Inês Neves

Molecular Epidemiology of HIV in Brazil: Polymorphism of the Antigenically Distinct HIV-1 B Subtype Strains

1Erika Castro, 2Gloria Echeverria, 2Leopoldo Deibis, 3Beatriz Gonzalez de Salmen, 1Aline Dos Santos Moreira, 1Monick L. Guimaraes, 4Francisco I. Bastos, and 1Mariza G. Morgado 1Department of Immunology, Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro, Brazil; 1Non Governmental Organization, CRIATEII, Porlamar, Margarita Island, Venezuela; 2Immunology Institute, Central University of Venezuela, Caracas, Venezuela; 3STDs and AIDS Program, State Hospital “Luis Ortega,” Porlamar, Margarita Island, Venezuela; and 4Department of Health Information, CICT, FIOCRUZ, Rio de Janeiro, Brazil

The value of rapid on-site evaluation during EBUS-TBNA

BACKGROUND Rapid on-site evaluation (ROSE) has the potential to increase endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) accuracy in the diagnosis of mediastinal lesions and lung cancer staging. However, studies have reported controversial results. The purpose of our study was to evaluate the influence of ROSE on sample adequacy and diagnostic accuracy of EBUS-TBNA. METHODS Prospective observational study that enrolled 81 patients who underwent EBUS-TBNA for investigation of hilo-mediastinal lesions or lung cancer staging. The first 41 patients underwent EBUS-TBNA with ROSE (ROSE group) and the last 40 patients without ROSE (non-ROSE group). Sample adequacy and diagnostic accuracy of EBUS-TBNA in both groups were compared. RESULTS Adequate samples were obtained in 93% of the patients in the ROSE group and 80% in non-ROSE group (p=0.10). The diagnostic accuracy of EBUS-TBNA was 91% in ROSE group and 83% in non-ROSE group (p=0.08). Analyzing the EBUS-TBNA purpose, in the subgroup of patients who underwent EBUS-TBNA for investigation of hilo-mediastinal lesions, these differences between ROSE and non-ROSE group were higher compared to lung cancer staging, 93% of patients with adequate samples in the ROSE group vs. 75% in the non-ROSE group (p=0.06) and 87% of diagnostic accuracy in ROSE group vs. 77% in non-ROSE group (p=0.10). CONCLUSIONS Despite the lack of statistical significance, ROSE appears to be particularly useful in the diagnostic work-up of hilo-mediastinal lesions, increasing the diagnostic yield of EBUS-TBNA.

Influência da distribuição do enfisema nos parâmetros de função pulmonar em pacientes com DPOC

A distribuicao do enfisema foi analisada em pacientes com DPOC, que foram classificados de acordo com um sistema de classificacao visual de cinco pontos a partir de achados de TC de torax. Avaliou-se a influencia do tipo de distribuicao do enfisema na apresentacao funcional e clinica da DPOC. Hipoxemia apos o teste da caminhada de seis minutos (TC6) foi tambem avaliada e a distância percorrida (DTC6) foi determinada.

Transbronchial cryobiopsy in the diagnosis of desquamative interstitial pneumonia.

Desquamative interstitial pneumonia (DIP) is a rare interstitial pneumonia usually associated with cigarette smoke.1,2 It is characterized by the accumulation of intra-alveolar macrophages, sometimes associated with giant cells.1,3 The diagnosis may be suggested by patchy ground-glass opacification with a predilection for the mid and lower lung lobes on high-resolution computed tomography (HRCT); subpleural involvement is also typical. Irregular lines, traction bronchiectasis, cysts, emphysema, and nodules are other possible findings of DIP.4 Bronchoalveolar lavage fluid nearly always contains an increased number of alveolar macrophages.2,4 Histologically, DIP is characterized by the accumulation of macrophages in the alveolar spaces associated with interstitial inflammation and/or fibrosis. The macrophages usually contain light brown pigment. Lymphoid nodules and a sparse but distinct eosinophilic infiltrate are common.3 Surgical lung biopsy is still required to make a definitive diagnosis.1--3 Transbronchial lung cryobiopsy (TBLC) is a new endoscopic technique that has recently shown superior diagnostic yield to conventional transbronchial biopsy (TBB).5--7 The advantage of the cryoprobe, compared with conventional TBB or TBB using jumbo forceps is that larger pieces of tissue, without crush artifacts, can be extracted during the freeze-thaw cycle, allowing the identification of complex pathologic patterns. The technique permits visualization of peripheral structures of the secondary pulmonary lobule and facilitates immunohistochemical staining. In addition, TBLC can be performed on an outpatient basis and is both an easier and safer procedure for patients with comorbidities, as it reduces the complications and mortality associated with surgical lung biopsy.6 Most of the data available to date is on TBLC overall diagnostic yield and complication rates.5 However, it is also important for clinicians to know the diagnostic accuracy of TBLC in particular diffuse lung diseases, especially in cases in which histologic evaluation is an essential component of

Mycobacterium tuberculosis, quanto tempo passeaste?

Aim: Determine the time elapsed between the onset of symptoms until the first observation by a health professional and the time from the first observation to diagnosis. Methods: We conducted a questionnaire-based survey to pts with active TB followed in the CDC treatment of VNG in May and June 2012. Results: 54 pts, 68% males, mean age of 48 years.The first healthcare place that the patient went after the onset of symptoms was to emergency department 20 pts (37%), a general practitioner 17 pts (31%), a hospital consultation 9 pts (17%), a private clinic 3 pts (5%), Chest Diagnosis Centre 3 pts (5%), a pharmacy 2 pts (4%). The median time from onset of symptoms and the observation by a health professional was 37 days. Patients with symptoms of anorexia and weight loss took longer to access to health care (53 vs 18 days, p = 0.01 and 52 vs 12 days, respectively). The pt was observed on average 3 times before the diagnosis was made. Pts who took less than 15 days to access to the health care system went mainly to the emergency department (48%), while pts who took more than 15 days were observed mainly by a general practitioner (52%, p = 0.03), The median time from the first consultation and diagnosis was 56 days. Pts with respiratory symptoms had on average a diagnosis faster than the others (38 vs 127 days, p = 0.01). The majority of pts in whom the diagnosis was made in less than 15 days, were first observed in the emergence department (57%), while pts whose diagnosis took longer than 15 days were observed by a general practitioner (39%, p=0.03). The median time from onset of symptoms and diagnosis was 92 days. Conclusion: These results suggest the need to implement strategies for earlier diagnosis of tuberculosis.

Withdrawing and Withholding Life Support in Patients With Cancer in an ICU Setting: A 5-Year Experience at a European Cancer Center.

Objective: This was an observational retrospective study aimed to examine the frequency and associated factors of withdrawing or withholding life support (WWLS) in the intensive care unit (ICU) of a comprehensive cancer center. Methods: Medical records of adult patients with cancer admitted to the ICU between January 2010 and December 2014 were reviewed. Patients who died during that period were classified into 2 groups: full life support and withdrawing and withholding life support. The relative impact of demographic and clinical factors was assessed using logistic regression. Results: A total of 247 patients died in our unit (mortality rate of 16.3%). Their median age was 62 (interquartile range [IQR] 51-73) years, there were 142 (57.5%) male patients, and they had predominantly solid malignancies (62.3%). The median Simplified Acute Physiology Score II and Acute Physiology and Chronic Health Evaluation scores were 67 (IQR 54-80) and 29 (IQR 23-55), respectively. Ninety-six (38.9%) patients died after WWLS with no statistically significant differences in decisions to limit therapy during the study period. Patients with advanced age, solid malignancies, nonneutropenic, and longer duration of mechanical ventilation were more likely to die after WWLS. In multivariate analysis, presenting with neutropenia was independently associated with a lower likelihood of dying after WWLS (odds ratio: 0.34, 95% confidence interval: 0.15-0.80). Conclusion: Limitation of therapy has been a common practice in oncologic ICUs over recent years. Neutropenia is an independent predictor of limitation of therapy.

Symptomatic assessment in COPD GOLD 2011 classification - mMRC/CAT agreement

Introduction: The mMRC dyspnea scale and the CAT quality of life questionnaire are tools used for COPD symptomatic evaluation although there is some data showing that they are not equivalent. Objectives: Assessment of mMRC/CAT agreement in COPD classification by groups according to GOLD 2011. Methods: Observational study including patients with stable COPD followed in an outpatient consultation.Application of mMRC and CAT and evaluation of the agreement between both using K of Cohen9s and Pearson9s correlation coefficient. Results: 87 patients were included, 90,8% (n=79) were men, mean age was 65,9± 10,4 years and mean FEV1 1,5L±0,6. The application of mMRC vs CAT allowed classification: Group A 36 (41,4%) vs 19 (21,8%) patients; Group B 17 (19,5%) vs 34 (39,1%); Group C 17 (19,5%) vs 7 (8%); Group D 17 (19,5%) vs 27 (31%); global correlation p=0,523 (moderate); degree of agreement K=0,429 (moderate). The application of both methods resulted into a different COPD group classification in 31% of the cases (mMRC A/CAT B in 17 (63%) and mMRC C/CAT D in 10 (37%)). CAT was allways responsible for the allocation into the most symptomatic group. The disagreement was more frequent between A/B groups, but when analysed separately the groups with mild/moderate and severe/very severe obstruction, K coefficient was similar (0,412 vs 0,418). Conclusion: Depending on the use of mMRC or CAT there was a reclassification of COPD group in 31% of cases which could imply a therapeutic strategy modification.

Characterization of patients with ACOS - Application of GINA/GOLD questionnaire vs SEPAR criteria

ACOS has assumed increasing relevance and has been recently recognized as a specific clinical entity. In 2012, SEPAR published a consensus document with clinical and analytical diagnostic criteria. In 2014, the joint initiative GINA/GOLD released for the first time guidelines addressed to this entity. However, there is not a consensual definition and the studies published are few. We aimed to identify and characterize (clinically and functionally) patients with ACOS according to GINA/GOLD and SEPAR (major and minor) criteria, followed in our Pulmonary Outpatient Department during 2014. We included patients ≥35 years old with history of asthma/COPD. Since it was a retrospective study, eosinophilia assessment in sputum (a major criteria by SEPAR) was not performed. Among 462 patients, 34 (7,4%) were recognized by GINA/GOLD while 11 (2,4%) matched the SEPAR criteria. The GINA/GOLD group had a higher mean age (61,1 vs 52,4 years) and the majority were male (55,9% vs 36,4%). All in the SEPAR group were current smokers (100% vs 85.3%). A history of atopy was more frequent with SEPAR (54,5% vs 29,4%) and ≥1 exacerbations/hospitalizations in the last year was higher in the GINA/GOLD (35,3% vs 27,3%). The presence of a functional severe obstruction was similar in both groups (44.1% vs. 45.5%). Combined inhaled therapy of ICS plus a long-acting bronchodilator was used by the majority on both groups (90,9% vs 94,1%). There was a clear discrepancy in the number of patients identified by the two criteria. Regarding SEPAR, a low sensitivity/specificity has been reported as well as the difficulty on its clinical application, justified by the unavailability of all the necessary criteria for diagnosis.

Combined intrapleural therapy in infectious pleural effusion

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Chest tube clamping in spontaneous pneumothorax: 6 hours versus 24 hours – A randomized pilot study

Introduction: In the treatment of a spontaneous pneumothorax (SP), there is consensus that chest tubes should be removed only when there is a re-expansion of lung and no clinical evidence of an air leak. There are different recommendations concerning the duration of chest tube clamping (CTC). In our department, 24 hours CTC is the conventional method. Objective: To compare the risk of recurrence of SP between 6 hours and 24 hours CTC. Methods: Forty-one patients were enrolled in the study. All subjects were randomized after the resolution of a SP: 6 hours CTC versus 24 hours CTC (control). The number and time of recurrence were analysed. Results: During the clamping time 2 patients were excluded (clamp had to be removed). Nineteen patients were included in the 6 hours group and 20 in the control group. Patients (30 males) with a median age of 28 had in 76.9% history of smoking habits and 30.8% used inhaled illicit drugs. There were no recurrences in the first 7 days after chest tube removal. No significant statistical differences were found in the risk to recurrence in the two groups (p=0.471). A considerable difference between the 2 groups was found in the time until recurrence (56 days in 6 hours group versus 303 days in control group). In the multivariate analysis the CTC duration didn9t influence the risk of recurrence. Conclusions: In this study, the risk of early (