Antonio Monteiro da Silva Chibante

Rendimento de variáveis clínicas, radiológicas e laboratoriais para o diagnóstico da tuberculose pleural

BACKGROUND: In Brazil, tuberculosis is the major cause of pleural effusion. In more than 50% of cases, treatment has been initiated prior to confirmation of the diagnosis. Our objective was to identify factors that can contribute to the diagnosis. METHOD: We studied 215 consecutive patients with pleural effusion: 104 from tuberculosis (TB) and 111 from other causes (41 were from malignancies, 29 involved transudation, 28 were parapneumonic and 13 were from other etiologies). Clinical, radiological and laboratorial variables were evaluated for differences between the two groups, individually or in combination. RESULTS: Male gender and PPD > 10 mm were significantly more frequent in the tuberculosis group. Radiological features were similar in both groups. Among the continuous variables, adenosine deaminase (ADA), percentile of cells, protein and age performed better as isolated diagnostic criteria. Between the group with tuberculosis and that with pleural effusion from other causes, no significant differences were found in Lactate dehydrogenase, total leukocytes or duration of disease. The correlation of ADA with any other well-developed continuous variable showed an LR+ > 10 and an LR- 39 at 95% sensitivity, the specificity can be improved to more than 90% if we consider non purulent effusion or effusion with a predominance of lymphocytes (> 50%).

Dosagem de proteínas totais e desidrogenase lática para o diagnóstico de transudatos e exsudatos pleurais: redefinindo o critério clássico com uma nova abordagem estatística

OBJECTIVE To propose a new classification criterion for the differentiation between pleural exudates and transudates-quantifying total proteins in pleural fluid (TP-PF) and lactate dehydrogenase in pleural fluid (LDH-PF) exclusively-as well as to compare this new criterion with the classical criterion in terms of diagnostic yield. METHODS This was an observational, cross-sectional study with a within-subject design, comprising 181 patients with pleural effusion treated at two university hospitals in the state of Rio de Janeiro, Brazil, between 2003 and 2006. The diagnostic parameters included in the classical criterion were identified, as were those included in the new criterion. RESULTS Of the 181 patients, 152 and 29 were diagnosed with pleural exudates and pleural transudates, respectively. For the classical criterion, the sensitivity, specificity, and accuracy for the diagnosis of pleural exudates were, respectively, 99.8%, 68.6%, and 94.5%, whereas the corresponding values for the diagnosis of pleural transudates were 76.1%, 90.1%, and 87.6%. For the new criterion (cut-off points set at 3.4 g/dL for TP-PF and 328.0 U/L for LDH-PF), the sensitivity, specificity, and accuracy for the diagnosis of exudates were, respectively, 99.4%, 72.6%, and 99.2%, whereas the corresponding values for the diagnosis of transudates were 98.5%, 83.4%, and 90.0%. The accuracy of the new criterion for the diagnosis of pleural exudates was significantly greater than was that of the classical criterion (p = 0.0022). CONCLUSIONS The diagnostic yield was comparable between the two criteria studied. Therefore, the new classification criterion can be used in daily practice.

Eficácia e segurança de dois inaladores de pó seco usados para a aplicação de furoato de mometasona em pacientes com asma

OBJECTIVE: Mometasone furoate (MF) is a new, potent synthetic inhaled corticosteroid. Worldwide, MF is administered via a dry-powder inhaler that contains multiple doses. As a preparation that would be more cost-effective, single-dose MF capsules were developed in Brazil. The objective of the present study was to evaluate the efficacy and safety of the two inhalers for MF administration in patients with asthma. METHODS: A randomized, multicenter, open-label, parallel-group clinical trial involving 74 adult patients with moderate, persistent asthma who were randomized into two groups to receive approximately 400 µg of MF once a day for 60 days, either via the multiple-dose inhaler or via the newly developed single-dose inhaler. RESULTS: No significant differences were observed between the two groups regarding the primary endpoints (FEV1 and rescue medication use) or the secondary endpoints (morning PEF, tolerability, and safety, the last as assessed on the basis of hypothalamic-pituitary-adrenal axis function). CONCLUSIONS: The use of the single-dose inhaler developed in Brazil for MF administration is as effective and safe as is that of a standard inhaler in the treatment of patients with asthma.

Comportamento anti-inflamatório da IL-6 nos derrames pleurais pós-revascularização do miocárdio

Resumo Introducao: O comportamento pleural pos-cirurgia de revascularizacao do miocardio (PCRM) nao esta devidamente esclarecido em relacao a resposta inflamatoria local e requer maior interesse por ser uma observacao constante e ainda pouco estudada. Objectivo: Avaliar o comportamento de algumas citocinas, em especial o possivel papel anti-inflamatorio da IL-6 ( proteina envolvida na sintese da cortisona), no liquido pleural PCRM, uma vez que a sua actividade pro-inflamatoria e constantemente referida, assim como o seu papel de citocina de fase de resposta aguda ao lado do TNF-α e da IL-1β nos processos inflamatorios agudos. Casuistica e metodo: foram estudadas e analisadas pelo metodo ELISA as citocinas TNF-α, IL-1β, IL-2, IL-6, IL-8, VEGF e TGF-β em 16 transudatos e 43

[IL-6 anti-inflammatory activity in pleural effusion post-coronary artery bypass graft surgery].

INTRODUCTION The local inflammatory reaction aspects of pleural behaviour post-coronary artery by- pass graft surgery (PCABG) are not completely evident, demanding further study and observation. AIM To evaluate the behaviour of some cytokines and the possible anti-inflammatory activity of IL-6 (a protein involved in cortisone synthesis) on acute PCA- BG pleural fluid, since this cytokine is usually considered as an acute phase reaction protein associated to high concentrations of TNF-alpha and IL-1 beta in immediate inflammatory reactions. MATERIAL AND METHODS The concentrations of the TNF-alpha, IL-1 beta, IL-2, IL-6, IL-8, VEGF and TGF-beta cytokines in 16 transudates and 43 exudates in acute PCABS pleural fluid of patients were analysed by the ELISA method 2, 24 and 48 hours after surgery at the Instituto do Coração and Serviço de Pneumologia da USP, Brazil. RESULTS While no increase was seen in either TNF-alpha or IL-2 in any of the three tests, IL-1 beta increased after 24 until 48 hours, coinciding with the TGF-beta curve decline which fell from the beginning to reach the transudates levels. IL-8 reminded higher from the beginning and through the two subsequent tests while VEGF levels were elevated from the first test and continued high for the following 24 and 48 hours. IL-6 had high concentrations from the beginning, suggesting an anti-inflammatory activity at the three times of testing. CONCLUSIONS We conclude that IL-6 seems to play an important anti-inflammatory part which is superior to the anti-inflammatory activity of TGF-beta in PCABG pleural effusions. This performance of IL-6 breaks with the traditional idea of it being a pro-inflammatory acute phase reaction cytokine, at least in this type of pleural effusion. This seems to be the first study involving the favourable behaviour of IL-6 in the inflammatory reaction of pleura in the acute phase of PCABG surgery.

Derrame pleural de origem indeterminada

In spite of the progress in the diagnostic methods, about 20% of the pleural effusions may remain without a proper diagnosis after the use of conventional exams. In order to determine the origin of these effusions, alternative methods and invasive procedures shall be used aiming to determine the etiology of the undiagnosed pleural effusions and institute the most appropriate therapeutics.