The impact of COPD on the private healthcare system in Brazil: an economic analysis / Impacto da DPOC no sistema de saúde privado no Brasil: uma análise econômica

Objective: To assess healthcare resource utilization and hospitalization costs of patients with chronic obstructive pulmonary disease (COPD) exacerbations in the Brazilian private healthcare system. Methods: A retrospective cohort study, considering data from an administrative database of a private company (Orizon). Patients aged ≥40 years old and with at least one COPD-related claim identified by the ICD-10 code (J40 to J44) at any time during the eligibility period (January/2010 to December/2013) were included in the analysis. Follow-up was performed until December/2014, death or inactivation of a health plan. Sociodemographic characteristics, number of emergency visits, hospital admissions (number and length of stay), length of hospital stay in an intensive care unit (ICU), number of severe COPD exacerbations, therapeutic approach, and hospitalization costs were assessed. Results: The analysis included 8,254 COPD patients. Emergency visits, hospital admission, and exacerbation rates were 0.4, 0.2, and 0.1 per person-year, respectively. The mean length of hospital stays and the length of stay of patients requiring or not ICU stay were 16.6 (SD = 77.0), 8.7 (SD = 36.9), and 27.6 (SD = 109.7), respectively. Mean costs associated to emergency department visits and hospitalizations were 258.2 BRL (SD = 383.1) and 38,165.4 BRL (SD = 124,683.5), respectively. Hospitalizations costs without ICU stay were 11,810.1 BRL (SD = 31,144.1) and 74,585.3 BRL (SD = 182,808.1) for those with ICU utilization. Conclusion: Costs for COPD management during disease exacerbation are very high and may reach almost 75 thousand BRL per hospitalization. The prevention of COPD exacerbations and better disease control may reduce the economic burden on the private healthcare system in Brazil.

Objetivo: Avaliar a utilização de recursos e custos de pacientes com exacerbação da doença pulmonar obstrutiva crônica (DPOC) no sistema de saúde suplementar (SSS) do Brasil. Métodos: Estudo de coorte retrospectiva, considerando banco de dados administrativo de uma empresa privada (Orizon). Pacientes com ≥40 anos e pelo menos um registro de admissão relacionado à DPOC identificado com CID-10 J40-J44, entre janeiro/2010 e dezembro/2013, foram incluídos e acompanhados até dezembro/2014, morte ou inativação no plano. Características sociodemográficas, número de visitas de emergência, admissões hospitalares (número e tempo de hospitalização), tempo de hospitalização em unidade de terapia intensiva (UTI), número de exacerbações graves, estratégias terapêuticas e custos hospitalares foram as variáveis analisadas. Resultados: A análise incluiu 8.254 pacientes com DPOC. As taxas de visita à emergência, internação hospitalar e exacerbação da doença foram de 0,4, 0,2 e 0,1 por pessoa-ano, respectivamente. Os tempos médios de hospitalização, hospitalização sem utilização de UTI e hospitalização com necessidade de UTI foram de 16,6 (DP = 77,0), 8,7 (DP = 36,9) e 27,6 (DP = 109,7) dias, respectivamente. Os custos médios relacionados à visita de emergência e por hospitalização foram de 258,2 BRL (DP = 383,1) e 38.165,4 BRL (DP = 124.683,5), respectivamente. Os custos para pacientes que não utilizaram UTI foram de 11.810,1 BRL (DP = 31.144,1) e de 74.585,3 BRL (DP = 182.808,1) para aqueles com necessidade desse serviço. Conclusão: Os custos para o manejo dos pacientes com exacerbação da DPOC são muito elevados, podendo chegar a 75.000 BRL por hospitalização. A prevenção de exacerbações e o melhor controle da doença podem reduzir esse impacto econômico no SSS.

The economic impact of asthma on private healthcare system in Brazil: Economic impact of asthma in Brazil.

To assess healthcare resource utilization and costs of patients with asthma in Brazilian Supplementary Healthcare System, focusing on hospitalization data. Retrospective cohort study, using data from an administrative database of a private company (Orizon). Patients aged ≥ 12 years with at least one record of emergency visit/hospitalization in the database with the ICD-10 J45 between January/2010 and June/2015 were included and followed until June/2016, death or inactivation of health plan. Sociodemographic characteristics, emergency visit and hospital admission per patient per year (exacerbation rate), physician visit with a procedure, exams, length of hospitalization (with/without intensive care unit (ICU)), and in-hospital treatments were assessed. A total of 54,568 patients were included in this analysis. Regarding resource utilization, emergency visit and hospital admission rates of 0.34 and 0.04 per person-year were observed, respectively. Mean length of hospital stay were 8.82 (SD = 36.48), 5.24 (SD = 19.06) and 19.53 (63.89) days for hospitalizations in general, without and with ICU, respectively. An exacerbation rate of 0.36 per person year was observed with a mean cost per episode of 3178 Brazilian Real (BRL) (SD = 31,667). Mean cost related to emergency department visits was estimated at 293 BRL (SD = 328). Hospitalization costs were stratified by the need of ICU and values observed were of 9307 BRL (SD = 18,979) without ICU, and 75,252 BRL (SD = 174,248) with ICU need. Asthma exacerbations may cost ~75,000 BRL for an ICU-dependent event in the Supplementary Healthcare System. To improve disease control may reduce disease burden for both healthcare system and patients.

Upper Limb Anaerobic Metabolism Capacity is Reduced in Mild and Moderate COPD Patients.

Limited information is available regarding the role of anaerobic metabolism capacity on GOLD 1 and 2 COPD patients during upper limb exercise. We aimed to compare the upper limb anaerobic power capacity, blood lactate concentration, cardiovascular and respiratory responses, in male COPD patients versus healthy subjects during the 30-s Wingate anaerobic test (WAnT). The rate of fatigue and time constant of the power output decay (τ, tau) were also calculated and a regression analysis model was built to assess the predictors of τ in these patients. Twenty-four male COPD patients (post-bronchodilator FEV1 73.2 ± 15.3% of predicted) and 17 healthy subjects (FEV1 103.5 ± 10.1% of predicted) underwent the WAnT. Measurements were performed at rest, at the end of the WAnT, and during 3' and 5' of recovery time. Peak power (p = 0.04), low power (p = 0.002), and mean power output (p = 0.008) were significantly lower in COPD patients than in healthy subjects. Power output decreased exponentially in both groups, but at a significantly faster rate (p = 0.007) in COPD patients. The time constant of power decay was associated with resistance (in ohms) and fat-free mass (r2 = 0.604, adjusted r2 = 0.555, and p = 0.002). Blood lactate concentration was significantly higher in healthy subjects at the end of the test, as well as during 3' and 5' of recovery time (p < 0.01). Compared with healthy subjects, COPD patients with GOLD 1 and 2 presented lower upper limb anaerobic capacity and a faster rate of power output decrease during a maximal intensity exercise. Also, the WAnT proved to be a valid tool to measure the upper limb anaerobic capacity in these patients.

Gender differences in the perception of asthma respiratory symptoms in five Latin American countries.

OBJECTIVES: To determine the differences between sexes in perceptions of asthma symptoms, asthma control, daily activities, and symptom exacerbation in Latin American countries. METHODS: This cross-sectional study was performed using data from the Latin America Asthma Insight and Management (LA-AIM) study (n = 2167) carried out in Argentina, Brazil, Mexico, Venezuela, and Puerto Rico. Face-to-face interviews were conducted, and patients orally completed a 53-question survey assessing five main domains of asthma: symptoms, impact on daily activities, disease control, exacerbation, and treatment/medication. RESULTS: Of the 2167 participants, 762 (35.2%) were males and 1405 (64.8%) were females. Male participants smoked more than females, but history of rhinitis and allergies was more common in females (p < 0.05). Women aged 18-40 years had a higher proportion of uncontrolled asthma compared to men of the same age (37.8% and 30.0%, respectively). A higher proportion of symptomatic females reported more frequent symptoms (daytime cough, shortness of breath, breathlessness/wheezing, sputum, tightness in the chest, etc.) than males (p < 0.05). Females also experienced more limitations in sports/recreational activities, normal physical exertion, social activities, sleep, and daily activities. Females consulted with health professionals more often than males (67.8% and 59.6%, respectively; p < 0.05). Asthma caused a feeling of lack of control over life in 42.6% of females and 31.4% of males. CONCLUSION: In Latin America, females report more asthma symptoms, poorer asthma control, more impact on their daily activities, and more visits with health professionals than males.

Perspective of Pulmonary Rehabilitation Centers in Latin America.

Pulmonary rehabilitation (PR) is a mandatory component of a comprehensive treatment of patients with chronic respiratory disease. However, there is no officially published data about PR Centers in Latin America.The objetive is to identify Latin American Pulmonary Rehabilitation Centers and evaluate their characteristics and organizational aspects.A cross-sectional study with the Pulmonary Rehabilitation Centers indicated by the Latin American Respiratory and Physiotherapy Societies and by our own personal survey among physicians and physiotherapists. An eletronic transmission questionnaire with 20 questions was sent to the Coordinator of each one of the Centers.217 Pulmonary Rehabilitation Centers were found throughout Latin America and a total of 160 (73.7%) Centers answered the questionnaire. Of these, 65.8% had private administration; 68.8% had an associated program for patients with heart disease; programs lasted an average of 24 sessions; the rehabilitation team consisted mainly of physiotherapists, physicians and dietitians; 90.6% of the centers evaluated the patients with different questionnaires; 91.9% used treadmill and 90.6% bicycle for exercises of lower limbs and 80.1% proprioceptive neuromuscular facilitation technique with weights to train the upper limbs of their patients; 55.6% had an educational program and 36.9% presented a home-based program.There has been a great increase in the number of Latin American Pulmonary Rehabilitation Centers, presenting diversity in organizational aspects.

Detected SARS-CoV-2 in Ascitic Fluid Followed by Cryptococcemia: a Case Report.

SARS coronavirus-2 (SARS-CoV-2) detection in different clinical specimens has raised important insights about its pathogenesis, but some details remain to be understood. In that respect, disrupt viral control seen in solid organ transplant patients on chronic immunosuppression can help unveil pathogenic mechanisms and characterize new coronavirus disease-19 (COVID-19) immunological and clinical aspects, as well as secondary complications. We herein report a case of SARS-CoV-2 detection in ascitic fluid from a kidney transplant patient with decompensated cirrhosis and COVID-19 and then discuss about immune, cellular, and virological aspects of such clinical presentation of the disease, which also included a disseminated infection, demonstrated by viral detection in his blood sample. We subsequently discuss about the fatal outcome caused by a secondary bloodstream infection by Cryptococcus neoformans. This unprecedented case report presents ascitic fluid as a novel specimen in which SARS-CoV-2 can be detected. Immune dysregulation and cumulative risk factors may lead to secondary infections by opportunistic agents, including Cryptococcus neoformans.

Impact of asthma control on different age groups in five Latin American countries.

BACKGROUND: Asthma is a chronic airway inflammatory condition of the airway and is classified as controlled, partially controlled, and uncontrolled. Patients with uncontrolled asthma are at greater risk for hospitalizations and visits to emergencies, and the condition has greater impact on their daily lives. The aim of this study was to evaluate asthma control, the use of health resources, and asthma's impact on the activities of daily living of patients with different age groups in 5 Latin American countries. METHODS: This was a retrospective analysis of The Latin America Asthma Insights and Management (LA AIM) study carried out in Argentina, Brazil, Mexico, Venezuela, and Puerto Rico. Asthmatics were splited into 3 age groups: 12-17, >17-40 and > 40 years old. An interview face to face was carried out and patients answered a questionnaire of 53 questions related to 5 main domains of asthma: symptoms, impact of asthma on daily living activities, patients' perceptions of asthma control, exacerbations, and treatment/medication. RESULTS: A total of 2167 asthmatics were interviewed. There was a low percentage of controlled patients (mean 9%) in all 3 groups with no particular difference among the five countries, but Venezuelan patients had a 71% chance of having uncontrolled asthma (p < 0.001). CONCLUSION: In the 3 age groups, patients experienced poor asthma control, with no significant differences among the countries. Patients who used control medication had a greater chance of controlling their asthma, and those who had emergency health care visits had a greater chance of having uncontrolled asthma.

The Glittre ADL-Test Differentiates COPD Patients with and without Self-Reported Functional Limitation.

The Glittre ADL-test is based on important and common activities of daily living (ADLs), and it is an useful test to objectively distinguish patients with and without self-reported functional limitations. This study aims to analyze if difficulty to perform ADLs, as self-reported by patients with COPD, would reflect a worse Glittre ADL-test performance. In the first visit, patients were evaluated for clinical and nutritional status, spirometry, maximal cardiopulmonary exercise test on a treadmill. One week later, the patients performed two Glittre ADL-tests. Maximal voluntary ventilation (MVV) and the VEGlittre/MVV, VO2Glittre/VO2peak, and HRGlittre/HRpeak ratios were calculated to analyze the ventilatory, metabolic, and cardiac reserves. The London Chest Activity of Daily Living (LCADL) scale was only answered after the two Glittre ADL-test were performed. Patients were splited into two subgroups based on the anchor question of the LCADL: those with and those without self-reported ADL limitation. Sixty-two COPD patients were included (65.3 ± 8.6 years, FEV1 62 ± 22%pred). Those with ADL limitation (39 patients) completed the Glittre ADL-test with a significantly longer time (p = 0.002), as well as higher VEGlittre/MVV (p = 0.005) and lower oxygen pulse (p = 0.021) than those without ADL limitation. The time spent to perform the Glittre ADL-test was significantly associated with total LCADL score (ρ = 0.327, p < 0.05). A cutoff of 253 s was able to distinguish those patients without and with ADL limitation. COPD patients who self-reported ADL limitation according to the LCADL scale took a longer time to perform the Glittre ADL-test with higher VEGlittre/MVV and lower oxygen pulse than those without ADL limitation.

Anthropometric status of individuals with COPD in the city of São Paulo, Brazil, over time - analysis of a population-based study.

OBJECTIVE: To evaluate the anthropometric data obtained for residents of the city of São Paulo, Brazil, in a study of Latin America conducted in two phases (baseline, in 2003, and follow-up, in 2012). METHODS: This was an analysis of data obtained for São Paulo residents in a two-phase population-based study evaluating the prevalence of COPD and its relationship with certain risk factors among individuals ≥ 40 years of age. The anthropometric data included values for weight, height, body mass index (BMI), and waist circumference. In the follow-up phase of that study, the same variables were evaluated in the same population sample as that of the baseline phase. RESULTS: Of the 1,000 São Paulo residents enrolled in the baseline phase of that study, 587 participated in the follow-up phase, and 80 (13.6%) of those 587 subjects had COPD. Comparing the baseline and follow-up phases, we found increases in all anthropometric measures in both groups (COPD and non-COPD), although the differences were significant only in the non-COPD group. The subjects with mild COPD showed increases in weight and BMI (Δweight = 1.6 ± 5.7 and ΔBMI = 0.7 ± 2.2), whereas those with moderate or severe COPD showed reductions (Δweight = -1.7 ± 8.1 and ΔBMI = -0.4 ± 3.0), as did those with severe or very severe COPD (Δweight = -0.5 ± 5.4 and ΔBMI = -0.8 ± 3.3). CONCLUSIONS: Between the two phases of the study, the subjects with mild COPD showed increases in weight and BMI, whereas those with a more severe form of the disease showed reductions.

Frequency of Osteoporosis and Vertebral Fractures in Chronic Obstructive Pulmonary Disease (COPD) Patients / Incidencia de osteoporosis y fracturas vertebrales en pacientes con enfermedad pulmonar obstructiva crónica (EPOC)

Background: Osteoporosis is a systemic skeletal disease characterized by low bone mass and/or microarchitectural deterioration of bone. Osteoporosis is a risk factor for fractures specially in patients with advanced COPD. The aim of this cross-sectional study was to determine the frequency of osteoporosis and vertebral fracture in COPD patients. Methods: We evaluated 91 COPD patients and compared to 82 healthy subjects (control group) matched for gender and age. We measured the bone mineral density by means of dual energy X-ray absorptiometry (DXA), evaluating the lumbar vertebra (L1-L4), proximal femur and total femur and evaluated vertebral fractures in thoracic and lumbar spine using X-ray. We questioned patients whether they had had any fall that resulted in any fracture in the past five years. Results: Males comprised 60.4% of COPD group and 57.3% of the control group. Mean age was 66.2 ± 9.2 years for COPD group and 64.,2 ± 8.8 for the control group. The frequency of osteoporosis in the COPD group was 29.7% and 18.3% in control group (p = 0.007). The frequency of vertebral fractures was 18.6% in the COPD group and 9.0% in control group (p = 0.06). The frequency of reported falls at resulting in any fracture was 36.3% in the COPD group and 7.3% in control group (p = 0.001). Conclusions: Our data indicate that COPD patients present a high frequency of osteoporosis and falls seem to be an important factor for vertebral fracture

Introducción: La osteoporosis es una enfermedad sistémica esquelética caracterizada por una baja densidad ósea y/o un deterioro de la microarquitectura del hueso. Constituye un factor de riesgo de fracturas, especialmente en pacientes con EPOC avanzada. El objetivo de este estudio transversal fue determinar la incidencia de osteoporosis y de fracturas vertebrales en pacientes con EPOC. Métodos: Se evaluaron 91 pacientes con EPOC y se compararon con 82 sujetos sanos (grupo control) emparejados por sexo y edad. Se midió la densidad mineral ósea mediante densitometría ósea (DXA) de la vértebra lumbar (L1-L4), el fémur proximal y el fémur total. Las fracturas en vértebras torácicas y lumbares se evaluaron mediante rayos X. Se preguntó a los pacientes por posibles caídas en los últimos cinco años que pudieran haber resultado en fractura. Resultados: Los hombres representaron el 60,4% del grupo EPOC y el 57,3% del grupo control. La edad media fue 66,2 ± 9,2 años en el grupo EPOC, y 64,2 ± 8,8 años en el grupo control. La incidencia de osteoporosis en el grupo EPOC fue del 29,7%, y del 18,3% en el grupo control (p = 0,06). Se registró una incidencia de caídas resultantes en fracturas del 36,3% en el grupo EPOC y del 7,3% en el grupo control (p = 0,001). Conclusión: Nuestros datos sugieren que los pacientes con EPOC presentan una mayor incidencia de osteoporosis. Las caídas parecen ser un factor relevante en la fractura vertebral

The Importance of Inhaler Adherence to Prevent COPD Exacerbations.

It has been shown that the better outcomes of chronic obstructive pulmonary disease (COPD) are closely associated with adherence to drug therapy, independent of the treatment administered. The clinical trial Towards a Revolution in COPD Health (TORCH) study clearly showed in a three year follow up that patients with good adherence to their inhaler treatment presented a longer time before the first exacerbation, a lower susceptibility to exacerbation and lower all-cause mortality. The Latin American Study of 24-hour Symptoms in Chronic Obstructive Pulmonary Disease (LASSYC), a real-life study, evaluated the self-reported inhaler adherence in COPD patients in seven countries in a cross-sectional non-interventional study and found that approximately 50% of the patients had good adherence, 30% moderate adherence and 20% poor adherence. Adherence to inhaler may be evaluated by the specific inhaler adherence questionnaire, the Test of Adherence to Inhalers (TAI). Several factors may predict the incorrect use of inhalers or adherence in COPD outpatient, including the number of devices and the daily dosing frequency. Ideally, patient education, simplicity of the device operation, the use of just one device for multiple medications and the best adaptation of the patient to the inhaler should guide the physician in prescribing the device.

Frequency of Osteoporosis and Vertebral Fractures in Chronic Obstructive Pulmonary Disease (COPD) Patients.

BACKGROUND: Osteoporosis is a systemic skeletal disease characterized by low bone mass and/or microarchitectural deterioration of bone. Osteoporosis is a risk factor for fractures specially in patients with advanced COPD. The aim of this cross-sectional study was to determine the frequency of osteoporosis and vertebral fracture in COPD patients. METHODS: We evaluated 91 COPD patients and compared to 82 healthy subjects (control group) matched for gender and age. We measured the bone mineral density by means of dual energy X-ray absorptiometry (DXA), evaluating the lumbar vertebra (L1-L4), proximal femur and total femur and evaluated vertebral fractures in thoracic and lumbar spine using X-ray. We questioned patients whether they had had any fall that resulted in any fracture in the past five years. RESULTS: Males comprised 60.4% of COPD group and 57.3% of the control group. Mean age was 66.2±9.2 years for COPD group and 64.2±8.8 for the control group. The frequency of osteoporosis in the COPD group was 29.7% and 18.3% in control group (p=0.007). The frequency of vertebral fractures was 18.6% in the COPD group and 9.0% in control group (p=0.06). The frequency of reported falls at resulting in any fracture was 36.3% in the COPD group and 7.3% in control group (p=0.001). CONCLUSIONS: Our data indicate that COPD patients present a high frequency of osteoporosis and falls seem to be an important factor for vertebral fracture.

Anthropometric status of individuals with COPD in the city of São Paulo, Brazil, over time - analysis of a population-based study / Análise evolutiva antropométrica em indivíduos com DPOC na cidade de São Paulo - estudo de base populacional

ABSTRACT Objective: To evaluate the anthropometric data obtained for residents of the city of São Paulo, Brazil, in a study of Latin America conducted in two phases (baseline, in 2003, and follow-up, in 2012). Methods: This was an analysis of data obtained for São Paulo residents in a two-phase population-based study evaluating the prevalence of COPD and its relationship with certain risk factors among individuals ≥ 40 years of age. The anthropometric data included values for weight, height, body mass index (BMI), and waist circumference. In the follow-up phase of that study, the same variables were evaluated in the same population sample as that of the baseline phase. Results: Of the 1,000 São Paulo residents enrolled in the baseline phase of that study, 587 participated in the follow-up phase, and 80 (13.6%) of those 587 subjects had COPD. Comparing the baseline and follow-up phases, we found increases in all anthropometric measures in both groups (COPD and non-COPD), although the differences were significant only in the non-COPD group. The subjects with mild COPD showed increases in weight and BMI (Δweight = 1.6 ± 5.7 and ΔBMI = 0.7 ± 2.2), whereas those with moderate or severe COPD showed reductions (Δweight = −1.7 ± 8.1 and ΔBMI = −0.4 ± 3.0), as did those with severe or very severe COPD (Δweight = −0.5 ± 5.4 and ΔBMI = −0.8 ± 3.3). Conclusions: Between the two phases of the study, the subjects with mild COPD showed increases in weight and BMI, whereas those with a more severe form of the disease showed reductions.

RESUMO Objetivo: Avaliar a evolução dos dados antropométricos obtidos em uma pesquisa latino-americana realizada em duas fases (basal, em 2003, e seguimento, em 2012) na cidade de São Paulo. Métodos: Estudo de base populacional que avaliou indivíduos com idade ≥ 40 anos com o objetivo de definir a prevalência da DPOC e sua relação com alguns fatores de risco. A avaliação antropométrica incluiu medições de peso, altura, índice de massa corpórea (IMC) e circunferência abdominal. Foram avaliadas as mesmas variáveis na mesma população na fase de seguimento. Resultados: Dos 1.000 indivíduos incluídos inicialmente, 587 participaram da fase de seguimento; desses, 80 (13,6%) tinham DPOC. Entre a avaliação inicial e a de seguimento ambos os grupos (DPOC e não DPOC) apresentaram aumentos nas medidas antropométricas, mas esses somente foram significativos no grupo não DPOC. Os indivíduos com DPOC leve tiveram aumentos de peso e IMC (Δpeso = 1,6 ± 5,7 kg e ΔIMC = 0,7 ± 2,2 kg/m2) enquanto aqueles com doença moderada ou grave tiveram reduções dessas medidas (DPOC moderada: Δpeso = −1,7 ± 8,1 kg e ΔIMC = −0,4 ± 3,0 kg/m2; e DPOC grave ou muito grave (Δpeso = −0,5 ± 5,4 kg e ΔIMC = −0,8 ± 3,3 kg/m2). Conclusões: Entre as duas fases da pesquisa, os pacientes com DPOC leve tiveram aumento de peso e IMC, enquanto aqueles com doença mais grave apresentaram perda ponderal e redução do IMC.

Chronic Obstructive Pulmonary Disease Exacerbations Are Influenced by Gastroesophageal Reflux Disease.

Gastroesophageal reflux disease (GERD) is associated with different pulmonary diseases, including chronic obstructive pulmonary disease (COPD). Whether GERD is contributory to COPD severity remains unclear. This study aims to evaluate the contribution of GERD to the clinical manifestation of COPD based on ventilatory parameters and yearly clinical exacerbations. We studied 48 patients (56% females, age 66 years) with COPD. All patients underwent high-resolution manometry and esophageal pH monitoring. The patients were separated into two groups according to the presence of GERD. GERD was present in 21 (44%) patients. GERD + and GERD - groups did not differ in regard to gender, age, and body mass index. Pulmonary parameters were not different in the absence or presence of GERD. The number of yearly exacerbations was higher in patients GERD+. The severity of GERD (as measured by DeMeester score) correlated with the number of exacerbations. Our results show the following: 1) GERD does not influence pulmonary parameters and 2) GERD is associated with a higher number of annual clinical exacerbations. We believe GERD must be objectively tested in patients with COPD because the prevalence of GERD in these patients is underestimated when only symptoms are considered. GERD treatment might decrease the frequency of episodes of exacerbation.

Evaluation of obstructive sleep apnea in non-cystic fibrosis bronchiectasis: A cross-sectional study.

The relationship between sleep disorders and bronchiectasis has not been well described. We hypothesize that, due to the irreversible dilatation of the bronchi, the presence of secretions, and airflow obstruction, patients with non-cystic fibrosis bronchiectasis may be predisposed to hypoxemia during sleep, or to symptoms that may lead to arousal. A cross-sectional observational study was performed involving 49 patients with a clinical diagnosis of non-cystic fibrosis bronchiectasis (NCFB). All patients underwent clinical evaluation, spirometry, and polysomnography, and were evaluated for the presence of excessive daytime sleepiness (EDS) and risk of obstructive sleep apnea (OSA). The mean age of the participants was 50.3 ± 13.6 years; 51.1% of patients were male and had a mean body mass index of 23.8 ± 3.4 kg/m2. The mean total sleep time (TST) was 325.15 ± 64.22 min with a slight reduction in sleep efficiency (84.01 ± 29.2%). Regarding sleep stages, stage 1 sleep and REM sleep were abnormal. OSA was present in 40.82% of the patients. The mean arousal index was 5.6 ± 2.9/h and snoring was observed in 71.43% of the patients. The oxygen desaturation index (ODI) was 14.35 ± 15.36/h, mean minimum oxygen saturation (SpO2 nadir) was 83.29 ± 7.99%, and mean TST with an SpO2 less than 90% was 30.21 ± 60.48 min. EDS was exhibited by 53.06% of the patients and 55.1% were at high risk of developing OSA. The patients infected by Pseudomonas aeruginosa had higher apnea-hypopnea indices, ODI, and TST with SpO2 < 90%, and lower values of SpO2 nadir. Adult patients with clinically stable NCFB, especially those infected by Pseudomonas aeruginosa, display EDS and a high prevalence of OSA, associated with considerable oxygen desaturation during sleep.

Physiological Requirements to Perform the Glittre Activities of Daily Living Test by Subjects With Mild-to-Severe COPD.

BACKGROUND: The Glittre activities of daily living (ADL) test is supposed to evaluate the functional capacity of COPD patients. The physiological requirements of the test and the time taken to perform it by COPD patients in different disease stages are not well known. The objective of this work was to compare the metabolic, ventilatory, and cardiac requirements and the time taken to carry out the Glittre ADL test by COPD subjects with mild, moderate, and severe disease. METHODS: Spirometry, Medical Research Council questionnaire, cardiopulmonary exercise test, and 2 Glittre ADL tests were evaluated in 62 COPD subjects. Oxygen uptake (V̇O2 ), carbon dioxide production, pulmonary ventilation, breathing frequency, heart rate, SpO2 , and dyspnea were analyzed before and at the end of the tests. Maximum voluntary ventilation, Glittre peak V̇O2 /cardiopulmonary exercise test (CPET) peak V̇O2 , Glittre V̇E/maximum voluntary ventilation, and Glittre peak heart rate/CPET peak heart rate ratios were calculated to analyze their reserves. RESULTS: Subjects carried out the Glittre ADL test with similar absolute metabolic, ventilatory, and cardiac requirements. Ventilatory reserve decreased progressively from mild to severe COPD subjects (P < .001 for Global Initiative for Chronic Obstructive Lung Disease [GOLD] 1 vs GOLD 2, P < .001 for GOLD 1 vs GOLD 3, and P < .001 for GOLD 2 vs GOLD 3). Severe subjects with COPD presented a significantly lower metabolic reserve than the mild and moderate subjects (P = .006 and P = .043, respectively) and significantly lower Glittre peak heart rate/CPET peak heart rate than mild subjects (P = .01). Time taken to carry out the Glittre ADL test was similar among the groups (P = .82 for GOLD 1 vs GOLD 2, P = .19 for GOLD 1 vs GOLD 3, and P = .45 for GOLD 2 vs GOLD 3). CONCLUSIONS: As the degree of air-flow obstruction progresses, the COPD subjects present significant lower ventilatory reserve to perform the Glittre ADL test. In addition, metabolic and cardiac reserves may differentiate the severe subjects. These variables may be better measures to differentiate functional performance than Glittre ADL time.

Comparative Postural Control in COPD Patients and Healthy Individuals During Dynamic and Static Activities.

PURPOSE: Patients with chronic obstructive pulmonary disease (COPD) have body balance deficits, with consequent fall risk. It is possible that body sway in patients with COPD affects their ability to perform daily activities. The purpose of this study was to determine whether body balance is similar in patients with COPD and healthy persons when performing static and dynamic activities. In addition, we wanted to assess whether impairment of balance is related to the presence of falls in patients with COPD. METHODS: This is a cross-sectional study, in which every spirometric classification in patients with COPD (mild, moderate, severe, and very severe degrees) and age-matched healthy subjects was assessed. Subjects who were current smokers and patients who underwent physical training in the last 6 months prior to the start of the study were excluded. Static balance was assessed by computerized posturography and dynamic body balance using the Berg Balance Scale. RESULTS: Ninety-three patients with COPD and 39 healthy persons were evaluated. Mean age was 67.3 (10.8) and 65.1 (9.7) years and mean forced expiratory volume in 1 second (FEV1) was 50.4 (19.0) and 89.2 (23.6) for patients with COPD and healthy individuals, respectively. The impairment of body balance was higher for the group of patients with COPD (P = .0005). Patients with greater impairment in body balance had greater incidence of falls, and body balance was more affected with age in patients with COPD than in healthy persons. CONCLUSION: Impairment of body balance is more frequent in patients with COPD than in healthy persons while performing dynamic activities, and a greater incidence of falls activities was also found for this group.

Prevalence of alpha-1 antitrypsin deficiency and allele frequency in patients with COPD in Brazil.

OBJECTIVE:: To determine the prevalence of alpha 1-antitrypsin (AAT) deficiency (AATD), as well as allele frequency, in COPD patients in Brazil. METHODS:: This was a cross-sectional study involving 926 COPD patients 40 years of age or older, from five Brazilian states. All patients underwent determination of AAT levels in dried blood spot (DBS) samples by nephelometry. Those with DBS AAT levels ≤ 2.64 mg/dL underwent determination of serum AAT levels. Those with serum AAT levels of < 113 mg/dL underwent genotyping. In case of conflicting results, SERPINA1 gene sequencing was performed. RESULTS:: Of the 926 COPD patients studied, 85 had DBS AAT levels ≤ 2.64 mg/dL, and 24 (2.6% of the study sample) had serum AAT levels of < 113 mg/dL. Genotype distribution in this subset of 24 patients was as follows: PI*MS, in 3 (12.5%); PI*MZ, in 13 (54.2%); PI*SZ, in 1 (4.2%); PI*SS, in 1 (4.2%); and PI*ZZ, in 6 (25.0%). In the sample as a whole, the overall prevalence of AATD was 2.8% and the prevalence of the PI*ZZ genotype (severe AATD) was 0.8. CONCLUSIONS:: The prevalence of AATD in COPD patients in Brazil is similar to that found in most countries and reinforces the recommendation that AAT levels be measured in all COPD patients. OBJETIVO:: Determinar a prevalência da deficiência de alfa 1-antitripsina (AAT), bem como a frequência alélica, em pacientes com DPOC no Brasil. MÉTODOS:: Estudo transversal com 926 pacientes com DPOC, com 40 anos ou mais, oriundos de cinco estados brasileiros. Todos os pacientes foram submetidos a dosagem de AAT em amostras de sangue seco por meio de nefelometria. Aqueles em que a concentração de AAT no sangue seco foi ≤ 2,64 mg/dl foram submetidos a dosagem sérica de AAT. Aqueles em que a concentração sérica de AAT foi < 113 mg/dl foram submetidos a genotipagem. Quando os resultados foram discrepantes, foi realizado o sequenciamento do gene SERPINA1. Dos 926 pacientes com DPOC estudados, 85 apresentaram concentração de AAT em sangue seco ≤ 2,64 mg/dl, e 24 (2,6% da amostra) apresentaram concentração sérica de AAT < 113 mg/dl. A distribuição genotípica nesse subgrupo de 24 pacientes foi a seguinte: PI*MS, em 3 (12,5%); PI*MZ, em 13 (54,2%); PI*SZ, em 1 (4,2%); PI*SS, em 1 (4,2%); e PI*ZZ, em 6 (25,0%). Na amostra estudada, a prevalência global da deficiência de AAT foi de 2,8% e a prevalência do genótipo PI*ZZ (deficiência grave de AAT) foi de 0,8%. CONCLUSÕES:: A prevalência da deficiência de AAT em pacientes com DPOC no Brasil é semelhante àquela encontrada na maioria dos países e reforça a recomendação de que se deve medir a concentração de AAT em todos pacientes com DPOC.

Prevalence of alpha-1 antitrypsin deficiency and allele frequency in patients with COPD in Brazil / Prevalência da deficiência de alfa-1 antitripsina e frequência alélica em pacientes com DPOC no Brasil

ABSTRACT Objective: To determine the prevalence of alpha 1-antitrypsin (AAT) deficiency (AATD), as well as allele frequency, in COPD patients in Brazil. Methods: This was a cross-sectional study involving 926 COPD patients 40 years of age or older, from five Brazilian states. All patients underwent determination of AAT levels in dried blood spot (DBS) samples by nephelometry. Those with DBS AAT levels ≤ 2.64 mg/dL underwent determination of serum AAT levels. Those with serum AAT levels of < 113 mg/dL underwent genotyping. In case of conflicting results, SERPINA1 gene sequencing was performed. Results: Of the 926 COPD patients studied, 85 had DBS AAT levels ≤ 2.64 mg/dL, and 24 (2.6% of the study sample) had serum AAT levels of < 113 mg/dL. Genotype distribution in this subset of 24 patients was as follows: PI*MS, in 3 (12.5%); PI*MZ, in 13 (54.2%); PI*SZ, in 1 (4.2%); PI*SS, in 1 (4.2%); and PI*ZZ, in 6 (25.0%). In the sample as a whole, the overall prevalence of AATD was 2.8% and the prevalence of the PI*ZZ genotype (severe AATD) was 0.8% Conclusions: The prevalence of AATD in COPD patients in Brazil is similar to that found in most countries and reinforces the recommendation that AAT levels be measured in all COPD patients.

RESUMO Objetivo: Determinar a prevalência da deficiência de alfa 1-antitripsina (AAT), bem como a frequência alélica, em pacientes com DPOC no Brasil. Métodos: Estudo transversal com 926 pacientes com DPOC, com 40 anos ou mais, oriundos de cinco estados brasileiros. Todos os pacientes foram submetidos a dosagem de AAT em amostras de sangue seco por meio de nefelometria. Aqueles em que a concentração de AAT no sangue seco foi ≤ 2,64 mg/dl foram submetidos a dosagem sérica de AAT. Aqueles em que a concentração sérica de AAT foi < 113 mg/dl foram submetidos a genotipagem. Quando os resultados foram discrepantes, foi realizado o sequenciamento do gene SERPINA1. Dos 926 pacientes com DPOC estudados, 85 apresentaram concentração de AAT em sangue seco ≤ 2,64 mg/dl, e 24 (2,6% da amostra) apresentaram concentração sérica de AAT < 113 mg/dl. A distribuição genotípica nesse subgrupo de 24 pacientes foi a seguinte: PI*MS, em 3 (12,5%); PI*MZ, em 13 (54,2%); PI*SZ, em 1 (4,2%); PI*SS, em 1 (4,2%); e PI*ZZ, em 6 (25,0%). Na amostra estudada, a prevalência global da deficiência de AAT foi de 2,8% e a prevalência do genótipo PI*ZZ (deficiência grave de AAT) foi de 0,8%. Conclusões: A prevalência da deficiência de AAT em pacientes com DPOC no Brasil é semelhante àquela encontrada na maioria dos países e reforça a recomendação de que se deve medir a concentração de AAT em todos pacientes com DPOC.

Sponsored multicentric clinical research conducted in Brazil in the respiratory area - losses and gains.

OBJECTIVE: To evaluate the sponsored centers for clinical trial in the respiratory care setting in Brazil: profile; logistics and structure. METHODS: Principal investigators (29) and subinvestigators (30) of 39 research centers completed the questionnaires that addressed personal identification and training of researchers, the centers' facilities and advantages and/or disadvantages of performing sponsored trials. RESULTS: 75.6% of the centers were located in southern and southeastern Brazil. Most principal investigators were men with a mean age of 53.4 years. The clinical trials in the respiratory care setting focus on asthma and chronic obstructive pulmonar disease (COPD). 80% of the researchers cited delay of the Conep and Anvisa as a barrier to performing research. The advantages of participating in clinical trials were updating knowledge of the researcher and the team, and additional income for the team. The main disadvantages mentioned by the researchers included low financial compensation for the performed workload, and time availability. The median number of professionals per research center was six people, predominantly physicians. CONCLUSION: The number of research centers in the respiratory care setting in Brazil is still relatively small. The teams have good training for performing the clinical trials. Asthma and COPD are the most studied diseases in sponsored clinical trials. The main barrier is delay by the Conep and Anvisa. The factors that lead investigators to participate range from being updated along with the team, to site and staff financial issues; the main disadvantage is the low compensation for the required workload demand.