C. Malaguti

The pattern and timing of breathing during incremental exercise: a normative study.

Clinical evaluation of the pattern and timing of breathing during submaximal exercise can be valuable for the identification of the mechanical ventilatory consequences of different disease processes and for assessing the efficacy of certain interventions. Sedentary individuals (60 male/60 female, aged 20–80 yrs) were randomly selected from >8,000 subjects and submitted to ramp incremental cycle ergometry. Tidal volume (VT)/ resting inspiratory capacity, respiratory frequency, total respiratory time (Ttot), inspiratory time (TI), expiratory time (TE), duty cycle (TI/Ttot) and mean inspiratory flow (VT/TI) were analysed at selected submaximal ventilatory intensities. Senescence and female sex were associated with a more tachypnoeic breathing pattern during isoventilation. The decline in Ttot was proportional to the TI and TE reductions, i.e. TI/Ttot was remarkably constant across age strata, independent of sex. The pattern, but not timing, of breathing was also influenced by weight and height; a set of demographically and anthropometrically based prediction equations are therefore presented. These data provide a frame of reference for assessing the normality of some clinically useful indices of the pattern and timing of breathing during incremental cycle ergometry in sedentary males and females aged 20–80 yrs.

Anemia in Inflammatory Bowel Disease Outpatients: Prevalence, Risk Factors, and Etiology

Anemia is common in inflammatory bowel disease (IBD). However, epidemiological studies of nonwestern IBD populations are limited and may be confounded by demographic, socioeconomic, and disease-related influences. This study evaluated the prevalence, risk factors, and etiology of anemia in Brazilian outpatients with IBD. Methods. In this cross-sectional study, 100 Crohns disease (CD) patients and 100 ulcerative colitis (UC) subjects were assessed. Anemia workup included complete blood count, ferritin, transferrin saturation, serum levels of folic acid and vitamin B12, and C-reactive protein (CRP) concentration. Results. The overall prevalence of anemia in IBD was 21%. There was no significant difference in the prevalence of anemia between CD subjects (24%) and UC (18%). Moderate disease activity (OR: 3.48, 95% CI, 1.95–9.64, P = 0.002) and elevated CRP levels (OR: 1.8, 95% CI, 1.04–3.11, P = 0.02) were independently associated with anemia. The most common etiologies of anemia found in both groups were iron deficiency anemia (IDA; 10% on CD and 6% on UC) followed by the anemia of chronic disease (ACD; 6% for both groups). Conclusions. In Brazilian IBD outpatients, anemia is highly concurrent condition. Disease moderate activity as well as increased CRP was strongly associated with comorbid anemia. IDA and/or ACD were the most common etiologies.

Upper and Lower Limb Muscles in Patients With COPD: Similarities in Muscle Efficiency But Differences in Fatigue Resistance

BACKGROUND: Peripheral muscle dysfunction is a common finding in patients with COPD; however, the structural adaptation and functional impairment of the upper and lower limb muscles do not seem to be homogenous. We compared muscle fatigue and recovery time between 2 representative muscles: the middle deltoid and the quadriceps femoris. METHODS: Twenty-one subjects with COPD (FEV1 46.1 ± 10.3% of predicted) underwent maximal voluntary isometric contraction and an endurance test (60% of maximal voluntary isometric contraction, to the limit of tolerance). The maximal voluntary isometric contraction test was repeated after 10 min, 30 min, 60 min, and 24 hours for both the quadriceps femoris and middle deltoid. Surface electromyography was recorded throughout the endurance test. RESULTS: Maximal voluntary isometric contraction significantly decreased only for the middle deltoid between 10 and 60 min after the endurance test. A significant increase of the root mean square and a greater decline in median frequency throughout the endurance test occurred for the middle deltoid, compared with the quadriceps femoris. When dyspnea and fatigue scores were corrected by endurance time, higher values were observed for the middle deltoid (0.07 and 0.08, respectively) in relation to the quadriceps femoris (0.02 and 0.03, respectively). CONCLUSIONS: Subjects with COPD had a higher fatigability of a representative upper limb muscle (middle deltoid) than a lower limb muscle (quadriceps femoris).

Small-Intestinal Bacterial Overgrowth is Associated With Concurrent Intestinal Inflammation But Not With Systemic Inflammation in Crohn’s Disease Patients

Goals: We studied the prevalence and predictors of small-intestinal bacterial overgrowth (SIBO) in Crohn’s disease (CD) outpatients and the relationship between SIBO and intestinal and/or systemic inflammation. Background: The relationship of SIBO with systemic and intestinal inflammation in CD patients is unclear. Study: In this cross-sectional study, conducted between June, 2013 and January, 2015, 92 CD patients and 97 controls with nonchronic gastrointestinal complaints were assessed for the presence of SIBO using the H2/CH4 glucose breath test. Multivariate logistic regression was performed to investigate the potential association between SIBO and demographic, disease-related data, systemic markers of inflammation (C-reactive protein, and erythrocyte sedimentation rate), and biomarker of intestinal inflammation [fecal calprotectin concentration (FCC)]. Results: The SIBO rate was significantly higher in CD patients than in controls (32.6% vs. 12.4%, respectively, P=0.0008). Patients with and without SIBO were comparable with regard to demographics, systemic inflammatory biomarkers, and disease characteristics, except for the stricturing phenotype being more common in SIBO-positive CD patients (43.3% vs. 19.3%, P=0.015). Notably, FCC was significantly higher in SIBO-positive patients (median of 485.8 vs.132.7 &mgr;g/g; P=0.004). Patients presenting increased FCC and stricturing disease had an odds of 9.43 (95% confidence interval, 3.04-11.31; P<0.0001) and 3.83 (95% confidence interval, 1.54-6.75; P=0.025) respectively, for SIBO diagnosis. Conclusions: In CD patients, SIBO is a highly prevalent condition. Stricturing phenotype and increased FCC were strongly and independently associated with the presence of SIBO. SIBO diagnostic work-up followed by directed treatment is recommended in CD patients who present stricturing disease, especially in those with concurrent intestinal inflammation.

Effects of an unsupervised pedometer-based physical activity program on daily steps of adults with moderate to severe asthma: a randomized controlled trial

ABSTRACT Supervised exercise has shown benefits for subjects with asthma, but little is known about the effectiveness of unsupervised physical activity on this population. We investigated the effects of a 12-week unsupervised pedometer-based physical activity program on daily steps and on clinical and psychological parameters of adults with asthma. Clinically stable adults with moderate to severe asthma were encouraged to take daily 30-minute walks and were randomized to pedometer and control groups. The pedometer group received pedometers and individualized daily step targets. Changes in daily steps (average of steps taken during six consecutive days), six-minute walk test (6MWT), health-related quality of life, asthma control and anxiety and depression levels were assessed 12 weeks after intervention and 24–28 weeks after randomization. Thirty-seven participants were recruited and 30 completed the intervention. At 12 weeks, the groups differed significantly in daily steps (adjusted average difference, 2488 steps; 95% confidence interval [CI], 803 to 4172; p = 0.005) and in the 6MWT (adjusted average difference, 21.9 m; 95% CI, 6.6 to 37.3; p = 0.006). These differences were not significant 24–28 weeks after randomization. The program was effective in increasing daily steps of adults with moderate to severe asthma 12 weeks after intervention.

Sixminute Stepper Test to Set Pulmonary Rehabilitation Intensity in Patients with COPD—A Retrospective Study – Letter to the Editor

We read with interest the recent paper by Bonnevie et al. (1),“Six-minute stepper test to set pulmonary rehabilitation intensity in patients with COPD− A retrospective study.” The central idea of the study was to use the heart rate (HR) obtained from the six-minute stepper test (6MST) to adjust the training intensity for patients with COPD. For that, the authors compared the mean HR during the first (HR1–3) and last (HR4–6) three minutes of the 6MST with the HR at the ventilatory threshold (HRvt) from the cardiopulmonary exercise test (CPET). The study has an interesting premise since the exercise intensity is a crucial aspect to obtaining the benefits of aerobic training, and simple strategies to prescribe it are still needed. However, some aspects are subject to criticism. First, HR is not suitable for determining target exercise training intensity for patients with COPD, because, even at maximum cardiopulmonary exercise testing, the peak HR is commonly low, i.e., they present with a high HR reserve (2). In addition, although the 6MST is time-limited, it is possible that, for some patients with COPD, it is a maximum test, and, for others, it is a submaximal test, as observed with the six-minute walk test in this population (3). Therefore, the HR obtained from the 6MST should be used cautiously to prescribe aerobic training in patients with COPD. To minimize possible imprecisions of this method, we suggest, in future studies, to associate dyspnea ratings to regulate the intensity of exercise training (4). Second, the external validity of adjusting the training intensity based on HR is reduced when the ventilatory threshold is not always detected in patients with COPD (5). In the present study, the authors had the elegance of describing that HR at the ventilatory threshold (HRvt) from CPET was not identified some patients (more than one-third). How, then, should the intensity be adjusted for these patients? Additionally, a previous study (5) showed a wide variability on HRvt when expressed as a percent of attained peak HR, predicted peak HR, and HR reserve in patients with COPD. Third, patients in the study by Bonnevie et al. (1) seemed to have presented mild impairment of functional capacity, since they performed a higher number of steps in the 6MST than did patients with COPD in the original study, but presented with similar performances to those observed in healthy subjects (6). Since cardiovascular responses to exercise in patients with

Impact of biological therapy on body composition of patients with Chron's disease

Introduction: Protein-energy malnutrition in Crohns disease (CD) has been reported in 20 to 92% of patients, and is associated with increased morbidity and mortality and higher costs for the health system. Anti-TNF drugs are a landmark in the clinical management, promoting prolonged remission in patients with CD. It is believed that the remission of this disease leads to nutritional recovery. The effect of biological therapy on body composition and nutritional status is unclear. Method: Prospective study of body assessment by bioelectrical impedance method in patients with moderate to severe CD undergoing treatment with infliximab. The main outcome was the body composition before and after 6 months of anti-TNF therapy. Results: There was a predominance of females (52%) with a mean age of 42±12 years. Most patients were eutrophic at baseline and remained so. There was an increase in all parameters of body composition after anti-TNF treatment: BMI (22.9±3.2 versus 25±3.8; p=0.005), waist circumference (88.1±6.7 versus 93.9±7.7; p=0.002), lean mass index (17.5±2.2 versus 18.2±2.3; p=0.000) and fat mass index (5.5±2.3 versus 6.8±2.3; p=0.000). Phase angle remained unchanged (6.2 versus 6.8; p=0.94). Conclusion: After therapy with IFX, all components of body composition increased, except for phase angle. The substantial increase in fat mass index and waist circumference led to concern regarding cardiovascular risk and, thus, to the need for further studies.

Avaliação do aprendizado de pacientes com doença pulmonar obstrutiva crônica em um programa de reabilitação pulmonar

Evaluation of learning in patients with chronic obstructive pulmonary disease during a pulmonary rehabilitation program Background: Patients who undergo pulmonary rehabilitation programs also participate in an educational program with classes covering matters related to their disease and treatment. Such programs aim to provide patients with the knowledge needed for them to be able to deal with their disease and its repercussions. Objective: To evaluate whether the educational program applied to patients undergoing pulmonary rehabilitation has effective results regarding their learning. Method: This was a prospective study involving 22 patients who underwent a pulmonary rehabilitation program. Their mean age was 63 years (SD ± 11.8). Initially, a questionnaire developed and validated by the Pulmonary Rehabilitation Center of UNIFESP/LESF was applied to evaluate the patients’ knowledge about the disease before and after the educational intervention. The patients were divided into two groups: one with the educational program and the other serving as a control group (no educational program). The educational program group answered the questionnaire twice (before and after the intervention), and the control group answered only once. Results: The patients who underwent the educational program presented an increase in the percentage of correct answers, from before to after the intervention (69% versus 84%, respectively), and a decrease in the percentage of mistakes, from before to after the intervention (20% versus 14%, respectively). Conclusion: The educational program applied to patients in the pulmonary rehabilitation program was effective to increase the patients’ knowledge about their disease, its consequences and its treatment.