Short- and long-term survival of patients with metastatic solid cancer admitted to the intensive care unit: prognostic factors.

Decisions for intensive care unit (ICU) admissions in patients with advanced cancer are complex, and the knowledge of survival rates and prognostic factors are essential to these decisions. Ours objectives were to describe the short- and long-term survival of patients with metastatic solid cancer admitted to an ICU due to emergencies and to study the prognostic factors presented at ICU admission that could be associated with hospital mortality. We retrospectively analysed the charts of all patients with metastatic solid cancer admitted over a 1-year period. This gave a study sample of 83 patients. The ICU, hospital, 1-year and 2-year survival rates were 55.4%, 28.9%, 12.0% and 2.4% respectively. Thrombocytopenia (odds ratio 26.2; P = 0.006) and simplified acute physiology score (SAPS II) (odds ratio 1.09; P = 0.026) were independent factors associated with higher hospital mortality. In conclusion, the survival rates of patients with metastatic solid cancer admitted to the ICU due to emergencies were low, but of the same magnitude as other groups of cancer patients admitted to the ICU. The SAPS II score and thrombocytopenia on admission were associated with higher hospital mortality. The characteristics of the metastatic disease, such as number of organs with metastasis and central nervous system metastasis were not associated with the hospital mortality.

Intraoperative autologous blood recovery in prostate cancer surgery: in vivo validation using a tumour marker.

BACKGROUND AND OBJECTIVE: Intraoperative autologous blood recovery during radical retro pubic prostatectomy has the potential of contamination with tumour cells. Its safety is proved by similar survival rates between allogeneic and autologous transfusion to oncology patients without standardization. Silencing of the gene encoding pi class of gluthatione-S transferase is a specific and sensitive molecular marker for prostate cancer, because it is present in more than 90% of prostate tumours. Using such tumour marker, we aimed to demonstrate that viable tumour cells could be eliminated using leucodepletion filters followed by irradiation. MATERIALS AND METHODS: Fifty patients with pi class of gluthatione-S transferase promoter hypermethylation in their primary prostate tumours were included in the analysis. Peripheral blood samples were collected during anaesthetic induction and recovered blood was collected throughout the surgery and then submitted to washing, leucoreduction and irradiation. Samples were analysed stepwise for the presence of promoter hypermethylation using real-time methylation-specific polymerase chain reaction. RESULTS: Positive hypermethylation was found in recovered blood (two samples), recovered and washed blood (three samples), and recovered washed and filtered blood (two samples). After filtration and irradiation of the recovered blood, this marker could not be detected in any of the cases analysed, suggesting the absence of viable tumour cells. CONCLUSION: Even though the risk of disseminating tumour cells in prostate cancer surgery by intraoperative autologous blood recovery is not yet fully established, no tumour-specific gene amplification was found after the association of blood filtration and irradiation, suggesting a significant reduction of such risk.

Noninvasive ventilation in immunocompromised pediatric patients: eight years of experience in a pediatric oncology intensive care unit

The experience of noninvasive positive pressure ventilation (NPPV) in the pediatric setting is limited. The aim of the present study is to retrospectively evaluate the effectiveness of NPPV in pediatric immunocompromised patient admitted in our PICU (Pediatric Intensive Care Unit) for acute respiratory failure. Retrospective cohort study of children admitted to the PICU of Hospital do Cancer between June 1997 and May 2005 requiring ventilatory support. A total of 239 admissions were included. The first mechanical ventilation (MV) technique used was NPPV in 120 (50.2%) patients [noninvasive ventilation (NIV) group] and conventional MV in 119 (49.8%) [invasive ventilation (IV) group]; 25.8% of the patients from the NIV group subsequently required intubation. Patients in the IV group were more likely to be in a severe clinical status. Characteristics associated with severe clinical status were median value for therapeutic intervention scoring system score (37.5 points IV vs. 29 points NIV, P2 organs failure (63.6% IV vs. 36.4% NIV, Por=40 points (P=0.018). Our results encourage the use of NPPV as a first-line treatment in children with malignancies who develops acute respiratory failure, except in those with severe hemodynamic status.

Incorrect use of thromboprophylaxis for venous thromboembolism in medical and surgical patients: results of a multicentric, observational and cross-sectional study in Brazil.

OBJECTIVES: Although effective strategies for the prevention of venous thromboembolism (VTE) are widely available, a significant number of patients still develop VTE because appropriate thromboprophylaxis is not correctly prescribed. We conducted this study to estimate the risk profile for VTE and the employment of adequate thromboprophylaxis procedures in patients admitted to hospitals in the state of São Paulo, Brazil. METHODS: Four hospitals were included in this study. Data on risk factors for VTE and prescription of pharmacological and non-pharmacological thromboprophylaxis were collected from 1454 randomly chosen patients (589 surgical and 865 clinical). Case report forms were filled according to medical and nursing records. Physicians were unaware of the survey. Three risk assessment models were used: American College of Chest Physicians (ACCP) Guidelines, Caprini score, and the International Union of Angiololy Consensus Statement (IUAS). The ACCP score classifies VTE risk in surgical patients and the others classify VTE risk in surgical and clinical patients. Contingency tables were built presenting the joined distribution of the risk score and the prescription of any pharmacological and non-pharmacological thromboprophylaxis (yes or no). RESULTS: According to the Caprini score, 29% of the patients with the highest risk for VTE were not prescribed any thromboprophylaxis. Considering the patients under moderate, high or highest risk who should be receiving prophylaxis, 37% and 29% were not prescribed thromboprophylaxis according to ACCP (surgical patients) and IUAS risk scores, respectively. In contrast, 27% and 42% of the patients at low risk of VTE, according to Caprini and IUAS scores, respectively, had thromboprophylaxis prescribed. CONCLUSION: Despite the existence of several guidelines, this study demonstrates that adequate thromboprophylaxis is not correctly prescribed: high-risk patients are under-treated and low-risk patients are over-treated. This condition must be changed to insure that patients receive adequate treatment for the prevention of thromboembolism.

Molecular evidence of tumour cell removal from salvaged blood after irradiation and leucocyte depletion.

Intra-operative autologous blood recovery offers many advantages. However, blood salvage during cancer surgery is of limited use due to the potential presence of circulating tumour cells. It was the aim of this study to show that intra-operative salvage blood can be freed of cells and cellular DNA after leucoreduction by filtration and irradiation of washed blood. Known amounts of tissue culture derived from carcinoma, melanoma and osteosarcoma were added to whole blood bags. This mixture was then submitted to washing, leucoreduction and irradiation. Samples were studied stepwise in relation to the integrity and size of DNA by the polymerase chain reaction (PCR). After filtration and irradiation, PCR targeting the beta-globin gene (268 bp amplicon) was negative. Our results were corroborated by studying plasma samples added with tumoural cells. Using PCR methodology, we showed the absence of DNA from cells in experimentally contaminated blood and plasma bags after filtration and irradiation. This experimental study is an effort to ensure the safety of intra-operative autologous transfusion.

Effects of tracheotomy on respiratory mechanics in spontaneously breathing patients.

Tracheotomy is a method of intubating the trachea, which is employed in several clinical settings, including the treatment of head and neck neoplasms. Tracheotomy is believed to facilitate weaning through changes in respiratory mechanics. Existing information concerning functional changes associated with tracheotomy are limited to comparisons with orotracheal intubation. In this study, respiratory mechanics were monitored in seven spontaneously breathing patients, before and after an elective tracheotomy was performed for surgical treatment of cancer. Campbell diagrams were constructed by plotting pressure, obtained with an oesophageal balloon catheter, against volume, obtained from a pneumotachograph placed at the airway opening. Work of breathing was calculated as the internal area of the Campbell diagram and was partitioned into its elastic and inspiratory and expiratory resistive components. Oesophageal pressure was also used to quantify intrinsic positive end-expiratory pressure (PEEPi) and the pressure-time product (PTP), which is considered to be proportional to the oxygen cost of breathing. PTP was divided into its resistive and elastic components. Inspiratory resistive work, PEEPi, inspiratory PTP, as well as its resistive and elastic components were significantly reduced by tracheotomy. Tracheotomy significantly reduces work of breathing and pressure-time product in spontaneously breathing patients.

Risk factors for postoperative complications in oral cancer and their prognostic implications.

BACKGROUND: The surgical treatment of head and neck cancer can be limited by the risk of postoperative complications. Early identification of risk factors based on clinical characteristics may assist therapeutic planning. OBJECTIVES: To identify risk factors for these complications and to evaluate their prognostic significance. METHODS: The medical records of 110 patients with oral squamous cell carcinoma admitted from January 1, 1990, to December 31, 1994, who underwent radical surgery were reviewed. Data collected included demographic information, comorbidities, extended clinical severity stage, treatment, complications, and survival. The chi(2) test was used to verify the association between the variables. Survival analysis was performed with the Kaplan-Meier method. Logistic and Cox proportional hazards regression were used to build models with independent predictive factors for the risk of complications and death, respectively. RESULTS: The overall complication rate was 50%. Dehiscence and infection rates were 20.9% and 22.7%, respectively. The death rate was 3.6%. Forty-seven patients (42.7%) were electively referred to the intensive care unit (ICU). The occurrence of postoperative complications was associated with extended clinical severity stage (P =.02), type of surgery (P =.03), ICU (P =.03), type of reconstruction (P =.02), Functional Severity Index (P =.03), neck dissection (P =.002), and APACHE II (Acute Physiology and Chronic Health Evaluation II) (P =.008). The number of complications was significantly correlated with the length of hospital stay (r = 0.24, P =.01) and with the Functional Severity Index (r = 0.19, P =.04). Five-year overall survival was affected by the type of complications (none, 41.7%; local, 34.1%; and local plus systemic, 0% [P<.001]), ICU (no, 46.3%; yes, 20.7% [P =.001]), and extended clinical severity stage (stage 1, 75.6%; stage 2, 50%; stage 3, 28.6%; and stage 4, 10.2% [P<.001]). In a multivariate analysis bilateral neck dissection (relative risk = 3.57, P =.01) and an APACHE II score greater than 10 (relative risk = 3.86, P =.02) were independent risk factors for complications. The predictive prognostic model consisted of the following: staying in the ICU (hazard ratio = 1.83), local plus systemic complications (hazard ratio = 6.27), and extended clinical severity stage (stage 3, hazard ratio = 3.57; stage 4, hazard ratio = 6.34). CONCLUSIONS: Bilateral neck dissection and the APACHE II score were identified as risk factors for postoperative complications in oral cancer, which also increase the length of hospital stay. The occurrence of systemic complications, advanced extended clinical severity stage, and staying in an ICU adversely affect the prognosis. Therefore, the prompt recognition of the adverse risk factors for postoperative complications may guide proactive interventions that may improve survival and achieve cost-effectiveness.

Hypomagnesemia in critically ill cancer patients: a prospective study of predictive factors.

Hypomagnesemia is the most common electrolyte disturbance seen upon admission to the intensive care unit (ICU). Reliable predictors of its occurrence are not described. The objective of this prospective study was to determine factors predictive of hypomagnesemia upon admission to the ICU. In a single tertiary cancer center, 226 patients with different diagnoses upon entering were studied. Hypomagnesemia was defined by serum levels <1.5 mg/dl. Demographic data, type of cancer, cause of admission, previous history of arrhythmia, cardiovascular disease, renal failure, drug administration (particularly diuretics, antiarrhythmics, chemotherapy and platinum compounds), previous nutrition intake and presence of hypovolemia were recorded for each patient. Blood was collected for determination of serum magnesium, potassium, sodium, calcium, phosphorus, blood urea nitrogen and creatinine levels. Upon admission, 103 (45.6%) patients had hypomagnesemia and 123 (54.4%) had normomagnesemia. A normal dietary habit prior to ICU admission was associated with normal Mg levels (P = 0.007) and higher average levels of serum Mg (P = 0.002). Postoperative patients (N = 182) had lower levels of serum Mg (0.60 +/- 0.14 mmol/l compared with 0.66 +/- 0.17 mmol/l, P = 0.006). A stepwise multiple linear regression disclosed that only normal dietary habits (OR = 0.45; CI = 0.26-0.79) and the fact of being a postoperative patient (OR = 2.42; CI = 1. 17-4.98) were significantly correlated with serum Mg levels (overall model probability = 0.001). These findings should be used to identify patients at risk for such disturbance, even in other critically ill populations.

Hypomagnesemia in critically ill cancer patients: a prospective study of predictive factors

Hypomagnesemia is the most common electrolyte disturbance seen upon admission to the intensive care unit (ICU). Reliable predictors of its occurrence are not described. The objective of this prospective study was to determine factors predictive of hypomagnesemia upon admission to the ICU. In a single tertiary cancer center, 226 patients with different diagnoses upon entering were studied. Hypomagnesemia was defined by serum levels <1.5 mg/dl. Demographic data, type of cancer, cause of admission, previous history of arrhythmia, cardiovascular disease, renal failure, drug administration (particularly diuretics, antiarrhythmics, chemotherapy and platinum compounds), previous nutrition intake and presence of hypovolemia were recorded for each patient. Blood was collected for determination of serum magnesium, potassium, sodium, calcium, phosphorus, blood urea nitrogen and creatinine levels. Upon admission, 103 (45.6 percent) patients had hypomagnesemia and 123 (54.4 percent) had normomagnesemia. A normal dietary habit prior to ICU admission was associated with normal Mg levels (P = 0.007) and higher average levels of serum Mg (P = 0.002). Postoperative patients (N = 182) had lower levels of serum Mg (0.60 ± 0.14 mmol/l compared with 0.66 ± 0.17 mmol/l, P = 0.006). A stepwise multiple linear regression disclosed that only normal dietary habits (OR = 0.45; CI = 0.26-0.79) and the fact of being a postoperative patient (OR = 2.42; CI = 1.17-4.98) were significantly correlated with serum Mg levels (overall model probability = 0.001). These findings should be used to identify patients at risk for such disturbance, even in other critically ill populations

Follow-up in lung cancer: how often and for what purpose?

OBJECTIVES: The present study evaluates the cost-effectiveness of two follow-up routines: a strict follow-up with frequent visits, imaging, and laboratory examinations was compared to a follow-up with infrequent visits that were scheduled mainly on the basis of the patient's symptoms. METHODS: A retrospective evaluation was undertaken of 130 patients who underwent a complete resection of non-small cell lung cancer (NSCLC). All patients had complete follow-up for at least 2 years after their operation. The patients were separated into two groups: strict (n = 67), with a routine follow-up policy; and symptom (n = 63), seen on a symptom-oriented basis. The costs of the follow-up routines and the yield of each schedule were compared between the two groups. RESULTS: There were no significant differences in the disease-free interval until the first detection of recurrence. In most patients, metastatic diseases were diagnosed on the basis of symptoms, rather than by routine tests. The patients who had recurrent cancer diagnosed after surgery had a dismal survival rate irrespective of the follow-up schedule. The majority of patients with recurrence died of malignancy within a 2-year period. The costs of strict vs symptom follow-up were significantly different, because of the greater number of routine imaging procedures performed in patients having strict follow-up. On the other hand, when we analyzed only the frequency of hospitalization and the cost per day of hospital treatment for medical problems other than cancer recurrence, the patients in the strict group had a less expensive follow-up than the patients in the symptom group. CONCLUSIONS: The present study showed that a more cost-effective routine follow-up scheme should be advised for patients with completely resected NSCLC, without affecting overall outcome. Routine imaging follow-up is of questionable value, and it may be indicated only in academic settings.

The unidirectional valve is the best method to determine maximal inspiratory pressure during weaning.

OBJECTIVES: Although maximal inspiratory pressure (MIP) is used as an index of inspiratory muscular strength, there is no consensus on how to measure it. We compared, during weaning from mechanical ventilation, two methods of measurement to determine which shows the greater values (MIPbest) and is more reproducible. One method measured MIP when negative pressure was maintained for at least 1 s after a forceful expiration, and the other method measured MIP with a unidirectional expiratory valve (MIPuni). DESIGN: The study had a crossover design, and patients randomly performed three measurements of each method (t1). The procedure was repeated by the same observer after 20 min (t2). The maximal value in each method was considered. SETTING: ICU, Hospital A.C. Camargo, São Paulo, Brazil. PATIENTS: Fifty-four consecutive patients undergoing short-term mechanical ventilation who became eligible for the study when their physicians decided to restore spontaneous breathing. RESULTS: MIPbest values were arrived at using MIPuni 75% of the time either in tl or t2. MIPuni yielded a higher average of MIPbest values in t1 and t2 (p < 0.0001). The effort-to-effort coefficient of variation of one method compared with the other during t1 and t2 was similar (p > 0.2 for t1; p > 0.8 for t2). Also, when comparing tl and t2, the coefficients of variation were similar for each method (p > 0.62). CONCLUSIONS: Because MIPuni displayed the maximal values, it is the best method for estimating MIP in patients undergoing short-term mechanical ventilation. The reproducibility of consecutive measurements was similar between the methods, even after a short period of time.

Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome.

BACKGROUND: In patients with the acute respiratory distress syndrome, massive alveolar collapse and cyclic lung reopening and overdistention during mechanical ventilation may perpetuate alveolar injury. We determined whether a ventilatory strategy designed to minimize such lung injuries could reduce not only pulmonary complications but also mortality at 28 days in patients with the acute respiratory distress syndrome. METHODS: We randomly assigned 53 patients with early acute respiratory distress syndrome (including 28 described previously), all of whom were receiving identical hemodynamic and general support, to conventional or protective mechanical ventilation. Conventional ventilation was based on the strategy of maintaining the lowest positive end-expiratory pressure (PEEP) for acceptable oxygenation, with a tidal volume of 12 ml per kilogram of body weight and normal arterial carbon dioxide levels (35 to 38 mm Hg). Protective ventilation involved end-expiratory pressures above the lower inflection point on the static pressure-volume curve, a tidal volume of less than 6 ml per kilogram, driving pressures of less than 20 cm of water above the PEEP value, permissive hypercapnia, and preferential use of pressure-limited ventilatory modes. RESULTS: After 28 days, 11 of 29 patients (38 percent) in the protective-ventilation group had died, as compared with 17 of 24 (71 percent) in the conventional-ventilation group (P<0.001). The rates of weaning from mechanical ventilation were 66 percent in the protective-ventilation group and 29 percent in the conventional-ventilation group (P=0.005): the rates of clinical barotrauma were 7 percent and 42 percent, respectively (P=0.02), despite the use of higher PEEP and mean airway pressures in the protective-ventilation group. The difference in survival to hospital discharge was not significant; 13 of 29 patients (45 percent) in the protective-ventilation group died in the hospital, as compared with 17 of 24 in the conventional-ventilation group (71 percent, P=0.37). CONCLUSIONS: As compared with conventional ventilation, the protective strategy was associated with improved survival at 28 days, a higher rate of weaning from mechanical ventilation, and a lower rate of barotrauma in patients with the acute respiratory distress syndrome. Protective ventilation was not associated with a higher rate of survival to hospital discharge.

Temporal hemodynamic effects of permissive hypercapnia associated with ideal PEEP in ARDS.

The associated use of permissive hypercapnia (PHY) and high PEEP levels (PEEP(IDEAL)) has been recently indicated as part of a lung-protective-approach (LPA) in acute respiratory distress syndrome (ARDS). However, the net hemodynamic effect produced by this association is not known. We analyzed the temporal hemodynamic effects of this combined strategy in 48 patients (mean age 34 +/- 13 yr) with ARDS, focusing on its immediate (after 1 h), early (first 36 h), and late (2nd-7th d) consequences. Twenty-five patients were submitted to LPA--with the combined use of permissive hypercapnia (PHY), VT < 6 ml/kg, distending pressures above PEEP < 20 cm H2O, and PEEP 2 cm H2O above the lower inflection point on the static inspiratory P-V curve (P(FLEX))- and 23 control patients were submitted to conventional mechanical ventilation. LPA was initiated at once, resulting in an immediate increase in heart rate (p = 0.0002), cardiac output (p = 0.0002), oxygen delivery (DO2l, p = 0.0003), and mixed venous Po2 (p = 0.0006), with a maintained systemic oxygen consumption (p = 0.52). The mean pulmonary arterial pressure markedly increased (mean increment 8.8 mm Hg; p < 0.0001), but the pulmonary vascular resistance did not change (p = 0.32). Cardiac filling pressures increased (p < 0.001) and the systemic vascular resistance fell (p = 0.003). All these alterations were progressively attenuated in the course of the first 36 h, despite persisting hypercapnia. Plasma lactate suffered a progressive decrement along the early period in LPA but not in control patients (p < 0.0001). No hemodynamic consequences of LPA were noticed in the late period and renal function was preserved. A multivariate analysis suggested that these acute hyperdynamic effects were related to respiratory acidosis, with no depressant effects ascribed to high PEEP levels. In contrast, high plateau pressures were associated with cardiovascular depression. Thus, as long as sufficiently low distending pressures are concomitantly applied, the sudden installation of PHY plus PEEP(IDEAL) induces a transitory hyperdynamic state and pulmonary hypertension without harmful consequences to this young ARDS population.

Upregulation of collagen messenger RNA expression occurs immediately after lung damage.

BACKGROUND: Mortality of ARDS still exceeds 50%. Though pulmonary fibrosis is a marker of severe prognosis in the evolution of ARDS, its onset is not yet established. Cardiopulmonary bypass (CPB), usually utilized in patients with a previously normal lung, can cause ARDS and often causes alveolar damage, the earliest lesion observed in ARDS, thus providing a unique opportunity to study the molecular mechanisms of fibrogenesis. OBJECTIVE: To measure immediately after CPB, at the onset of alveolar damage, the expression of messenger RNAs (mRNAs) for collagen type I. METHODS: Pre-CPB and post-CPB lung biopsy specimens were obtained from patients submitted to myocardial revascularization for coronary artery disease. Alveolar damage was characterized by comparison between before and after specimens and quantified by point counting of polymorphonuclear cells (PMN). Type I collagen mRNAs were quantified by scanning densitometry of Northern blot autoradiographs, corrected for RNA loading by 18S ribosomal RNA hybridization. RESULTS: Alveolar damage was characterized by lung interstitial edema and by polymorphonuclear cell infiltration after CPB (PMN pre-CPB 0.010+/-0.004xPMN post-CPB 0.052+/-0.022; n=7; p=0.0017, t test). Type I collagen mRNA increased 91.1+/-68.2% (Ln pre-CPBxLn post-CPB; n=15; p<0.00001, t test) immediately after CPB (mean CPB time, 108.8+/-37.2 min). CONCLUSION: Fibrogenesis, as measured at the molecular level, is a very early event following diffuse alveolar damage, attributable mainly to resident fibroblast activation.

Quantitation in inflammatory pleural disease to distinguish tuberculous and paramalignant from chronic non-specific pleuritis.

AIM: To determine by morphometry if pleural biopsies with the histopathological diagnosis of "non-specific pleuritis", malignant, and tuberculous disease could be distinguished morphologically from those with truly non-specific disease. METHODS: Each pleural biopsy was reviewed taking into account three compartments of reference: the visceral/parietal mesothelial compartment, the submesothelial screen compartment, and the submesothelial adipose tissue compartment. Normal connective tissue, granulation tissue, fibrocellular proliferation, fibrin, polymorphonuclear cells, mononuclear cells, and mesothelial cells were measured using conventional point counting procedures in terms of the fractional area occupied by each parameter within each compartment of reference. Ranking was carried out on 164 patients, based on their diagnosis: chronic non-specific disease (n = 57), tuberculosis (n = 27), malignant disease (n = 58), and conditions associated with transudative effusions (n = 22). RESULTS: Stepwise discriminant analysis of the resulting data showed that biopsies from patients with tuberculosis, malignant disease, and chronic non-specific disease could be distinguished between themselves and normal cases. Statistical differences among the four groups were observed for eight morphometric parameters related to components of inflammation and extension throughout the three pleural anatomical compartments. A robust discriminant function permitted an adequate classification of the three groups of disease in 88.41% of the cases. Pleural biopsies with fibrin incorporated within granulation tissue on the submesothelial screen compartment showed 100% specificity for patients with tuberculosis, while mononuclear cells in a band-like infiltrate on the submesothelial adipose tissue compartment showed 93.1% specificity for patients with malignant disease. The truly non-specific pleuritis was characterised by deposits of fibrin in the subpleural compartment and discrete signs of chronic inflammation and reparatory fibrosis on the submesothelial screen. CONCLUSIONS: Morphometric analysis of pleural biopsies may be a useful supplementary histological procedure to support the diagnosis of pleural tuberculosis and malignant disease.

Interstitial lung disease in primary Sjögren's syndrome. Clinical-pathological evaluation and response to treatment.

Interstitial disease is a recognized form of lung involvement in primary Sjögren's syndrome in which frequency and severity have not yet been established. We studied 20 patients 61.2 +/- 36.4 mo after the first symptoms of the syndrome that fulfilled criteria for both xerostomia and xerophtalmia. Eighteen patients exhibited pulmonary symptoms; nine presented a restrictive functional pattern. The chest roentgenogram disclosed interstitial involvement in nine patients. Gallium-67 lung scan presented hypercaptation in 15 of 19 patients studied. Thirteen patients who submitted to bronchoalveolar lavage presented higher cell counts with increases of lymphocytes and/or polymorphonuclear cells. All patients had abnormal results in at least one of the above. Lung biopsy, undertaken in 12 patients, showed a whole spectrum of interstitial disease, from a follicular bronchiolitis to a lymphoid interstitial pneumonia and finally fibrosis with honeycombing. One patient presented with associated sarcoid granulomas. We treated 11 patients with an azathioprine-based regimen and found a significant improvement in the forced vital capacity (p < 0.05) after at least 6 mo when compared with nontreated patients. We conclude that the frequency of interstitial lung disease is high in Sjögren's syndrome and that an azathioprine-based treatment can favorably change the outcome in this population.

[Predictive factors of abandoning treatment in tuberculosis patients]. / Fatores preditivos de abandono de tratamento por pacientes com tuberculose.

In spite of the efforts to control the spread of tuberculosis worldwide this disease remains one of the biggest problems in public health. Multiresistance has a dramatic effect in this scenario. Non compliance with treatment is directly related to disease spread and the appearance of multiresistance bacilli. Aiming to verify if it is possible to identify patients prone to non compliance from data obtained in the first visit we have studied a population enrolled in a prospective study. Among 257 consecutive patients evaluated between january 1991 and january 1994, we compared 87 patients that abandoned treatment before six months (group A) with 97 that completed six months of treatment (group C). The abandon rate in this group as 33.85% which is larger than 12.9% rate reported by the Health Ministry. Comparing A to C, only the prevalence of alcoholism (A 33.3% x C 22.5%, p = 0.015) and risk behavior for HIV infection (A 27.6% x C 10.2%, p = 0.046), as well as the frequency of non pulmonary disease (A 38.0% x C 24.5%, p = 0.034) were significantly different between both groups. Regarding the moment of abandon (0, 1st or 3rd month) there was no difference in the A group. We conclude that patients at high risk of abandoning tuberculosis treatment can be identified with data obtained at the first visit, allowing to establish a different policy such as supervised treatment for this population.

Beneficial effects of the "open lung approach" with low distending pressures in acute respiratory distress syndrome. A prospective randomized study on mechanical ventilation.

Alveolar overdistention and cyclic reopening of collapsed alveoli have been implicated in the lung damage found in animals submitted to artificial ventilation. To test whether these phenomena are impairing the recovery of patients with acute respiratory distress syndrome (ARDS) submitted to conventional mechanical ventilation (MV), we evaluated the impact of a new ventilatory strategy directed at minimizing "cyclic parenchymal stretch." After receiving pre-established levels of hemodynamic, infectious, and general care, 28 patients with early ARDS were randomly assigned to receive either MV based on a new approach (NA, consisting of maintenance of end-expiratory pressures above the lower inflection point of the P x V curve, VT < 6 ml/kg, peak pressures < 40 cm H2O, permissive hypercapnia, and stepwise utilization of pressure-limited modes) or a conventional approach (C = conventional volume-cycled ventilation, VT = 12 ml/kg, minimum PEEP guided by FIO2 and hemodynamics and normal PaCO2 levels). Fifteen patients were selected to receive NA, exhibiting a better evolution of the PaO2/FIO2 ratio (p < 0.0001) and of compliance (p = 0.0018), requiring shorter periods under FIO2 > 50% (p = 0.001) and a lower FIO2 at the day of death (p = 0.0002). After correcting for baseline imbalances in APACHE II, we observed a higher weaning rate in NA (p = 0.014) but not a significantly improved survival (overall mortality: 5/15 in NA versus 7/13 in C, p = 0.45). We concluded that the NA ventilatory strategy can markedly improve the lung function in patients with ARDS, increasing the chances of early weaning and lung recovery during mechanical ventilation.

Derrame pleural tuberculoso: avaliacao clinica e laboratorial / Tuberculous pleural effusion: clinical and laboratory evaluation

Sao apresentados os resultados do estudo de 44 pacientes com diagnostico de derrame pleural tuberculoso. A idade media foi 35 anos. Houve predominio do sexo masculino e da raca branca. As queixas principais foram febre (41/44), dor toracica (41/44) e emagrecimento (34/44), com tempo medio de duracao de sintomas de seis semanas. Em 21 pacientes o derrame foi localizado do lado direito, em 23 no lado esquerdo e em um paciente em ambos os lados. Em 23 por cento dos pacientes foi observado acometimento do parenquima pulmonar ipsilateral. Destes, tres apresentavam cultura de escarro positiva. Foram realizadas 49 biopsias de pleura em 44 pacientes. A primeira biopsia foi diagnostica em 82,5 por cento dos pacientes. A cultura do fragmento de pleura foi positiva em 75,8 por cento e a cultura do liquido pleural em 22,5 por cento. O liquido pleural era um exsudato com uma relacao liquido pleural/sangue maior que 0,5 para proteinas e maior que 0,6 para DHL em todos os casos. O estudo citologico mostrou predominio de linfocitos e escassez de celulas mesoteliais. Os pacientes receberam esquema terapeutico adequado, apresentando boa evolucao. Houve apenas uma falha. Os pacientes apresentaram melhora significativa (p < 0,05) com relacao ao peso, hemoglobina e diminuicao de VHS. Dos 44 pacientes, 23 evoluriam...

[Tuberculous pleural effusion: clinical and laboratory evaluation]. / Derrame pleural, tuberculoso: avaliação clínca e laboratorial.

Clinical data concerning 44 patients with pleural tuberculosis are presented. The average age was 35 years. The main symptoms were fever (41/44), chest pain (41/44) and weight loss (34/44). In all but one case the pleural effusion was unilateral without preference for one or other hemithorax. In ten patients (23%) parenchymal lesions could be recognized on chest roentgenograms. Three patients had coexisting active pulmonary disease with positive sputum culture. Forty-nine pleural biopsies were performed in 44 patients. The culture of pleural tissue was positive in 75%, and culture of pleural fluid in 22.5%. The pleural fluid was exudative with fluid-to-serum ratios of protein and LDH exceeding 0.5 and 0.6 respectively. The cellular characterization of pleural fluid has demonstrated predominance of lymphocytes and scarcity of mesothelial cells. The patients received adequate treatment with excellent results, exhibiting an increased weight, increased hemoglobin and decreased ESR. The development of residual pleural thickening occurred in 23 out of 44 cases.