[Results of a psychotherapeutic program for smoking after 12 months of follow-up]. / Resultados de un programa psicoterapéutico de deshabituación tabáquica tras 12 meses de seguimiento.

OBJECTIVE: To compare the efficacy of psychological counseling for smokers in a cessation program in comparison with treatment based only on providing information about damage caused by tobacco and advice for quitting, and to determine the reasons patients started to smoke. PATIENTS AND METHODS: We studied 249 patients who came to a preliminary interview; 226 began treatment for smoking cessation. The average level of dependence, quantified the Fagerstrom test was 7.26 +/- 1.85 points. Two treatment groups were formed: the first patients seen made up the control group (n = 37), which received information about the dangers of tobacco and strategies for quitting, and the psychological counseling group (n = 189). Follow-up examinations were performed three, six and twelve months after treatment, with abstinence checked by measurement of CO in exhaled air. Only patients with CO levels less than 5 ppm (particles per million) in exhaled air were considered non-smokers. RESULTS: Most patients of both sexes named social pressure as the reason for starting to smoke. The rate of abstinence in the information and strategies group was 8.1% at all three follow-up visits, whereas the rate was 37%, 25.4% and 24.3% at three, six and twelve months, respectively, in the group receiving counseling. The differences between the two groups were significant at all visits. CONCLUSIONS: Social pressure is the main reason for starting to smoke. We observed a success rate of 24.3% after one year of follow-up after psychological treatment only, a rate that was significantly higher than that of the group that received only information. We believe that psychological counseling is an effective alternative for smokers who want to quit.

Resultados de un programa psicoterapéutico de deshabituación tabáquica tras 12 meses de seguimiento / Psychological cunseling for smoking cessation: results after twelve months

Objetivo: El objetivo de nuestro estudio ha sido conocer la efectividad de un programa psicoterapéutico de deshabituación tabáquica en relación con una intervención basada en información sobre el daño del tabaco y consejos para su abandono, así como los motivos de inicio del tabaquismo. Pacientes y métodos: Estudiamos a un total de 249 pacientes que acudieron a una entrevista preliminar, de los cuales 226 comenzaron un tratamiento para la deshabituación tabáquica. El nivel medio de dependencia, cuantificado por el test de Fagerström, fue de 7,26 ñ 1,85 puntos. Se formaron dos grupos de estudio: un grupo control de información sobre los peligros del tabaco y diversas estrategias de abandono (n = 37) con los primeros pacientes, y un grupo de intervención psicoterapéutica (n = 189) en el que se incluyeron de forma consecutiva el resto. Se efectuaron revisiones a los 3, 6 y 12 meses una vez finalizado el tratamiento, objetivándose mediante cooximetría la situación de abstinencia. Fueron considerados como no fumadores exclusivamente aquellos individuos en que se pudieron objetivar valores iguales o menores a 5 ppm (partículas por millón) de CO en aire espirado. Resultados: La mayoría de los pacientes en ambos sexos indicaron como motivo de inicio del tabaquismo la presión social. El porcentaje de abstinencia en el grupo de información y estrategias de abandono fue del 8,1 por ciento en las tres revisiones efectuadas, mientras que en el grupo de intervención psicoterapéutica fue del 37, 25,4 y 24,3 por ciento, respectivamente, a los 3, 6 y 12 meses, existiendo diferencias significativas respecto al primer grupo en todas las revisiones. Conclusiones: Los factores de presión social son fundamentales en el inicio del tabaquismo. Hemos objetivado un 24,3 por ciento de éxitos en la abstinencia al año de seguimiento exclusivamente con tratamiento psicológico, existiendo diferencias significativas en relación con el grupo que sólo recibió información. Creemos que la terapia psicológica se presenta como alternativa eficaz en el abandono del tabaquismo. (AU)

[Tuberculosis management unit: 7-year experience]. / Unidad monográfica de tuberculosis: experiencia de 7 años de funcionamiento.

Between January 1992 and December 1998 we collected clinical, epidemiological and treatment data on all patients diagnosed of tuberculosis in our specialized unit. Five hundred sixty-seven patients (70% male and 30% female) were studied prospectively. The rate of new cases increased until 1995 and decreased during the last three years of study. Mean patient age was 38.8 years, with nearly 64% of patients under 45 years of age. Predisposing disease, mainly chronic alcoholism, was present in 36%. Fifteen percent belonged to a high-risk social group (6.5% were drug addicts and 6.3% lived inside secure institutions). The mean time elapsing from the appearance of symptoms until referral to our service was 80.4 days and the most common clinical picture at presentation was general unwellness with cough and expectoration (46%) followed by hemoptysis (18%). Cavitation was visible in 48.5% of x-rays, while alveolar infiltrates were seen in 33%, pleural effusion in 12% and lymph node involvement in 10%. Adult tuberculosis was diagnosed in 80% of cases, 10% were reactivations and 9% were primary. Bacteriological diagnosis was available for 85%. Therapy usually involved six months with hydrazide, rifampicin and pyrazinamide (81%). Therapy was generally well-tolerated, although analyses revealed some anomalies, such as transaminase alteration (18%) and hyperuricemia (19%). Therapy was changed because of toxicity in only 2.6%. Follow-up after therapy was strict and the rate of successful cure was 97.5%. We conclude that diagnosis was not prompt enough and believe that knowledge of epidemiological, clinical and evolutionary data, as well as monitoring of real rates of cure of treated patients justifies the existence of specialized centers for managing tuberculosis.

Unidad monográfica de tuberculosis: experiencia de 7 años de funcionamiento / Tuberculosis management unit: 7 years experience

Desde enero de 1992 hasta diciembre de 1998 y de forma prospectiva hemos recogido los datos clínicos, epidemiológicos y terapéuticos de todos los pacientes diagnosticados de tuberculosis (TBC) en nuestra unidad monográfica. Controlamos 567 pacientes (70 por ciento varones y 30 por ciento mujeres). Su número aumentó progresivamente hasta 1995 para ir descendiendo en los últimos 3 años. La edad media fue de 38,8 años, y un 64 por ciento de los pacientes eran menores de 45 años. El 36 por ciento presentaban alguna patología predisponente, principalmente etilismo crónico. Un 15 por ciento de los pacientes pertenecían a un grupo de riesgo social, especialmente adictos a drogas (6,5 por ciento) e ingresados en instituciones cerradas (6,3 por ciento). El tiempo medio transcurrido desde el comienzo de la sintomatología hasta ser remitidos a nuestra consulta fue de 80,4 días y la presentación clínica más frecuente consistió en sintomatología general junto a tos y expectoración (46 por ciento), seguida de hemoptisis (18 por ciento). Radiológicamente, un 48,5 por ciento de casos presentaron imágenes cavitadas, frente a un 33 por ciento de infiltrados alveolares, un 12 por ciento de derrames pleurales y un 10 por ciento de formas adenopáticas. Respecto a la forma patogénica inicial, un 80 por ciento de casos se consideraron tuberculosis inicial del adulto, un 10 por ciento recidivas y el 9 por ciento primoinfecciones TBC. Se consiguió un diagnóstico bacteriológico en el 85 por ciento de casos. La pauta más utilizada fue la de 6 meses con hidracida, rifampicina y piracinamida (81 por ciento), en general bien tolerada, aunque resultaron frecuentes algunos trastornos analíticos como la alteración de las transaminasas (18 por ciento) o la hiperuricemia (19 por ciento). Únicamente en el 2,6 por ciento de los casos hubo que modificarla por toxicidad. Se realizó un seguimiento estricto tras la finalización del tratamiento con un 97,5 por ciento de curaciones. Como conclusión encontramos excesiva la demora diagnóstica y creemos que el conocimiento de datos epidemiológicos, clínicos y evolutivos, así como un control de los porcentajes reales de curación de los pacientes tratados justifica la existencia de unidades monográficas de control de la tuberculosis. (AU)

Investigation of tuberculosis contacts in a nonhospital pneumology practice.

The aim of this study was to analyze the results of the tuberculosis contact tracing carried out in an outpatient pneumology setting and to assess its performance with regard to the detection of new cases of tuberculosis and infected contacts. One thousand two hundred and twenty-eight contacts of 302 tuberculosis patients were evaluated in the Tuberculosis Unit of the Dr. Fleming Specialities Center between 1992 and 1996. Contacts were categorized into groups with regard to bacteriological status of the index case (Group A, smear-positive; Group B, culture-positive only; Group C, smear- and culture-negative) and intimacy of exposure to the index case (close or casual). The possible association between the existence of infection or disease and the bacteriological status of the index case and degree of intimacy of exposure was analyzed. There were 582 infected contacts (47.4%) and 42 new cases of tuberculosis (3.4%), six of which were smear-positive. The proportion of infected and diseased contacts was significantly higher for those who had contact with smear-positive patients and those who had close contact with the index case. Chemoprophylaxis was completed in 431 (35.1%) of the contacts evaluated. Systematic investigation of contacts represents an efficient means of discovering new cases of tuberculosis and infection, especially among contacts of smear-positive index cases and among those who are closer to the index case. The administration of appropriate treatment to these contacts will contribute to controlling the transmission of tuberculosis within the community.

[Spontaneous pneumomediastinum as a complication of asthmatic crisis]. / Neumomediastino espontáneo como complicación de una crisis asmática.

Pneumomediastinum is an uncommon self-limited clinical entity which usually involves young adults. In asthmatic patients, the manifestation of pneumomediastinum as complication of an asthmatic crisis is considered to be a rare event, and its course is usually favourable with scarce complications. We report here the main clinical and epidemiologic characteristics in four patients with pneumomediastinum secondary to an asthmatic exacerbation, admitted to the Neumology Department in our hospital for a three year period. The clinical course of our patients was favourable, and the picture resolved with conventional medical therapy for the asthmatic crisis.

[Peripheral muscle strength in stable COPD patients: correlation with respiratory function variables and quality of life]. / Fuerza de los músculos periféricos en pacientes con EPOC estable: correlación con parámetros funcionales respiratorios y de calidad de vida.

The aim of this study was to assess peripheral muscle strength in patients with chronic obstructive pulmonary disease (COPD) using a simple test and to look for correlation with function variables, physiological strength variables and quality of life parameters. Twenty-three COPD patients with moderate to severe air-flow limitation (FEV1 = 39 +/- 12%) in stable phase but displaying inability to carry out daily tasks were enrolled. Peripheral muscle strength was assessed in all patients by measuring the maximum load in a single repetition of five simple upper and lower extremity exercises performed at a multi-gymnastics station. Results were compared to respiratory function variables (FVC, FEV1, FEV1/FVC and gasometry), to results of an exercise test on a cycle ergometer with monitoring of respiratory gases (VEmax, VO2max and Wmax), to endurance (minutes) to dyspnea (Mahler's scale) and to quality of life (Chronic Respiratory Disease Questionnaire-CRDQ). No relation between functional parameters and endurance in minutes was found. Minute ventilation (VE) proved to be significantly related to oxygen intake (VO) and maximum work in the stress test. Dyspnea on Mahler's scale was unrelated, but fatigue variables and emotional function variables on the CRDQ were related. We conclude that peripheral muscle strength is unrelated to level of flow limitation or exercise tolerance in COPD patients. Peripheral muscle strength is related, however, to maximum work load and some aspects of quality of life.

[Reproducibility of a shuttle walking test in patients with chronic obstructive pulmonary disease]. / Reproducibilidad de un test de paseo de carga progresiva (shuttle walking test) en pacientes con enfermedad pulmonar obstructiva crónica.

To analyze the reproducibility of the shuttle walking test (SWT) in comparison to the six min walking test in patients with chronic obstructive pulmonary disease (COPD). The stress tests were performed by 13 patients diagnosed of COPD with moderate-to-severe air flow obstruction (FEV1 45.85 +/- 18.82% of theoretical values). Each patient performed the SWT six times (twice a week over three consecutive weeks). The 6 min walking test was performed an equal number of times. At baseline and at the end of both types of test, heart rate and degree of dyspnea (on a modified version of Borg's scale) were recorded, as well as the level reached and the number of meters walked. No significant differences in distance walked, heart rate or degree of dyspnea were found for the six SWTs performed. The interclass correlation coefficients for the aforementioned parameters were 0.875, 0.879 and 0.896, respectively; the variation coefficient for distance covered ranged between -10.7% and 10.2%. In the six min walking test significant differences were seen between distance walked in the first two tests and the other four tests. The variation co-efficient ranged between 11.4% and 17.5%. The SWT is a reproducible stress test in which the patient must exert progressively greater effort. The low degree of variability observed assures that the level of effort attained is steady and consistent.

[Comparison of a shuttle walking test with an exertion test with cycloergometer in patients with COPD]. / Comparación de un test de paseo de carga progresiva (shuttle walking test) con una prueba de esfuerzo en cicloergómetro en pacientes con EPOC.

To validate a shuttle walking test in a group of patients with COPD, comparing responses to those produced by a conventional stress test limited by symptoms on the cycle ergometer, and to analyze the relation between the shuttle walking test and maximal effort parameters. We enrolled 20 patients with COPD, mean age 60 years (SD 7), FEV1/46.6% (SD 19.2) of theoretical value and FEV1/FVC% 47.3% (SD 11.2). All the patients underwent a maximal effort test on the cycle ergometer, determination of initial dyspnea by applying Mahler's baseline dyspnea index, and a quality of life questionnaire specific to COPD the Chronic Respiratory Disease Questionnaire). To compare the responses of patients to the two tests, we analyzed heart rate, dyspnea and lactic acid at the end of each test. To see the relations between the two tests, we examined distance walked and maximal effort parameters. The relation between the walking test and lung function parameters at rest, initial dyspnea and quality of life were also analyzed. No statistically significant differences were found for heart rate [128.2 (SD 19.8) versus 131.6 (SD 12.9)], dyspnea 17.1 (SD 1.78) versus 7.24 (SD 2.64)] or lactic acid [5.24 (SD 2.34) versus 6.19 (SD 2.12)] at the end of the tests. Distance covered on the shuttle walking test correlated significantly with V'O2ml/min/Kgmax (r = 0.71), as well as with the remaining parameters of maximal effort. There was only a slight relation between lung function at rest and quality of life. The COPD patient's cardiovascular, metabolic and subjective responses to the shuttle walking test are similar to those of the cycle ergometer test, and oxygen consumption is significantly correlated. The shuttle walking test gives a valid estimate of the functional capacity of COPD patients.