Denise Duprat Neves

Predictive model for the diagnosis of tuberculous pleural effusion

This study developed a predictive model to identify pleural tuberculosis. A consecutive cases study of patients investigating the cause of pleural effusion, in an area of high prevalence of tuberculosis (Rio de Janeiro, Brazil). Clinical and laboratory variables were compared among patients with tuberculosis (TB) and without tuberculosis (NTB), individually and using logistic regression. The performance was described as diagnostic accuracy, compared to a gold standard in a masked way. We have studied 104 TB patients, 41 with malignant, 29 transudates, 28 parapneumonic, 13 with miscellaneous diseases. After identification of individual discrimination power aided by clinical, radiological and laboratory variables, the following ones were included in a multivariate analysis: ADA, total leukocytes, percentile of lymphocytes, protein, lactate dehydrogenase, duration of disease, age and gender. A logistic regression model to predict pleural tuberculosis including the five first variables showed the best performance. A receiver operating characteristic curve identified the best cutoff at 0.7, resulting in a sensitivity and specificity of more then 95%. The predictive model improved the specificity of ADA alone, keeping its sensitivity. This model seems helpful when a microbiological or histological diagnosis of pleural tuberculosis could not be established. External validation of these results is necessary before recommendation for routine application.

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%).

Drug-induced sleep endoscopy in the obstructive sleep apnea: comparison between NOHL and VOTE classifications

Obstructive sleep apnea (OSA) is characterized by recurrent episodes of partial or complete collapse of the pharynx that result in a decrease in oxyhemoglobin saturation. Nasofibrolaryngoscopy under induced sleep is a promising alternative for identifying sites of upper airway obstruction in patients with OSA. This study aimed to compare the obstruction sites screened by drug-induced sleep endoscopy (DISE) using the Nose oropharynx hypopharynx and larynx (NOHL) and Velum oropharynx tongue base epiglottis (VOTE) classifications. We also determined the relationship between OSA severity and the number of obstruction sites and compared the minimum SaO2 levels between DISE and polysomnography (PSG). This was a prospective study in 45 patients with moderate and severe OSA using DISE with target-controlled infusion of propofol bispectral index (BIS) monitoring. The retropalatal region was the most frequent obstruction site, followed by the retrolingual region. Forty-two percent of patients had obstruction in the epiglottis. Concentrically shaped obstructions were more prevalent in both ratings. The relationship between OSA severity and number of obstruction sites was significant for the VOTE classification. Similar minimum SaO2 values were observed in DISE and PSG. The VOTE classification was more comprehensive in the analysis of the epiglottis and pharynx by DISE and the relationship between OSA severity and number of affected sites was also established by VOTE. The use of BIS associated with DISE is a reliable tool for the assessment of OSA patients.

Which functional parameters can help differentiate severe asthma from COPD

The aim of this study was to identify the respiratory function parameters that help in the accurate diagnosis of asthma and COPD. We studied 20 asthma and 30 COPD patients who underwent lung function tests including spirometry and plethysmography both with bronchodilator test and diffusion with carbon monoxide (DLCO). The tests were performed according to International Guidelines (ATS/ERS). The asthma patients were younger (mean age = 48) than those in the COPD group (mean age = 59) and this group also had more female patients (65%) than the COPD group (40%). The results showed a more severe obstruction in the asthma group: FEV1/FVC= 59% versus 66% for COPD. There was also a greater bronchodilator response as shown by changes in absolute and percentage values for FEV1 in the asthma group. Average DLCO values were normal in the asthma group (103%P) and lower in the COPD (69%). In plethysmography the asthma group had a higher residual volume (%P) and a higher airway resistance. We concluded that many functional parameters were useful in distinguishing the asthma and COPD groups. In individual analysis, DLCO was the parameter which best aided in an accurate diagnosis in both groups, with a higher specificity for COPD. The bronchodilator response measured by changes in FEV1 showed a higher sensitivity for asthma. Thus, these two tests are highlighted in the differential diagnosis of obstructive diseases.

Nocturnal Hypoxemia is Associated With Low Testosterone Levels in Overweight Males and Older Men With Normal Weight

STUDY OBJECTIVES The relationship among obstructive sleep apnea (OSA), body mass index (BMI), and testosterone levels has long been suggested. Obese men have shown a negative correlation between testosterone level and sleep apnea severity. Yet, little is known about the association between testosterone levels and sleep apnea in men who are not obese. This study evaluated the association between the total testosterone (TT) level and OSA in patients who are not obese. METHODS A retrospective review of 523 records of patients in whom OSA was diagnosed from 2013-2016 was performed. The study included men with a BMI < 30 kg/m2 and with TT levels measured in a blood sample collected the morning after a sleep study. RESULTS In all, 153 nonobese men met inclusion criteria, of whom 47 (30.7%) had testosterone levels below the reference values; 44 of these individuals (93.6%) were overweight (P = .029). Reduced testosterone levels showed significant correlations with the oxygen desaturation index, the lowest oxygen saturation < 80% (O2 nadir < 80%), and rapid eye movement (REM) sleep duration, after adjusting for BMI. Among patients with normal weight, only 3 who had O2 nadir < 80% and were older than 50 years presented with a reduced TT level. CONCLUSIONS In a large population of nonobese men with OSA, we demonstrated that hypoxemia (O2 nadir < 80%) and overweight are associated with reduced testosterone levels. This association was only observed among normal-weight individuals older than 50 years.

Hiperreactividade brônquica na sarcoidose

The purpose of this study was to measure airway responsiveness in patients with sarcoidosis using bronchoprovocation test with methacholine (BPT) in comparison to roentgenographic findings, respiratory symptoms, activity and duration of the disease. There were 17 patients with Sarcoidosis, 20 asthmatics and 21 assymptomatics. We used the tidal breathing method with standardizes output for the nebulizers. We administered increasing and successively concentrations of methacholine beginning with 0.125 to 16 mg/ml. The responses were measured by changes in FEV1 or the final concentration was reached. The results were expressed as the concentration of methacholine causing 20% fall in FEV1 (PC20). Aerosolized bronchodilator was given at the completion of all tests. There were 4 patients with sarcoidosis who had positive BPT, 3 of them with PC20<8 mg/ml associated with respiratory symptoms, bilateral hilar adenopathy, more than twoyear duration and active disease. All the asthmatic subjects had positive BPT with CP20<8 mg/ml. The entire assymptomatic group had negative BPT. Positive bronchodilator response was reached in 6 patients with sarcoidosis, 20 asthmatics and 8 assymptomatic subjects. We concluded that: (a) airway responsiveness can be reached in 17.6% patients with sarcoidosis related to bilateral hilar adenopathy, chronic and active disease; (b) 50% of sarcoidosis patients with cough and/or wheeze had positive BPT, (c) the BPT was able to discriminate asthmatic from assymptomatic subjects. Rev Port Pneumol 2005; XI (2): 97-110

The Effect of Sedating Agents on Drug-Induced Sleep Endoscopy Findings: Agents' Sedating Effect on DISE Findings

Drug‐induced sleep endoscopy (DISE) has gained interest for upper airway evaluation in patients with snoring and obstructive sleep apnea (OSA), and different drugs have been used to induce sedation. Nevertheless, all drugs have presented specific advantages and disadvantages with differential effects on respiratory physiology. This study evaluated and compared the effects of midazolam, propofol and dexmedetomidine on DISE findings, O2 nadir, and bispectral index (BIS) in the same sample of patients.

Reply to Dijemeni et al.’s comments concerning: “The comparability of drug-induced sedation classification systems”

classification [3]. BIS has been shown to be a relevant parameter in the orientation of the depth of sedation with propofol by target controlled infusion technique, avoiding deep sedations and severe desaturations. The mean of lowest oxygen saturation values was higher in DISE (85%) than in PSG (78%). The 2014 European position paper [4] in relation with the DISE classification system, which aimed to represent patterns of obstruction in terms of obstruction structures and/or levels of obstruction, was based on studies available at that moment. Building upon new research, the European position can be updated. The description in the VOTE classification (sites) appears to be more precise, or even easier, than the NOHL classification (levels), but the DISE imagens during the apnea are often not as clear as we would like. We can always find cases that will not fit into the classification systems chosen to describe the findings. We believe that whatever classification that is used will always present shortcomings. More studies are important to identify and select a classification that can minimize biases. We agree that classification standardization will be an important step, especially among world-wide research centers [5]. Additional correlations between the DISE findings, through the classifications that are being used, and other polysomnographic outcome, such as the oxygen desaturation index, also need to be considered. Moreover, another relevant aspect to consider is the observers’ experience in the identification of the anatomical structures during an apnea event (sites and levels) and the capacity of reproduction of the results. New questions and answers are valuable to demonstrate the usefulness of the DISE in the evaluation of patients with OSA, be it for surgical indication or contraindication, and be it for clinical treatment. The authors are thankful for the overall positive opinion expressed about our paper “Drug-induced sleep endoscopy in the obstructive sleep apnea: comparison between NOHL and VOTE classifications” [1] in the letter to the editor entitled “The comparability of drug-induced sedation classification systems”. We wish briefly to reply to the questions raised by the authors of the letter. Our study correlated the severity of obstruction sleep apnea (OSA) with obstruction sites (VOTE) (p value O1 = 0.05 and O2 = 0.04), not identifying this correlation between obstruction levels (NOHL) (p value O1 = 0.21 and O2 = 0.14). Regarding the epiglottis, the VOTE classification [2] is more detailed, since it allows to identify the form and degree of obstruction, different from the NOHL

AVALIAÇÃO DA QUALIDADE DO SONO ATRAVÉS DA ACTIGRAFIA EM HIPERTENSOS REFRATÁRIOS

Houve correlação positiva fraca, porém significativa, entre idade e porcentagem de erros (tipo 1) no teste D2 e a duração da vigília e número de despertares durante o sono. A intensidade de ansiedade correlacionou-se, positiva e moderadamente com a intensidade de depressão e fracamente com queixas de desatenção e de sono, latência objetiva do sono e pior desempenho no PVT. A correlação negativa positiva (fraca) foi observada entre a idade e queixas de desatenção (ASRS) e hipersonolência diurna. Não houve correlação da duração média de sono relatada pelo PSQI ou registrada pelo actígrafo com nenhuma das variáveis. Uso inadequado da cama e uso frequente de aparelhos eletrônicos próximo ao horário de dormir, foram relatos frequentes.

Correlation between the oropharyngo-laryngoscopic findings and the severity of obstructive sleep apnea.

OBJECTIVE To correlate anatomical and functional changes of the oral cavity, pharynx and larynx to the severity of obstructive sleep apnea syndrome (OSAS). METHODS We conducted a cross-sectional study of 66 patients of both genders, aged between 21 and 59 years old with complaints of snoring and / or apnea. All underwent full clinical evaluation, including physical examination, nasolarybgoscopy and polisonography. We classified individuals into groups by the value of the apnea-hypopnea index (AHI), calculated measures of association and analyzed differences by the Kruskal-Wallis and chi-square tests. RESULTS all patients with obesity type 2 had OSAS. We found a relationship between the uvula projection during nasoendoscopy and OSAS (OR: 4.9; p-value: 0.008; CI: 1.25-22.9). In addition, there was a major strength of association between the circular shape of the pharynx and the presence of moderate or severe OSAS (OR: 9.4, p-value: 0.002), although the CI was wide (1.80-53.13). The septal deviation and lower turbinate hypertrophy were the most frequent nasal alterations, however unrelated to gravity. Nasal obstruction was four times more common in patients without daytime sleepiness. The other craniofacial anatomical changes were not predictors for the occurrence of OSAS. CONCLUSION oral, pharyngeal and laryngeal disorders participate in the pathophysiology of OSAS. The completion of the endoscopic examination is of great value to the evaluation of these patients.