Diagnostic performance of nocturnal oximetry in the detection of obstructive sleep apnea syndrome: a Brazilian study.

OBJECTIVE: Due to the increasing prevalence of obstructive sleep apnea (OSA), more practical diagnostic methods than polysomnography (PSG) have become necessary. This research aims to analyze the performance of nocturnal oximetry (NO) in the diagnosis of OSA. METHODS: In this cross-sectional study, we analyzed 41 variables provided by the oximetry of all PSG performed by the LabSono of University Hospital Gaffrée and Guinle, a total of 83 exams. We evaluated the correlation coefficients (Spearman) between these data and the Apnea/Hypopnea Index (AHI) and then calculated the diagnostics performances, by the area under the curve (ROC) (AUC), of the best correlated variables and their respective cutoffs, in the identification of an AHI ≥ 15/h. RESULTS: Virtually all oximetric data showed good correlations with AHI, except for some temporal data. We chose 5 of them and calculated their diagnostic performances. T < 90% shows AUC of 0.904 (0.835-0.972) and, at cutoff > 19 min, a sensitivity (Sens.) of 75.68% and specificity (Spec.) of 95.65%. DO3/10Total, AUC 0.936 (0.888-0.989), and at the cutoff > 51 has Sens. 97.3% and Spec. 76.09%. ODI3/10/h has AUC 0.932 (0.884-0.988), at the cutoff > 7/h, Sens. 97.3% and Spec. 78.26%. DO4/5Total AUC 0.932 (0.882-0.981), at the cutoff > 64 has Sens. 86.49% and Spec. 82.61% and ODI4/5/h has AUC 0.930 (0.880-0.981), the cutoff > 5.69/h Sens. 97.3% and Spec. 73.91%. CONCLUSIONS: Our study concludes that NO is accurate in identifying AHI > 15/h, and provides reliable information on PSG replacement, which could make the diagnosis of OSA cheaper and more comfortable.

Drug-induced sleep endoscopy in the obstructive sleep apnea: comparison between NOHL and VOTE classifications.

Obstructive sleep apnea (OSA) is characterized by recurrent episodes of partial or complete collapse of the pharynx that result in a decrease in oxyhemoglobin saturation. Nasofibrolaryngoscopy under induced sleep is a promising alternative for identifying sites of upper airway obstruction in patients with OSA. This study aimed to compare the obstruction sites screened by drug-induced sleep endoscopy (DISE) using the Nose oropharynx hypopharynx and larynx (NOHL) and Velum oropharynx tongue base epiglottis (VOTE) classifications. We also determined the relationship between OSA severity and the number of obstruction sites and compared the minimum SaO2 levels between DISE and polysomnography (PSG). This was a prospective study in 45 patients with moderate and severe OSA using DISE with target-controlled infusion of propofol bispectral index (BIS) monitoring. The retropalatal region was the most frequent obstruction site, followed by the retrolingual region. Forty-two percent of patients had obstruction in the epiglottis. Concentrically shaped obstructions were more prevalent in both ratings. The relationship between OSA severity and number of obstruction sites was significant for the VOTE classification. Similar minimum SaO2 values were observed in DISE and PSG. The VOTE classification was more comprehensive in the analysis of the epiglottis and pharynx by DISE and the relationship between OSA severity and number of affected sites was also established by VOTE. The use of BIS associated with DISE is a reliable tool for the assessment of OSA patients.

Nocturnal oximetry in the diagnosis of obstructive sleep apnea syndrome in potentially hypoxic patients due to neuromuscular diseases.

INTRODUCTION: Polysomnography is the recommended method for the diagnosis of obstructive sleep apnea (OSA); however, it is expensive, uncomfortable, and inaccessible. Alternative diagnostic methods are necessary, and Nocturnal Oximetry (NO) has proven to be reliable. Nevertheless, there have been doubts about its accuracy in patients with a history of hypoxia. Hence, the objective of this study was to evaluate the performance of NO in patients with neuromuscular diseases (NMD). METHOD: This was a cross-sectional study in patients with NMD suspected of having OSA. We performed a statistical analysis using Spearman's correlation coefficients (SCCs). We used the value of the area under the ROC curve (AUCROC), just as we calculated the sensitivities (Sens) and specificities (Spec) for the chosen variables. RESULTS: The sample comprised 41 patients; 51.2% with muscular dystrophies and 48.8% with motor neuron diseases, with a predominance of men (63.4%). Median age was 42 (19.7-55) years, body mass index (BMI) was 27.9 (23.8-32) kg/m2, forced vital capacity was 67% (54%-76.5%), and maximum inspiratory pressure was-60 cmH2O (-87.5 to -50). The prevalence of OSA was 75.7%. We analyzed and selected the best four oximetric variables with the following performance in identifying the apnea/hypopnea index >5/h, ODI3/2, cutoff>5/h, AUCROC 0.919, Sens 82.3%, Spec 91.7%; ODI3/5, cutoff>11.2/h, AUCROC 0.904, Sens 82.3%, Spec 87.5%; ODI4/5, cutoff>6.02, AUCROC 0.839, Sens 70.6%, Spec 91.6%, and ODI5/5, cutoff>0.87/h, AUCROC 0.870, Sens 94.1%, and Spec 70.8%. CONCLUSION: NO can be used as a diagnostic tool for OSA, even in patients with neuromuscular diseases and potentially hypoxic diseases.

Performance of the STOP-Bang in the Detection of OSA, a Brazilian study.

OBJECTIVES: Assess the performance of the Stop-Bang questionnaire in Brazilian patients for the screening of OSA. METHODS: A cross-sectional study with historical and consecutive analysis of all patients who underwent polysomnography tests in the Sleeping Sector of the Ear, Nose, and Throat, and Cardiopulmonary (LabSono) Departments of the Gaffrée and Guinle University Hospital (HUGG), from 10/17/2011 to 04/16/2015. The variables relating to the SB questionnaire were collected by direct research from the medical records of patients. RESULTS: In a series of 83 patients, we found that our sample were similar to other studies conducted in specialized centers of Sleep Medicine, and the population presented characteristics similar to those found by studies in Latin America. Men and women only behaved similarly in relation to the presence of Observed Apnea and body mass index, with a predominance of women who had systemic hypertension over men. In our study, the discriminatory value of 4 or more positive answers to the questionnaire had the best performance in identifying patients with an hourly Apnea-Hypopnea Index greater than 15/h, with a sensitivity of 72.97% (55.9% - 86.2%) and specificity of 67.39% (52.0% - 80.5%). CONCLUSIONS: The Stop-Bang questionnaire proved to be, in our sample, a good screening instrument for diagnosing OSA Syndrome.

The Effect of Sedating Agents on Drug-Induced Sleep Endoscopy Findings.

OBJECTIVE: Drug-induced sleep endoscopy (DISE) has gained interest for upper airway evaluation in patients with snoring and obstructive sleep apnea (OSA), and different drugs have been used to induce sedation. Nevertheless, all drugs have presented specific advantages and disadvantages with differential effects on respiratory physiology. This study evaluated and compared the effects of midazolam, propofol and dexmedetomidine on DISE findings, O2 nadir, and bispectral index (BIS) in the same sample of patients. STUDY DESIGN: Case series prospective study. METHODS: Consecutive patients who elected to undergo surgery for OSA treatment and were intolerant to conservative therapies underwent DISE with propofol, dexmedetomidine, and midazolam between July 2015 and July 2016. RESULTS: Fifty-two patients were analyzed, and 43 (82.7%) were men. Agreement among drugs for both degree and patterns of obstruction was excellent at all sites (velum, oropharynx, and epiglottis) except for the tongue base. Dexmedetomidine had the least complete collapse sites and highest O2 nadir and was the only drug for which apnea severity and obstruction levels (upper, lower, or combined) were correlated. The variability among drug treatments for the BIS index was considerable, and propofol had the lowest variability and average value. CONCLUSION: Drug selection had a relevant influence in DISE findings. Compared with dexmedetomidine, midazolam and propofol presented higher incidence of tongue base collapse, lower O2 levels, and lower BIS index values. Propofol resulted in an O2 nadir that most resembled that observed during polysomnography. The BIS index variability differed among drugs, and its use was considered relevant for sedation orientation. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:506-513, 2019.

Predictive model for the diagnosis of tuberculous pleural effusion.

This study developed a predictive model to identify pleural tuberculosis. A consecutive cases study of patients investigating the cause of pleural effusion, in an area of high prevalence of tuberculosis (Rio de Janeiro, Brazil). Clinical and laboratory variables were compared among patients with tuberculosis (TB) and without tuberculosis (NTB), individually and using logistic regression. The performance was described as diagnostic accuracy, compared to a gold standard in a masked way. We have studied 104 TB patients, 41 with malignant, 29 transudates, 28 parapneumonic, 13 with miscellaneous diseases. After identification of individual discrimination power aided by clinical, radiological and laboratory variables, the following ones were included in a multivariate analysis: ADA, total leukocytes, percentile of lymphocytes, protein, lactate dehydrogenase, duration of disease, age and gender. A logistic regression model to predict pleural tuberculosis including the five first variables showed the best performance. A receiver operating characteristic curve identified the best cutoff at 0.7, resulting in a sensitivity and specificity of more then 95%. The predictive model improved the specificity of ADA alone, keeping its sensitivity. This model seems helpful when a microbiological or histological diagnosis of pleural tuberculosis could not be established. External validation of these results is necessary before recommendation for routine application.

[Airway responsiveness in sarcoidosis].

The purpose of this study was to measure airway responsiveness in patients with sarcoidosis using bronchoprovocation test with methacholine (BPT) in comparison to roentgenographic findings, respiratory symptoms, activity and duration of the disease. There were 17 patients with Sarcoidosis, 20 asthmatics and 21 assymptomatics. We used the tidal breathing method with standardizes output for the nebulizers. We administered increasing and successively concentrations of methacholine beginning with 0.125 to 16 mg/ml. The responses were measured by changes in FEV1 or the final concentration was reached. The results were expressed as the concentration of methacholine causing 20% fall in FEV1 (PC20). Aerosolized bronchodilator was given at the completion of all tests. There were 4 patients with sarcoidosis who had positive BPT, 3 of them with PC20<8 mg/ml associated with respiratory symptoms, bilateral hilar adenopathy, more than two-year duration and active disease. All the asthmatic subjects had positive BPT with CP20<8 mg/ml. The entire assymptomatic group had negative BPT. Positive bronchodilator response was reached in 6 patients with sarcoidosis, 20 asthmatics and 8 assymptomatic subjects. We concluded that: (a) airway responsiveness can be reached in 17.6% patients with sarcoidosis related to bilateral hilar adenopathy, chronic and active disease; (b) 50% of sarcoidosis patients with cough and/or wheeze had positive BPT, (c) the BPT was able to discriminate asthmatic from assymptomatic subjects.

Correlation between the oropharyngo-laryngoscopic findings and the severity of obstructive sleep apnea.

OBJECTIVE: To correlate anatomical and functional changes of the oral cavity, pharynx and larynx to the severity of obstructive sleep apnea syndrome (OSAS). METHODS: We conducted a cross-sectional study of 66 patients of both genders, aged between 21 and 59 years old with complaints of snoring and / or apnea. All underwent full clinical evaluation, including physical examination, nasolarybgoscopy and polisonography. We classified individuals into groups by the value of the apnea-hypopnea index (AHI), calculated measures of association and analyzed differences by the Kruskal-Wallis and chi-square tests. RESULTS: all patients with obesity type 2 had OSAS. We found a relationship between the uvula projection during nasoendoscopy and OSAS (OR: 4.9; p-value: 0.008; CI: 1.25-22.9). In addition, there was a major strength of association between the circular shape of the pharynx and the presence of moderate or severe OSAS (OR: 9.4, p-value: 0.002), although the CI was wide (1.80-53.13). The septal deviation and lower turbinate hypertrophy were the most frequent nasal alterations, however unrelated to gravity. Nasal obstruction was four times more common in patients without daytime sleepiness. The other craniofacial anatomical changes were not predictors for the occurrence of OSAS. CONCLUSION: oral, pharyngeal and laryngeal disorders participate in the pathophysiology of OSAS. The completion of the endoscopic examination is of great value to the evaluation of these patients.

What is the probability of a patient presenting a pleural effusion due to tuberculosis?

INTRODUCTION: In Rio de Janeiro, in almost half of the cases of pleural tuberculosis (PT) treatment begins without substantiation of diagnosis. We examined variables associated with this disease. METHOD: We studied 215 consecutive patients; 104 had tuberculosis (TB) and 111 did not (NTB): 41 neoplasms, 29 transudates, 28 para-pneumonic and 13 other etiologies. Clinical and laboratory variables were assessed in a combined manner using likelihood ratios (LR) and Bayes' theorem to determine the probability of PT. RESULTS: Among the variables examined, adenosine deaminase (ADA) levels, lymphocyte cell percentage, protein and age were the best indicators for the diagnosis of PT. Association of ADA with any of the other variables led to a LR+ higher than 10 and a LR- lower than 0.1, indicating the presence or absence of PT, with an individual probability of more than 90% or of less than 10% considering that there was a 50% initial probability associated with the presence of PT. CONCLUSIONS: Since ADA is highly sensitive, we can practically exclude TB as the cause of effusion when there are low ADA values. However, to confirm the possibility of TB we recommend that other variables, such as prevalence of lymphocytes (higher than 90%), and high protein levels (more than 4 g/dL); low age (less than 45 years) also should be considered.

[Tuberculosis profile in HIV+ patient before and after the use of high activity antiretroviral treatment]. / O perfil da tuberculose no paciente VIH+ antes e após a era dos anti-retrovirais de elevada eficácia.

The high activity antiretroviral treatment (HAART) induces the restoration of the number and function of CD4+ T lymphocytes and is changing the landscape of tuberculosis in patients HIV-infected. The objective of this study is to evaluate the clinical, radiographic features and evolution of these patients and compare to the results obtained in a previous study with patients with no HAART use. A retrospective transversal study (with HAART) was done with patients HIV-infected that began the tuberculosis treatment in the Gaffrée e Guinle University Hospital, from 1997 to 2001 and compared to a previous study (no HAART) that was done from 1989 to 1990. The population studied was: 107 patients (with HAART) and 152 patients (no HAART) and in both studies there were a higher frequency in young white males. The relevant results included: (a) an increase in bacteriology and histopathology diagnosis confirmation; (b) a decrease number of associated diseases during tuberculosis treatment; (c) a higher end-treatment and the death rate decreased from 55% (no HAART) to 8% (with HAART); (d) pulmonary tuberculosis was more frequent in both studies although extra-pulmonary forms were more common than in general population. We concluded that the use of HAART turned the history of tuberculosis in HIV patients getting similar to that non-immunosupressed.

Performance of the STOP-Bang in the Detection of OSA, a Brazilian study

SUMMARY OBJECTIVES Assess the performance of the Stop-Bang questionnaire in Brazilian patients for the screening of OSA. METHODS A cross-sectional study with historical and consecutive analysis of all patients who underwent polysomnography tests in the Sleeping Sector of the Ear, Nose, and Throat, and Cardiopulmonary (LabSono) Departments of the Gaffrée and Guinle University Hospital (HUGG), from 10/17/2011 to 04/16/2015. The variables relating to the SB questionnaire were collected by direct research from the medical records of patients. RESULTS In a series of 83 patients, we found that our sample were similar to other studies conducted in specialized centers of Sleep Medicine, and the population presented characteristics similar to those found by studies in Latin America. Men and women only behaved similarly in relation to the presence of Observed Apnea and body mass index, with a predominance of women who had systemic hypertension over men. In our study, the discriminatory value of 4 or more positive answers to the questionnaire had the best performance in identifying patients with an hourly Apnea-Hypopnea Index greater than 15/h, with a sensitivity of 72.97% (55.9% - 86.2%) and specificity of 67.39% (52.0% - 80.5%). CONCLUSIONS The Stop-Bang questionnaire proved to be, in our sample, a good screening instrument for diagnosing OSA Syndrome.

RESUMO OBJETIVO Avaliar o desempenho no Questionário Stop-Bang (QSB) em pacientes brasileiros para rastrear a Apneia Obstrutiva do Sono. MÉTODO Estudo transversal, com análise histórica e consecutiva de todos os pacientes que realizaram exames de polissonografia pelo Setor de Sono da Otorrinolaringologia e da Cardiopulmonar (LabSono) do Hospital Universitário Gaffrée e Guinle (HUGG), no período de 17/10/2011 a 16/04/2015. As variáveis referentes ao QSB foram colhidas por pesquisa direta nos prontuários dos pacientes. RESULTADOS Numa casuística de 83 pacientes, encontramos amostras semelhantes a outros estudos realizados em Centros Especializados em Medicina do Sono, com características da população semelhantes aos estudos feitos na América Latina. Homens e mulheres só se comportaram de forma semelhante em relação à presença de apneias presenciadas e o índice de massa corporal, com um predomínio de mulheres com hipertensão arterial sistêmica sobre os homens. Em nosso estudo, o valor discriminatório de quatro ou mais respostas positivas ao questionário mostrou o melhor desempenho em identificar pacientes com um índice de apneia/hipopneia por hora maior do que 15/h, obtendo sensibilidade de 72,97% (55,9% - 86,2%) e especificidade de 67,39% (52,0% - 80,5%). CONCLUSÕES O QSB mostrou-se, em nossa amostra, um bom instrumento de rastreio da Síndrome da Apneia Obstrutiva do Sono.

Derrame pleural em pacientes com Síndrome da Imunodeficiência Humana Adquirida / Pleural effusion in patients with Acquired Immunodeficiency Syndrome

Atualmente, com advento da terapia antirretroviral altamente ativa (HAART - highly active antiretroviral therapy) a etiologia dos derrames pleurais em indivíduos com HIV positivo é bastante semelhante à observadanaqueles não infectados pelo HIV. AU

Currently with the advent of highly active antiretroviral therapy (HAART) the etiology of pleural effusions in HIV positive individuals is quite similar to that observed in those not infected with HIV. AU

Which functional parameters can help differentiate severe asthma from COPD?

The aim of this study was to identify the respiratory function parameters that help in the accurate diagnosis of asthma and COPD. We studied 20 asthma and 30 COPD patients who underwent lung function tests including spirometry and plethysmography both with bronchodilator test and diffusion with carbon monoxide (DLCO). The tests were performed according to International Guidelines (ATS/ERS). The asthma patients were younger (mean age = 48) than those in the COPD group (mean age = 59) and this group also had more female patients (65%) than the COPD group (40%). The results showed a more severe obstruction in the asthma group: FEV1/FVC= 59% versus 66% for COPD. There was also a greater bronchodilator response as shown by changes in absolute and percentage values for FEV1 in the asthma group. Average DLCO values were normal in the asthma group (103%P) and lower in the COPD (69%). In plethysmography the asthma group had a higher residual volume (%P) and a higher airway resistance. We concluded that many functional parameters were useful in distinguishing the asthma and COPD groups. In individual analysis, DLCO was the parameter which best aided in an accurate diagnosis in both groups, with a higher specificity for COPD. The bronchodilator response measured by changes in FEV1 showed a higher sensitivity for asthma. Thus, these two tests are highlighted in the differential diagnosis of obstructive diseases.

Correlation between the oropharyngo-laryngoscopic findings and the severity of obstructive sleep apnea / Correlação entre os achados orofaringolaringoscópicos e a gravidade da síndrome da apneia obstrutiva do sono

Objective: To correlate anatomical and functional changes of the oral cavity, pharynx and larynx to the severity of obstructive sleep apnea syndrome (OSAS). Methods : We conducted a cross-sectional study of 66 patients of both genders, aged between 21 and 59 years old with complaints of snoring and / or apnea. All underwent full clinical evaluation, including physical examination, nasolarybgoscopy and polisonography. We classified individuals into groups by the value of the apnea-hypopnea index (AHI), calculated measures of association and analyzed differences by the Kruskal-Wallis and chi-square tests. Results : all patients with obesity type 2 had OSAS. We found a relationship between the uvula projection during nasoendoscopy and OSAS (OR: 4.9; p-value: 0.008; CI: 1.25-22.9). In addition, there was a major strength of association between the circular shape of the pharynx and the presence of moderate or severe OSAS (OR: 9.4, p-value: 0.002), although the CI was wide (1.80-53.13). The septal deviation and lower turbinate hypertrophy were the most frequent nasal alterations, however unrelated to gravity. Nasal obstruction was four times more common in patients without daytime sleepiness. The other craniofacial anatomical changes were not predictors for the occurrence of OSAS. Conclusion : oral, pharyngeal and laryngeal disorders participate in the pathophysiology of OSAS. The completion of the endoscopic examination is of great value to the evaluation of these patients.

Objetivo: correlacionar alterações anatômicas e funcionais de cavidade oral, faringe e laringe com a gravidade da síndrome da apneia obstrutiva do sono (SAOS). Métodos: estudo transversal com 66 pacientes de ambos os sexos, com idade entre 21 e 59 anos e queixas de roncos e/ou apneia. Todos passaram por avaliação clínica otorrinolaringológica completa incluindo exame físico, nasolaringofibroscopia epolissonografia noturna. Foram classificados em grupos pelo valor do índice de apneia-hipopneia (IAH), calculadas medidas de associação e analisadas diferenças pelo teste Kruskal-Wallis e do c2. Resultados: todos os pacientes com obesidade tipo 2 avaliados eram portadores de SAOS. Foi observada relação entre a projeção de úvula durante o exame fibronasoendoscopico e a SAOS (OR:4,9; p-valor: 0.008; IC: 1.25-22.9). Além disso, notou-se uma importante força de associação entre o formato circular da faringe e a presença de SAOS moderado ou grave (OR: 9,4, p-valor: 0,002), embora o IC seja amplo (1.80-53.13).O desvio septal e a hipertrofia de concha inferior foram as alterações nasais mais frequentes, porém sem relação com a gravidade. A obstrução nasal foi quatro vezes mais comum nos pacientes sem sonolência diurna. As demais alterações anatômicas craniofaciais não se mostraram preditoras para a ocorrência de SAOS. Conclusão: concluímos que alterações orais, faríngeas e laríngeas participam da fisiopatologia da SAOS. A realização do exame endoscópico é de grande valia para a avaliação destes pacientes.

Evaluation of adenosine deaminase in the diagnosis of pleural tuberculosis: a Brazilian meta-analysis.

OBJECTIVE: To evaluate Brazilian studies by summarizing the accuracy of adenosine deaminase in the diagnosis of pleural tuberculosis, with the objective of lending support to the movement to make the test part of the routine investigation of pleural effusions. METHODS: A search for Brazilian studies related to the determination of adenosine deaminase levels in the pleural liquid was carried out. These studies were evaluated and included in this study. The data were analyzed using summary receiver operating characteristic (SROC) curves, which enabled the studies to be collected and evaluated regarding the accuracy of the diagnosis. As for the global values of sensitivity and specificity, the Bayes' theorem was applied to calculate the post-test probabilities in different prevalences of the disease. RESULTS: Twenty-five studies dating from 1987 to 2005 and including enough information to be used in the meta-analysis were identified. After evaluation, nine studies were included, totaling 1674 patients. According to the SROC curve, a sensitivity of 91.8% (95% CI: 89.8-93.6%) and a specificity of 88.4% (95% CI: 86.0-90.5%) were found, with an area of 0.969 below the curve. The overall odds ratio was 112.0 (95% CI: 51.6-243.2). Considering a prevalence of tuberculosis of 50% (considered neutral), the post-test probability was 88.7% for a positive test and 91.5% for a negative test. CONCLUSIONS: Despite the differences found among studies, it is possible to conclude that the determination of adenosine deaminase levels has high accuracy in the diagnosis of the pleural tuberculosis and should be used as a routine test in its investigation.

Avaliação da adenosina desaminase no diagnóstico da tuberculose pleural: uma metanálise brasileira / Evaluation of adenosine deaminase in the diagnosis of pleural tuberculosis: a Brazilian meta-analysis

OBJETIVO: Avaliar trabalhos brasileiros resumindo a acurácia da adenosina desaminase no diagnóstico da tuberculose pleural, com o intuito de contribuir para a concretização do exame como rotina na investigação dos derrames pleurais. MÉTODOS: Depois de realizada uma busca por trabalhos brasileiros referentes à dosagem da adenosina desaminase no líquido pleural, estes foram avaliados e incluídos no estudo. A análise dos dados foi feita por meio da curva summary receiver operating characteristic (SROC) que possibilitou a reunião dos estudos quanto a acurácia para o diagnóstico. Com os valores globais de sensibilidade e especificidade foi aplicado o teorema de Bayes para calcular as probabilidades pós-teste em diferentes prevalências da doença. RESULTADOS: Entre 1987 e 2005 foram encontrados 25 estudos contendo informações suficientes que poderiam ser utilizadas na metanálise. Após avaliação, foram incluídos nove estudos, totalizando 1.674 pacientes. De acordo com a curva SROC, foi encontrada uma sensibilidade de 91,8 por cento (IC95 por cento: 89,8-93,6 por cento) e uma especificidade de 88,4 por cento (IC95 por cento: 86,0-90,5 por cento), com uma área abaixo da curva de 0,969. O odds ratio global foi de 112,0 (IC95 por cento: 51,6-243,2). Considerando uma prevalência da tuberculose pleural de 50 por cento (considerada neutra), a probabilidade do diagnóstico pós-teste positivo é de 88,7 por cento e sua exclusão após resultado negativo de 91,5 por cento. CONCLUSÕES: Apesar das diferenças encontradas entre os estudos, é possível concluir que a adenosina desaminase possui alta acurácia no diagnóstico da tuberculose pleural, devendo ser utilizada de rotina em sua investigação.

OBJECTIVE: To evaluate Brazilian studies by summarizing the accuracy of adenosine deaminase in the diagnosis of pleural tuberculosis, with the objective of lending support to the movement to make the test part of the routine investigation of pleural effusions. METHODS: A search for Brazilian studies related to the determination of adenosine deaminase levels in the pleural liquid was carried out. These studies were evaluated and included in this study. The data were analyzed using summary receiver operating characteristic (SROC) curves, which enabled the studies to be collected and evaluated regarding the accuracy of the diagnosis. As for the global values of sensitivity and specificity, the Bayes' theorem was applied to calculate the post-test probabilities in different prevalences of the disease. RESULTS: Twenty-five studies dating from 1987 to 2005 and including enough information to be used in the meta-analysis were identified. After evaluation, nine studies were included, totaling 1674 patients. According to the SROC curve, a sensitivity of 91.8 percent (95 percent CI: 89.8-93.6 percent) and a specificity of 88.4 percent (95 percent CI: 86.0-90.5 percent) were found, with an area of 0.969 below the curve. The overall odds ratio was 112.0 (95 percent CI: 51.6-243.2). Considering a prevalence of tuberculosis of 50 percent (considered neutral), the post-test probability was 88.7 percent for a positive test and 91.5 percent for a negative test. CONCLUSIONS: Despite the differences found among studies, it is possible to conclude that the determination of adenosine deaminase levels has high accuracy in the diagnosis of the pleural tuberculosis and should be used as a routine test in its investigation.

Novos métodos no diagnóstico da tuberculose pleural / New diagnostic tools for pleural tuberculosis

Mesmo frente a uma grande evolução da medicina com relação ao diagnóstico e diante da possibilidade atual de tratamento eficaz para as diferentes causas do derrame pleural, o diagnóstico da tuberculose nesta localização continua sendo baseado em critérios estabelecidos há mais de 50 anos. São necessários testes mais sensíveis que o BAAR e mais rápidos que a cultura tradicional para este diagnóstico. Os autores apresentam uma atualização sobre o rendimento dos novos métodos para o diagnóstico da tuberculose pleural. Pode-se afirmar que a dosagem da adenosina desaminase (ADA), apesar de ser um método indireto (não bacteriológico), tem rendimento superior ao dos métodos tradicionais e já foi mais estudada que os demais novos métodos. Sua alta sensibilidade permite excluir a possibilidade do diagnóstico de tuberculose frente a valores inferiores a 30U/L. Diante de valores elevados de ADA, em um paciente jovem com um exsudato não purulento ou com predomínio de linfócitos, a probabilidade de o derrame ser secundário à tuberculose é superior a 90%. Outros exames podem auxiliar neste diagnóstico, mas um maior número de estudos ainda será necessário antes de incorporá-los à rotina.

Alterações oculares após nebulização com brometo de ipratrópio / Ocular alterations after nebulized ipratropium bromide

Introdução: O brometo de ipratrópio, medicamento derivado da atropina, é bastante utilizado na prática médica, com a finalidade de reduzir o broncoespasmo. Poucos são seus efeitos colaterais, mas pode levar ao desenvolvimento do glaucoma e, conseqüentemente, ao risco de cegueira. O objetivo foi verificar se existe alteração da pressão intra-ocular (PIO), ou da acuidade visual, após nebulização com brometo de ipratrópio, em adultos jovens, sem alteração ocular prévia. Metodologia: Estudo experimental utilizando voluntários saudáveis (alunos do curso de Medicina) que aceitassem participar da pesquisa. Foram excluídos aqueles com alterações oculares previamente identificadas, especialmente hipertensão ocular no exame basal, e cardiopatia grave. Os indivíduos foram submetidos à avaliação da acuidade visual e à medida da PIO, com tonômetro Carl Zeiss AT 020, antes e trinta minutos após a nebulização de uma solução contendo 1mL de brometo de ipratrópio em 5mL de soro fisiológico. As medidas da pressão ocular, antes e após a nebulização, foram comparadas. Resultados: Foram avaliados 60 indivíduos, sendo 51,7% do sexo feminino, com idade variando entre 21 e 33 anos. Excluímos um indivíduo por apresentar PIO inicial elevada. Não houve relato de borramento da visão, xeroftalmia ou alteração da medida da acuidade visual. Todos apresentaram uma PIO dentro da normalidade no exame pós NBZ, não havendo diferença significativa entre as medidas. Conclusão: O uso de brometo de ipratrópio, por meio de nebulização, não apresenta alterações oculares significativas em pacientes jovens sem lesão diagnosticada previamente.

Predictive model for the diagnosis of tuberculous pleural effusion

This study developed a predictive model to identify pleural tuberculosis. A consecutive cases study of patients investigating the cause of pleural effusion, in an area of high prevalence of tuberculosis (Rio de Janeiro, Brazil). Clinical and laboratory variables were compared among patients with tuberculosis (TB) and without tuberculosis (NTB), individually and using logistic regression. The performance was described as diagnostic accuracy, compared to a gold standard in a masked way. We have studied 104 TB patients, 41 with malignant, 29 transudates, 28 parapneumonic, 13 with miscellaneous diseases. After identification of individual discrimination power aided by clinical, radiological and laboratory variables, the following ones were included in a multivariate analysis: ADA, total leukocytes, percentile of lymphocytes, protein, lactate dehydrogenase, duration of disease, age and gender. A logistic regression model to predict pleural tuberculosis including the five first variables showed the best performance. A receiver operating characteristic curve identified the best cutoff at 0.7, resulting in a sensitivity and specificity of more then 95 percent. The predictive model improved the specificity of ADA alone, keeping its sensitivity. This model seems helpful when a microbiological or histological diagnosis of pleural tuberculosis could not be established. External validation of these results is necessary before recommendation for routine application.