Denise Rossato Silva

Mortality among patients with tuberculosis requiring intensive care: a retrospective cohort study

BackgroundTo describe the characteristics of patients with tuberculosis (TB) requiring intensive care and to identify the factors that predicts in-hospital mortality in a city of a developing country with intermediate-to-high TB endemicity.MethodsWe conducted a retrospective, cohort study, between November 2005 and November 2007. The patients with TB requiring intensive care were included. Predictors of mortality were assessed. The primary outcome was the in-hospital mortality.ResultsDuring the study period, 67 patients with TB required intensive care. Of them, 62 (92.5%) had acute respiratory failure and required mechanical ventilation. Forty-four (65.7%) patients died. Coinfection with human immunodeficiency virus was present in 46 (68.7%) patients. Early intensive care unit admission and ventilator-associated pneumonia were independently associated with the in-hospital mortality.ConclusionsIn this study we found a high mortality rate in TB patients requiring intensive care, especially in those with an early ICU admission.

Osteoporosis Prevalence and Associated Factors in Patients With COPD: A Cross-Sectional Study

BACKGROUND: Osteoporosis is one of the systemic features of COPD. OBJECTIVE: To determine the prevalence of osteoporosis in a sample of COPD out-patients, and investigate the correlation between T-score (a comparison of the patients bone mineral density to that of a healthy 30-year-old of the same sex and ethnicity) and several factors suggested to be associated with osteoporosis. METHODS: In a cross-sectional study, we conducted dual-energy X-ray absorptiometry bone mineral density scans of the hips and lumbar spine, and collected data on smoking and alcohol habits, menopausal status, comorbidities, inhaled and oral corticosteroid dose and duration of treatment, previous bone fractures, pulmonary function tests, calcium intake (via questionnaire on food frequency), vitamin D intake (via questionnaire on sunlight exposure), and physical activity (via the International Physical Activity Questionnaire). RESULTS: We evaluated 95 patients. Forty (42%) were osteoporotic, 40 (42%) were osteopenic, and 15 (16%) had normal bone mass. We found significant bivariate correlations between femoral-neck T-score and body mass index (r = 0.551, P < .001), and femoral-neck T-score and International Physical Activity Questionnaire total activity score (r = 0.378, P < .001). There was a significant inverse relationship between femoral-neck T-score and BODE (body mass index, air-flow obstruction, dyspnea, and exercise capacity) index (r = −0.246, P = .02). We also found significant correlations between T-score and FEV1 (r = 0.251, P = .01), forced vital capacity (r = 0.229, P = .03), percent-of-predicted functional residual capacity (r = −0.415, P < .001), inspiratory capacity (r = 0.252, P = .01), ratio of inspiratory capacity to total lung capacity (r = 0.241, P = .02), and absolute and percent-of-predicted diffusing capacity of the lung for carbon monoxide (r = 0.366, P < .001, and r = 0.338, P = .003, respectively). CONCLUSIONS: We identified a high prevalence of osteoporosis and osteopenia in out-patients with COPD. Patients with osteoporosis had more severe COPD than patients with normal bone mass.

Fibrose Pulmonar idiopática simultânea a enfisema em pacientes tabagistas

OBJETIVO: Descrever os achados clinicos e funcionais de pacientes com enfisema em lobos superiores e fibrose pulmonar idiopatica (FPI) em lobos inferiores, recentemente descrita na literatura. METODOS: Um grupo de 11 pacientes com a presenca simultânea de enfisema e FPI foi identificado retrospectivamente. Todos os pacientes realizaram tomografia computadorizada de torax com alta resolucao e provas de funcao pulmonar. RESULTADOS: Entre os 11 pacientes identificados, havia 8 homens e 3 mulheres, com media de idade de 70,7 ± 7,2 anos (variacao, 61-86 anos). Todos os pacientes eram tabagistas (carga tabagica, 61,5 ± 43,5 anos-maco). As medias da capacidade vital forcada (CVF), do volume expiratorio forcado no primeiro segundo (VEF1) e da relacao VEF1/CVF foram 72,1% ± 12,7%, 68,2% ± 11,9% e 74,4 ± 10,8, respectivamente. Os volumes pulmonares foram normais em 7 pacientes. Um padrao restritivo foi observado em 3 pacientes e hiperinsuflacao estava presente em um. A capacidade de difusao pulmonar apresentou reducao moderada a grave em todos os pacientes (media, 27,7% ± 12,9% do previsto). No teste da caminhada de seis minutos, realizado por 10 pacientes, a distância caminhada media foi de 358,4 ± 143,1 m, ocorrendo dessaturacao >4% em 9 pacientes. Achados ecocardiograficos sugestivos de hipertensao pulmonar estavam presentes em 4 pacientes (media da pressao sistolica da arteria pulmonar, 61,8 mmHg; variacao, 36-84 mmHg). CONCLUSOES: A presenca simultânea de enfisema e FPI causa alteracoes caracteristicas nas provas de funcao pulmonar. O achado mais importante e a discrepância entre a capacidade de difusao e a espirometria.

Factors Associated with Mortality in Hospitalized Patients with Newly Diagnosed Tuberculosis

The purpose of this study was to identify clinical and epidemiological factors associated with death in patients with an in-hospital diagnosis of tuberculosis (TB), in a city with a high prevalence of TB and human immunodeficiency virus (HIV) infection. The study was a retrospective, cohort study conducted at a general, tertiary-care, university-affiliated hospital. Patients who began treatment for TB after hospitalization were included. Predictors of mortality were assessed. The primary outcomes were the in-hospital mortality and the mortality after discharge. We evaluated the medical records of 311 patients with TB. The overall mortality rate of all study participants was 99/311 (31.8%). The mortality rates during hospitalization and after discharge were 50/311 (16.1%) and 49/261 (18.8%), respectively. Mechanical ventilation, consolidation in chest X-ray, and negative sputum smear were predictors of in-hospital death in multivariate analysis. Independent predictors of mortality after discharge in multivariate analysis included total duration of hospitalization and being a current smoker. We found a high overall mortality rate for patients hospitalized with TB in a region with a high prevalence of TB and HIV. The risk of mortality once patients with TB are hospitalized is unlikely to be explained only by the HIV epidemic.

Respiratory viral infections and effects of meteorological parameters and air pollution in adults with respiratory symptoms admitted to the emergency room

Respiratory viral infections (RVIs) are the most common causes of respiratory infections. The prevalence of respiratory viruses in adults is underestimated. Meteorological variations and air pollution are likely to play a role in these infections.

Factors associated with delayed diagnosis of tuberculosis in hospitalized patients in a high TB and HIV burden setting: a cross-sectional study

BackgroundThe most essential components of TB control are early diagnosis and adequate treatment. Delay in the diagnosis and treatment of tuberculosis may result in more extensive disease and more complications, increase severity of the disease and is associated with higher risk of mortality. The purpose of this study was to identify factors associated with delayed diagnosis of TB in hospitalized patients.MethodsWe conducted a cross-sectional study in a general, tertiary care, university-affiliated hospital. Adult patients with TB that were hospitalized were identified retrospectively, and risk factors for delayed diagnosis were collected.ResultsThe median delay until diagnosis was 6 days (IQR: 2-12 days). One hundred and sixty six (54.4%) patients were diagnosed ≤ 6 days, and 139 (45.6%) > 6 days after admission. The main factors associated with diagnostic delay (> 6 days) were extra-pulmonary TB and negative sputum smear.ConclusionsAlthough hospitalization permits a rapid management of the patient and favors a faster diagnosis, we found an unacceptable time delay before the diagnosis of pulmonary TB was made. Future studies should focus on attempt to explain the reasons of diagnostic retard in the patients with the characteristics related to delay in this study.

Hipertensão arterial pulmonar e doenças da tireoide

Recent studies have suggested an association between pulmonary arterial hypertension (PAH) and thyroid diseases (hypothyroidism and hyperthyroidism). This combination has a good prognosis, because the increase in the pulmonary artery pressure is usually slight and reverses after the treatment of the thyroid disease. Although the exact mechanism involved in the pathogenesis of this combination has not yet been established, it has been hypothesized that thyroid hormones and autoimmunity have a direct influence. Due to the high prevalence of thyroid disease in patients with PAH, thyroid function tests should be considered in the investigation of every patient with PAH. In this review, we describe the prevalence of PAH in patients with thyroid diseases and the prevalence of thyroid disease in patients with PAH, as well as addressing the principal effects that thyroid diseases have on the respiratory system. In addition, we report the treatment effects in patients with these diseases.

Doença de Kikuchi-Fujimoto

Kikuchi-Fujimoto disease is characterized by fever and lymphadenopathy, usually localized in the cervical region. This disease principally affects young females. It can be confused with lymphoma, adenocarcinoma metastasis and tuberculosis. We report two cases of Kikuchi-Fujimoto disease. In the first case, a 28-year-old female had been treated for tuberculosis one year prior and presented with a clinical and histological profile compatible with Kikuchi-Fujimoto disease. The second patient, a 58-year-old female, initially received treatment for Wegeners granulomatosis and, subsequently, for tuberculosis. Histopathological examination followed by immunohistochemical analysis confirmed the diagnosis of Kikuchi-Fujimoto disease in both cases. After the definitive diagnosis had been made, both patients were treated symptomatically, and both presented clinical improvement within one month. Subsequently, the latter patient developed systemic lupus erythematosus.

Características clínicas e evolução de pacientes imunocomprometidos não HIV com diagnóstico intra-hospitalar de tuberculose

OBJECTIVE To investigate the characteristics of and risk factors for mortality among non-HIV-infected immunocompromised patients with an in-hospital diagnosis of tuberculosis. METHODS This was a two-year, retrospective cohort study of patients with an in-hospital diagnosis of tuberculosis. The predictive factors for mortality were evaluated. RESULTS During the study period, 337 hospitalized patients were diagnosed with tuberculosis, and 61 of those patients presented with immunosuppression that was unrelated to HIV infection. Extrapulmonary tuberculosis was found in 47.5% of cases. In the latter group, the in-hospital mortality rate was 21.3%, and the mortality rate after discharge was 18.8%. One-year survival was significantly higher among the immunocompetent patients than among the HIV patients (p = 0.008) and the non-HIV-infected immunocompromised patients (p = 0.015), although there was no such difference between the two latter groups (p = 0.848). Among the non-HIV-infected immunocompromised patients, the only factor statistically associated with mortality was the need for mechanical ventilation. Among the patients over 60 years of age, fibrosis/atelectasis on chest X-rays and dyspnea were more common, whereas fever and consolidations were less common. Fever was also less common among the patients with neoplasms. The time from admission to the initiation of treatment was significant longer in patients over 60 years of age, as well as in those with diabetes and those with end-stage renal disease. Weight loss was least common in patients with diabetes and in those using corticosteroids. CONCLUSIONS The lower prevalence of classic symptoms, the occurrence of extrapulmonary tuberculosis, the delayed initiation of treatment, and the high mortality rate reflect the diagnostic and therapeutic challenges of tuberculosis in non-HIV-infected immunocompromised patients.

Tuberculose grave com necessidade de internação em UTI

Tuberculosis is a curable disease that can evolve to severe forms, requiring the treatment of the patients in an ICU, especially if there is a delay in the diagnosis or if it affects elderly patients, those on dialysis, or those with HIV infection or other states of immunosuppression, as well as in cases of multidrug resistant disease. Knowledge of the radiological presentation of the cases can help diagnose these severe forms, as can the introduction of new tests, such as the early detection of the etiological agent by PCR and chest CT, which favors the early initiation of treatment. In addition, the use of regimens without isoniazid and rifampin, as well as uncertain enteral absorption and low serum concentrations of antituberculosis drugs, can reduce the efficacy of treatment. For such patients, the prognosis is generally poor and mortality rates are high.