Carlos Gomes

End-of-life care in COPD: A survey carried out with Portuguese Pulmonologists

INTRODUCTION End-of-life (EoL) care is a major component in the management of patients with advanced COPD. Patient-physician communication is essential in this process. AIM To evaluate the practice of Portuguese Pulmonologists in EoL communication and palliative care in COPD. METHODS An on-line survey was sent to physicians affiliated to the Portuguese Pneumology Society. RESULTS We obtained 136 answers from 464 eligible participants (29.3%). About half of the physicians reported that they have rarely introduced EoL discussions with their COPD patients (48.5%). Most had never/rarely suggested decision-making on the use of invasive mechanical ventilation (68.4%). Discussions were described as occurring mostly during/after a major exacerbation (53.7%). Only 37.5% of participants reported treating dyspnoea with opioids frequently/always. Only 9.6% stated that they never/rarely treated anxiety/depression. Most participants perceive the discussion of EoL issues as being difficult/very difficult (89.0%). The reasons most frequently given were feeling that patients were not prepared for this discussion (70.0%), fear of taking away a patients hope (58.0%) and lack of training (51.0%). CONCLUSION Patient and medical staff EoL communication in COPD is still not good enough. Training in this area and the creation of formal protocols to initiate EoL have been identified as major factors for improvement.

Comparative analysis of multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis - Epidemiology and predictive factors

INTRODUCTION Extensively drug-resistant tuberculosis (XDR-TB) is defined as a form of multidrug-resistant tuberculosis (MDR-TB) with additional resistance to fluoroquinolones and at least one of the injectable drugs used in tuberculosis treatment: amikacin, kanamycin and capreomycin. It was classified by WHO as a serious threat to tuberculosis (TB) control, with world-wide consequences, taking on the proportions of a real pandemic in some regions. AIM To compare patients with XDR-TB versus other MDR-TB profiles with regard to epidemiological and demographic characteristics, aetiopathogenic factors and inhospital outcomes. METHODS Patients admitted to Pulido Valente Hospital (Pulmonology Service III) in the period ranging from April 1999 to June 2007 with MDR-TB diagnosis microbiologically confirmed. The following variables were evaluated: gender, age, race, forms of TB presentation, treatment groups, resistance profile, immigrant status, number and duration of previous treatments, WHO classification, HIV co-infection, alcoholism and/or drug addiction, average length of hospital stay and inhospital mortality. Statistical analysis was performed using the SPSS (Statistical Package for the Social Sciences), version 15.0. In categorical variables, the statistical differences between groups were evaluated by the Chi-square test and numeric variables using the T-test. Logistical regression analysis was used to build the predictive model of XDR-TB existence (dependent variable), which included the following independent variables: WHO classification, HIV co-infection, immigrant status, alcoholism and/or drug addiction and number and duration of previous treatments. RESULTS We recorded 132 patients with MDR-TB, of which 69 (52.3%) were XDR-TB. Statistically significant differences were observed in the following variables: race (black race was associated with XDRTB in 74% of cases versus 46% of the Caucasian race); WHO classification (patients with retreatment for therapeutic failure, stopping treatment or relapse were 69.5% of XDR-TB cases versus 44.5% of Not XDR-TB cases; average duration of previous treatments (4.2 months for XDR-TB cases versus 2.8 months for Not XDR-TB cases); HIV co-infection (patients with HIV co-infection constituted 65.2% of XDR-TB cases versus 42.9% of Not XDR-TB cases), mortality (33.3% in patients with XDR-TB versus 14.3% in Not XDR-TB patients). CONCLUSIONS The variables with predictive value for the diagnosis of XDR-TB vs. Not XDR-TB were presence of HIV co-infection (odds ratio [OR] for XDRTB 2.5; 95% confidence interval [CI], 1.24 - 5.05) and increased average duration of previous treatments ([OR] for XDR-TB 1.2; 95% [CI], 1.11 - 2.30).

Impacto da diabetes na forma de apresentacão da tuberculose em doentes hospitalizados

INTRODUCTION Diabetes mellitus (DM) is a risk factor for tuberculosis (TB) and may modify its presenting features. The aim of this study was to find out the influence of DM on clinical, radiological and treatment features of TB in hospitalized patients. MATERIAL AND METHODS In a retrospective study we reviewed the records of 123 patients with TB and DM admitted from 2000 to 2008 and compared this group with another one of 123 patients with TB without DM. RESULTS Although in both groups multilobar lung lesions predominated, there were more cases of isolated lower lung field (LLF) involvement in diabetics than in nondiabetics (10.6% vs 3.3% p=0.03). Cavitary lesions were less frequent (63.4% vs 82.1% p=0.01) and extra-pulmonary TB manifestations were more frequent (28.5% vs 16.3% p=0.02) in diabetics than in nondiabetics. There were no significant differences between groups regarding multidrug resistant - TB (MDR-TB) and adverse effects of anti-tuberculosis drugs. The in-hospital mortality was higher in diabetics (8.1% vs 0.8% p=0.01), but using a binary logistic regression there was significant difference in mortality only in respect to the variable MDR-TB. CONCLUSIONS This study showed that DM affected some clinical and radiological presenting features in hospitalized TB patients. LLF involvement and extra-pulmonary TB manifestations were more frequent in diabetic patients than in nondiabetic ones.

Análise comparativa entre tuberculose multirresistente e tuberculose extensivamente resistente - Epidemiologia e factores preditivos

Introduction: Extensively drug-resistant tuberculosis (XDR-TB) is defined as a form of multidrug-resis-tant tuberculosis (MDR-TB) with additional resistance to fluoroquinolones and at least one of the injectable drugs used in tuberculosis treatment: amikacin, kanamycin and capreomycin. It was classified by WHO as a serious threat to tuberculosis (TB) control, with world-wide consequences, taking on the proportions of a real pandemic in some regions. Aim: To compare patients with XDR-TB versus other MDR-TB profiles with regard to epidemiological and demographic characteristics, aetiopathogenic factors and inhospital outcomes. Methods: Patients admitted to Pulido Valente Hospital (Pulmonology Service III) in the period ranging from April 1999 to June 2007 with MDR-TB diagnosis microbiologically confirmed. The following variables were evaluated: gender, age, race, forms of TB presentation, treatment groups, resistance profile, immigrant status, number and duration of previous treatments, WHO classification, HIV co-infection, alcoholism and/or drug addiction, average length of hospital stay and inhospital mortality. Statistical analysis was performed using the SPSS (Statistical Package for the Social Sciences), version 15.0. In categorical variables, the statistical differences between groups were evaluated by the Chisquare test and numeric variables using the T-test. Logistical regression analysis was used to build the predictive model of XDR-TB existence (dependent variable), which included the following independent variables: WHO classification, HIV co-infection, immigrant status, alcoholism and/or drug addiction and number and duration of previous treatments. Results: We recorded 132 patients with MDR-TB, of which 69 (52.3%) were XDR-TB. Statistically significant differences were observed in the following variables: race (black race was associated with XDRTB in 74% of cases versus 46% of the Caucasian race); WHO classification (patients with retreatment for therapeutic failure, stopping treatment or relapse were 69.5% of XDR-TB cases versus 44.5% of Not XDR-TB cases; average duration of previous treatments (4.2 months for XDR-TB cases versus 2.8 months for Not XDR-TB cases); HIV co-infection (patients with HIV co-infection constituted 65.2% of XDR-TB cases versus 42.9% of Not XDR-TB cases), mortality (33.3% in patients with XDR-TB versus 14.3% in Not XDR-TB patients). Conclusions: The variables with predictive value for the diagnosis of XDR-TB vs. Not XDR-TB were presence of HIV co-infection (odds ratio [OR] for XDRTB 2.5; 95% confidence interval [CI], 1.24 - 5.05) and increased average duration of previous treatments ([OR] for XDR-TB 1.2; 95% [CI], 1.11 – 2.30). Rev Port Pneumol 2008; XIV (6): 829-842

Tuberculose miliar: Revisão de casos internados numa Unidade de Tuberculose

Now a days, Miliary Tuberculosis (TM) refers to all forms of progressive disease resulting from massive dissemination of Mycobacterium tuberculosis. This is a retrospective analysis of all TM cases in a Tuberculosis Unit of a Central Hospital between April 1999 and November 2001. The mean age was 37,7 ± 13,1 years and 78% were Human Immunodefiency Virus co-infected patients. The results show the difficulty in the diagnosis of TM and alert for correct diagnostic methods. REV PORT PNEUMOL 2002; VIII (4): 315-327

Miliary tuberculosis: A 10 years´ experience of an infectious pulmonology unit in Portugal

Introduction: Miliary tuberculosis (MTB) represents almost 1-3% of all Tuberculosis cases and remains a potentially lethal disease if not diagnosed and treated timely. Formerly it was considered a childhood disease, but nowadays it is also recognized as a condition of adults, especially in immunosuppressed patients with HIV infection or by the use of biological agents and immunosuppressive drugs. Objective: describe the clinical presentation and outcomes of hospitalized patients with MTB. Methods: retrospective study over 10 years in patients admitted with MTB Results: 53 patients were included. Mean age: 44 years; 77,4% males; 71,7% Caucasians and 28,3% Blacks. The comorbidities were: HIV infection (66%), alcoholism (28%), smoking (26%), hepatitis C (25%), drug addiction (23%) and malnutrition (23%). On admission, patients presented anemia (62%), hyponatremia (34%), acute renal failure (17%) and pancytopenia (7,5%). Beyond the micronodular pattern (91%), the patients presented with alveolar pattern (13,2%), reticular pattern (5,7%) and cavitation (3,8%). 51% patients had acid-fast bacillus sputum negative. In addition to lung location, 43% had Tuberculosis in another organ. The adverse reactions occurred in 28,5% (n=15) cases, 80% of them with hepatotoxicity. In HIV subgroup, adverse reactions occurred in 31,4%, 77,8% of them had CD4 count Conclusions: This study highlights the importance of HIV infection and risk behaviors in triggering MTB and points out the adverse reactions, prolonged hospitalization and in-hospital mortality as characteristic attributes of this condition.

Análise da mortalidade numa unidade hospitalar de tuberculose

RESUMO Efectuamos um estudo transversal que abarcou a totalidade dos doentes falecidos na nossa Unidade, de Abril de 1999 a Abril de 2001. Analisamos: 1) caracteristicas clinico-epide miologicas referentes a idade, sexo, raca, classificacao dos casos de tuberculose (baseada no sistema de notificacao da OMS), dias de internamento, numero de tratamentos antibacilares previos e forma de tuberculose; 2) grupos nosologicos, de acordo com infeccao VIH e/ou tuberculose multirresistente (TBMR) concomitante, patologia associada, complicacoes e causa de morte; 3) parâmetros laboratoriais a data da admissao (concentracao de hemoglobina, neutrofilos totais, leucocitos totais, crea- tinina, TGO, TGP, LDH, amilase, albumina, pH, PaO2, PaCO2, CD4, carga viral e resultados do teste de sensibilidade aos antibacilares). Foram revistos 32 processos clinicos que se distribuiram segundo 4 grupos: VIH(+)/TB-11 (34,4%); VIH(+)/TBMR-7 (21,9%); TB-10 (31,3%); TBMR-4 (12,4%). Em relacao a patologia associada contabilizamos 18 casos de SIDA (56,2%), 6 com doenca neoplasica e/ou imunossupressao “minor” (18,8%) e 5 casos de doenca pulmonar cronica (15,6%). A causa de morte foi atribuida a uma complicacao nao relacionada com a tuberculose ou patologias associadas em 18 doentes (56,2%), a SIDA em 7 casos (21,9%) e a TB tambem em 7 doentes (21,9%). Concluimos que o grupo cuja causa de morte foi a TB se caracterizou por ser constituido por doentes de escalao etario superior, representando casos novos a que nao se associaram complicacoes; pelo contrario, no grupo cuja causa de morte foi a SIDA figuravam os casos de retratamento por interrupcao da terapeutica antibacilar, em doentes maioritariamente mais jovens. Niveis elevados de TGO associaram-se significativamente as complicacoes relativas ao aparelho cardiovascular (tromboembolismo pulmonar e arritmias), assim como os valores medios mais baixos de hemoglobina se associaram as complicacoes de natureza infecciosa (pneumonia nosocomial, sepsis e infeccao oportunista). REV PORT PNEUMOL 2002; VIII (3):

Resistência aos antibacilares

RESUMO Neste trabalho abordamos o fenomeno da resistencia aos antibacilares explicitando conceitos, mecanismos, tipos de resistencias e suas implicacoes em termos de significado para a compreensao dos indicadores epidemiologicos. Revemos, tambem, os problemas relacionados com a metodologia laboratorial e, por ultimo, abordamos as estrategias de prevencao e os resultados obtidos pelo Programa de Vigilância Global da OMS, particularizando a situacao em Portugal. REV PORT PNEUMOL 1998; IV (2): 155-163