Assessment of functional status by the Duke Activity Status Index in stable bronchiectasis.

INTRODUCTION: Bronchiectasis is a growing global health problem. OBJECTIVE AND METHODS: To evaluate the functional status of stable bronchiectasis patients recruited from a terciary hospital in Fortaleza, Brazil.The patients were submitted to spirometry, six minute walking test (6MWT), step test (6MST),   measurement of fibrinogen,E-FACED scores(incorporates FEV1 ,age,colonisation by Pseudomonas,radiological extension, dyspnoea and exarcebation) and Duke Activity Status Index(DASI) test.Each item of DASI scored proportionally to the metabolic equivalentes(METs). The sum of DASI scores was applied for an estimation of oxygen consumption(VO2). RESULTS: The sample comprised 101 patients.Patients with post-tuberculosis bronchiectsis had the lowest level of functional parameters than those with others etiologies[DASI(19.9 ±10.9 vs 31.2±14.4 p<0.001); VO2 (18.1 ± 4.7 vs 23.1 ± 6.1 p< 0.001 respectively)]. DASI scores and estimated VO2 correlated with E-FACED(r= -0.44 p=0.001; and  r= -0.44 p=0.001 respectively) and 6MST r= 0.37 p<0.001 and r=0.40 p<0.001 respectively). CONCLUSION: After multivariate analysis , bronchiectasis post-TB , E-FACED and 6MWT explained the impact on performance in bronchiectasis patients.

ASSOCIATION BETWEEN FATIGUE AND EXERCISE CAPACITY IN PATIENTS WITH CHRONIC LIVER DISEASE AWAITING LIVER TRANSPLANTATION.

BACKGROUND: Fatigue is highly prevalent in end stage liver disease, the studies about its association with exercise capacity in cirrhotic patients before liver are scarse. OBJECTIVE: In this study, we evaluated fatigue in 95 in end stage liver disease patients awaiting transplantation, compared to healthy volunteers, and tested the association between exercise capacity and fatigue. METHODS: Cross-sectional study of patients with chronic liver disease treated at a referral center in Fortaleza, Brazil. Fatigue was quantified with the Fatigue Severity Scale. The patients were submitted to the 6-min walk test, the 6-min step test, the Hospital Anxiety and Depression Scale, C-reative protein measurement and hematocrit count, measurement of dyspnea among other tests. Fatigue data were obtained from healthy individuals for comparison with patients. RESULTS: The mean age of patients was 45.9±12.3 years, and 53.7% were male. Fatigue, anxiety and depression levels were higher among end stage liver disease patients than among controls. A negative correlation was observed between 6 min step test and Fatigue Severity Scale score (r= -0.2; P=0.02) and between hematocrit count and Fatigue Severity Scale score (r= -0.24; P=0.002). Dyspnea on the Borg scale and fatigue were positively correlated (r=31; P=0.002). In the multivariate analysis, low 6-min step test values and high levels of dyspnea were associated with fatigue. CONCLUSION: Fatigue was more prevalent and severe in end stage liver disease patients than in healthy controls. Low 6MST values and high levels of dyspnea were associated with fatigue in this scenario.

Associação da fadiga com capacidade do exercício em pacientes hepatopatas crônicos candidatos a transplante hepático / Association between fatigue and exercise capacity in patients with chronic liver disease awaiting liver transplantation

ABSTRACT BACKGROUND: Fatigue is highly prevalent in end stage liver disease, the studies about its association with exercise capacity in cirrhotic patients before liver are scarse. OBJECTIVE: In this study, we evaluated fatigue in 95 in end stage liver disease patients awaiting transplantation, compared to healthy volunteers, and tested the association between exercise capacity and fatigue. METHODS: Cross-sectional study of patients with chronic liver disease treated at a referral center in Fortaleza, Brazil. Fatigue was quantified with the Fatigue Severity Scale. The patients were submitted to the 6-min walk test, the 6-min step test, the Hospital Anxiety and Depression Scale, C-reative protein measurement and hematocrit count, measurement of dyspnea among other tests. Fatigue data were obtained from healthy individuals for comparison with patients. RESULTS: The mean age of patients was 45.9±12.3 years, and 53.7% were male. Fatigue, anxiety and depression levels were higher among end stage liver disease patients than among controls. A negative correlation was observed between 6 min step test and Fatigue Severity Scale score (r= -0.2; P=0.02) and between hematocrit count and Fatigue Severity Scale score (r= -0.24; P=0.002). Dyspnea on the Borg scale and fatigue were positively correlated (r=31; P=0.002). In the multivariate analysis, low 6-min step test values and high levels of dyspnea were associated with fatigue. CONCLUSION: Fatigue was more prevalent and severe in end stage liver disease patients than in healthy controls. Low 6MST values and high levels of dyspnea were associated with fatigue in this scenario.

RESUMO CONTEXTO: A fadiga é uma queixa comum em indivíduos com doença hepática crônica candidatos a transplante hepático. Estudos sobre sua associação com capacidade do exercício são escassos. OBJETIVO: Avaliar a fadiga de pacientes com hepatopia crônica candidatos a transplante hepático comparando com um grupo de indivíduos saudáveis. Avaliar a associação da fadiga com capacidade de exercício. MÉTODOS: Este é um estudo transversal com pacientes hepatopatas crônicos num centro de referência em Fortaleza, Brasil. Foi utilizado o questionário de gravidade da fadiga. Os pacientes realizaram o teste da caminhada dos 6 min, teste do degrau 6 min, foi aplicada a escala de ansiedade e depressão, foram dosados proteína C reativa e hematócrito. RESULTADO: A idade média dos pacientes foi de 45,9±12,3 anos, sendo que 53,7% eram homens. Os níveis de fadiga e ansiedade e depressão eram maiores entre os pacientes hepatopatas crônicos quando comparados ao grupo controle. Uma correlação inversa foi observada entre fadiga e o teste do degrau (r= -0,2; P=0,02) também entre hematócrito e fadiga (r= -0,24; P=0,002). Houve uma correlação positiva entre dispneia, através da escala de Borg, e fadiga (r=31; P=0,002). Na análise multivariada um baixo desempenho no teste do degrau e um nível maior de dispneia mostraram uma associação com fadiga. CONCLUSÃO: A fadiga é mais frequente entre os pacientes hepatopatas crônicos quando comparados ao grupo controle. O baixo desempenho na capacidade de exercício e uma queixa maior de dispneia apresentaram uma associação com fadiga nestes pacientes.

Short-term effects of non-invasive ventilation on cerebral blood flow and cognitive function in COPD.

OBJECTIVES: Investigate the acute effects of non-invasive ventilation (NIV) on cerebral blood flow (CBF) and on cognitive functions in COPD. METHODS: Nine non-hypercapnic stable COPD and twelve healthy controls were enrolled. CBF (transcranial Doppler), cognitive tests and cardiorespiratory response were performed at baseline, during one hour of NIV and after 30 min. RESULTS: Both groups had an increase in tidal volume and reduction in respiratory rate during NIV, but only controls showed PaCO2 reductions (41.2 ±â€¯4.6 to 36.5 ±â€¯7.3 in controls vs. 40.9 ±â€¯4.5 to 42.9 ±â€¯5.9 in COPD). During NIV CBF was significantly reduced in healthy controls and COPD, although this effect was less pronounced in the latter. At the same time, healthy controls demonstrated an improvement in cognitive executive function compared to COPD in the Trail Making Test part B (90.5 vs. 180s; respectively). CONCLUSION: NIV application for one hour reversibly reduced CBF in healthy controls and non-hypercapnic stable COPD patients, despite no significant reductions of the PaCO2 in the latter group. It was associated with minor cognitive improvements in the executive function in healthy volunteers, but not in COPD.

Exercise Capacity and Respiratory Profile in Patients after Orthopedic Liver Transplantation: a Follow-up Study.

INTRODUCTION: We sought to describe: 1) The influence of orthotopic liver transplantation (OLT) on exercise capacity, pulmonary function and respiratory muscle strength after surgery, 2) The relationship between exercise capacity and symptoms of anxiety and depression. MATERIAL AND METHODS: This is a prospective follow up study conducted with patients submitted to OLT. All patients were assessed before and 1 month after surgery through measurements: six minute walk test (6MWT), 6 min step test (6MST) and HADS (Hospital Anxiety and Depression Scale). FEV1% (forced expiratory volume), maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) were measured in the pre-operative and on 1st, 3rd, 5th day and 1 month after surgery. RESULTS: In 77 patients , 6MWD improved 20.2 m (95%CI 8.1-32.3) and 6MST improved 7.8 steps after surgery (95%CI 3.9-11.6). Change in 6 MWD and 6 MST did not correlated with change HADS. The FEV1% at each time point were 88.8 ± 21.3 before surgery, 32.9 ± 9.9 on 1st day, 39.6 ± 11.5 on 3rd day, 46 ± 12.1 on 5th day and 86.6 ± 21.1 one month after surgery. MIP and MEP values at each time point were -67.4 ± 23.2 and 79.7 ± 26 before surgery, -30.8 ± 12.3 and 36.4 ± 15.4 on 1st day, -38.6 ± 14.1 and 43.8 ± 17 on 3rd day, -45.8 ± 15.9 and 49.7 ± 18.7 on 5th day and -67.1 ± 29.4 and 80.9 ± 23.9 one month after surgery. CONCLUSION: Exercise capacity was modestly increased after OLT without any correlation with symptoms of anxiety and depression. Pulmonary function and respiratory muscle strength decreased immediately after liver transplantation, and progressively recovered, returning to baseline values after 1 month.

Risk factors for acute kidney injury and 30-day mortality after liver transplantation.

INTRODUCTION: The aim of this study is to evaluate the risk factors for acute kidney injury (AKI) and 30-day mortality after liver transplantation. MATERIAL AND METHODS: This is a retrospective cohort of consecutive adults undergoing orthotopic liver transplantation (OLT) at a referral hospital in Brazil, from January 2013 to January 2014. Risk factors for AKI and death were investigated. RESULTS: A total 134 patients were included, with median age of 56 years. AKI was found in 46.7% of patients in the first 72 h after OLT. Risk factors for AKI were: viral hepatitis (OR 2.9, 95% CI = 1.2-7), warm ischemia time (OR 1.1, 95% CI = 1.01-1.2) and serum lactate (OR 1.3, 95%CI = 1.02-1.89). The length of intensive care unit (ICU) stay was longer in AKI group: 4 (3-7) days vs. 3 (2-4) days (p = 0.001), as well as overall hospitalization stay: 16 (9-26) days vs. 10 (8- 14) days (p = 0.001). The 30-day mortality was 15%. AKI was an independent risk factor for mortality (OR 4.3, 95% CI = 1.3-14.6). MELD-Na ≥ 22 was a predictor for hemodialysis need (OR 8.4, 95%CI = 1.5-46.5). Chronic kidney disease (CKD) was found in 36 patients (56.2% of AKI patients). CONCLUSIONS: Viral hepatitis, longer warm ischemia time and high levels of serum lactate are risk factors for AKI after OLT. AKI is a risk factor for death and can lead to CKD in a high percentage of patients after OLT. A high MELD-Na score is a predictor for hemodialysis need.

Comparison of face-to-face interview and telephone interview administration of COPD assessment test: a randomized study.

OBJECTIVE: To assess the measurement properties of the COPD assessment test (CAT) in a randomized trial comparing a face-to-face interview (FFI) with a telephone interview (TI). METHODS: A randomized study was conducted at two teaching hospitals in Fortaleza, Brazil. Patients were randomly assigned to answer the CAT questionnaire either in a FFI or by TI. The two groups were assessed for internal consistency reliability, cross-sectional validity and test-retest reliability. All patients performed spirometry and answered the modified medical research council dyspnea scale and the St. George's respiratory questionnaire (SGRQ). RESULTS: The total scores of the CAT questionnaire were similar for face-to-face and TI groups, 20.71 (95 % CI 18-23.4) versus 20.81 (95 % CI 19.31-21.7), respectively. For both mode of administration, we found good internal consistency reliability, the Cronbach's alpha ranged from 0.74 (95 % CI 0.61-0.84) to 0.89 (95 % CI 0.84-0.93) for the TI and FFI, respectively. In general, moderate-to-high correlations of CAT with SGRQ were observed, independent of the administration format. For the test-retest reliability, the intraclass correlation coefficients were very similar for both FFI and TI group 0.96 (95 % CI 0.93-0.97) versus 0.98 (95 % CI 0.96-0.98), respectively. CONCLUSION: This study demonstrated that the CAT questionnaire administration either in a FFI or by TI presents moderate-to-high measurement properties. This provides support for the use of both modes of questionnaire administration.

Different patterns in a cohort of patients with severe leptospirosis (Weil syndrome): effects of an educational program in an endemic area.

The aim of this study is to investigate the changes in clinical pattern and therapeutic measures in leptospirosis-associated acute kidney injury; a retrospective study with 318 patients in Brazil. Patients were divided according to the time of admission: 1985-1996 (group I) and 1997-2010 (group II). Patients were younger in group I (36 ± 13 versus 41 ± 16 years, P = 0.005) and the numbers of oliguria increased (21% versus 41% in group II, P = 0.014). Higher frequency of lung manifestations was observed in group II (P < 0.0001). Although increased severity, there was a significant reduction in mortality (20% in group I versus 12% in group II, P = 0.03). Mortality was associated with advanced age, low diastolic blood pressure, oliguria, arrhythmia, and peritoneal dialysis, besides a trend to better mortality with penicillin administration. Leptospirosis is occurring in an older population, with a higher number of oliguria and lung manifestations. However, mortality is decreasing and can be the result of changes in treatment.

Improvement of cognitive function after a three-month pulmonary rehabilitation program for COPD patients.

The objective of the study was to evaluate the effect of multidisciplinary pulmonary rehabilitation program on cognitive function in COPD patients, adjusting for potential confounders (gender, age, tobacco consumption, and educational level). In this prospective study, 34 COPD patients were submitted to neuropsychological testing before and after a 3-month pulmonary rehabilitation program. A control group with 18 healthy subjects of similar age, sex, and educational status was used to compare the cognitive function of COPD patients and healthy subjects at baseline. The association between the rehabilitation and change on th scores of cognitive variables, adjusted for each covariate, was estimated by means of linear random-intercept regression models. At baseline, the COPD patients had worse cognitive function with regard to verbal learning, memory, subjective organization, and verbal processing in comparison to the healthy volunteers. The improvement in cognitive performance by the COPD patients was evidenced even after adjusting for the sociodemographic factors that could potentially interfere on cognitive function. Male gender and age less than 65 years old were associated to higher scores in verbal learning and memory at baseline and after the rehabilitation program. The clinical approach to COPD-induced cognitive dysfunction should include participation in pulmonary rehabilitation programs. There were gender- and age-related differences in cognitive scores that persisted after rehabilitation.

Continuous positive airway pressure effects on regional lung aeration in patients with COPD: a high-resolution CT scan study.

BACKGROUND: The effects of nasal continuous positive airway pressure (CPAP) on the lung parenchyma of patients with COPD, to our knowledge, have never been assessed by high-resolution CT (HRCT) scanning. METHODS: HRCT scans were obtained at the apex, hilum, and basis of the lungs at functional residual capacity while on spontaneous respiration and at the end of CPAP trials of 5 cm water (H(2)O), 10 cm H(2)O, and 15 cm H(2)O in 11 stable patients with COPD and eight healthy volunteers. Lung aeration was assessed by quantitative density parameters and by qualitative analysis of each CT image after processing by means of a density-based color-mask computational algorithm. The quantitative parameters were density histograms, the relative area of the lungs with attenuation values < -950 Hounsfield units (percentage of hyperaerated areas) and the 15th percentile (the density value separating the 15% voxels of least density). RESULTS: A CPAP of 5 cm H(2)O caused little increase in lung aeration in both groups, but in some patients with COPD, CPAP deflated some regions of the lungs. CPAP levels of 10 cm H(2)O and 15 cm H(2)O increased the emphysematous zones in all sectors of the lungs, including dorsal and apical regions in patients with COPD compared to little hyperaeration predominantly in the ventral areas in healthy volunteers. CONCLUSIONS: Nasal CPAP causes variable effects on regional lung aeration in relation to the applied pressure and the regional distribution of emphysema in patients with COPD. Low pressure levels may cause regional lung deflation in some patients. High levels increase the emphysematous areas wherever they are located inside the lungs.

Assessment of the burden of caregiving for patients with chronic obstructive pulmonary disease.

OBJECTIVE: To determine the effect of chronic obstructive pulmonary disease (COPD) on the quality of life of caregivers. DESIGN AND METHODS: A cross-sectional study was carried out with forty-two COPD patients and their primary caregivers. Patients were assessed with the medical outcome survey short form (SF-36), the physical and mental component summary (PCS and MCS), Saint George's respiratory questionnaire (SGRQ), 6-min walking test, and spirometric and blood gas measurements. Caregivers were assessed using the medical outcome survey short form (SF-36), the physical and mental component summary (PCS and MCS), the 5-point Likert scale for measuring caregiver/patient relationships and the caregiver burden scale (CB scale). RESULTS: The majority of caregivers were female (85.3%), married (59%) and had low levels of income and schooling. The mean age was 51.6+/-16 years. Mean caregiver PCS and MCS scores were 45.9+/-10 and 46+/-12, while the mean total burden score was 1.79+/-0.6. The regression analysis showed caregiver/patient relationship quality, caregiver MCS scores and patient PCS scores to be important predictors of burden and explained 63% of the variance. CONCLUSIONS: COPD causes a significant impact on the quality of life of caregivers. The two most important predictors of COPD burden are the relationship between caregivers and patients and caregiver MCS scores.

Efeitos do fumo ambiental no trato respiratório inferior de crianças com até 5 anos de idade / Effects of environmental tobacco smoke on lower respiratory system of children under 5 years old

Objetivo: Avaliar a associaçäo do fumo passivo com morbidade respiratória em crianças abaixo de 5 anos de idade. Métodos: Estudo transversal incluindo 1.104 crianças abaixo de 5 anos de idade residentes na cidade de Fortaleza, Ceará. Por meio de um questionário com os pais das crianças, foram obtidas informaçöes sobre sintomas e doenças respiratórias, história familiar de morbidade respiratória, presença de fumantes nas casas e condiçöes de moradia. Resultados: Foram estudados 546 meninas e 558 meninos. Das 611 crianças fumantes passivas, 82 por cento tinham problemas respiratórios ("odds ratio" = 1,64; IC 95 por cento: 1,21-2,20). As queixas respiratórias mais freqüentes foram: chiado no peito ("odds ratio" = 1,66; IC 95 por cento: 1,21-2,27), dispinéia ("odds ratio" = 1,91; IC 95 por cento: 1,36-2,67)tosse e/ou expectoraçäo ("odds ratio" = 1,58; IC 95 por cento: 1,13-2,84). A chance de apresentar asma, bronquite ou pneumonia foi maior para as crianças fumantes passivas ("odds ratio" = 1,60; IC 95 por cento: 1,11-2,31). Conclusöes: Os principais fatores de risco com chance de predizer morbidade respiratória em crianças com idade de 0 a 5 anos foram: crianças que conviviam com mäes fumantes, pais fumantes, presença de mofo em casa, história familiar de asma ou rinite