Assessment of dyspnea and dynamic hyperinflation in male patients with chronic obstructive pulmonary disease during a six minute walk test and an incremental treadmill cardiorespiratory exercise test.

The six minute walk test (6MWT) is a standardized test that provides information on exercise capacity in patients with COPD. It is considered a submaximal test in opposition to incremental cardiopulmonary exercise tests (CPET) that provide valuable information on all the systems involved in exercise. OBJECTIVES: 1. To compare the perceptive, physiological responses and degree of dynamic hyperinflation during two exercise tests: the 6MWT and the incremental CPET on a treadmill. 2. To evaluate how dyspnea is related to dynamic hyperinflation (DH) and other functional parameters in both tests. METHODS: 29 stable COPD male patients, age 68±5.8 years, mean post-bronchodilator FEV1 57±11%, were recruited. To evaluate dynamic hyperinflation, inspiratory capacity (IC) was measured at rest and upon completing each one of the tests. At the same time, perceived dyspnea and leg discomfort were rated on specific modified Borg scales. RESULTS: The mean walk distance in 6MWT was 494±88m. The Borg scale rating for shortness of breath upon completing the test was 4.7±2, whilst 2.9±2 for leg discomfort. IC changed from 2.53±0.63l before to 2.34±0.60l after completion of the test. In the treadmill CPET, maximal oxygen consumption (V˙O2max) was 21.8±5mL/kg/min with 6.6±2 dyspnea and 4.3±2 leg discomfort on Borg scales. IC changed from 2.17±0.53l to 1.20±0.43l. CONCLUSIONS: Dynamic hyperinflation occurs in male COPD patients during submaximal exercise such as the 6MWT. This phenomenon is more pronounced after incremental CPET on a treadmill. Despite being dyspnea the dominant limiting symptom for both tests, we observed different physiological responses.

Inspiratory fraction as a marker of skeletal muscle dysfunction in patients with COPD.

BACKGROUND: An inspiratory capacity to total lung capacity (IC/TLC) ratio of ≤25% has emerged as a better marker of mortality in chronic obstructive pulmonary disease (COPD) patients. The relationship among the IC/TLC ratio to lower extremity skeletal muscle function remains unknown. METHODS: Thirty-five men with moderate to severe COPD were divided into those with IC/TLC≤25% (n=16) and >25% (n=19). The subjects were tested for thigh muscle mass volume (MMT), maximal strength, power output of the lower extremities, and physical activity. RESULTS: Total MMT in the IC/TLC<25% group was significantly lower (413.91±89.42cm3) (p<0.001) than in the IC/TLC>25% group (575.20±11.76cm3). In the IC/TLC≤25% group, maximal strength of the lower extremities and muscle peak power output of the lower extremities were 36-56% lower (p<0.01) than among the patients in the IC/TLC>25% group. CONCLUSION: IC/TLC≤25% is associated with reduced maximal strength and peak power output of the lower extremities. IC/TLC≤25% may have an important clinical relevance as an index to determine peripheral muscle dysfunction.

[Treatment of pulmonary tuberculosis]. / Tratamiento de la tuberculosis pulmonar.

The treatment of tuberculosis is important both to preserve the health of the patient and to prevent the spread of the disease amongst the population. Its bacteriological bases are found in the high number of bacillae existing in the majority of human TB lesions and the capacity to mutate of Mycobacterium tuberculosis when it achieves a high number of divisions; this makes it essential to associate drugs that avoid the selection of resistant mutants. In our setting the pharmacological therapy that has shown greatest efficacy consists in the association during two months of isoniacide, rifampicine and pyrazinamide followed by four additional months with the first two drugs. In general the first choice tuberculostatic drugs are well tolerated, but they can produce potentially serious secondary effects that it is necessary to understand and know how to manage. This article also describes how to act from the therapeutic point of view facing certain special situations and when the initial treatments have been abandoned or have failed. In the last five years in Navarre, there has been a significant increase in the presence of immigrants proceeding from developing countries with high rates of tuberculosis and primary resistances. Because of its specific socio-economic conditions and its cultural idiosyncrasy, this group frequently generates difficulties with respect to complying with the treatment, as well in follow-up and control. The treatment of tuberculosis must always be carried out by expert doctors.

Tratamiento de la tuberculosis pulmonar / Treatment of pulmonary tuberculosis

El tratamiento de la tuberculosis es importante tanto para preservar la salud del paciente como para prevenir la propagación de la enfermedad entre la población. Sus bases bacteriológicas estriban en el elevado número de bacilos que existen en la mayor parte de lesiones humanas de la TB y en la capacidad de mutar que tiene el M. tuberculosis cuando alcanza un número elevado de divisiones; ello hace imprescindible la asociación de fármacos que eviten la selección de mutantes resistentes. En nuestro medio la terapia farmacológica que se ha demostrado más eficaz consiste en la asociación durante dos meses de isoniacida, rifampicina y piracinamida seguida durante cuatro meses más con los dos primeros fármacos. En general los tuberculostáticos de primera elección son bien tolerados, pero pueden producir efectos secundarios potencialmente graves que conviene conocer y saber manejar. En el presente trabajo describimos también cómo se debe actuar desde el punto de vista terapéutico ante determinadas situaciones especiales y cuando los tratamientos iniciales se han abandonado o han fracasado. En los últimos cinco años en Navarra, se ha incrementado de forma importante la presencia de inmigrantes procedentes de países en vías de desarrollo con altas tasas de tuberculosis y de resistencias primarias. Este colectivo genera con frecuencia, como consecuencia de sus particulares condiciones socioeconómicas y su idiosincrasia cultural, dificultades respecto al cumplimiento del tratamiento, así como en los seguimientos y controles. El tratamiento de la tuberculosis siempre debe ser realizado por médicos expertos en el tema

The treatment of tuberculosis is important both to preserve the health of the patient and to prevent the spread of the disease amongst the population. Its bacteriological bases are found in the high number of bacillae existing in the majority of human TB lesions and the capacity to mutate of Mycobacterium tuberculosis when it achieves a high number of divisions; this makes it essential to associate drugs that avoid the selection of resistant mutants. In our setting the pharmacological therapy that has shown greatest efficacy consists in the association during two months of isoniacide, rifampicine and pyrazinamide followed by four additional months with the first two drugs. In general the first choice tuberculostatic drugs are well tolerated, but they can produce potentially serious secondary effects that it is necessary to understand and know how to manage. This article also describes how to act from the therapeutic point of view facing certain special situations and when the initial treatments have been abandoned or have failed. In the last five years in Navarre, there has been a significant increase in the presence of immigrants proceeding from developing countries with high rates of tuberculosis and primary resistances. Because of its specific socio-economic conditions and its cultural idiosyncrasy, this group frequently generates difficulties with respect to complying with the treatment, as well in follow-up and control. The treatment of tuberculosis must always be carried out by expert doctors

[Occupational asthma]. / Asma ocupacional.

Occupational asthma is an entity caused by conditions deriving from a certain work milieu and not from stimuli found outside the workplace. Nowadays, occupational asthma is the most frequent respiratory occupational disease in the majority of the industrialised countries and it is estimated that the proportion of new cases of asthma that can be attributed to exposure at work is around 10-15%. It can be developed due to an immunological mechanism or to a non-immunological mechanism. Influential in its development are the type of agent exposed to, the level and form of exposure and genetic factors of susceptibility. In the diagnostic process there is a concurrent confirmation that the patient has bronchial asthma and that this has been caused by occupational reasons. As shown by the natural history of the disease, an early diagnosis and the consequent posterior actions result in an improved prognosis.

[Hypersensitivity Pneumonitis (extrinsic allergic alveolitis)]. / Neumonitis por hipersensibilidad (alveolitis alérgica extrínseca).

Farmer's lung was first described in 1932. We can define hypersensitivity pneumonitis as a pulmonary and systemic disease that is accompanied by dyspnoea and coughing; it is caused by an immunological type of inflammation of the alveolar walls and the terminal airways and it is secondary to the repeated inhalation of a variety of antigens by a susceptible host. It can be said that it is an underdiagnosed disease and only a high degree of clinical manifestations and a detailed history of exposure can lead to an early diagnosis and satisfactory treatment. A combination among clinical-radiological, functional, cytological or pathological findings leads in some cases to a diagnosis. Treatment is based on avoiding further exposure to the causal agent and in the more serious cases the administration of systemic corticoid treatment.

Asma ocupacional / Occupational asthma

Asma ocupacional es aquella entidad que se desarrollapor causas o condiciones derivadas de un determinadomedio laboral y no por estímulos que seencuentran fuera del trabajo. El asma ocupacionalconstituye hoy en día la enfermedad respiratoria ocupacionalmás frecuente en la mayoría de los paísesindustrializados y se calcula que la proporción de nuevoscasos de asma atribuibles a la exposición laboralse sitúa en torno al 10-15%.Puede desarrollarse tanto por un mecanismoinmunológico como no inmunológico. En su desarrolloinfluyen el tipo de agente al que se está expuesto, elnivel y modo de exposición y factores genéticos de susceptibilidad.En el proceso diagnóstico concurre laconfirmación de que el paciente tiene asma bronquialy la confirmación de que ésta se produce por causalaboral. Como demuestra la historia natural de la enfermedad,un diagnóstico precoz y las consiguientesacciones posteriores redundan en un mejor pronósticode la misma

Occupational asthma is an entity caused byconditions deriving from a certain work milieu and notfrom stimuli found outside the workplace. Nowadays,occupational asthma is the most frequent respiratoryoccupational disease in the majority of theindustrialised countries and it is estimated that theproportion of new cases of asthma that can beattributed to exposure at work is around 10-15%.It can be developed due to an immunologicalmechanism or to a non-immunological mechanism.Influential in its development are the type of agentexposed to, the level and form of exposure and geneticfactors of susceptibility. In the diagnostic processthere is a concurrent confirmation that the patient hasbronchial asthma and that this has been caused byoccupational reasons. As shown by the natural historyof the disease, an early diagnosis and the consequentposterior actions result in an improved prognosis

Neumonitis por hipersensibilidad (alveolitis alérgica extrínseca) / Hypersensitivity Pneumonitis (extrinsic allergic alveolitis)

El pulmón del granjero se describió por primeravez en 1932. Podemos definir la neumonitis por hipersensibilidadcomo una enfermedad pulmonar y sistémicaque cursa con disnea y tos, y que se produce porla inflamación de tipo inmunológico de las paredesalveolares y vías aéreas terminales y que es secundariaa la inhalación repetida de una variedad de antígenospor un huésped susceptible. Puede decirse que es unaenfermedad infradiagnosticada y sólo un alto grado desospecha clínica y una historia detallada de la exposiciónpueden llevar a un diagnóstico precoz y un tratamientosatisfactorio. Una combinación entre los hallazgosclínico-radiológicos, funcionales, citológicos o anatonomopatológicos,en algunos casos, nos llevarán aldiagnóstico

Farmer’s lung was first described in 1932. We candefine hypersensitivity pneumonitis as a pulmonaryand systemic disease that is accompanied by dyspnoeaand coughing; it is caused by an immunological type ofinflammation of the alveolar walls and the terminalairways and it is secondary to the repeated inhalationof a variety of antigens by a susceptible host. It can besaid that it is an underdiagnosed disease and only ahigh degree of clinical manifestations and a detailedhistory of exposure can lead to an early diagnosis andsatisfactory treatment. A combination among clinicalradiological,functional, cytological or pathologicalfindings leads in some cases to a diagnosis

Situación en Navarra del diagnóstico y tratamiento en el síndrome de apneas-hipopneas obstructivas durante el sueño / Diagnosis and treatment of obstructive sleep apnea-hypopnea syndrome: the situation in Navarra (Spain)

OBJETIVO: Evaluar la situación del diagnóstico y tratamiento en el síndrome de apneas-hipopneas obstructivas durante el sueño (SAHS) y conocer algunas características de los pacientes tratados con presión nasal positiva continua en la vía aérea (n-CPAP) en nuestra comunidad. METODOLOGÍA: Se incluyó en el estudio a todos los pacientes que en julio de 2000 recibían tratamiento con n-CPAP a cargo del Servicio Navarro de Salud. Una enfermera realizó una visita a cada paciente en la que rellenaba un formulario con datos epidemiológicos, antropométricos y clínicos; posteriormente llevaba a cabo las siguientes exploraciones: medición del CO en el aire espirado, determinación de la presión de n-CPAP utilizada y lectura del contador horario de la n-CPAP.Entre uno y 2 meses después, y sin previo aviso, se ponía de nuevo en contacto con el usuario y se procedía a una segunda visita en la que realizaba una segunda determinación de CO en el aire espirado y nueva lectura del contador. RESULTADOS: La tasa de prevalencia de tratamientos con n-CPAP en nuestra comunidad fue de 125 por 100.000 habitantes, y se comprobó un progresivo incremento de las prescripciones anuales. Se visitó en el domicilio a 535 pacientes (el 80,7 per cent del total). El 83,5 per cent de las indicaciones fueron realizadas por neumólogos; la media de horas/día reales de utilización de n-CPAP fue de 6,1 y existió una correlación estadísticamente significativa entre las horas de uso de n-CPAP declaradas y las reales; el índice de apneas-hipopneas (IAH) medio fue de 51,5 y este índice no se determinó en el 4,2 per cent de los casos. Un 83,7 per cent de los pacientes declaraban tener una tolerancia del tratamiento muy buena o buena y el 24,8 per cent llevaba más de 4 años con esta terapia. La enfermedad asociada con el SAHS más frecuente fue la obesidad, presente en el 73,4 per cent de las personas, seguida de la hipertensión arterial en el 40 per cent; 299 enfermos (55,8 per cent) padecían dos o más enfermedades asociadas y 54 (9,7 per cent) no tenían ninguna. El 45,9 per cent de los casos disponía de polisomnografía convencional como método diagnóstico y un 49,7 per cent de poligrafía respiratoria; en el 19,4 per cent la nivelación de la presión se realizó con polisomnografía y el 32,1 per cent no disponía de ningún estudio para este fin. Un 50,8 per cent de las personas referían presentar algún efecto secundario al tratamiento. CONCLUSIONES: Elevada tasa de prevalencia de tratamientos con n-CPAP en Navarra y progresivo incremento de prescripciones. Buena tolerancia y cumplimiento de la terapia por parte de los pacientes. Disponibilidad en la mayoría de los casos de polisomnografía o poligrafía respiratoria como métodos diagnósticos de SAHS y alto porcentaje de titulaciones de n-CPAP sin haberse realizado los estudios recomendados (AU)

[Diagnosis and treatment of obstructive sleep apnea-hypopnea syndrome: the situation in Navarra (Spain)]. / Situación en Navarra del diagnóstico y tratamiento en el síndrome de apneas-hipopneas obstructivas durante el sueño.

OBJECTIVE: To assess the diagnosis and treatment of obstructive sleep apnea-hypopnea syndrome (OSAHS) in Navarra (Spain) and to know the characteristics of patients treated with nasal continuous positive airway pressure (n-CPAP) in our community. METHOD: All patients receiving nasal n-CPAP from the public health service of Navarra in July 2000 were enrolled. A nurse visited each patient and filled in a form with epidemiological data, and patient and clinical characteristics. The nurse then measured CO in expired air and the n-CPAP pressure used and recorded the hour counter reading on the n-CPAP device. Between one and two months later and without prior warning, the patient was once again contacted and a second visit was made. The counter was read again and expired CO was measured. RESULTS: The prevalence of treatment with n-CPAP in Navarra was 125/100,000 inhabitants, and a gradual increase in annual prescriptions was observed. Home visits were made to 535 patients (80.7% of the total). Pneumologists wrote 83.5% of the prescriptions. n-CPAP was used a mean 6.1 hours/day, and the numbers of declared and real hours of use were statistically correlated. The mean apnea-hypopnea index was 51.5, although results were not available for 4.2% of the patients. The treatment was well tolerated according to 83.7% of the patients and 24.8% had been following it for over four years. The pathology most often associated with OSAHS was obesity (73.4% of the patients), followed by high blood pressure (40%); 299 patients (55.8%) had two or more associated diseases and 54 (9.7%) had none. Conventional polysomnography was the diagnostic method used in 45.9% of the cases, and respiratory polygraphs were available for 49.7%. Pressure was adjusted with the aid of polysomnography for 19.4% patients, whereas 32.1% had undergone no testing. Side effects of treatment were reported by 50.8%. CONCLUSIONS: a) The prevalence of n-CPAP treatment in Navarra is high and prescriptions are increasing; b) patient tolerance of and compliance with therapy are good, c) polysomnographs or respiratory polygraphs are available for diagnosis of OSAHS in most cases but the n-CPAP pressure level is adjusted without the recommended studies for many patients.

AIDS education: the Rhode Island experience.

AIDS prevention, by public school education, is designed to change knowledge, attitudes, and future behavior. This study evaluated the impact of a state-mandated educational program on a sample of 2709 adolescents. Changes from pre to posttest were evaluated using standardized change scores and comparisons between the experimental and a delayed education control group were made. The experimental group, but not the control group, changed to a statistically significant degree (p less than .001). They became more knowledgeable, endorsed slightly more tolerant attitudes, and reported an increased intention to avoid intercourse as a means of AIDS prevention. The extent of change was substantially greater for knowledge than for attitudes. Age, gender, and AIDS-related anxiety were found to be significant variables in the AIDS education process. The modest changes observed emphasize that the dissemination of AIDS information by public schools is only the first step in changing adolescent behavior as a means to AIDS prevention and that other, additional approaches are needed.