Estimating prevalence of chronic obstructive pulmonary disease in the Southern Cone of Latin America: how different spirometric criteria may affect disease burden and health policies.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death worldwide. The study aimed to determine and compare the prevalence of COPD in the general population aged 45-74 years old according to fixed ratio and lower limit of normal (LLN) thresholds in four cities in the Southern Cone of Latin America. METHODS: The Pulmonary Risk in South America (PRISA) study used a 4-stage stratified sampling method to select 5814 participants from 4 cities in the Southern Cone of Latin America (Bariloche and Marcos Paz, Argentina; Temuco, Chile; and Pando-Barros Blancos, Uruguay). Data on demographic information, medical history, risk factors, pre-bronchodilator and post-bronchodilator spirometry were obtained using a standard protocol. According to GOLD, COPD was defined as a post-bronchodilator ratio of forced expiratory volume in one second (FEV1) over forced vital capacity (FVC) less than 70%. The LLN threshold was defined as the lower fifth percentile for predicted FEV1/FVC, and was evaluated as an alternative COPD definition. RESULTS: Overall COPD prevalence was 9.3% (95% CI 8.4, 10.2%), and men had a higher prevalence [11.8% (95% CI 10.3, 13.3%)] than women [7.3% (95% CI 6.2, 8.3%)] with the fixed ratio. Overall COPD prevalence using LLN was 4.7% (95% CI 4.1, 5.3%), higher in men: 5.8% (95% CI 4.7, 6.8%) than women: 3.9% (95% CI 3.1, 4.7%). COPD prevalence was significantly higher among those who were older, had

Analyzing respiratory muscle weakness and thoracopulmonary restriction in subjects with Duchenne muscular dystrophy.

OBJECTIVE: To analyze the underlying components of reduced maximal static inspiratory (MIP) and expiratory (MEP) pressures in subjects with Duchenne muscular dystrophy. METHODS: Forty-three subjects were assessed based on routine pulmonary function tests. MIP and MEP were measured the subjects performed maximal expirations and inspirations using a snorkel mouthpiece. Lung volumes were measured using the helium dilution technique. RESULTS: The mean age was 13 years (range, 7-20 years). Median total lung capacity (TLC) and residual volume (RV) were 78.0 (49.0-94.0) and 27.0 (19.7-30.1) of the predicted values respectively. The RV/TLC relationship was 35.3% (28.1-47.7). Thirty-five subjects had a TLC below the lower limit of normal, while 31 had an RV/TLC ratio above the upper limit of normal. The median (IQR) MIP and MEP values were -53.0 (-65.5 to -41.8) and 58.0 (41.5-74.8) cmH2O respectively. MIP and MEP in percent of the predicted values (predicted TLC and RV) were 42.6 (33.3-50.8) and 33.7 (23.9-44.5). MIP in percent of the RV reached for Group A (7-11 years old) was higher (p 0.025) while MEP in percent of the TLC reached for Group B (12-16 years) and C (17-20 years) were higher too (0.031). CONCLUSIONS: In subjects with Duchenne muscular dystrophy, the intrinsic weakness of respiratory muscles and mechanical disadvantage lead to inadequate maximal static pressure generation. Maximal static pressures should be interpreted cautiously as they overestimate respiratory muscle weakness when compared to predicted values obtained at TLC and RV. Our results provide additional data supporting absolute values use rather than predicted values.

OBJETIVO: Analizar los componentes subyacentes de las presiones inspiratorias (MIP) y espiratorias (MEP) estáticas máximas reducidas en sujetos con distrofia de Duchenne (DMD). Métodos: Se evaluaron 43 pacientes mediante pruebas de función pulmonar rutinarias. MIP y MEP fueron medidas a inspiración y espiración máximas. Los volúmenes pulmonares se midieron mediante dilución de helio. RESULTADOS: Edad media 13 años (rango 7-20 años). La capacidad pulmonar total (TLC) y el volumen residual (RV) fueron 78.0% (49.0-94.0) y 27.0% (19.7- 30.1) de los valores predichos. El RV/TLC fue de 35.3% (28.1-47.7). Treinta y cinco sujetos tenían una TLC por debajo del límite inferior de normalidad, 31 tenían una RV/TLC por encima del límite superior de la normalidad. MIP y MEP fueron -53.0 (-65.5 a -41.8) y 58.0 (41.5-74.8) cmH2O, mientras que en % de los predichos (TLC y RV predichos) fueron 42.6 (33.3-50.8) y 33.7 (23.9-44.5). MIP en % del RV alcanzado (Grupo A 7-11 años) fue mayor (p 0.025), y MEP en % de la TLC alcanzada Grupo B (12-16 años) y C (17-20 años), también fue mayor (0.031). CONCLUSIONES: En sujetos con DMD, debilidad intrínseca de los músculos respiratorios y desventaja mecánica conducen a generación de presión estática máxima inadecuada. Las mismas deben interpretarse con cautela, ya que sobrestiman la debilidad de los músculos respiratorios si se las compara con las tablas de valores predichos obtenidos a TLC y RV. Nuestros resultados proporcionan datos adicionales que respaldan la utilización de valores absolutos en lugar de los predichos.

Argentine consensus recommendations for lung cancer screening programmes: a RAND/UCLA-modified Delphi study.

BACKGROUND: Lung cancer (LC) screening improves LC survival; the best screening method in terms of improving survival is low-dose CT (LDCT), outpacing chest X-ray and sputum cytology. METHODS: A consensus of experts in Argentina was carried out to review the literature and generate recommendations for LC screening programmes. A mixed-method study was used with three phases: (1) review of the literature; (2) modified Delphi consensus panel; and (3) development of the recommendations. The Evidence to Decision (EtD) framework was used to generate 13 evaluation criteria. Nineteen experts participated in four voting rounds. Consensus among participants was defined using the RAND/UCLA method. RESULTS: A total of 16 recommendations scored ≥7 points with no disagreement on any criteria. Screening for LC should be performed with LDCT annually in the population at high-risk, aged between 55 and 74 years, regardless of sex, without comorbidities with a risk of death higher than the risk of death from LC, smoking ≥30 pack-years or former smokers who quit smoking within 15 years. Screening will be considered positive when finding a solid nodule ≥6 mm in diameter (or ≥113 mm3) on baseline LDCT and 4 mm in diameter if a new nodule is identified on annual screening. A smoking cessation programme should be offered, and cardiovascular risk assessment should be performed. Institutions should have a multidisciplinary committee, have protocols for the management of symptomatic patients not included in the programme and distribute educational material. CONCLUSION: The recommendations provide a basis for minimum requirements from which local institutions can develop their own protocols adapted to their needs and resources.

Detection and follow-up of chronic obstructive pulmonary disease (COPD) and risk factors in the Southern Cone of Latin America: the pulmonary risk in South America (PRISA) study.

BACKGROUND: The World Health Organization has estimated that by 2030, chronic obstructive pulmonary disease will be the third leading cause of death worldwide. Most knowledge of chronic obstructive pulmonary disease is based on studies performed in Europe or North America and little is known about the prevalence, patient characteristics and change in lung function over time in patients in developing countries, such as those of Latin America. This lack of knowledge is in sharp contrast to the high levels of tobacco consumption and exposure to biomass fuels exhibited in Latin America, both major risk factors for the development of chronic obstructive pulmonary disease. Studies have also demonstrated that most Latin American physicians frequently do not follow international chronic obstructive pulmonary disease diagnostic and treatment guidelines. The PRISA Study will expand the current knowledge regarding chronic obstructive pulmonary disease and risk factors in Argentina, Chile and Uruguay to inform policy makers and health professionals on the best policies and practices to address this condition. METHODS/DESIGN: PRISA is an observational, prospective cohort study with at least four years of follow-up. In the first year, PRISA has employed a randomized three-staged stratified cluster sampling strategy to identify 6,000 subjects from Marcos Paz and Bariloche, Argentina, Temuco, Chile, and Canelones, Uruguay. Information, such as comorbidities, socioeconomic status and tobacco and biomass exposure, will be collected and spirometry, anthropometric measurements, blood sampling and electrocardiogram will be performed. In year four, subjects will have repeat measurements taken. DISCUSSION: There is no longitudinal data on chronic obstructive pulmonary disease incidence and risk factors in the southern cone of Latin America, therefore this population-based prospective cohort study will fill knowledge gaps in the prevalence and incidence of chronic obstructive pulmonary disease, patient characteristics and changes in lung function over time as well as quality of life and health care resource utilization. Information gathered during the PRISA Study will inform public health interventions and prevention practices to reduce risk of COPD in the region.

Radiological versus histopathological diagnosis of usual interstitial pneumonia in the clinical practice: does it have any survival difference?

BACKGROUND: Recent studies have shown that quantification of specific histopathologic features found in usual interstitial pneumonia (UIP) are useful in defining a prognosis, suggesting the need of biopsy in all patients. OBJECTIVES: This study examines whether UIP-associated mortality is different in patients diagnosed by high-resolution computed tomography (HRCT) features considered definite of UIP and in patients with no definite radiological diagnosis that required histological confirmation of diagnoses. METHODS: Forty-five patients were included (30 males, mean age 65.3 +/- 10.7 years). Two groups of patients were identified: those with HRCT findings of definite UIP (n = 26) and those whose radiological diagnosis was not definite and required a surgical biopsy to confirm the presence of UIP (n = 19). Forced vital capacity, forced expiratory volume in 1 s and diffusing capacity for carbon monoxide were measured in all patients. All data were obtained from medical records, and the survival status was obtained by telephone or personal interview. All clinical parameters and HRCTs were obtained within 1 month before surgical lung biopsy. RESULTS: Median survival was not different across groups and was similar to that previously reported (35 months). Kaplan-Meier analysis did not show any difference in 5-year survival between both groups. CONCLUSIONS: In a clinical context in which the diagnosis of UIP can be obtained as a dynamic process that includes an integrated clinical, radiological and pathologic approach, a reliable diagnosis of UIP can be obtained based on a typical definite HRCT with no risk of including patients with a more benign disease and a more prolonged survival.

[New argentine consensus of respiratory rehabilitation 2008]. / Nuevo Consenso Argentino de Rehabilitación Respiratoria ActualizaciOn 2008.

Respiratory rehabilitation (RR) is a multidisciplinary program of care for patients with chronic respiratory impairment, individually tailored, designed to optimize physical and social performance and patient autonomy. It is particularly indicated in chronic obstructive pulmonary disease (COPD) patients with exercise intolerance. The objectives of respiratory rehabilitation are: reduction in symptoms and exercise intolerance, improvement of health-related quality of life, and reduction of health costs. A group of neumonologists, nutritionists and physical therapists performed a systematic review of the evidence in RR to update previous local guidelines. Inclusion and exclusion criteria, guidelines for initial evaluation and follow up and resources needed are defined. Training characteristics are recommended regarding frequency of the visits, intensity, progression and duration of the exercise training. Aerobic training was recommended for lower limb (1A), upper limb (1B). Strength training must be added (1B). Respiratory muscle training and other physiotherapy techniques were recommended only for specific patients (1C). In addition recommendations have been made for educational objectives of the program including smoking cessation, nutritional and psychological support. The positive impact of RR on reductions of health care costs and reductions on hospitalizations (Evidence A) and mortality (Evidence B) were analized. Respiratory rehabilitation is a key component in the modern treatment of COPD patients. This consensus statement was prepared based on the most recent scientific evidence and adjusted to the local environment with the aim of being implemented nationally.

Analyzing respiratory muscle weakness and thoracopulmonary restriction in subjects with duchenne muscular dystrophy / Análisis de la debilidad de los músculos respiratorios y de la restricción toracopulmonar en sujetos con distrofia muscular de Duchenne

Abstract Objective: To analyze the underlying components of reduced maximal static inspiratory (MIP) and expiratory (MEP) pressures in subjects with Duchenne muscular dystrophy. Methods: Forty-three subjects were assessed based on routine pulmonary function tests. MIP and MEP were measured the subjects performed maximal expirations and inspirations using a snorkel mouthpiece. Lung volumes were measured us ing the helium dilution technique. Results: The mean age was 13 years (range, 7-20 years). Median total lung capacity (TLC) and residual volume (RV) were 78.0 (49.0-94.0) and 27.0 (19.7-30.1) of the predicted values re spectively. The RV/TLC relationship was 35.3% (28.1-47.7). Thirty-five subjects had a TLC below the lower limit of normal, while 31 had an RV/TLC ratio above the upper limit of normal. The median (IQR) MIP and MEP values were -53.0 (-65.5 to -41.8) and 58.0 (41.5-74.8) cmH2O respectively. MIP and MEP in percent of the predicted values (predicted TLC and RV) were 42.6 (33.3-50.8) and 33.7 (23.9-44.5). MIP in percent of the RV reached for Group A (7-11 years old) was higher (p 0.025) while MEP in percent of the TLC reached for Group B (12-16 years) and C (17-20 years) were higher too (0.031). Conclusions: In subjects with Duchenne muscular dystrophy, the intrinsic weakness of respiratory muscles and mechanical disadvantage lead to inadequate maximal static pressure generation. Maximal static pressures should be interpreted cautiously as they overestimate respiratory muscle weakness when compared to predicted values obtained at TLC and RV. Our results provide additional data supporting absolute values use rather than predicted values.

Resumen Objetivo: Analizar los componentes subyacentes de las presiones inspiratorias (MIP) y espiratorias (MEP) es táticas máximas reducidas en sujetos con distrofia de Duchenne (DMD). Métodos: Se evaluaron 43 pacientes mediante pruebas de función pulmonar rutinarias. MIP y MEP fueron medidas a inspiración y espiración máximas. Los volúmenes pulmonares se midieron mediante dilución de helio. Resultados: Edad media 13 años (rango 7-20 años). La capacidad pulmonar total (TLC) y el volumen residual (RV) fueron 78.0% (49.0-94.0) y 27.0% (19.7- 30.1) de los valores predichos. El RV/TLC fue de 35.3% (28.1-47.7). Treinta y cinco sujetos tenían una TLC por debajo del límite inferior de normalidad, 31 tenían una RV/TLC por encima del límite superior de la normalidad. MIP y MEP fueron -53.0 (-65.5 a -41.8) y 58.0 (41.5-74.8) cmH2O, mientras que en % de los predichos (TLC y RV predichos) fueron 42.6 (33.3-50.8) y 33.7 (23.9-44.5). MIP en % del RV alcanzado (Grupo A 7-11 años) fue mayor (p 0.025), y MEP en % de la TLC alcanzada Grupo B (12-16 años) y C (17-20 años), también fue mayor (0.031). Conclusiones: En sujetos con DMD, debilidad intrínseca de los músculos respiratorios y desventaja mecánica conducen a generación de presión estática máxima inadecuada. Las mismas deben interpretarse con cautela, ya que sobrestiman la debilidad de los músculos respiratorios si se las compara con las tablas de valores predichos obtenidos a TLC y RV. Nuestros resultados proporcionan datos adicionales que respaldan la utilización de valores absolutos en lugar de los predichos.

[Diagonal earlobe crease, a sign of coronary artery disease]. / Surco diagonal en el lóbulo de la oreja, signo de enfermedad arterial coronaria?

The diagonal earlobe crease is a sign theorically related to coronary artery disease. The purpose of this study was to prove the usefulness of this sign. A total of 104 patients were examined (ages 30 to 80) grouped by age and sex. Forty nine of them were diagnosed of having coronary artery disease by coronary angiography (a 70% obstruction of one of the major arteries), and/or myocardial perfusion imaging with Thallium 201 (fixed defects). The control group included 55 patients (asymptomatic with normal electrocardiogram). Data here obtained included sensitivity (61.2%), specificity (78 2%), positive predictive value (71.4%) and negative predictive value (69.3%). We found a significant relation between the presence of the diagonal earlobe crease and coronary artery disease. We consider it a sign that could prove useful in clinical practice, mainly among patients aged between 30 and 60.

Socioeconomic status and COPD among low- and middle-income countries.

BACKGROUND: Socioeconomic status (SES) is a strong social determinant of health. There remains a limited understanding of the association between SES and COPD prevalence among low- and middle-income countries where the majority of COPD-related morbidity and mortality occurs. We examined the association between SES and COPD prevalence using data collected in Argentina, Bangladesh, Chile, Peru, and Uruguay. METHODS: We compiled lung function, demographic, and SES data from three population-based studies for 11,042 participants aged 35-95 years. We used multivariable alternating logistic regressions to study the association between COPD prevalence and SES indicators adjusted for age, sex, self-reported daily smoking, and biomass fuel smoke exposure. Principal component analysis was performed on monthly household income, household size, and education to create a composite SES index. RESULTS: Overall COPD prevalence was 9.2%, ranging from 1.7% to 15.4% across sites. The adjusted odds ratio of having COPD was lower for people who completed secondary school (odds ratio [OR] =0.73, 95% CI 0.55-0.98) and lower with higher monthly household income (OR =0.96 per category, 95% CI 0.93-0.99). When combining SES factors into a composite index, we found that the odds of having COPD was greater with lower SES (interquartile OR =1.23, 95% CI 1.05-1.43) even after controlling for subject-specific factors and environmental exposures. CONCLUSION: In this analysis of multiple population-based studies, lower education, lower household income, and lower composite SES index were associated with COPD. Since household income may be underestimated in population studies, adding household size and education into a composite index may provide a better surrogate for SES.

Respuesta post broncodilatadora en la capacidad vital forzada en pacientes con EPOC / Volume Response to a Bronchodilator in Patients with COPD

La enfermedad pulmonar obstructiva crónica (EPOC), caracterizada por una limitación progresiva al fujo aéreo, es una patología frecuente, conocida y tratable que para su diagnóstico requiere de historia personal de tabaquismo o antecedentes exposicionales y una espirometria con mediciones pre y post broncodilatadoras con patrón obstructivo. El grado de reversibilidad al flujo aéreo difiere entre pacientes, no predice la respuesta al tratamiento broncodilatador y puede verse en términos de capacidad vital forzada o de flujo espiratorio forzado, dependiendo del grado de severidad de la enfermedad. En el presente trabajo se detalla la diferencia en respuesta broncodilatadora en término tanto de respuesta en el flujo como en el volumen en pacientes con diagnóstico de EPOC y en diferentes estadios de GOLD, analizando la respuesta broncodilatadora y su relación con la severidad de la enfermedad.

The chronic obstructive pulmonary disease (COPD) is characterized by persistent airflow limitation. It is a frequent, known and treatable disease. The diagnosis requires tobacco smoking personal history or expositional history and evidence of an obstructive pattern at the spirometry measured before and after bronchodilators. The degree of reversibility of airfow differs between patients, and does not predict the response to bronchodilator therapy. It can be seen in terms of forced vital capacity or forced expiratory fow, depending on the severity of the disease. This paper presents the differences in bronchodilator response in terms of measurements of the flow and the volume in patients diagnosed with COPD at different stages of GOLD. The bronchodilator response and its relationship to the severity of the disease were analized.

Efectos de la ceniza volcánica sobre la función pulmonar en una cohorte de personas mayores de 45 años en Bariloche (Argentina) / Effects of Volcanic Ash on Lung Function in a Cohort of People over 45 Years of Age in Bariloche (Argentina)

Casi 500 millones de personas viven dentro de los límites de exposición de los volcanes activos. En junio de 2011, el complejo volcánico Puyehue-Cordón Caulle, situado en el norte de la Patagonia chilena, comenzó un ciclo eruptivo emitiendo un enorme volumen de cenizas. Los vientos dispersaron este material hacia el SE afectando a la ciudad de San Carlos de Bariloche, Argentina. El estudio de cohortes CESCAS y su rama respiratoria, PRISA (Pulmonary Risk in South America Study), se estaba realizando en esa ciudad. Se utilizaron los datos del estudio PRISA para tratar de responder a la pregunta de si la presencia de ceniza volcánica afectó la función respiratoria de los residentes de Bariloche. Tomamos muestras de 767 pruebas de función pulmonar durante los tres meses anteriores (n = 297) y seis meses después (n = 470) de la erupción volcánica. Los participantes no eran los mismos antes y después de la exposición, pero pertenecían a la muestra originalmente seleccionada e incluida en el estudio PRISA. El objetivo fue evaluar si la exposición a la ceniza volcánica se asoció a alteraciones en la función pulmonar evaluada por espirometría. No se encontraron diferencias en FEV1 pre-broncodilatador (p = 0,30), FEV1 post-broncodilatador (p = 0,19), FVC pre-broncodilatador (p = 0,51) o FVC post-broncodilatador (p = 0,26) entre los grupos no expuestos y expuestos. Tampoco hubieron diferencias en la tasa de respuesta a broncodilatador (p = 0,87) o en el subgrupo de asma y EPOC. La exposición a la ceniza volcánica no se asoció con ningún efecto sobre la función respiratoria en una cohorte representativa de la población de San Carlos de Bariloche.

Almost 500 million people live within the exposure range of active volcanoes. In June 2011, the Puyehue-Cordón Caulle Volcanic Complex, located in northern Chilean Patagonia, began an eruptive cycle emitting an enormous volume of ash. Winds dispersed this material toward the SE, affecting the city of San Carlos de Bariloche, Argentina. The CESCAS cohort study and its respiratory branch, PRISA (Pulmonary Risk in South America Study), was underway in that city. We used data from the CESCAS/PRISA study to attempt to answer the question of whether the presence of volcanic ash affected the respiratory function of the residents of Bariloche.This study is nested within the CESCAS/ PRISA study. We sampled 767 pulmonary function tests carried out within three months before (n = 297) and six months after (n = 470) the volcanic eruption. Participants were not the same before and after exposure, but belonged to the original sample included in the PRISA study. The objective was to evaluate whether exposure to volcanic ash was associated to impaired lung function assessed by spirometry. No differences were found in the pre-bronchodilator FEV1 (p = 0.30), post bronchodilator FEV1 (p=0.19), pre-bronchodilator FVC (p=0.51) or post-bronchodilator FVC (p = 0.26) between the non-exposed and exposed group, nor in the rate of bronchodilator responsiveness (p = 0.87)or in the asthmatic and COPD subgroup. Exposure to volcanic ash was not associated to any effect on respiratory function in a representative cohort from the population of San Carlos de Bariloche.

Número necesario para tratar y la enfermedad pulmonar obstructiva crónica / Number needed to process and the obstructive pulmonary disease chronicle

Se llama medidas de efecto a las herramientas que utilizamos para describir los resultados de los ensayos clínicos. Todas estas medidas de asociación comparan la probabilidad o el riesgo de un determinado evento en el grupo experimental versus el riesgo en el grupo de control. La forma de expresar la eficacia de un tratamiento puede influir en su grado de aceptación por parte de los médicos y los pacientes. Dependiendo de la medida de efecto que utilicemos, el impacto nos puede parecer muy grande o muy chico, aunque los datos sean los mismos, es decir, estamos influenciados por los resultados de los estudios pero también por cómo estos son presentados

Nuevo consenso argentino de rehabilitación respiratoria: Actualización 2008 / New Argentine Consensus of Respiratory Rehabilitation 2008

La rehabilitación respiratoria (RR) es un tratamiento multidisciplinario para pacientes con enfermedad respiratoria crónica, adaptado individualmente y diseñado para optimizar la capacidad física, la actividad social y la autonomía de los mismos. Está especialmente indicado en pacientes con enfermedad pulmonar obstructiva crónica (EPOC). Los objetivos de la RR son: reducir los síntomas, mejorar la tolerancia al ejercicio físico y la calidad de vida. Un grupo de neumonólogos, nutricionistas y kinesiólogos realizó un análisis sistemàtico de la evidencia científica con el objetivo de actualizar las normativas anteriores de RR. Se definieron los criterios de inclusión y exclusión, la evaluación inicial y de seguimiento como así también los elementos y material necesarios. Las características del entrenamiento en cuanto a la frecuencia de las visitas, la intensidad, progresión y duración del ejercicio han sido revisadas. Se recomendó el entrenamiento de los miembros inferiores (1A), miembros superiores (1B), complementando el entrenamiento de fuerza (1B). El entrenamiento de músculos respiratorios, otras técnicas kinesiológicas y pautas nutricionales se recomiendan sólo para casos particulares (1C). Se fijan también objetivos educativos para los programas de rehabilitación que incluyen la cesación de fumar, aspectos nutricionales y apoyo psicológico. La RR ha demostrado reducir las exacerbaciones, hospitalizaciones y costos (Evidencia A), y mejoraría la sobrevida (Evidencia B). La RR es un componente fundamental en el tratamiento moderno de la EPOC. Estas pautas basadas en la más reciente evidencia científica, adaptadas al medio local tienen por objetivo que la RR pueda aplicarse en todo el país.

Respiratory rehabilitation (RR) is a multidisciplinary program of care for patients with chronic respiratory impairment, individually tailored, designed to optimize physical and social performance and patient autonomy. It is particularly indicated in chronic obstructive pulmonary disease (COPD) patients with exercise intolerance. The objectives of respiratory rehabilitation are: reduction in symptoms and exercise intolerance, improvement of health-related quality of life, and reduction of health costs. A group of neumonologists, nutritionists and physical therapists performed a systematic review of the evidence in RR to update previous local guidelines. Inclusion and exclusion criteria, guidelines for initial evaluation and follow up and resources needed are defined. Training characteristics are recommended regarding frequency of the visits, intensity, progression and duration of the exercise training. Aerobic training was recommended for lower limb (1A), upper limb (1B). Strength training must be added (1B). Respiratory muscle training and other physiotherapy techniques were recommended only for specific patients (1C). In addition recommendations have been made for educational objectives of the program including smoking cessation, nutritional and psychological support. The positive impact of RR on reductions of health care costs and reductions on hospitalizations (Evidence A) and mortality (Evidence B) were analized. Respiratory rehabilitation is a key component in the modern treatment of COPD patients. This consensus statement was prepared based on the most recent scientific evidence and adjusted to the local environment with the aim of being implemented nationally.

Surco diagonal en el lóbulo de la oreja: ¿signo de enfermedad arterial coronaria? / Diagonal earlobe crease, a sign of coronary artery disease?

El surco diagonal es un signo encontrado en el lóbulo de la oreja, que estaría relacionado con la enfermedad arterial coronaria. Nuestro objetivo fue estudiar la utilidad del signo. Se examinaron 104 pacientes (entre 30 y 80 años) clasificados por sexo y edad. Cuarenta y nueve tenían enfermedad arterial coronaria diagnosticada por coronariografía (obstrucción > del 70% en una de las grandes arterias) y/o gamagrafía de perfusión miocárdica con Talio 201 (defecto fijo). El grupo control estuvo compuesto por 55 pacientes (asintomáticos, con electrocardiograma normal). Los datos obtenidos fueron sensibilidad (61.2%), especificidad (78.2%), valor predictivo positivo de (71.4%) y valor predictivo negativo (69.3%.). Observamos una relación significativa entre la presencia de surco diagonal y enfermedad arterial coronaria. Consideramos que este signo podría resultar de utilidad en la práctica clínica, fundamentalmente para los pacientes entre 30 y 60 años.(AU)

The diagonal earlobe crease is a sign theorically related to coronary artery disease. The purpose of this study was to prove the usefulness of this sign. A total of 104 patients were examined (ages 30 to 80) grouped by age and sex. Forty nine of them were diagnosed of having coronary artery disease by coronary angiography (a 70% obstruction of one of the major arteries), and/or myocardial perfusion imaging with Thallium 201 (fixed defects). The control group included 55 patients (asymptomatic with normal electrocardiogram). Data here obtained included sensitivity (61.2%), specificity (78.2%), positive predictive value (71.4%) and negative predictive value (69.3%). We found a significant relation between the presence of the diagonal earlobe crease and coronary artery disease. We consider it a sign that could prove useful in clinical practice, mainly among patients aged between 30 and 60.(AU)

Surco diagonal en el lóbulo de la oreja: ¿signo de enfermedad arterial coronaria? / Diagonal earlobe crease, a sign of coronary artery disease?

El surco diagonal es un signo encontrado en el lóbulo de la oreja, que estaría relacionado con la enfermedad arterial coronaria. Nuestro objetivo fue estudiar la utilidad del signo. Se examinaron 104 pacientes (entre 30 y 80 años) clasificados por sexo y edad. Cuarenta y nueve tenían enfermedad arterial coronaria diagnosticada por coronariografía (obstrucción > del 70% en una de las grandes arterias) y/o gamagrafía de perfusión miocárdica con Talio 201 (defecto fijo). El grupo control estuvo compuesto por 55 pacientes (asintomáticos, con electrocardiograma normal). Los datos obtenidos fueron sensibilidad (61.2%), especificidad (78.2%), valor predictivo positivo de (71.4%) y valor predictivo negativo (69.3%.). Observamos una relación significativa entre la presencia de surco diagonal y enfermedad arterial coronaria. Consideramos que este signo podría resultar de utilidad en la práctica clínica, fundamentalmente para los pacientes entre 30 y 60 años.

The diagonal earlobe crease is a sign theorically related to coronary artery disease. The purpose of this study was to prove the usefulness of this sign. A total of 104 patients were examined (ages 30 to 80) grouped by age and sex. Forty nine of them were diagnosed of having coronary artery disease by coronary angiography (a 70% obstruction of one of the major arteries), and/or myocardial perfusion imaging with Thallium 201 (fixed defects). The control group included 55 patients (asymptomatic with normal electrocardiogram). Data here obtained included sensitivity (61.2%), specificity (78.2%), positive predictive value (71.4%) and negative predictive value (69.3%). We found a significant relation between the presence of the diagonal earlobe crease and coronary artery disease. We consider it a sign that could prove useful in clinical practice, mainly among patients aged between 30 and 60.

Ventilacion mecanica no invasiva como tratamiento de la neumonia severa en un paciente con serologia HIV positiva / Non-invasive mechanical ventilation as treatment for severe pneumonia in an HIV positive patient

Paciente de 27 años, HIV+ que ingresa en insuficiencia respiratoria por probable neumonía por Pneumocystis carinii (NPC). Presentaba disnea severa, uso de músculos accesorios y frecuencia respiratoria 44 por minuto. El a/AO(2) era 0.35. Se aplicó BiPAP durante 12 horas. Al retirarla el a/AO(2) era O.42, con alivio de la disnea, disminución de la frecuencia respiratoria (25 por min) y sin uso de músculos accesorios. No se observaron complicaciones. Al momento del alta el a/AO(2) era 0.68. La aplicación de CPAP ha sido comunicada en pacientes con PCP, pero no la BiPAP. Nuestro paciente mostró claras evidencias de mejoría sugiriendo que la BiPAP en PCP es una alternativa útil que debería ser incorporada al manejo de estos pacientes. (AU)

Ventilacion mecanica no invasiva como tratamiento de la neumonia severa en un paciente con serologia HIV positiva / Non-invasive mechanical ventilation as treatment for severe pneumonia in an HIV positive patient

Paciente de 27 años, HIV+ que ingresa en insuficiencia respiratoria por probable neumonía por Pneumocystis carinii (NPC). Presentaba disnea severa, uso de músculos accesorios y frecuencia respiratoria 44 por minuto. El a/AO(2) era 0.35. Se aplicó BiPAP durante 12 horas. Al retirarla el a/AO(2) era O.42, con alivio de la disnea, disminución de la frecuencia respiratoria (25 por min) y sin uso de músculos accesorios. No se observaron complicaciones. Al momento del alta el a/AO(2) era 0.68. La aplicación de CPAP ha sido comunicada en pacientes con PCP, pero no la BiPAP. Nuestro paciente mostró claras evidencias de mejoría sugiriendo que la BiPAP en PCP es una alternativa útil que debería ser incorporada al manejo de estos pacientes.