A randomized, controlled, crossover study in patients with mild and moderate asthma undergoing treatment with traditional Chinese acupuncture

OBJECTIVES:This study sought to verify the effects of acupuncture as an adjuvant treatment for the control of asthma.METHODS:This was a randomized, controlled, crossover trial conducted at the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. A total of 74 patients with mild/moderate, persistent asthma were randomized into two therapeutic groups: Group A - 31 patients underwent 10 real weekly acupuncture sessions, followed by a 3-week washout period and 10 sham weekly acupuncture sessions; and Group B - 43 patients underwent 10 sham weekly acupuncture sessions, followed by a 3-week washout period and 10 real weekly acupuncture sessions. Patients used short- and long-acting β-2 agonists and inhaled corticosteroids when necessary. Prior to treatment and after each period of 10 treatment sessions, the patients were evaluated for spirometry, induced sputum cell count, exhaled nitric oxide (NO) and with the Short Form 36 (SF-36) and Questionnaire on Quality of Life-Asthma (QQLA) questionnaires. Daily peak flow and symptom diaries were registered. The level of significance adopted was 5% (α=0.05).RESULTS:In Group B, after real acupuncture, there was a decrease in eosinophils (p=0.035) and neutrophils (p=0.047), an increase in macrophages (p=0.001) and an improvement in peak flow (p=0.01). After sham acupuncture treatment, patients experienced less coughing (p=0.037), wheezing (p=0.013) and dyspnea (p=0.014); similarly, after real acupuncture, patients reported less coughing (p=0.040), wheezing (p=0.012), dyspnea (p<0.001) and nocturnal awakening episodes (p=0.009). In Group A, there was less use of rescue medication (p=0.043). After the sham procedure, patients in Group A experienced less coughing (p=0.007), wheezing (p=0.037), dyspnea (p<0.001) and use of rescue medication (p<0.001) and after real acupuncture, these patients showed improvements in functional capacity (p=0.004), physical aspects (p=0.002), general health status (p<0.001) and vitality (p=0.019). Sham acupuncture also led to significant differences in symptoms, but these were not different from those seen with real acupuncture. Spirometry and exhaled NO levels did not show a difference between sham and real acupuncture treatment. In addition, no significant difference was demonstrated between treatments regarding the quality of life evaluation.CONCLUSION:Real and sham acupuncture have different effects and outcomes on asthma control. The crossover approach was not effective in this study because both interventions led to improvement of asthma symptoms, quality of life and inflammatory cell counts. Thus, sham acupuncture cannot serve as a placebo in trials with acupuncture as the main intervention for asthma.

Clinical characteristics of children and adolescents with severe therapy-resistant asthma in Brazil / Características clínicas de crianças e adolescentes brasileiros com asma grave resistente a terapia

AbstractObjective: To describe the clinical characteristics, lung function, radiological findings, and the inflammatory cell profile in induced sputum in children and adolescents with severe therapy-resistant asthma (STRA) treated at a referral center in southern Brazil.Methods: We retrospectively analyzed children and adolescents (3-18 years of age) with uncontrolled STRA treated with high-dose inhaled corticosteroids and long-acting β2 agonists. We prospectively collected data on disease control, lung function, skin test reactivity to allergens, the inflammatory cell profile in induced sputum, chest CT findings, and esophageal pH monitoring results.Results: We analyzed 21 patients (mean age, 9.2 ± 2.98 years). Of those, 18 (86%) were atopic. Most had uncontrolled asthma and near-normal baseline lung function. In 4 and 7, induced sputum was found to be eosinophilic and neutrophilic, respectively; the inflammatory cell profile in induced sputum having changed in 67% of those in whom induced sputum analysis was repeated. Of the 8 patients receiving treatment with omalizumab (an anti-IgE antibody), 7 (87.5%) showed significant improvement in quality of life, as well as significant reductions in the numbers of exacerbations and hospitalizations.Conclusions: Children with STRA present with near-normal lung function and a variable airway inflammatory pattern during clinical follow-up, showing a significant clinical response to omalizumab. In children, STRA differs from that seen in adults, further studies being required in order to gain a better understanding of the disease mechanisms.

ResumoObjetivo: Descrever as principais características clínicas, a função pulmonar, as características radiológicas e o perfil inflamatório do escarro induzido de crianças e adolescentes com asma grave resistente a terapia (AGRT) tratados em um centro de referência do sul do Brasil.Métodos: Foram analisadas retrospectivamente crianças e adolescentes de 3-18 anos com diagnóstico de AGRT não controlada acompanhados durante pelo menos 6 meses e tratados com doses elevadas de corticoide inalatório associado a um β2-agonista de longa duração. Foram coletados prospectivamente dados relativos ao controle da doença, função pulmonar, teste cutâneo para alérgenos, perfil inflamatório do escarro induzido, TC de tórax e pHmetria esofágica.Resultados: Foram analisados 21 pacientes (média de idade: 9,2 ± 2,98 anos). Dos 21, 18 (86%) eram atópicos. A maioria apresentava asma não controlada e função pulmonar basal próxima do normal. Em 4 e 7 pacientes, o escarro induzido revelou-se eosinofílico e neutrofílico, respectivamente, e 67% dos pacientes que repetiram o exame apresentaram mudança no perfil inflamatório. Dos 8 pacientes que receberam omalizumabe (um anticorpo anti-IgE), 7 (87,5%) apresentaram melhora importante da qualidade de vida, com redução importante das exacerbações e hospitalizações.Conclusões: Crianças com AGRT apresentam função pulmonar próxima do normal e padrão inflamatório das vias aéreas variável durante o seguimento clínico, com importante resposta clínica ao omalizumabe. A AGRT em crianças difere da AGRT em adultos, e são necessários mais estudos para esclarecer os mecanismos da doença.

Acceptability of Sputum Specimens for Diagnosing Pulmonary Tuberculosis

The evaluation of the quality of a sputum specimen prior to bacterial culture has been an accepted practice. However, optimal sputum criteria for pulmonary tuberculosis (TB) are not well established. We investigated indicators for sputum acceptability in tuberculosis cultures and acid-fast bacilli (AFB) smear. A post-hoc analysis of a randomized trial with 228 sputum specimens from 77 patients was conducted. In the trial, pulmonary TB suspects were requested for collecting three sputum specimens. We performed both TB study (AFB smear and M. tuberculosis culture) and Gram staining in each specimen. By using generalized estimating equations, the association between sputum characteristics and positive TB testings were analyzed. Although acceptable specimens for bacterial pneumonia showed higher TB-culture positive rates than unacceptable specimens (adjusted odds ratio [aOR]=1.66; 95% confidence interval [CI]=1.11-2.49), a specimen with > or =25 white blood cells/low-power field was the better predictor for positive M. tuberculosis cultures (aOR=2.30; 95% CI=1.48-3.58) and acid-fast bacilli smears (aOR=1.85; 95% CI=1.05-3.25). Sputum leukocytosis could be an indicator of sputum acceptability for diagnosing pulmonary tuberculosis.

An Appropriate Lower Respiratory Tract Specimen Is Essential for Diagnosis of Middle East Respiratory Syndrome (MERS)

No abstract available.

Reliability of a rapid hematology stain for sputum cytology / Confiabilidade da coloração hematológica rápida para citologia de escarro

Objective: To determine the reliability of a rapid hematology stain for the cytological analysis of induced sputum samples. Methods: This was a cross-sectional study comparing the standard technique (May-Grünwald-Giemsa stain) with a rapid hematology stain (Diff-Quik). Of the 50 subjects included in the study, 21 had asthma, 19 had COPD, and 10 were healthy (controls). From the induced sputum samples collected, we prepared four slides: two were stained with May-Grünwald-Giemsa, and two were stained with Diff-Quik. The slides were read independently by two trained researchers blinded to the identification of the slides. The reliability for cell counting using the two techniques was evaluated by determining the intraclass correlation coefficients (ICCs) for intraobserver and interobserver agreement. Agreement in the identification of neutrophilic and eosinophilic sputum between the observers and between the stains was evaluated with kappa statistics. Results: In our comparison of the two staining techniques, the ICCs indicated almost perfect interobserver agreement for neutrophil, eosinophil, and macrophage counts (ICC: 0.98-1.00), as well as substantial agreement for lymphocyte counts (ICC: 0.76-0.83). Intraobserver agreement was almost perfect for neutrophil, eosinophil, and macrophage counts (ICC: 0.96-0.99), whereas it was moderate to substantial for lymphocyte counts (ICC = 0.65 and 0.75 for the two observers, respectively). Interobserver agreement for the identification of eosinophilic and neutrophilic sputum using the two techniques ranged from substantial to almost perfect (kappa range: 0.91-1.00). Conclusions: The use of Diff-Quik can be considered a reliable alternative for the processing of sputum samples. .

Objetivo: Determinar a confiabilidade da coloração hematológica rápida para a análise do escarro induzido. Métodos: Estudo transversal comparando a técnica padrão (coloração May-Grünwald-Giemsa) com a coloração hematológica rápida (panótico rápido). Participaram do estudo 50 indivíduos (21 asmáticos, 19 portadores de DPOC e 10 controles). Após a coleta do escarro induzido, foram preparadas 4 lâminas, sendo 2 coradas por May-Grünwald-Giemsa e 2 por panótico rápido. As lâminas foram lidas de forma independente por dois pesquisadores capacitados para o exame de escarro induzido e cegados para a identificação das lâminas. A confiabilidade para as contagens celulares dos dois métodos foi avaliada pela determinação dos coeficientes de correlação intraclasse (CCI) para as concordâncias intraobservador e interobservador. As concordâncias na identificação de escarro neutrofílico e eosinofílico entre observadores e entre as duas colorações foram calculadas por estatística kappa. Resultados: Nas duas colorações, os CCI apontaram concordância interobservador quase perfeita para as contagens de neutrófilos, eosinófilos e macrófagos (variação do CCI: 0,98-1,00) e substancial para as contagens de linfócitos (variação do CCI: 0,76-0,83). Na análise intraobservador, a concordância foi quase perfeita para as contagens de neutrófilos, eosinófilos e macrófagos (variação do CCI: 0,96-0,99) e de moderada a substancial para as contagens de linfócitos (CCI = 0,65 e 0,75 para observadores 1 e 2, respectivamente). A concordância interobservador na identificação de escarro eosinofílico e neutrofílico para os dois métodos de ...

Biomarkers for screening of lung cancer and pre-neoplastic lesions in a high risk Chilean population

BACKGROUND: The mortality of lung cancer (LC), increases each year in the world, in spite of any advances, in development of new drugs to advance stages of LC. The high incidence of LC has been associated with smoking habit, genetic diversity and environmental pollution. Antofagasta region has been reported to have the highest LC mortality rate in Chile and its inhabitants were exposed to arsenic in their drinking water in concentrations as high as 870 µg/L. Non-invasive techniques such as biomarkers (Automatic Quantitative Cytometry: AQC and DR70) and Auto Fluorescence Bronchoscopy (AFB) might be potentially useful as a supplementary diagnostic approach and early detection. Early detection is one of the most important factors to intervene and prevent cancer progression in LC. This is a work of an ongoing prospective bimodality cancer surveillance study in high risk LC volunteers. Enrolment was done in subjects from Antofagasta and Metropolitan regions. In addition, we enrolled subjects who were suspected of having lung cancer. AQC, DR70 and AFB were used as tools in the detection of pre-neoplastic (PNL) and neoplastic lesions (NL). RESULTS: Half of the samples, classified as suspicious by AFB, were confirmed as metaplasia or dysplasia by histopathology. For LC, DR70 showed a higher sensitivity (95.8%) and specificity (91.9%) than AQC. However, for PNL AQC showed a higher sensitivity (91.9%) than DR70 (27.3%), although both with low PPV values. As a pre screener, both biomarkers might be employed as complementary tools to detect LC, especially as serially combined tests, with a sensitivity of 60% and a PPV of 65.2%. Additionally, the use of parallel combined tests might support the detection of PNL (sensitivity 91.2%; PPV 49.1%). CONCLUSION: This work adds information on cellular and molecular biomarkers to complement imaging techniques for early detection of LC in Latin America that might contribute to formulate policies concerning screening of LC. Supported by INNOVA-CORFO, Chile.

Synchronous invasive or preinvasive bronchial lesions detected by autofluorescence bronchoscopy in patients with lung cancer

Objectives: In support with field cancerization theory, some patients with lung cancer [LC] will also have synchronous invasive or pre-invasive bronchial lesions. In this cross sectional - analytic study autofluorescence bronchoscopy [AFB] was used to assess the prevalence of synchronous lesions in patients with LC

Materials and methods: All patients with abnormal sputum cytology underwent white light and AFB. From 335 patients with abnormal sputum cytology referred for AFB, lung cancer was detected in 91 patients [89 male and 2 female] of age [mean +/- SD], 67 +/- 8 years. 77 had squamous cell carcinoma [SqCC], 13 had adenocarcinoma and one patient with small cell lung cancer [SCLC]

Results: Synchronous lesions detected in 26 [29%] patients, 25 [33%] of patients with SqCC, one with adenocarcinoma, no synchronous lesion detected in one patient with SCLC. The most severe detected synchronous lesion was adenocarcinoma in one patient, Carcinoma insitu [CIS] in 4 patients, severe dysplasia in 3 patients, moderate dysplasia in 10 patients, and mild dysplasia in 8 patients. Synchronous lesions were more frequently detected in current smokers [35%], than in ex-smokers [20%] and non-smokers [15%]

Conclusion: Synchronous preinvasive lesions are frequent in patients with LC and AFB should be included in pre-operative evaluation of these patients

Utilidad de la adenosina deaminasa (ADA): interferón gamma y biopsia pleural para el diagnóstico de tuberculosis pleural / Efficacy of the adenosine deaminase: interferon gamma and pleural biopsy for the diagnosis of pleural tuberculosis

El diagnóstico de la tuberculosis pleural es difícil usando solo los métodos convencionales. El objetivo de este trabajo es demostrar la eficacia de la adenosina deaminasa, interferón gamma y biopsia pleural para el diagnóstico de tuberculosis pleural y si estos biomarcadores podrían obviar la práctica de la biopsia. Se realizó el estudio prospectivo de 52 muestras de líquido pleural y 54 biopsias pleurales de 52 pacientes (M/F: 30/22). La edad promedio fue 38,8 ± 20,6 años. Los derrames fueron: tuberculosis pleural, 33 (63,46%), asociados a infección respiratoria baja. 10 (19,23%) y 9 neoplásicos (17,30%). La sensibilidad de interferon gamma, adenosina deaminasa y biopsia fue de: 88,0%, 76,0% y 65,0%, respectivamente y especificidad de: 78,0%, 63,0% y 100,0% respectivamente. Conclusiones: la adenosina deaminasa no es util aislada como método diagnóstico para la tuberculosis pleural. Se recomienda no obviar el cultivo ni la biopsia plaural y siendo Venezuela un país de alta prevalencia de tuberculosis, hacer de rutina, la medición de interferón gamma y la toracoscopia.

The diagnosis of pleural tuberculous is difficult using only conventional methods. The aim of this paper is to demostrate the efficacy of the adenosine deaminase Interferon gamma and pleural biopsy for the diagnosis of pleural tuberculosis and if these biomarkers could ignore the practice of the biopsy. The prospective study of 52 samples of pleural fluid and 54 pleural biopsies of 52 patients was conducted. The median age was 38.8 (20.6 years.). Tuberculosis etiology spills were 33 (63.46%): associated with low respiratory infection 10 (19.23%) and 9 neoplastic (17,30%). The sensitivity of Interferon gamma, adenosine deaminase and biopsy was 88.0%, 76.0% to 65.0% respectively and the specificity was 78.0% and 63.0% 100.0% respectively. Conclusions: the adenosine deaminase is not useful only as a diagnostic method for the pleural tuberculosis. It is recommended to not override the cultivation or do the pleural biopsy and being Venezuela as a country of high prevalence of tuberculosis. make routine, the measurement of gamma interferon and the thoracoscopy it is recommended.

Valor del estudio celular del esputo en el seguimiento de las enfermedades inflamatorias de la vía aérea / Value of sputum analysis in the management of inflammatory airway diseases

El análisis celular del esputo, espontáneo u obtenido mediante la técnica de esputo inducido, se ha transformado en una herramienta ampliamente difundida para la evaluación y orientación del tratamiento de las enfermedades inflamatorias de la vía aérea, principalmente asma, enfermedad pulmonar obstructiva crónica y bronquitis eosinofílica. Se han aportado evidencias sobre la utilidad de la técnica del esputo inducido, validada y estandarizada, para ser empleada en pacientes con dificultades para expectorar. Numerosas investigaciones dieron cuenta de la efectividad de basar las decisiones terapéuticas en el componente inflamatorio de la vía aérea mediante el recuento de células en el esputo. Varios estudios mostraron que, en pacientes con asma el análisis celular de esputo guía en la determinación de estrategias para disminuir las exacerbaciones y para mejorar la función pulmonar, aun en pacientes con asma grave, para disminuir el remodelamiento; también se ha descrito su utilidad en pacientes con EPOC, para la disminución de las exacerbaciones.

Cellular analysis of sputum either spontaneous or by induced sputum technique, has become a widespread tool for the evaluation and guidance of treatment of inflammatory diseases of the airway, primarily asthma, COPD and eosinophilic bronchitis. Induced sputum method is a validated, standardized and non-invasive technique, useful in patients with difficulties to expectorate. Its implementation is simple and cost effective. Numerous investigations have shown the effectiveness of basing treatment decisions on the inflammatory component of the airway by counting cells in sputum. Several studies have demonstrated that in patients with asthma, results of this analysis can guide in defining strategies to reduce exacerbations and to improve lung function even in patients with severe asthma, as well as to decrease the remodeling; in addition, a reduction in exacerbations in COPD patients, monitored by this sputum examination, has also been described.

Neutrophil predominance in induced sputum from asthmatic patients: Therapeutic implications and role of clara cell 16-KD protein / Predominio de neutrófilos en esputo inducido de asmáticos: Implicancias terapéuticas y rol de la proteína 16-kD de la célula clara

Eosinophil is considered to be a main protagonist in asthma; however, often discordances between clinical manifestations and response to treatment are observed. We aimed to determine the occurrence of neutrophil predominance in asthma and to identify its characteristics on the basis of clinical-functional features, induced sputum cellular pattern and soluble molecules, to guide the appropriated anti-inflammatory therapy. A total of 41 patients were included in randomized groups: 21-40 year-old, with stable mild-to-severe asthma, steroid-naïve and non-smokers. An induced sputum sample was obtained under basal conditions, a second one after treatment with budesonide (400 µg b.i.d.) or montelukast (10 mg/d) for six weeks, and a final one after a 4-week washout period. By cytospin we evaluated eosinophil (EP) or neutrophil predominance (NP), and in supernatant we determined LTE4, and CC16. Peak expiratory flow variability (PEFV) was measured. A total of 23/41 patients corresponded to EP and 18/41 patients to NP. The PEFV was higher in EP than in NP. LTE4 was higher with NP than with EP. No difference was found for CC16. Montelukast reduced the predominant cell in both subsets, whereas budesonide only reduced eosinophils in EP. Budesonide and montelukast reduced PEFV in EP but not in NP. Considering the total treated-samples in each subset, CC16 level increased significantly in EP. In conclusion: a NP subset of asthmatic patients was identified. These patients show a lower bronchial lability; the leukotriene pathway is involved which responds to anti-leukotriene treatment. This phenotype shows a poor recovery of CC16 level after treatment.

El eosinófilo es considerado la célula protagonista principal en el asma; sin embargo, a menudo se observan discordancias entre las manifestaciones clínicas y la respuesta de los pacientes al tratamiento. Nos propusimos determinar la ocurrencia de predominio de neutrófilos en el asma e identificar las características clínico-funcionales, el patrón celular y las moléculas solubles del esputo inducido, para guiar el tratamiento apropiado anti-inflamatorio. Se incluyeron 41 pacientes: 21 a 40 años de edad, con asma estable leve a grave, no tratados con esteroides tópicos ni sistémicos y no fumadores. Se obtuvo una muestra de esputo inducido en condiciones basales, una segunda muestra después del tratamiento al azar con budesonida (400 µg dos veces al día) o el montelukast (10 mg/d) durante seis semanas, y una final después de un período de lavado de 4 semanas. En el frotis por citocentrifugado se evaluó el predominio de eosinófilos (EP) o neutrófilos (NP), y en el sobrenadante se determinó LTE4, y CC16. Se midió la variabilidad del flujo espiratorio máximo (PEFV). Un total de 23/41 pacientes correspondieron al EP y 18/41 pacientes con NP. El PEFV fue mayor en el EP que en NP. LTE4 fue mayor en NP que en EP. No se encontraron diferencias de los niveles de CC16 en ambos grupos. Montelukast redujo la célula predominante en ambos subgrupos, mientras que budesonida sólo redujo los eosinófilos en EP. Tanto budesonida como montelukast redujeron PEFV en EP, pero no en NP. El nivel de CC16 aumentó significativamente en el EP luego del tratamiento antiinflamatorio. En conclusión: se identificó un subgrupo de asmáticos NP que presentan una menor labilidad bronquial, la vía de los leucotrienos parece estar involucrada y responde al tratamiento anti-leucotrienos. Este fenotipo muestra una escasa recuperación del nivel de CC16 posterior al tratamiento.

Composição celular do escarro induzido em adultos saudáveis / Cellular composition of induced sputum in healthy adults

OBJETIVO: Estabelecer valores de referência para a celularidade de amostras de escarro induzido coletadas de indivíduos adultos saudáveis. MÉTODOS: O escarro induzido foi obtido de 88 adultos saudáveis que nunca fumaram (39 homens) com média de idade de 36 anos (variação: 18-68 anos) residentes há pelo menos dois anos em Florianópolis, uma cidade brasileira não industrial e de tamanho médio. As amostras foram processadas, e foi realizada a contagem total e diferencial das células. RESULTADOS: A média da contagem celular total foi de 4,8 ± 4,2 × 10(6) células/g. Houve predomínio de macrófagos (média de 77,5 ± 14,7 por cento) e de neutrófilos (média de 23,4 ± 14,3 por cento). Os eosinófilos estiveram virtualmente ausentes (média de 0,1 ± 0,3 por cento). A proporção de linfócitos e de células broncoepiteliais foi pequena. Não houve efeito da idade ou de atopia sobre a contagem celular total ou diferencial. CONCLUSÕES: Nesta população de indivíduos saudáveis, macrófagos e neutrófilos foram as células predominantes no escarro induzido. Contudo, a proporção de neutrófilos foi inferior à previamente relatada, sugerindo que os valores de normalidade podem variar de acordo com o local onde ele é amostrado.

OBJECTIVE: To establish reference values for cellularity in induced sputum samples collected from healthy adults. METHODS: Induced sputum samples were obtained from 88 healthy adult never-smokers (39 males). The mean age was 36 years (range, 18-68 years). The participants had been residing in the city of Florianópolis, Brazil (a medium-sized non-industrial city) for at least two years. After the samples had been processed, we obtained total and differential cell counts. RESULTS: The mean total cell count was 4.8 ± 4.2 × 10(6) cells/g. There was a predominance of macrophages (mean, 77.5 ± 14.7 percent) and neutrophils (mean, 23.4 ± 14.3 percent). Eosinophils were virtually absent (mean, 0.1 ± 0.3 percent). Lymphocytes and bronchial epithelial cells were scarce. Neither age nor atopy had any effect on the total or differential cell counts. CONCLUSIONS: In the induced sputum of this healthy adult population, macrophages and neutrophils predominated. However, the proportion of neutrophils was lower than that reported in previous studies, which suggests that reference values might vary depending on geographic location.

Algunos factores epidemiológicos relacionados con la tuberculosis en la provincia de Santiago de Cuba (2005-2007) / Some epidemiologic factors related to tuberculosis in Santiago de Cuba province 2005-2007

Se realizó un estudio descriptivo y transversal para caracterizar a los 155 pacientes con tuberculosis en la provincia de Santiago de Cuba durante los años 2005-2007. Hubo un ligero incremento de la tasa de incidencia de la enfermedad en ese trienio, con predominio en los municipios de Santiago de Cuba, Palma Soriano y Julio Antonio Mella (en este último aumentó de forma significativa en el 2007). Se observó, de forma general, que los afectados tenían entre 2 y 3 factores de riesgo y la mayoría pertenecieron a los grupos etarios de más de 55 años. Primaron la tuberculosis pulmonar y la positividad del bacilo ácido-alcohol resistente. En la atención primaria se diagnosticó el mayor número de personas infectadas, las cuales tenían menos de 23 días de haber estado experimentando los síntomas. Hubo 5 pacientes que presentaron coinfección con el virus de inmunodeficiencia adquirida.

A descriptive and cross-sectional study was carried out to characterize the 155 patients with tuberculosis in Santiago de Cuba province during the years 2005-2007. There was a slight increase of the incidence rate of the disease in that triennium, with prevalence in Santiago de Cuba, Palma Soriano and Julio Antonio Mella municipalities (in this last one it increased in a significant way in 2007). In general it was observed, that the affected ones had between 2 and 3 risk factors and most of them were in the age group of more than 55 years. The lung tuberculosis and the positivity of the acid-alcohol resistant bacillus prevailed. The highest number of infected people who had less than 23 days of experiencing the symptoms, was diagnosed in the primary care. There were 5 patients that presented co-infection with the acquired immunodeficiency virus.

Avaliação dos descritores de asma grave em pacientes incluídos na portaria de saúde pública que regulamenta a distribuição gratuita de medicamentos para o tratamento de manutenção da asma / Evaluation of diagnostic criteria for severe asthma described in a public health directive regulating the free distribution of medications for the maintenance treatment of asthma

OBJETIVO: Avaliar a capacidade dos critérios descritos na Portaria Complementar SAS/MS nº12, de 12 de novembro de 2002, em identificar pacientes asmáticos graves, bem como descrever e comparar dados clínicos, funcionais e de tratamento destes pacientes. MÉTODOS: Estudo caso-controle aninhado em um banco de dados estruturado de atendimento ambulatorial de asmáticos. Foram considerados casos os pacientes asmáticos que preencheram os critérios de inclusão determinados na portaria e considerados controles os que não preencheram os mesmos critérios. Foram coletados e comparados dados demográficos; história pregressa da asma; medicamentos em uso; presença de comorbidades; história de tabagismo; presença, no último ano, de exacerbações, de hospitalizações e de admissões em unidades de terapia intensiva devido à asma; e resultados de espirometria e de citologia de escarro. RESULTADOS: Foram incluídos 29 e 31 pacientes, respectivamente, nos grupos caso e controle. O grupo caso apresentou maior número de exacerbações e maior número de visitas ao pronto-socorro no último ano, maior porcentagem de pacientes que receberam pelo menos um pulso de corticosteroide oral, assim como menores valores de CVF pré-broncodilatador em relação ao grupo controle. O grupo caso também apresentou um aumento significante de eosinófilos na citologia do escarro induzido. CONCLUSÕES: Os critérios de inclusão descritos na portaria são adequados para estratificar pacientes com asma grave.

OBJECTIVE: To evaluate the capacity of the criteria described in Complementary Directive SAS/MS 12, issued on November 12, 2002, to identify patients with severe asthma, describing and comparing clinical, functional and treatment data of such patients. METHODS: This was a nested case-control study using a structured database for adult asthma outpatients. We defined cases as asthma patients who met the inclusion criteria described in the directive, defining controls as those who did not. We collected and compared data related to the following: demographic characteristics; history of asthma; medications in use; comorbidities; history of tobacco use; number of exacerbations within the last 12 months, asthma-related hospitalizations and intensive care unit admissions within the last 12 months; spirometry; and sputum cytology. RESULTS: The case and control groups consisted of 29 and 31 patients, respectively. The number of asthma exacerbations and emergence room visits within the last 12 months, as well as the number of patients that received at least one pulse of oral corticosteroids, was significantly higher in the case group than in the control group. In addition, prebronchodilator FVC was lower among the cases than among the controls. Furthermore, cytology revealed that eosinophil counts were significantly higher in the induced sputum of cases than in that of controls. CONCLUSIONS: The criteria described in the directive are suited to stratifying patients with severe asthma.

Analysis of the sputum and inflammatory alterations of the airways in patients with common variable immunodeficiency and bronchiectasis

INTRODUCTION: Common variable immunodeficiency is characterized by defective antibody production and recurrent pulmonary infections. Intravenous immunoglobulin is the treatment of choice, but the effects of Intravenous immunoglobulin on pulmonary defense mechanisms are poorly understood. OBJECTIVE: The aim of this study was to verify the impact of intravenous immunoglobulin on the physical properties of the sputum and on inflammatory alterations in the airways of patients with Common variable immunodeficiency associated with bronchiectasis. METHOD: The present study analyzed sputum physical properties, exhaled NO, inflammatory cells in the sputum, and IG titers in 7 patients with Common variable immunodeficiency and bronchiectasis with secretion, immediately before and 15 days after Intravenous immunoglobulin. A group of 6 patients with Common variable immunodeficiency and bronchiectasis but no sputum was also studied for comparison of the basal IgG level and blood count. The 13 patients were young (age=36±17 years) and comprised predominantly of females (n=11). RESULTS: Patients with secretion presented significantly decreased IgG and IgM levels. Intravenous immunoglobulin was associated with a significant decrease in exhaled NO (54.7 vs. 40.1 ppb, p<0.05), sputum inflammatory cell counts (28.7 vs. 14.6 cells/mm³, p<0.05), and a significant increase in respiratory mucus transportability by cough (42.5 vs. 65.0 mm, p < 0.05). CONCLUSION: We concluded that immunoglobulin administration in Common variable immunodeficiency patients results in significant improvement in indexes of inflammation of the airways with improvement in the transportability of the respiratory mucus by cough.

Neutrophilic asthma: a new horizon in the pathogenesis of bronchial asthma

Eosinophilic asthma has emerged as a distinct phenotype of asthma. However there is increasing recognition of neutrophilic form of asthma. To study the possible role of neutrophilic airway inflammation among patients with moderate persistent asthma. The study included 2 groups of subjects. Group I included 40 patients with moderate persistent asthma subjected for sputum induction. Sputum cell count, esoinophil catalonic protein[ECP] and rnyeloperoxidase enzyme were assessed. peak expiratory flow rate [PEFR] was also estimated. Group 11 included 15 healthy subjects served as control group. Neutrophilic asthmatics represents 45% of the studied asthmatic patients, while Eosinophilic asthmatics constitute 55%. Ncutrophilic asthmatic patients had higher sputum neutrophils and myelopcroxidase in comparison to eosinophilic group [p<0.001], also eosinophilic asthmatic patients had higher sputum eosinophils and ECP in comparison to neutrophilic group [p<0.001]. Sputum neutrophilis and myeloperoxidase correlated negatively to PEFR in neutrophilic asthmatics. Sputum eosinophilis and ECP correlated negatively to PEFR in esoinophilic group. Asthma is known to involve a heterogeneous airway inflammatory response where many cells play a part. Neutrophilic asthma is a sizeable subgroup of asthma which might lead to further understanding the pathogenesis of such disease and though, a new modalities in treatment is required

Influência da técnica de pressão expiratória positiva oscilante e da técnica de expiração forçada na contagem de células e quantidade do escarro induzido em portadores de asma ou doença pulmonar obstrutiva crônica / Influence of oscillating positive expiratory pressure and the forced expiratory technique on sputum cell counts and quantity of induced sputum in patients with asthma or chronic obstructive pulmonary disease

OBJETIVO: Avaliar se técnicas fisioterápicas interferem no número de células e na quantidade do escarro obtido por coleta induzida, em pacientes com asma e doença pulmonar obstrutiva crônica (DPOC). MÉTODOS: Ensaio clínico prospectivo e randomizado, no qual os pacientes com asma ou DPOC sob intervenção (n = 16 e 10, respectivamente) foram comparados com grupos controle (n = 16 e 10). Pacientes dos grupos asma/intervenção (A/I) e DPOC/intervenção (D/I) foram submetidos a manobras de pressão expiratória positiva oscilante por 5 min, seguidas de 10 repetições da técnica de expiração forçada. Além disso, esses pacientes foram submetidos a um protocolo de indução de escarro com a inalação de solução salina hipertônica (3 por cento, 4 por cento e 5 por cento), no caso dos A/I, e de solução salina isotônica, no caso dos D/I. Os grupos asma/controle(A/C) e DPOC/controle (D/C) foram somente submetidos ao protocolo padrão de indução de escarro. RESULTADOS: Houve aumento significante do peso média final de escarro no grupo A/I vs. grupo A/C (2.767,25 ± 998,08 mg e 1.689,17 ± 1.189,96 mg, respectivamente; p = 0,03). O número absoluto de células (×10(6)/mL) foi maior nos grupos A/I e D/I do que nos grupos A/C e D/C (média/mediana, 4,06/0,95 e 0,63/0,39, respectivamente; p = 0,05; e 5,08/1,77 e 0,64/0,40; p = 0,02). A viabilidade celular não apresentou diferença estatisticamente significante entre os grupos. CONCLUSÕES: O uso de técnicas respiratórias pode aumentar o peso do escarro em pacientes com asma, assim como aumentar o número absoluto de células em pacientes com asma ou DOPC.

OBJECTIVE: To evaluate whether respiratory therapy techniques influence the number of cells within and quantity of induced sputum in patients with asthma or chronic obstructive pulmonary disease (COPD). METHODS: Randomized clinical trial, in which patients with asthma or COPD under intervention (n = 16 and 10, respectively) were compared with control groups (n = 16 and 10). Patients in the asthma/intervention (A/I) and COPD/intervention (C/I) groups were submitted to oscillating positive expiratory pressure maneuvers for 5 min, followed by 10 forced expiratory technique sequences. These patients were also submitted to an induced sputum protocol with inhaled hypertonic saline (3 percent, 4 percent or 5 percent; A/I group) or inhaled isotonic saline (C/I group). The asthma/control (A/C) and COPD/control (C/C) groups were submitted only to the standard induced sputum protocol. RESULTS: The final mean weight of the sputum samples was significantly greater in the A/I group than in the A/C group (2,767.25 ± 998.08 mg vs. 1,689.17 ± 1,189.96 mg; p = 0.03). The mean/median total cell counts (×10(6)/mL) were higher in the A/I and C/I groups than in the A/C and C/C groups (4.06/0.95 and 0.63/0.39, p = 0.05, vs. 5.08/1.77 and 0.64/0.40, p = 0.02). There were no statistically significant differences among the groups in terms of cell viability. CONCLUSIONS: The use of respiratory therapy techniques can increase sputum sample weight in asthma patients, as well as increasing total cell counts in patients with asthma or COPD.

Determinação do componente inflamatório das doenças das vias aéreas através do escarro induzido: utilização na prática clínica / Determination of the inflammatory component of airway diseases by induced sputum cell counts: use in clinical practice

OBJETIVO: Avaliar a utilização e a influência da determinação do componente inflamatório das doenças das vias aéreas (inflamometria), através do exame do escarro induzido, nas decisões terapêuticas de um serviço terciário de pneumologia. MÉTODOS: Foram analisadas 151 amostras de escarro induzido de 132 pacientes consecutivamente referidos para indução de escarro com propósitos clínicos por cinco pneumologistas, no período entre julho de 2006 e fevereiro de 2007. As indicações para a realização do teste e a conduta terapêutica adotada em função do resultado foram analisadas através de um questionário estruturado preenchido pelo médico que solicitou o escarro induzido. O escarro foi obtido e processado de acordo com uma técnica previamente descrita. RESULTADOS: As principais indicações do teste foram: titulação da dose do corticosteróide inalatório na asma moderada a grave (54,3%), investigação de tosse crônica (30,5%), monitoração da inflamação em pacientes com bronquiectasias (7,3 %) e monitoração da inflamação na doença pulmonar obstrutiva crônica (6%). Dos 82 pacientes com asma, 47 (57%) apresentaram bronquite eosinofílica (eosinófilos > 3%). Bronquite eosinofílica sem asma foi diagnosticada em 9 (19%) dos 46 pacientes que realizaram o exame para investigar tosse crônica. Bronquite neutrofílica (neutrófilos > 65%) foi observada em 13 pacientes; 5 com asma, 2 com tosse crônica e 6 com doença pulmonar obstrutiva crônica/bronquiectasias. Com base nos resultados do exame do escarro induzido, 48 (64,7%) pacientes com asma tiveram sua dose de corticosteróide modificada. CONCLUSÕES: A aplicação sistemática da inflamometria através do exame do escarro induzido pode trazer importantes benefícios aos pacientes com doenças respiratórias, principalmente àqueles portadores de asma e/ou tosse crônica.

OBJECTIVE: To evaluate the usefulness of determining the inflammatory component of airway diseases (inflammometry) by induced sputum cell counts, as well as its influence on treatment decisions in a tertiary facility for the treatment of respiratory diseases. METHODS: We analyzed 151 sputum samples from 132 consecutive patients referred for clinical sputum induction by five pulmonologists between July of 2006 and February of 2007. A structured questionnaire related to the reasons for requesting the test and to the therapeutic decision making based on test results was completed by each attending physician upon receiving the test results. Induced sputum was obtained and processed according to a technique previously described. RESULTS: The principal motives for ordering the test were inhaled corticosteroid dose titration in patients with moderate-to-severe asthma (in 54.3%), investigation of chronic cough (in 30.5%), and monitoring airway inflammation in patients with bronchiectasis (in 7.3%) or chronic obstructive pulmonary disease (in 6%). Of the 82 patients with asthma, 47 (57%) presented eosinophilic bronchitis (>3% eosinophils). Nonasthmatic eosinophilic bronchitis was diagnosed in 9 (19%) of the 46 patients with chronic cough. Neutrophilic bronchitis (>65% neutrophils) was found in 13 patients, of which 5 had asthma, 2 had chronic cough, and 6 had chronic obstructive pulmonary disease/bronchiectasis. Based on the induced sputum results, the corticosteroid dose was modified in 48 asthma patients (64.7%). CONCLUSIONS: The systematic application of inflammometry using induced sputum cell counts can be beneficial for patients with airway diseases, particularly those with asthma or chronic cough.

Interrelationship between serum and sputum inflammatory mediators in chronic obstructive pulmonary disease

Little is known about airway inflammatory markers in chronic obstructive pulmonary disease (COPD). The objective of the present study was to identify and try to correlate pulmonary and peripheral blood inflammatory markers in COPD. In a cross-sectional study on patients with stable COPD, induced sputum and blood samples were collected for the determination of C-reactive protein, eosinophilic cationic protein, serum amyloid A protein, a-1 antitrypsin (a-1AT), and neutrophil elastase. Twenty-two patients were divided into two groups according to post-bronchodilator forced expiratory volume in the first second ( percentFEV1): group 1 (N = 12, FEV1 <40 percent) and group 2 (N = 10, FEV1 ³40 percent). An increase in serum elastase, eosinophilic cationic protein and a-1AT was observed in serum markers in both groups. Cytology revealed the same total number of cells in groups 1 and 2. There was a significantly higher number of neutrophils in group 1 compared to group 2 (P < 0.05). No difference in eosinophils or macrophages was observed between groups. Serum elastase was positively correlated with serum a-1AT (group 1, r = 0.81, P < 0.002 and group 2, r = 0.83, P < 0.17) and negatively correlated with FEV1 (r = -0.85, P < 0.03 and -0.14, P < 0.85, respectively). The results indicate the presence of chronic and persistent pulmonary inflammation in stable patients with COPD. Induced sputum permitted the demonstration of the existence of a subpopulation of cells in which neutrophils predominated. The serum concentration of all inflammatory markers did not correlate with the pulmonary functional impairment.