis that was treated in childhood, with a new infection and treatment in adulthood that evolved to a left pleural effusion. Thirteen years after completing her last treatment for tuberculosis, the patient developed general fatigue and dyspnea on exertion. Computed tomography of the chest confirmed the presence of a pleural collection in the same location as in adolescence, suggesting a chronic evolution with encystation. The patient underwent ultrasound-guided diagnostic thoracentesis. The collected liquid was thick, chocolate-colored, with the following biochemical characteristics: pH, 7.3; glucose, 37.9 mg/dL; LDL, 2059.8 IU/L; total protein, 8.8 mg/dL; triglycerides, 90 mg/dL; adenosine deaminase, 56 U/L; and cholesterol, 300 mg/dL. The effusion was characterized as a pseudochylothorax. The cell count showed 631 000 leukocytes/µL, with 87.9% polymorphonuclear cells. Owing to the patient's respiratory symptoms, an evacuatory thoracentesis was performed. After the procedure, the patient's symptoms improved. CONCLUSIONS Although pseudochylothorax is a rare condition, its possibility must always be kept in mind to avoid the hazards of misdiagnosis. In addition to the 'classic' milky and machine oil appearance, a chocolate-colored appearance should also serve as a clue to the diagnosis of pseudochylothorax.

High levels of pro-inflammatory SARS-CoV-2-specific biomarkers revealed by in vitro whole blood cytokine release assay (CRA) in recovered and long-COVID-19 patients.

BACKGROUND: Cytokines induced by SARS-CoV-2 infection play a crucial role in the pathophysiology of COVID-19 and hyperinflammatory responses have been associated with poor clinical outcomes, with progression to severe conditions or long-term subacute complications named as long-COVID-19. METHODS: In this cross-sectional study, we aimed to evaluate a set of antigen-specific inflammatory cytokines in blood from recovered COVID-19 individuals or who suffered a post-acute phase of SARS-CoV-2 infection compared to healthy individuals with no history of COVID-19 exposition or infection. Interferon-gamma (IFN-γ), IFN-γ-induced protein 10 (IP-10), tumor necrosis factor (TNF), IL-1ß, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, and IL-17A were quantified by multiplex cytometric bead assay and enzyme-linked immunosorbent assay after stimulation of whole blood with recombinant Spike protein from SARS-CoV-2. Additionally, all participants have evaluated for anti-(S) protein-specific IgG antibodies. Clinical specimens were collected within two months of COVID-19 diagnosis. RESULTS: A total of 47 individuals were enrolled in the study, a median age of 43 years (IQR = 14.5), grouped into healthy individuals with no history of infection or exposure to SARS-CoV-2 (unexposed group; N = 21); and patients from the Health Complex of the Rio de Janeiro State University (UERJ), Brazil, who were SARS-CoV-2 positive by RT-PCR (COVID-19 group)-categorized as recovered COVID-19 (N = 11) or long-COVID-19 (N = 15). All COVID-19 patients presented at least one signal or symptom during the first two weeks of infection. Six patients were hospitalized and required invasive mechanical ventilation. Our results showed that COVID-19 patients had significantly higher levels of IFN-γ, TNF, IL-1ß, IL-2, IL-6, IL-8, and IP-10 than the unexposed group. The long-COVID-19 group has presented significantly high levels of IL-1ß and IL-6 compared to unexposed individuals, but not from recovered COVID-19. A principal-component analysis demonstrated 84.3% of the total variance of inflammatory-SARS-CoV-2 response in the first two components, and it was possible to stratify IL-6, TNF, IL-1ß, IL-10, and IL-2 as the top-five cytokines which are candidates to discriminate COVID-19 group (including long-COVID-19 subgroup) and healthy unexposed individuals. CONCLUSION: We revealed important S protein-specific differential biomarkers in individuals affected by COVID-19, bringing new insights into the inflammatory status or SARS-CoV-2 exposition determination.

Assessment of short- and long-term functionality and quality of life in patients with post-acute COVID-19 syndrome.

BACKGROUND: Although the number of new cases of coronavirus 2019 (COVID-19) has been drastically reduced worldwide, patients who demonstrate long-term symptoms need more attention from health systems, as these symptoms can negatively affect functionality and quality of life. OBJECTIVE: To evaluate muscle function and quality of life at 3, 6, 9 and 12 months in patients with post-acute COVID-19 syndrome and to assess their associations with general fatigue and lung function. METHODS: This observational and longitudinal study evaluated patients with post-acute COVID-19 syndrome. Participants were subjected to the following evaluations: Short Form-36; handgrip strength; Functional Assessment of Chronic Illness Therapy-Fatigue scale; and spirometry. RESULTS: Among the 350 participants who were evaluated in the third month, 74.6%, 61.4% and 45.4% reported general fatigue, dyspnoea and cough, respectively. In the comparisons between the third month and the sixth month, there were significant increases in Functional Assessment of Chronic Illness Therapy-Fatigue scale, pulmonary function and several Short Form-36 domains. In the comparisons between the sixth month and the ninth month, there was a significant increase only in the social functioning domain of the Short Form-36. In the comparisons between the ninth month and the twelfth month, there was an increase only in some Short Form-36 domains. Significant correlations were observed between the Short Form-36 domains with Functional Assessment of Chronic Illness Therapy-Fatigue scale, handgrip strength and pulmonary function. CONCLUSION: In patients with post-acute COVID-19 syndrome, there was a progressive improvement in quality of life, general fatigue and pulmonary function during the 12 months of follow-up, with this improvement being more pronounced in the first 6 months. There was a relationship between functionality and quality of life in these patients.

Home-based rehabilitation improves functional capacity and quality of life in women with systemic sclerosis: A preliminary study.

BACKGROUND: Recent initiatives, such as earlier diagnosis and treatment, have enhanced the survival of patients with systemic sclerosis (SSc). Despite these initiatives, there is extreme variability in rehabilitation strategies for these patients. In 2006, the Glittre-ADL test (TGlittre) was developed to evaluate functional capacity using multiple tasks similar to the activities of daily living (ADLs). OBJECTIVES: To evaluate the impact of therapist-oriented home rehabilitation (TOHR) on functional capacity using TGlittre and to examine the effects of TOHR on physical function, hand function, and quality of life (QoL) among women with SSc. METHODS: This quasi-experimental and longitudinal study included 12 women with SSc who underwent TOHR 3 times per week for 12 weeks. Before and after TOHR, functional capacity was assessed using TGlittre, physical function was examined by the Health Assessment Questionnaire Disability Index (HAQ-DI), hand function was evaluated using the Cochin Hand Functional Scale (CHFS) and handgrip strength (HGS), and QoL was evaluated using the Short Form-36 Health Survey Questionnaire (SF-36). RESULTS: When comparing the pre- and post-TOHR values of TGlittre, a significant reduction was found in total time (p= 0.002) and manual time (p= 0.010). There was a nonsignificant decrease in HAQ-DI scores between pre- and post-TOHR (p= 0.07). Regarding hand function, there was a significant reduction in the CHFS between pre- and post-TOHR (p= 0.036), although no significant difference was observed in HGS between pre- and post-TOHR (p= 0.08). Regarding QoL, there was an increase in all SF-36 categories, although physical function was the only category that was significantly increased (p= 0.008). CONCLUSION: After TOHR, patients with SSc are able to more quickly perform TGlittre tasks when considering both total and manual times. TOHR also positively affects manual skills and QoL.

Reanalysis and validation of the transcriptional pleural fluid signature in pleural tuberculosis.

Introduction: Pleural tuberculosis (PlTB), the most common site of extrapulmonary TB, is characterized by a paucibacillary nature and a compartmentalized inflammatory response in the pleural cavity, both of which make diagnosis and management extremely challenging. Although transcriptional signatures for pulmonary TB have already been described, data obtained by using this approach for extrapulmonary tuberculosis and, specifically, for pleural tuberculosis are scarce and heterogeneous. In the present study, a set of candidate genes previously described in pulmonary TB was evaluated to identify and validate a transcriptional signature in clinical samples from a Brazilian cohort of PlTB patients and those with other exudative causes of pleural effusion. Methods: As a first step, target genes were selected by a random forest algorithm with recursive feature elimination (RFE) from public microarray datasets. Then, peripheral blood (PB) and pleural fluid (PF) samples from recruited patients presenting exudative pleural effusion were collected during the thoracentesis procedure. Transcriptional analysis of the selected top 10 genes was performed by quantitative RT-PCR (RT-qPCR). Results: Reanalysis of the public datasets identified a set of candidate genes (CARD17, BHLHE40, FCGR1A, BATF2, STAT1, BTN3A1, ANKRD22, C1QB, GBP2, and SEPTIN4) that demonstrated a global accuracy of 89.5% in discriminating pulmonary TB cases from other respiratory diseases. Our validation cohort consisted of PlTB (n = 35) patients and non-TB (n = 34) ones. The gene expressions of CARD17, GBP2, and C1QB in PF at diagnosis were significantly different between the two (PlTB and non-TB) groups (p < 0.0001). It was observed that the gene expressions of CARD17 and GBP2 were higher in PlTB PF than in non-TB patients. C1QB showed the opposite behavior, being higher in the non-TB PF. After anti-TB therapy, however, GBP2 gene expression was significantly reduced in PlTB patients (p < 0.001). Finally, the accuracy of the three above-cited highlighted genes in the PF was analyzed, showing AUCs of 91%, 90%, and 85%, respectively. GBP2 was above 80% (sensitivity = 0.89/specificity = 0.81), and CARD17 showed significant specificity (Se = 0.69/Sp = 0.95) in its capacity to discriminate the groups. Conclusion: CARD17, GBP2, and C1QB showed promise in discriminating PlTB from other causes of exudative pleural effusion by providing accurate diagnoses, thus accelerating the initiation of anti-TB therapy.

The Importance of Radiological Patterns and Small Airway Disease in Long-Term Follow-Up of Postacute COVID-19: A Preliminary Study.

Postacute COVID-19 has become a relevant public health problem, and radiological and pulmonary function tests are tools that help physicians in decision-making. The objectives of this study are to characterize the findings and patterns on a chest radiograph (CXR) and computed tomography (CT) that are most important in the postacute phase and to evaluate how these changes correlate with clinical data, spirometry, and impulse oscillometry (IOS). This was a retrospective study of 29 patients who underwent CXR, CT, spirometry, and IOS. The inclusion criteria were age >18 years and persistent respiratory symptoms after four weeks. The exclusion criteria were radiological exams with low technical quality and non-COVID-19 acute lung diseases. The inferential analysis was carried out with the chi-square (χ 2) or Fisher's exact test to evaluate the interrelationships between the clinical and COVID-19 variables according to spirometry, IOS, CT, and CXR. In our sample, 19 patients were women (65.5%). The predominance of abnormal spirometry was associated with CT's moderate/severe degree of involvement (p = 0.017; 69.2%, CI 95%: 44.1%-94.3%). There was no significant association between IOS and tomographic and radiographic parameters. A significant association was found between the classifications of the moderate/severe and normal/mild patterns on CT and CXRs (p = 0.003; 93.3%, CI 95%: 77.8%-100%). Patients with moderate/severe impairment on CXR were associated with a higher frequency of hospitalization (p = 0.033; 77.8%, CI 95%: 58.6%-97.0%) and had significantly more moderate/severe classifications in the acute phase than the subgroup with normal/mild impairment on CXR (p = 0.017; 88.9%, CI 95%: 74.4%-100%). In conclusion, the results of this study show that CXR is a relevant examination and may be used to detect nonspecific alterations during the follow-up of post-COVID-19 patients. Small airway disease is an important finding in postacute COVID-19 syndrome, and we postulate a connection between this pattern and the persistently low-level inflammatory state of the lung.

Can home rehabilitation impact impulse oscillometry and lung ultrasound findings in patients with scleroderma-associated interstitial lung disease? A pilot study.

OBJECTIVE: Exercise has been demonstrated to be beneficial for improving physical capacity and quality of life in people with scleroderma, although knowledge of its impact on the respiratory system is limited. This study evaluated the impact of therapist-oriented home rehabilitation (TOHR) on impulse oscillometry (IOS) and lung ultrasound (LUS) findings in patients with scleroderma-associated interstitial lung disease (ILD). RESULTS: Twelve women with scleroderma underwent spirometry, IOS, and LUS before and after performing TOHR. Regarding spirometry, a normal pattern and restrictive damage were observed in five (41.7%) and seven (58.3%) participants pre-TOHR and post-TOHR, respectively. For IOS, an abnormal result was detected in nine (75%) pre-TOHR participants and six (50%) post-TOHR participants. Heterogeneity of resistance between 4-20 Hz (R4-R20) > 20% of the predicted value was observed in eight (66.7%) pre-TOHR participants and three (25%) post-TOHR participants (P = 0.031). An abnormal LUS result was observed in nine (75%) participants both pre-TOHR and post-TOHR. The main change observed was B-lines > 2, which was noted in nine (75%) participants both pre-TOHR and post-TOHR. Our findings suggest that TOHR for women with scleroderma-associated ILD improves the resistance and reactance measured by IOS, including small airway disease. Trial Registration ClinicalTrials.gov ID: NCT05041868 Registered on: 13th September 2021.

Mortality and comorbidities in patients with bronchiectasis over a 3-year follow-up.

To identify the risk factors associated with all-cause mortality in patients with noncystic fibrosis bronchiectasis (NCFB). This prospective cohort study included 120 adult patients with NCFB, who were regularly treated at a specialized outpatient clinic of a university hospital between January 2017 and June 2020. All patients were diagnosed using high-resolution computed tomography. Demographic and clinical data, pulmonary function tests, and the Euro-quality-of-life 5-domain 3-level questionnaire were analyzed. The factors associated with death were determined using the Cox proportional hazards model. The all-cause mortality rate at 41 months was 10.8%. Adjusted multivariate analysis showed that the main contributing predictors for mortality were female sex, smoking, diabetes, chronic obstructive pulmonary disease, emergency visits, use of antibiotics due to exacerbation, secretion color change, exacerbation, predicted forced expiratory volume in 1 second, predicted forced vital capacity, lack of respiratory physiotherapy, absence of vaccination against pneumococci, and mobility domain. Multiple factors contribute to unfavorable outcomes in patients with NCFB, and early recognition of these factors may improve care management.

Hyporexia and cellular/biochemical characteristics of pleural fluid as predictive variables on a model for pleural tuberculosis diagnosis.

OBJECTIVES: Pleural tuberculosis (PlTB) diagnosis is a challenge due to its paucibacillary nature and to the need of invasive procedures. This study aimed to identify easily available variables and build a predictive model for PlTB diagnosis which may allow earlier and affordable alternative strategy to be used in basic health care units. METHODS: An observational cross-sectional study compared PlTB and non-TB patients followed at a tertiary Brazilian hospital between 2010 and 2018. Unconditional logistic regression analysis was performed and a Decision Tree Classifier (DTC) model was validated and applied in additional PlTB patients with empiric diagnosis. The accuracy (Acc), sensitivity (Se), specificity (Sp), positive and negative predictive values were calculated. RESULTS: From 1,135 TB patients, 160 were considered for analysis (111 confirmed PlTB and 49 unconfirmed PlTB). Indeed, 58 non-TB patients were enrolled as controls. Hyporexia [adjusted odds ratio (aOR) 27.39 (95% CI 6.26 - 119.89)] and cellular/biochemical characteristics on pleural fluid (PF) (polimorphonuclear in two categories: 3-14% aOR 26.22, 95% CI 7.11 - 96.68 and < 3% aOR 28.67, 95% CI 5.51 - 149.25; and protein ≥ 5g/dL aOR 7.24, 95% CI 3.07 - 17.11) were associated with higher risk for TB. The DTC constructed using these variables showed Acc=87.6%, Se=89.2%, Sp=84.5% for PlTB diagnosis and was successfully applied in unconfirmed PlTB patients. CONCLUSION: The DTC model showed an excellent performance for PlTB diagnosis and can be considered as an alternative diagnostic strategy by using clinical patterns in association with PF cellular/biochemical characteristics, which were affordable and easily performed in basic health care units.

Small airway dysfunction on impulse oscillometry and pathological signs on lung ultrasound are frequent in post-COVID-19 patients with persistent respiratory symptoms.

BACKGROUND: Thousands of people worldwide are suffering the consequences of coronavirus disease-2019 (COVID-19), and impulse oscillometry (IOS) and lung ultrasound (LUS) might be important tools for the follow-up of this population. Our objective was to prospectively evaluate abnormalities detected using these two methods in a cohort of COVID-19 survivors with respiratory symptoms. METHODS: In this follow-up study, 59 patients underwent clinical evaluations, spirometry, IOS and LUS in the 2nd (M1) and 5th (M2) months after diagnostic confirmation of COVID-19 by real-time reverse transcriptase-polymerase chain reaction. Aeration scores were obtained from the LUS exams based on the following findings: B-lines >2, coalescent B-lines, and subpleural consolidations. RESULTS: Fifty-nine (100%) participants had cough and/or dyspnea at M1, which decreased to 38 (64.4%) at M2 (p = 0.0001). Spirometry was abnormal in 26 (44.1%) and 20 (33.9%) participants at M1 and M2, respectively, although without statistical significance (p = 0.10). Normal examination, restrictive patterns, and obstructive patterns were observed in 33 (55.9%), 18 (30.5%), and 8 (13.6%) participants, respectively, at M1 and in 39 (66.1%), 13 (22%), and 7 (11.9%) participants at M2 (p = 0.14). Regarding IOS, considering changes in resistive and reactive parameters, abnormal exams were detected in 52 (88.1%) and 42 (71.2%) participants at M1 and M2, respectively (p = 0.002). Heterogeneity of resistance between 4 and 20 Hz >20% was observed in 38 (64.4%) and 33 (55.9%) participants at M1 and M2, respectively (p = 0.30). Abnormal LUS was observed in 46 (78%) and 36 (61%) participants at M1 and M2, respectively (p = 0.002), with a reduction in aeration scores between M1 and M2 [5 (2-8) vs. 3 (0-6) points, p<0.0001]. CONCLUSIONS: IOS and LUS abnormalities are frequent in the first 5 months post-COVID-19 infection; however, when prospectively evaluated, significant improvement is evident in the parameters measured by these two methods.

The impact of healthcare-associated infections on COVID-19 mortality: a cohort study from a Brazilian public hospital.

OBJECTIVE: This study aims to analyze the risk factors for in-hospital mortality in a cohort of patients admitted to a newly adapted intensive care unit in a public hospital in Rio de Janeiro. METHODS: This was an observational, retrospective, and descriptive study. Data were obtained from electronic medical records. Coronavirus disease 2019 (COVID-19) was diagnosed by detecting viral ribonucleic acid using reverse transcription polymerase chain reaction. Factors associated with the risk/protection from death were determined using the odds ratio and adjusted odds ratio. RESULTS: Fifty-one patients were admitted to the hospital. The median age of the patients was 63 years, 60% were male patients, and 54% were white patients. Sixty-seven percent of the patients were diagnosed with COVID-19. Sepsis at admission increased the chance of in-hospital death by 21 times (adjusted odds ratio=21.06 [0.79-555.2]; p=0.06). The strongest risk factor for death was the development of septic shock during hospitalization (adjusted odds ratio=98.56 [2.75-352.5]; p=0.01), and one in four patients had multidrug-resistant bacteria. Mechanical ventilation, vasopressors, neuromuscular blockers, and sedatives were also the risk factors for in-hospital mortality. The in-hospital mortality rate was 41%, and the mortality rate of patients on mechanical ventilation was 60%. The diagnosis of COVID-19 was not statistically related to the adverse outcomes. CONCLUSIONS: In this cohort, the strongest risk factor for in-hospital death was the development of nosocomial septic shock. Healthcare-associated infections have a significant impact on mortality rates. Therefore, to have a better outcome, it is important to consider not only the availability of beds but also the way healthcare is delivered.

A 34-Year-Old Woman from Brazil with Pulmonary Lymphangioleiomyomatosis Diagnosed by Raised Serum Vascular Endothelial Growth Factor-D (VEGF-D) Levels and Lung Cysts on Computed Tomography Imaging Presenting with COVID-19 Pneumonia.

BACKGROUND There is growing concern about the clinical course of certain diseases in patients who are simultaneously infected by SARS-CoV-2. This report is of a 34-year-old woman from Brazil with a recent diagnosis of pulmonary lymphangioleiomyomatosis (LAM) diagnosed by raised serum VEGF-D levels and the finding of lung cysts on computed tomography (CT) imaging, who presented with COVID-19 pneumonia. CASE REPORT Five months after the diagnosis of pulmonary LAM, which was based on the presence of diffuse and bilateral cystic lesions on CT scan associated with high serum VEGF-D levels, the patient presented with worsening dyspnea, drop in peripheral oxygen oxygenation, fever, and diffuse myalgia. She was using Sirolimus because it inhibits the development of LAM cells. A worsening of lung abnormalities was demonstrated in a chest CT examination, with the appearance of areas of consolidation and ground-glass abnormalities. A nasal swab sample tested positive for SARS-CoV-2 infection using reverse-transcription polymerase chain reaction. Thus, Sirolimus was suspended because of concern about its immunosuppressive action. She received hospital support following the institutional protocol in force at the time, without the need for invasive mechanical ventilation. After 2 weeks, she was discharged from the hospital, with supplemental oxygen at home and return of Sirolimus. CONCLUSIONS This report has described the presentation of COVID-19 pneumonia due to SARS-CoV-2 infection in a 34-year-old woman with a recent diagnosis of LAM involving the lungs.

Reference Value for the Distance Walked in the Six-Minute Walk Test in Obese Brazilian Men in the Preoperative Period of Bariatric Surgery.

BACKGROUND: Obesity has several effects on the mechanics of the rib cage that may impair the exercise performance of obese individuals and therefore impact the assessment of surgical risk. This study aimed to establish a reference value for the 6-minute walk distance (6 MWD) in obese Brazilian men in the preoperative period of bariatric surgery that considers the effect of lung function. METHODS: This was a cross-sectional study in which 104 obese men underwent the six-minute walk test (6 MWT) before bariatric surgery. They also underwent the spirometry test and respiratory muscle strength measurement before the 6 MWT. RESULTS: The 6 MWD was correlated with age (r = -0.388, p=0.0005), weight (r = -0.365, p=0.0007), height (r = 0.285, p=0.022), body mass index (BMI) (r = -0.543, p < 0.0001), forced vital capacity (FVC) (r = 0.472, p < 0.0001), peak expiratory flow (r = 0.253, p=0.031), and maximal inspiratory pressure (r = 0.313, p=0.017). In the stepwise forward regression analysis, BMI, FVC, and age were the only variables that independently predicted the 6 MWD and explained 40% of its variability. The reference equation proposed for obese Brazilian men is 6 MWD (m) = 570.5 - (3.984 × BMIkg/m2) + (1.093 × FVC%predicted) - (0.836 × ageyrs). CONCLUSION: In this sample of obese Brazilian men, lung function contributed to poor performance in the 6 MWT. In these individuals, BMI, FVC, and age were the variables that composed the reference equation for the 6 MWD. Thus, in several clinical settings, such as in the evaluation before bariatric surgery, pulmonary function data are important to determine the reference value for the 6 MWD.

The impact of healthcare-associated infections on COVID-19 mortality: a cohort study from a Brazilian public hospital

SUMMARY OBJECTIVE: This study aims to analyze the risk factors for in-hospital mortality in a cohort of patients admitted to a newly adapted intensive care unit in a public hospital in Rio de Janeiro. METHODS: This was an observational, retrospective, and descriptive study. Data were obtained from electronic medical records. Coronavirus disease 2019 (COVID-19) was diagnosed by detecting viral ribonucleic acid using reverse transcription polymerase chain reaction. Factors associated with the risk/protection from death were determined using the odds ratio and adjusted odds ratio. RESULTS: Fifty-one patients were admitted to the hospital. The median age of the patients was 63 years, 60% were male patients, and 54% were white patients. Sixty-seven percent of the patients were diagnosed with COVID-19. Sepsis at admission increased the chance of in-hospital death by 21 times (adjusted odds ratio=21.06 [0.79-555.2]; p=0.06). The strongest risk factor for death was the development of septic shock during hospitalization (adjusted odds ratio=98.56 [2.75-352.5]; p=0.01), and one in four patients had multidrug-resistant bacteria. Mechanical ventilation, vasopressors, neuromuscular blockers, and sedatives were also the risk factors for in-hospital mortality. The in-hospital mortality rate was 41%, and the mortality rate of patients on mechanical ventilation was 60%. The diagnosis of COVID-19 was not statistically related to the adverse outcomes. CONCLUSIONS: In this cohort, the strongest risk factor for in-hospital death was the development of nosocomial septic shock. Healthcare-associated infections have a significant impact on mortality rates. Therefore, to have a better outcome, it is important to consider not only the availability of beds but also the way healthcare is delivered.

Diagnostic performance of the Xpert MTB/RIF assay in BAL fluid samples from patients under clinical suspicion of pulmonary tuberculosis: a tertiary care experience in a high-tuberculosis-burden area.

OBJECTIVE: To assess the diagnostic performance of the Xpert MTB/RIF assay, a rapid molecular test for tuberculosis, comparing it with that of AFB staining and culture, in BAL fluid (BALF) samples from patients with clinically suspected pulmonary tuberculosis (PTB) who are sputum smear-negative or produce sputum samples of insufficient quantity. METHODS: This was a retrospective study of 140 cases of suspected PTB in patients who were smear-negative or produced insufficient sputum samples and were evaluated at a tertiary teaching hospital in the city of Rio de Janeiro, Brazil. All of the patients underwent fiberoptic bronchoscopy with BAL. The BALF specimens were evaluated by AFB staining, mycobacterial culture, and the Xpert MTB/RIF assay. RESULTS: Among the 140 patients, results for all three microbiological examinations were available for 73 (52.1%), of whom 22 tested positive on culture, 17 tested positive on AFB staining, and 20 tested positive on the Xpert MTB/RIF assay. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy for AFB staining were 68.1%, 96.1%, 88.2%, 87.5%, and 87.6%, respectively, compared with 81.8%, 96.1%, 90.0%, 92.4%, and 91.8%, respectively, for the Xpert MTB/RIF assay. The agreement between AFB staining and culture was 82.3% (kappa = 0.46; p < 0.0001), whereas that between the Xpert MTB/RIF assay and culture was 91.8% (kappa = 0.8; p < 0.0001). CONCLUSIONS: In BALF samples, the Xpert MTB/RIF assay performs better than do traditional methods, providing a reliable alternative to sputum analysis in suspected cases of PTB. However, the rate of discordant results merits careful consideration.

One-month outcomes of patients with SARS-CoV-2 infection and their relationships with lung ultrasound signs.

BACKGROUND: The role of lung ultrasound (LUS) in evaluating the mid- and long-term prognoses of patients with COVID-19 pneumonia is not yet known. The objectives of this study were to evaluate associations between LUS signs at the time of screening and clinical outcomes 1 month after LUS and to assess LUS signs at the time of presentation with known risk factors for COVID-19 pneumonia. METHODS: This was a retrospective study of data prospectively collected 1 month after LUS screening of 447 adult patients diagnosed with COVID-19 pneumonia. Sonographic examination was performed in screening tents with the participants seated. The LUS signs (B-lines > 2, coalescent B-lines, and subpleural consolidations) were captured in six areas of each hemithorax and a LUS aeration score was calculated; in addition, the categories of disease probability based on patterns of LUS findings (high-probability, intermediate-probability, alternate, and low-probability patterns) were evaluated. The LUS signs at patients' initial evaluation were related to the following outcomes: symptomatology, the need for hospitalization or invasive mechanical ventilation (IMV), and COVID-19-related death. RESULTS: According to the evaluations performed 1 month after LUS screening, 36 patients were hospitalised, eight of whom required intensive care unit (ICU) admission and three of whom died. The presence of coalescent B-lines was associated with the need for hospitalization (p = 0.008). The presence of subpleural consolidations was associated with dyspnoea (p < 0.0001), cough (p = 0.003), the need for hospitalization (p < 0.0001), the need for ICU admission (p < 0.0001), and death (p = 0.002). A higher aeration score was associated with dyspnoea (p < 0.0001), the need for hospitalization (p < 0.0001), the need for ICU admission (p < 0.0001), and death (p = 0.003). In addition, patients with a high-probability LUS pattern had a higher aeration score (p < 0.0001) and more dyspnoea (p = 0.024) and more often required hospitalization (p < 0.0001) and ICU admission (p = 0.031). CONCLUSIONS: In patients with COVID-19 pneumonia, LUS signs were related to respiratory symptoms 1 month after LUS screening. Strong relationships were identified between LUS signs and the need for hospitalization and death.

Comparison Between Lung Ultrasound and Computed Tomographic Findings in Patients With COVID-19 Pneumonia.

OBJECTIVES: The aim of this study was to describe findings from lung ultrasound (LUS) and computed tomography (CT) in health professionals with coronavirus disease 2019 pneumonia and to evaluate the associations of the findings of both tests. METHODS: This cross-sectional observational study evaluated 45 health professionals who were initially seen in screening tents and had a diagnosis of coronavirus disease 2019 as confirmed by a reverse transcription polymerase chain reaction and lung involvement diagnosed by LUS. Subsequently, these individuals were admitted to the hospital, where chest CT was performed. Aeration scores were obtained for the LUS examinations based on the following findings: more than 2 B-lines, coalescent B-lines, and subpleural consolidations. A subjective assessment of the extent of lung disease on CT was performed on the basis of the percentage of lung parenchyma involvement as follows: 25% or less, 25% to 50%, and greater than 50%. RESULTS: Regarding LUS signs, more than 2 B-lines, coalescent B-lines, and subpleural consolidations were present in 73.3%, 68.2%, and 24.4% of cases, respectively. The main findings on CT were ground glass opacities, a crazy-paving pattern, and consolidations (66.7%, 20%, and 20% of cases); 17.8% of cases had examinations without abnormalities. Patients with more than 2 B-lines on LUS had more ground glass opacity areas on CT (P = .0007), whereas patients with subpleural consolidations on LUS had more consolidations on CT (P < .0001). In addition, patients with higher LUS aeration scores had more extensive disease on CT (P < .0001). CONCLUSIONS: Lung ultrasound can detect lung injury even in the presence of normal CT results. There are associations between the abnormalities detected by both methods, and a relationship also exists between LUS aeration scores and the disease extent on CT.

Diagnostic performance of the Xpert MTB/RIF assay in BAL fluid samples from patients under clinical suspicion of pulmonary tuberculosis: a tertiary care experience in a high-tuberculosis-burden area / Desempenho diagnóstico do teste Xpert MTB/RIF em amostras de LBA de pacientes com suspeita clínica de tuberculose pulmonar: experiência na atenção terciária em uma área com alta carga de tuberculose

ABSTRACT Objective: To assess the diagnostic performance of the Xpert MTB/RIF assay, a rapid molecular test for tuberculosis, comparing it with that of AFB staining and culture, in BAL fluid (BALF) samples from patients with clinically suspected pulmonary tuberculosis (PTB) who are sputum smear-negative or produce sputum samples of insufficient quantity. Methods: This was a retrospective study of 140 cases of suspected PTB in patients who were smear-negative or produced insufficient sputum samples and were evaluated at a tertiary teaching hospital in the city of Rio de Janeiro, Brazil. All of the patients underwent fiberoptic bronchoscopy with BAL. The BALF specimens were evaluated by AFB staining, mycobacterial culture, and the Xpert MTB/RIF assay. Results: Among the 140 patients, results for all three microbiological examinations were available for 73 (52.1%), of whom 22 tested positive on culture, 17 tested positive on AFB staining, and 20 tested positive on the Xpert MTB/RIF assay. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy for AFB staining were 68.1%, 96.1%, 88.2%, 87.5%, and 87.6%, respectively, compared with 81.8%, 96.1%, 90.0%, 92.4%, and 91.8%, respectively, for the Xpert MTB/RIF assay. The agreement between AFB staining and culture was 82.3% (kappa = 0.46; p < 0.0001), whereas that between the Xpert MTB/RIF assay and culture was 91.8% (kappa = 0.8; p < 0.0001). Conclusions: In BALF samples, the Xpert MTB/RIF assay performs better than do traditional methods, providing a reliable alternative to sputum analysis in suspected cases of PTB. However, the rate of discordant results merits careful consideration.

RESUMO Objetivo: Avaliar o desempenho diagnóstico do teste Xpert MTB/RIF - teste molecular rápido para tuberculose, comparando-o com o da pesquisa de BAAR e da cultura, em amostras de LBA de pacientes com suspeita clínica de tuberculose pulmonar (TBP) que apresentam baciloscopia de escarro negativa ou produzem amostras com quantidade insuficiente de escarro. Métodos: Estudo retrospectivo de 140 casos suspeitos de TBP em pacientes que apresentaram baciloscopia negativa ou produziram amostras de escarro insuficientes e foram avaliados em um hospital-escola terciário na cidade do Rio de Janeiro (RJ). Todos os pacientes foram submetidos à fibrobroncoscopia com LBA. Os espécimes de LBA foram avaliados por meio da realização de pesquisa de BAAR, cultura para micobactérias e teste Xpert MTB/RIF. Resultados: Entre os 140 pacientes, resultados de todos os três exames microbiológicos estavam disponíveis para 73 (52,1%), dos quais 22 apresentaram cultura positiva, 17, pesquisa de BAAR positiva, e 20, teste Xpert MTB/RIF positivo. A sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo e precisão global da pesquisa de BAAR foram de 68,1%, 96,1%, 88,2%, 87,5% e 87,6%, respectivamente, contra 81,8%, 96,1%, 90,0%, 92,4% e 91,8%, respectivamente, do teste Xpert MTB/RIF. A concordância entre a pesquisa de BAAR e a cultura foi de 82,3% (kappa = 0,46; p < 0,0001), enquanto a concordância entre o teste Xpert MTB/RIF e a cultura foi de 91,8% (kappa = 0,8; p < 0,0001). Conclusões: Em amostras de LBA, o teste Xpert MTB/RIF tem melhor desempenho do que os métodos tradicionais, fornecendo uma alternativa confiável à análise do escarro em casos suspeitos de TBP. No entanto, a taxa de resultados discordantes merece uma reflexão cuidadosa.