Association between pulmonary artery to aorta diameter ratio with pulmonary hypertension and outcomes in diffuse cystic lung diseases.

ABSTRACT: To investigate the importance of pulmonary vascular measurements on computed tomography (CT) in predicting pulmonary hypertension (PH) and worse outcomes in diffuse cystic lung diseases (DCLDs).We conducted a cross-sectional study of patients with DCLDs. Patients underwent pulmonary function tests, a six-minute walk test (6MWT), chest CT, transthoracic echocardiography, and right heart catheterization. Pulmonary artery (PA) diameter and PA-ascending aorta ratio (PA-Ao ratio) were obtained from CT. Mean pulmonary artery pressure (mPAP) from right heart catheterization was correlated with tomographic, functional, and echocardiographic variables. The association between the PA-Ao ratio with outcomes was determined by Kaplan-Meier curves.Thirty-four patients were included (18 with pulmonary Langerhans cell histiocytosis and 16 with lymphangioleiomyomatosis, mean age 46 ±â€Š9 years). Forced expiratory volume in the first second and lung diffusing capacity for carbon monoxide were 47 ±â€Š20% and 38 ±â€Š21% predicted, respectively. PA diameter and PA-Ao ratio were 29 ±â€Š6 mm and 0.95 ±â€Š0.24, respectively. PA-Ao ratio > 1 occurred in 38.2% of patients. PA-Ao ratio was a good predictor of PH. mPAP correlated best with PA-Ao ratio, PA diameter, oxygen desaturation during six-minute walk test, and echocardiographic variables. Patients with PA-Ao ratio > 1 had greater mPAP, and a higher risk of death or lung transplantation (log-rank, P < .001) than those with PA-Ao ratio ≤ 1.The PA-Ao ratio measured on CT scan has a potential role as a non-invasive tool to predict the presence of PH and as a prognostic parameter in patients with DCLDs.

Mechanisms of Exercise Limitation and Prevalence of Pulmonary Hypertension in Pulmonary Langerhans Cell Histiocytosis.

BACKGROUND: Pulmonary Langerhans cell histiocytosis (PLCH) determines reduced exercise capacity. The speculated mechanisms of exercise impairment in PLCH are ventilatory and cardiocirculatory limitations, including pulmonary hypertension (PH). RESEARCH QUESTION: What are the mechanisms of exercise limitation, the exercise capacity, and the prevalence of dynamic hyperinflation (DH) and PH in PLCH? STUDY DESIGN AND METHODS: In a cross-sectional study, patients with PLCH underwent an incremental treadmill cardiopulmonary exercise test with an evaluation of DH, pulmonary function tests, and transthoracic echocardiography. Those patients with lung diffusing capacity for carbon monoxide (Dlco) < 40% predicted and/or transthoracic echocardiogram with tricuspid regurgitation velocity > 2.5 m/s and/or with indirect PH signs underwent right heart catheterization. RESULTS: Thirty-five patients were included (68% women; mean age, 47 ± 11 years). Ventilatory and cardiocirculatory limitations, impairment suggestive of PH, and impaired gas exchange occurred in 88%, 67%, 29%, and 88% of patients, respectively. The limitation was multifactorial in 71%, exercise capacity was reduced in 71%, and DH occurred in 68% of patients. FEV1 and Dlco were 64 ± 22% predicted and 56 ± 21% predicted. Reduction in Dlco, an obstructive pattern, and air trapping occurred in 80%, 77%, and 37% of patients. FEV1 and Dlco were good predictors of exercise capacity. The prevalence of PH was 41%, predominantly with a precapillary pattern, and mean pulmonary artery pressure correlated best with FEV1 and tricuspid regurgitation velocity. INTERPRETATION: PH is frequent and exercise impairment is common and multifactorial in PLCH. The most prevalent mechanisms are ventilatory, cardiocirculatory, and suggestive of PH limitations. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; No.: NCT02665546; URL: www.clinicaltrials.gov.

Pulmonary hypertension in lymphangioleiomyomatosis: prevalence, severity and the role of carbon monoxide diffusion capacity as a screening method.

BACKGROUND: Lymphangioleiomyomatosis (LAM) is included within group 5 of the current PH classification (unclear multifactorial mechanisms). However, data regarding the occurrence of PH in LAM are scarce. The aims of the study were to describe the prevalence and characteristics of PH in a large cohort of LAM patients with different levels of severity, and to evaluate the role of echocardiography and carbon monoxide diffusion capacity (DLCO) as screening methods for PH in LAM. METHODS: One hundred five LAM patients underwent transthoracic echocardiography, pulmonary function tests (PFTs) and 6-min walk test (6MWT). Patients with a suspicion of PH on echocardiography, defined by the presence of estimated systolic pulmonary artery pressure (PAP) over 35 mmHg or PFT showing DLco below 40% of the predicted value, underwent right heart catheterisation to confirm the diagnosis of PH. RESULTS: Eight patients (7.6%) had PH confirmed on right heart catheterisation, six patients (5.7%) had a pre-capillary pattern and two patients (1.9%) had a post-capillary profile. Only one patient (1%) had mean PAP over 35 mmHg. Patients with PH had lower FEV1 and DLCO in PFTs and greater oxygen desaturation and dyspnea intensity during 6MWT compared with those without PH. In 63% of the patients with confirmed PH, the right heart catheterisation was performed based only on DLCO result. CONCLUSIONS: The prevalence of PH is low in LAM patients. Pulmonary hypertension in LAM is typically mild and significantly associated with pulmonary parenchymal involvement. Carbon monoxide diffusion capacity significantly improved the identification of PH in LAM patients.

Denervação simpática renal como estratégia de tratamento da hipertensão arterial resistente / Renal sympathetic denervation as a treatment strategy for resistant hypertension

Cerca de um bilhão de pessoas foi classificada como hipertensa no ano de 2010. O crescimento expressivo da prevalência de hipertensão arterial sistêmica (HAS) no mundo torna esta patologia um tema sempre atual, recorrente e de grande impacto, sobretudo no que diz respeito à mortalidade cardiovasculares e à políticas de Saúde Pública. A despeito das terapias farmacológicas, porcentagem de pacientes que atingem as metas de controle pressórico ainda permanece baixo,tornando urgente o desenvolvimento de novas estratégias de manejo desta patologia. No contexto da hipertensão arterial é importante ressaltar que a variação do tônus vascular é regulada por diferente fatores funcionais, dentre os quais de destaca a atividade simpática...

Fatores de risco para óbito em pacientes idosos gravemente enfermos / Risk factors for death among critically ill elderly patients

OBJETIVO: A população idosa está aumentando em todo o mundo, assim como a necessidade de cuidados intensivos para os idosos. Existem poucos estudos que investiguem os fatores de risco para óbito em pacientes idosos gravemente enfermos. Este estudo teve o objetivo de investigar os fatores associados ao óbito em uma população de pacientes idosos gravemente enfermos admitidos a uma unidade de terapia intensiva no Brasil. MÉTODOS: Estudo retrospectivo de coorte que incluiu todos os pacientes idosos (idade ≥ 60 anos) admitidos a uma unidade de terapia intensiva em Fortaleza, Brasil, de janeiro a dezembro de 2007. Foi realizada uma comparação entre os sobreviventes e os não sobreviventes, e os fatores de risco para óbito foram investigados por meio de análise univariada e multivariada. RESULTADOS: Foi incluído um total de 84 pacientes, com uma média de idade de 73 ± 7,6 anos, sendo 59 por cento do gênero feminino. A mortalidade foi de 62,8 por cento. A principal causa de morte foi disfunção de múltiplos órgãos (42,3 por cento), seguido por choque séptico (36,5 por cento) e choque cardiogênico (9,7 por cento). As complicações durante a permanência na unidade de terapia intensiva associadas com óbito foram insuficiência respiratória (OR = 61; p<0.001), lesão renal aguda (OR =23, p<0,001), sepse (OR = 12; p<0,001), acidose metabólica (OR = 17; p<0,001), anemia (OR = 8,6; p<0,005), distúrbios da coagulação (OR = 5,9; p<0,001) e fibrilação atrial (OR = 4,8; P<0,041). Os fatores de risco independentes para óbito foram idade (OR = 1,15; p<0,005), coma (OR = 7,51; p<0,003), hipotensão (OR = 21,75; p=0,003), insuficiência respiratória (OR = 9,93; p<0,0001), e lesão renal aguda (OR = 16,28; p<0,014). CONCLUSÕES: A mortalidade é elevada em pacientes idosos gravemente enfermos. Os fatores associados ao óbito foram idade, coma, hipotensão, insuficiência respiratória e lesão renal aguda.

BACKGROUND: The elderly population is increasing all over the world. The need of intensive care by the elderly is also increasing. There is a lack of studies investigating the risk factors for death among critically ill elderly patients. This study aims to investigate the factors associated with death in a population of critically ill elderly patients admitted to an intensive care unit in Brazil. METHODS: This is a retrospective cohort study including all elderly patients (>60 years) admitted to an intensive care unit in Fortaleza, Brazil, from January to December 2007. A comparison between survivors and nonsurvivors was done and the risk factors for death were investigated through univariate and multivariate analysis. RESULTS: A total of 84 patients were included, with an average age of 73 ± 7.6 years; 59 percent were female. Mortality was 62.8 percent. The main cause of death was multiple organ dysfunction (42.3 percent), followed by septic shock (36.5 percent) and cardiogenic shock (9.7 percent). Complications during intensive care unit ICU stay associated with death were respiratory failure (OR=61, p<0.001), acute kidney injury (OR=23, p<0.001), sepsis (OR=12, p<0.001), metabolic acidosis (OR=17, p<0.001), anemia (OR=8.6, p<0.005), coagulation disturbance (OR=5.9, p<0.001) and atrial fibrillation (OR=4.8, p<0.041). Independent risk factors for death were age (OR=1.15, p<0.005), coma (OR=7.51, p<0.003), hypotension (OR=21.75, p=0.003), respiratory failure (OR=9.93, p<0.0001) and acute kidney injury (OR=16.28, p<0.014). CONCLUSION: Mortality is high among critically ill elderly patients. Factors associated with death were age, coma, hypotension, respiratory failure and acute kidney injury.

Risk factors for death among critically ill elderly patients. / Fatores de risco para óbito em pacientes idosos gravemente enfermos.

BACKGROUND: The elderly population is increasing all over the world. The need of intensive care by the elderly is also increasing. There is a lack of studies investigating the risk factors for death among critically ill elderly patients. This study aims to investigate the factors associated with death in a population of critically ill elderly patients admitted to an intensive care unit in Brazil. METHODS: This is a retrospective cohort study including all elderly patients (>60 years) admitted to an intensive care unit in Fortaleza, Brazil, from January to December 2007. A comparison between survivors and nonsurvivors was done and the risk factors for death were investigated through univariate and multivariate analysis. RESULTS: A total of 84 patients were included, with an average age of 73 ± 7.6 years; 59% were female. Mortality was 62.8%. The main cause of death was multiple organ dysfunction (42.3%), followed by septic shock (36.5%) and cardiogenic shock (9.7%). Complications during intensive care unit ICU stay associated with death were respiratory failure (OR=61, p<0.001), acute kidney injury (OR=23, p<0.001), sepsis (OR=12, p<0.001), metabolic acidosis (OR=17, p<0.001), anemia (OR=8.6, p<0.005), coagulation disturbance (OR=5.9, p<0.001) and atrial fibrillation (OR=4.8, p<0.041). Independent risk factors for death were age (OR=1.15, p<0.005), coma (OR=7.51, p<0.003), hypotension (OR=21.75, p=0.003), respiratory failure (OR=9.93, p<0.0001) and acute kidney injury (OR=16.28, p<0.014). CONCLUSION: Mortality is high among critically ill elderly patients. Factors associated with death were age, coma, hypotension, respiratory failure and acute kidney injury.

Incidência de fratura do quadril em área urbana do Nordeste brasileiro / Hip fracture incidence in an urban area in Northeast Brazil

A fratura do quadril causa grande morbidade e mortalidade e envolve alto custo, sendo reconhecida como um problema de saúde pública. Sua incidência varia amplamente entre vários países e mesmo entre cidades de uma mesma região. O objetivo do estudo foi determinar a taxa de incidência de fratura de quadril na cidade de Fortaleza, Ceará, Brasil. Foram identificados prospectivamente todos casos de fratura de fêmur, em indivíduos acima de 45 anos, atendidos nos hospitais públicos e privados da cidade de Fortaleza no período de julho de 2001 a junho de 2002. Seiscentos e setenta e três pacientes fraturaram o fêmur, sendo 382 provenientes da cidade de Fortaleza. A incidência anual de fratura de quadril na cidade de Fortaleza em indivíduos acima de 60 anos foi de 21,7/10 mil habitantes (13/10 mil no sexo masculino e 27,7/10 mil no sexo feminino). As fraturas de quadril foram mais freqüentes no sexo feminino e aumentaram progressivamente com a idade. A taxa de incidência do quadril na cidade de Fortaleza foi uma das mais baixas quando comparadas com estudos realizados em várias partes do mundo.

[Hip fracture incidence in an urban area in Northeast Brazil]. / Incidência de fratura do quadril em área urbana do Nordeste brasileiro.

Hip fractures involve high morbidity and mortality and extensive treatment costs and are thus considered an important public health issue. Hip fracture incidence varies greatly between countries and even between cities in the same region. This study aimed to determine hip fracture incidence in Fortaleza, Ceará State, Brazil. Hip fracture cases were identified prospectively in patients aged 45 and over attending private and public hospitals in Fortaleza from July 2001 to June 2002. The study identified 673 patients with hip fractures, 382 of whom from Fortaleza. Annual hip fracture incidence in Fortaleza for patients over 60 years was 21.7/10,000 inhabitants (13.0/10,000 for men and 27.7/10,000 for women). Hip fractures were more frequent among women and with advancing age. Hip fracture incidence in Fortaleza was very low compared to rates reported from other parts of the world.