Carla Ribeiro

Validation of the Portuguese Severe Respiratory Insufficiency Questionnaire for home mechanically ventilated patients

The aim of this study was to develop and validate the professional translation and cultural adaptation of the Portuguese Severe Respiratory Insufficiency (SRI) Questionnaire. The sample was composed of 93 patients (50 male patients, 53.8%) with a mean age of 66.3 years. The most frequent diagnostic groups were chronic obstructive pulmonary disease, obesity hypoventilation syndrome and restrictive chest wall disorders. The patients were asked to fill in both the SRI and SF-36 questionnaires. Factor analysis of the SRI questionnaire was performed leading to an explained variance of 73%, and resulted in 13 components. When analyzing the reliability, we obtained values for Cronbachs alpha above 0.70 for most subscales with the reliability of the summary scale being even higher (0.84). This professional translation and cultural adaptation of the Portuguese SRI Questionnaire has good psychometric properties which are similar, not only to the original, but also to other translations. These characteristics make this questionnaire applicable to the Portuguese population receiving home mechanical ventilation for severe respiratory insufficiency.

Pneumonia pneumocócica - serão os novos scores mais precisos a prever eventos desfavoráveis?

INTRODUCTION The site-of-care decision is one of the most important factors in the management of patients with community-acquired pneumonia. The severity scores are validated prognostic tools for community-acquired pneumonia mortality and treatment site decision. The aim of this paper was to compare the discriminatory power of four scores - the classic PSI and CURB65 ant the most recent SCAP and SMART-COP - in predicting major adverse events: death, ICU admission, need for invasive mechanical ventilation or vasopressor support in patients admitted with pneumococcal pneumonia. METHODS A five year retrospective study of patients admitted for pneumococcal pneumonia. Patients were stratified based on admission data and assigned to low-, intermediate-, and high-risk classes for each score. Results were obtained comparing low versus non-low risk classes. RESULTS We studied 142 episodes of hospitalization with 2 deaths and 10 patients needing mechanical ventilation and vasopressor support. The majority of patients were classified as low risk by all scores - we found high negative predictive values for all adverse events studied, the most negative value corresponding to the SCAP score. The more recent scores showed better accuracy for predicting ICU admission and need for ventilation or vasopressor support (mostly for the SCAP score with higher AUC values for all adverse events). CONCLUSIONS The rate of all adverse outcomes increased directly with increasing risk class in all scores. The new gravity scores appear to have a higher discriminatory power in all adverse events in our study, particularly, the SCAP score.

Anterior Cervical Osteophyte Presenting as a Pharyngeal Mass

We describe the case of a 73-year-old-man, non-smoker, with recurrent respiratory infections. He had a medical history of bronchiectasis and an asthma/COPD overlap syndrome. The patient was submitted to a fiberoptic bronchoscopy, which showed a tumefaction in the posterior wall of hypopharynx and inferior oropharynx, approximately 2 cm in diameter, with hard consistency and preserved mucosa (Fig. 1A). Cervical computed tomography (CT) revealed extrinsic compression of the posterior wall of pharynx, caused by large osteophytes of the cervical vertebrae (Fig. 1B). Anterior cervical osteophytes have a prevalence of 20–30% in the elderly population and are diagnosed on the basis of radiologic findings. They are generally asymptomatic; however, in rare cases, they can lead to dysphagia, dysphonia, and dyspnoea.1 Asymptomatic patients, like the case referred, don’t need treatment. Symptomatic patients should be treated according to the severity of disease. Initial conservative management includes diet modifications, muscle relaxants, antireflux and anti-inflammatory

Uso de la ecografía torácica en la comprobación de la resolución del neumotórax tras drenaje

Pneumothorax follow-up is based on chest radiographs (CR), despite the previously demonstrated poor sensitivity of CR for small volume pneumothorax detection.1–3 According to American College of Chest Physicians guidelines, chest tubes should be removed in a staged manner, with most physicians performing a CR before clamping or removing the chest tube.4 In spite of these precautions, pneumothorax recurrence rates are as high as 54% within the first 4 years,5 and some of these recurrences may be due to residual pneumothorax that was present before clamping or removing the chest tube but overlooked on CR.2 In recent years, ultrasonography (US) has emerged as a sensitive, non-invasive procedure for the diagnosis of pneumothorax.1–3 However, its routine use in pneumothorax follow-up has not yet been well established. This purpose of this study was to evaluate the effectiveness of US in detecting absence of residual pneumothorax before chest tube removal in comparison with CR. All patients with pneumothorax requiring drainage admitted to our pulmonology department between April 2014 and October 2015 were consecutively included. The absence of visualization of the pleural line on US for any clinical reason was an exclusion criterion. The primary endpoint was the number of residual pneumothoraces correctly diagnosed by US. No patient was excluded from our study. US and CR were performed consecutively after bubbling had stopped. In the absence of residual pneumothorax on both US and CR the chest drain was clamped for 24 h, then removed and the patient discharged. US was performed by a single chest physician using a 5–13 MHz linear probe with the patient erect. US diagnosis of residual pneumothorax relied on the presence of any of these signs: lung point or abolition of lung sliding; lung pulse or Blines in B-mode; and absence of seashore sign in M-mode. CR was performed with patient erect and interpreted by the physician in charge of the patient. Sixteen male patients with unilateral pneumothorax were included (median age, 29 years). Pneumothorax cause was as follows: primary spontaneous (n = 12), secondary to pulmonary emphysema (n = 2), and iatrogenic (n = 2). No residual pneumothorax was diagnosed by US or CR. Thus, chest drains were successfully clamped and removed in all patients, with no pneumothorax recurrence. Our study showed that US is at least as good as CR in detecting residual pneumothoraces before chest drain removal in a

Tuberculosis and TNFα antagonists--what are we missing?

In 2012 Portugal had a tuberculosis incidence of 21.6/100,000 inhabitants (2286 new cases, 942 of which were reported in the northern region). A recent retrospective study in Portugal identified, from 2001 to 2012, 25 cases of tuberculosis out of 765 patients under anti-TNF (297/100,000 patient-years). Treatment with tumor necrosis factor antagonists (antiTNF ) is associated with an elevated risk for development of tuberculosis mostly due to reactivation of latent tuberculosis infection. Since 2006, national guidelines advise tuberculosis screening for all candidates for anti-TNF therapy including chest X ray, tuberculin skin test (TST) and Interferon-Gamma Release Assay (IGRA) and treatment should be offered to every patient with evidence of LTBI, provided major toxicity is excluded. Worldwide, the application of tuberculosis screening guidelines in these patients has been related to a decrease of tuberculosis within this group. In order to understand the pitfalls that can still lead to the development of tuberculosis in these patients, we