Aquiles Assunção Camelier

Impacto clínico do diagnóstico de sepse à admissão em UTI de um hospital privado em Salvador, Bahia

OBJECTIVE: To describe the clinical characteristics, laboratory data, and clinical outcomes of patients with and without sepsis admitted to the ICU of a private hospital in the city of Salvador, Brazil, and to identify clinical variables related to a worse prognosis in those with sepsis. METHODS: This was a longitudinal study including all patients admitted to the general ICU of the Hospital Portugues, in the city of Salvador, Brazil, between June of 2008 and March of 2009. At ICU admission, two groups of patients were identified: with sepsis and without sepsis. Epidemiological, clinical and laboratory data were collected, and the Acute Physiology and Chronic Health Evaluation II (APACHE II) score was calculated. RESULTS: Of the 144 patients in the study, 29 (20.1%) had sepsis. Among the patients with sepsis, males accounted for 55.2%, the mean age was 73.1 ± 14.6 years, and the mean APACHE II score was 23.8 ± 9.1, compared with 36.3%, 68.7 ± 17.7 years, and 18.4 ± 9.5, respectively, among those without sepsis. There were significant associations between a diagnosis of sepsis and the following variables: APACHE II score; in-hospital mortality; ICU mortality; HR; mean arterial pressure; hematocrit level; white blood cell count; and antibiotic use. The use of life support measures and lower hematocrit levels were associated with a worse prognosis in the patients with sepsis. CONCLUSIONS: The patients diagnosed with sepsis presented worse clinical outcomes, probably due to their greater severity. Hematocrit level was the only variable that was a predictor of mortality risk in the patients with sepsis.

Avaliação de atopia em portadores de DPOC

OBJECTIVE: To determine the prevalence of atopy and to evaluate clinical, laboratory, and radiological profiles in patients with COPD. METHODS: This was a cross-sectional study involving outpatients with stable COPD (defined by the clinical history and a post-bronchodilator FEV1/FVC < 70% of the predicted value). The patients completed a questionnaire regarding clinical characteristics and atopy, after which they underwent nasal lavage cytology, skin prick testing, chest X-rays, arterial blood gas analyses, and determination of total serum IgE. RESULTS: Of the 149 subjects studied, 53 (35.6%), 49 (32.8%), and 88 (59.1%) presented with nasal eosinophilia, a positive skin prick test result, and symptoms of allergic rhinitis, respectively. Correspondence analysis confirmed these findings, showing two distinct patterns of disease expression: atopy in patients with COPD that was less severe; and no evidence of atopy in those with COPD that was more severe (reduced FEV1 and hyperinflation). There was a statistically significant association between nasal eosinophilia and a positive bronchodilator response. CONCLUSIONS: Using simple and reproducible methods, we were able to show that there is a high frequency of atopy in patients with COPD. Monitoring inflammation in the upper airways can be a useful tool for evaluating respiratory diseases in the elderly and in those with concomitant asthma and COPD, a clinical entity not yet fully understood.OBJETIVO: Determinar a prevalencia de atopia e avaliar o perfil clinico, laboratorial e radiologico de pacientes com DPOC. METODOS: Estudo de corte transversal com pacientes ambulatoriais portadores de DPOC estavel (definida pela historia clinica e relacao VEF1/CVF < 70% do previsto apos broncodilatador). Os pacientes responderam um questionario clinico e de atopia e foram submetidos a citologia de lavado nasal, teste cutâneo de alergia, radiografia de torax, hemogasometria arterial e dosagem de IgE total. RESULTADOS: Dos 149 individuos avaliados, 53 (35,6%), 49 (32,8%) e 88 (59,1%), respectivamente, apresentavam eosinofilia no lavado nasal, teste cutâneo positivo e sintomas de rinite alergica. A analise de correspondencia confirmou esses achados, evidenciando dois perfis distintos de doenca: a presenca de atopia em pacientes com estagios mais leves de DPOC, e a ausencia de caracteristicas de atopia em pacientes com aspectos de doenca mais grave (VEF1 reduzido e hiperinsuflacao). Houve uma associacao estatisticamente significante entre eosinofilia no lavado nasal e prova farmacodinâmica positiva. CONCLUSOES: Este estudo identificou uma alta frequencia de atopia em pacientes com DPOC, utilizando ferramentas simples e reprodutiveis. A monitorizacao inflamatoria de vias aereas parece ser uma ferramenta util para avaliar as doencas respiratorias em idosos, assim como em pacientes com sobreposicao de asma e DPOC, entidade clinica ainda pouco compreendida.

Validation of the Airways Questionnaire 20 - AQ20 in patients with chronic obstructive pulmonary disease (COPD) in Brazil

INTRODUCTION: A great emphasis has been placed on health-related quality of life of COPD patients and specific questionnaires have been developed in order to measure it. OBJECTIVE: This study describes the language and cultural adaptation of a new (and short) disease-specific health status questionnaire developed for chronic obstructive pulmonary diseases: the Airways Questionnaire 20 (AQ20). METHODS: In order to validate this questionnaire in Brazil, it was initially translated into Portuguese. The cultural adaptation was taken into consideration and then a back translation to English was undertaken, in order to obtain a final Portuguese version. Correlations were made with FEV1, SpO2, BMI and another disease-specific health status questionnaire, the Saint George Respiratory Questionnaire (SGRQ), previously validated in Brazil. The interclass correlation ratio was done to test the reproducibility of AQ20. RESULTS: The interclass correlation ratio for the total score was a = 0.90 (intra-observer variability) and a = 0.93 (inter-observer variability) (p < 0.05 for both). The correlation with total SGRQ score was 0.76, with p < 0.001. The average time to answer the AQ20 was 4 min and 6 s. CONCLUSION: The Brazilian Portuguese version of AQ20 is reproducible, of fast application and with good a correlation with SGRQ total score, which makes it a valid questionnaire to measure health status in obstructive patients in Brazil.

Accuracy of the Timed Up and Go test for predicting sarcopenia in elderly hospitalized patients

OBJECTIVES: The ability of the Timed Up and Go test to predict sarcopenia has not been evaluated previously. The objective of this study was to evaluate the accuracy of the Timed Up and Go test for predicting sarcopenia in elderly hospitalized patients. METHODS: This cross-sectional study analyzed 68 elderly patients (≥60 years of age) in a private hospital in the city of Salvador-BA, Brazil, between the 1st and 5th day of hospitalization. The predictive variable was the Timed Up and Go test score, and the outcome of interest was the presence of sarcopenia (reduced muscle mass associated with a reduction in handgrip strength and/or weak physical performance in a 6-m gait-speed test). After the descriptive data analyses, the sensitivity, specificity and accuracy of a test using the predictive variable to predict the presence of sarcopenia were calculated. RESULTS: In total, 68 elderly individuals, with a mean age 70.4±7.7 years, were evaluated. The subjects had a Charlson Comorbidity Index score of 5.35±1.97. Most (64.7%) of the subjects had a clinical admission profile; the main reasons for hospitalization were cardiovascular disorders (22.1%), pneumonia (19.1%) and abdominal disorders (10.2%). The frequency of sarcopenia in the sample was 22.1%, and the mean length of time spent performing the Timed Up and Go test was 10.02±5.38 s. A time longer than or equal to a cutoff of 10.85 s on the Timed Up and Go test predicted sarcopenia with a sensitivity of 67% and a specificity of 88.7%. The accuracy of this cutoff for the Timed Up and Go test was good (0.80; IC=0.66-0.94; p=0.002). CONCLUSION: The Timed Up and Go test was shown to be a predictor of sarcopenia in elderly hospitalized patients.

Dynamic hyperinflation during activities of daily living in COPD patients

The objective of this study was to investigate whether some activities of daily living (ADLs) usually related to dyspnea sensation in patients with chronic obstructive pulmonary disease (COPD) are associated with dynamic lung hyperinflation (DH) and whether the use of simple energy conservation techniques (ECTs) might reduce this possible hyperinflation. Eighteen patients (mean age: 65.8 ± 9.8 years) with moderate-to-severe COPD performed six ADLs (walking on a treadmill, storing pots, walking 56 meters carrying a 5-kilogram weight, climbing stairs, simulating taking a shower, and putting on shoes) and had their inspiratory capacity (IC) measured before and after each task. The patients were moderately obstructed with forced expiratory volume in 1 second (FEV1): 1.4 ± 0.4 L (50% ± 12.4); FEV1/forced vital capacity: 0.4 ± 8.1; residual volume/total lung capacity: 52.7 ± 10.2, and a reduction in IC was seen after all six activities (p < 0.05): (1) going upstairs, 170 mL; (2) walking 56 meters carrying 5 kilogram weight, 150 mL; (3) walking on a treadmill without and with ECT, respectively, 230 mL and 235 mL; (4) storing pots without and with ECT, respectively, 170 mL and 128 mL; (5) taking a shower without and with ECT, respectively, 172 mL and 118 mL; and (6) putting on shoes without and with ECT, respectively, 210 mL and 78 mL). Patients with moderate to severe COPD develop DH after performing common ADLs involving the upper and lower limbs. Simple ECTs may avoid DH in some of these ADLs.

Reliability of the Brazilian Portuguese version of the fatigue severity scale and its correlation with pulmonary function, dyspnea, and functional capacity in patients with COPD.

OBJECTIVE: To describe the intra-rater and inter-rater reliability of the Brazilian Portuguese version of the fatigue severity scale (FSS) in patients with COPD and to identify the presence of its association with parameters of pulmonary function, dyspnea, and functional capacity. METHODS: This was an observational cross-sectional study involving 50 patients with COPD, who completed the FSS in interviews with two researchers in two visits. The FSS scores were correlated with those of the Medical Research Council (MRC) scale, as well as with FEV1, FVC, and six-minute walk distance (6MWD). RESULTS: The mean age of the patients was 69.4 ± 8.23 years, whereas the mean FEV1 was 46.5 ± 20.4% of the predicted value. The scale was reliable, with an intraclass correlation coefficient of 0.90 (95% CI, 0.81-0.94; p < 0.01). The FSS scores showed significant correlations with those of MRC scale (r = 0.70; p < 0.01), as well as with 6MWD (r = –0.77; p < 0.01), FEV1 (r = –0.38; p < 0.01), FVC (r = –0.35; p < 0.01), and stage of the disease in accordance with the Global Initiative for Chronic Obstructive Lung Disease criteria (r = 0.37; p < 0.01). CONCLUSIONS: The Brazilian Portuguese version of the FSS proved reliable for use in COPD patients in Brazil and showed significant correlations with sensation of dyspnea, functional capacity, pulmonary function, and stage of the disease.

Perfil inflamatório e imunológico em pacientes com DPOC: relação com a reversibilidade do VEF 1

Objetivo: Determinar se a gravidade da DPOC se correlaciona com a contagem de celulas no escarro, atopia e asma. Metodos: Estudo transversal com 37 pacientes com DPOC e 22 individuos saudaveis com funcao pulmonar normal (controles). As contagens de celulas no escarro foram determinadas por microscopia apos a centrifugacao das amostras. Foram realizados testes cutâneos de puntura, e as citocinas sericas foram determinadas por ELISA. Resultados: Os pacientes foram estratificados pela resposta ao broncodilatador: o grupo de limitacao ao fluxo aereo nao reversivel (LFAnr) envolveu 24 pacientes sem alteracao significativa do VEF1 pos-broncodilatador, e o grupo de limitacao ao fluxo aereo parcialmente reversivel (LFApr) envolveu 13 pacientes com reversibilidade do VEF1 (aumento do VEF1 pos-broncodilatador ≥ 12%). A proporcao de eosinofilos no escarro foi maior no grupo LFApr do que no LFAnr (p < 0,01), e houve uma correlacao inversa entre a proporcao de eosinofilos e VEF1 (p < 0,05). Entretanto, nenhum dos pacientes apresentou historico de asma e os resultados dos testes cutâneos nao diferiram entre os dois grupos. Nas amostras de escarro dos pacientes, os neutrofilos predominaram. Os niveis sericos de TNF, IL-6, IL-8 e RANTES (CCL5) foram maiores nos pacientes que nos controles (p < 0,001), mas nao diferiram entre os dois grupos de pacientes. Conclusoes: Pacientes com DPOC e reversibilidade parcial do VEF1 parecem apresentar maiores contagens de eosinofilos no escarro e maior hiper-responsividade das vias aereas que aqueles sem reversibilidade do VEF1. Entretanto, a gravidade da DPOC nao se correlacionou com atopia ou perfil das citocinas.

Inflammatory and immunological profiles in patients with COPD: relationship with FEV 1 reversibility

ABSTRACT Objective: To determine whether COPD severity correlates with sputum cell counts, atopy, and asthma. Methods: This was a cross-sectional study involving 37 patients with COPD and 22 healthy subjects with normal lung function (controls). Sputum cell counts were determined by microscopy after centrifugation of samples. Skin prick tests were performed, and serum cytokines were determined by ELISA. Results: Patients were stratified by bronchodilator response: a non-reversible airflow limitation (nonRAL) group comprised 24 patients showing no significant post-bronchodilator change in FEV1; and a partially reversible airflow limitation (partialRAL) group comprised 13 patients showing FEV1 reversibility (post-bronchodilator FEV1 increase ≥ 12%). The proportion of eosinophils in sputum was higher in the partialRAL group than in the nonRAL group (p < 0.01), and there was an inverse correlation between the proportion of eosinophils and FEV1 (p < 0.05). However, none of the patients had a history of asthma and skin prick test results did not differ between the two groups. In the patient sputum samples, neutrophils predominated. Serum levels of TNF, IL-6, IL-8, and RANTES (CCL5) were higher in patients than in controls (p < 0.001) but did not differ between the two patient groups. Conclusions: COPD patients with partial FEV1 reversibility appear to have higher sputum eosinophil counts and greater airway hyperresponsiveness than do those with no FEV1 reversibility. However, we found that COPD severity did not correlate with atopy or with the cytokine profile.

SEGURANÇA E REPRODUTIBILIDADE DO TESTE TIMED UP AND GO EM IDOSOS HOSPITALIZADOS

Introducao: Testes fisicos seguros e confiaveis sao importantes para rastrear risco de queda em idosos, entretanto, nao existem estudos que tenham avaliado a seguranca e a confiabilidade do teste Timed Up and Go (TUG) em idosos hospitalizados. Objetivos: Avaliar a seguranca e reprodutibilidade do TUG em idosos hospitalizados. Metodos: Trata-se de um estudo transversal no qual foram coletadas tres afericoes do TUG para cada idoso, sendo considerado o melhor desempenho em segundos (s). Outras variaveis coletadas foram funcao cognitiva (MEEM), indice de comorbidades de Charlson, perfil admissional (clinico ou cirurgico), relato de quedas no ultimo ano e IMC. Para avaliar a confiabilidade relativa utilizou-se o coeficiente de correlacao intraclasse (CCI) e para a confiabilidade absoluta, a analise de Bland-Altman. Resultados: Foram incluidos 68 idosos com media de idade de 70,4 ± 7,7 anos, indice de Charlson 5,4 ± 2,0 e predominio do perfil clinico (64,7%). Nenhum dos 204 testes foi interrompido pelos criterios estabelecidos. Houve reducao gradativa entre a primeira e a terceira afericao (1a = 11,6 ± 6,54; 2a = 10,7 ± 6,22 e 3a = 10,3 ± 5,54; p = 0,001) e elevado CCI (1a e 2a: CCI = 0,98; 1a e 3a: CCI = 0,98; 2a e 3a: CCI = 0,98; p = 0,001), sendo que a maior correlacao com o melhor desempenho foi associada a 3a afericao (CCI = 0,99; p = 0,001). Identificou-se que os menores vies (0,29 s) e limites de concordância (-1,1 a 1,68 s) ocorreram tambem entre a terceira afericao e a de melhor desempenho. A medida de erro do metodo para avaliacao da variabilidade foi 0,5 s e a alteracao clinicamente significante 3,4 s. Conclusao: O TUG foi um instrumento seguro e com boa reprodutibilidade para mensuracao do desempenho fisico em idosos hospitalizados.

SAFETY AND REPRODUCIBILITY OF THE TIMED UP AND GO TEST IN HOSPITALIZED ELDERLY

Introducao: Testes fisicos seguros e confiaveis sao importantes para rastrear risco de queda em idosos, entretanto, nao existem estudos que tenham avaliado a seguranca e a confiabilidade do teste Timed Up and Go (TUG) em idosos hospitalizados. Objetivos: Avaliar a seguranca e reprodutibilidade do TUG em idosos hospitalizados. Metodos: Trata-se de um estudo transversal no qual foram coletadas tres afericoes do TUG para cada idoso, sendo considerado o melhor desempenho em segundos (s). Outras variaveis coletadas foram funcao cognitiva (MEEM), indice de comorbidades de Charlson, perfil admissional (clinico ou cirurgico), relato de quedas no ultimo ano e IMC. Para avaliar a confiabilidade relativa utilizou-se o coeficiente de correlacao intraclasse (CCI) e para a confiabilidade absoluta, a analise de Bland-Altman. Resultados: Foram incluidos 68 idosos com media de idade de 70,4 ± 7,7 anos, indice de Charlson 5,4 ± 2,0 e predominio do perfil clinico (64,7%). Nenhum dos 204 testes foi interrompido pelos criterios estabelecidos. Houve reducao gradativa entre a primeira e a terceira afericao (1a = 11,6 ± 6,54; 2a = 10,7 ± 6,22 e 3a = 10,3 ± 5,54; p = 0,001) e elevado CCI (1a e 2a: CCI = 0,98; 1a e 3a: CCI = 0,98; 2a e 3a: CCI = 0,98; p = 0,001), sendo que a maior correlacao com o melhor desempenho foi associada a 3a afericao (CCI = 0,99; p = 0,001). Identificou-se que os menores vies (0,29 s) e limites de concordância (-1,1 a 1,68 s) ocorreram tambem entre a terceira afericao e a de melhor desempenho. A medida de erro do metodo para avaliacao da variabilidade foi 0,5 s e a alteracao clinicamente significante 3,4 s. Conclusao: O TUG foi um instrumento seguro e com boa reprodutibilidade para mensuracao do desempenho fisico em idosos hospitalizados.