Julieta Klaassen

Six-Minute Walk Test and Maximum Exercise Test in Cycloergometer in Chronic Obstructive Pulmonary Disease. Are the Physiological Demands Equivalent?

a b s t r a c t Background and objectives: The physiological load imposed by the six minute walk test (SMWT) in chronic obstructive pulmonary disease (COPD) patients come from small studies where the influence of disease severity has not been assessed. The aim of the present study was to compare the SMWT with an incremental cardiopulmonary exercise test (CPET) in patients classified by disease severity according to FEV1 (cutoff 50% predicted). Patients and methods: Eighty-one COPD patients (53 with FEV1 ≥50%) performed both tests on two consecutive days. Oxygen consumption (V. O2), carbon dioxide production (V. O2), minute ventilation (V. E), heart rate (HR) and pulse oximetry (SpO2) were measured during SMWT and CPET using portable equipment. Dyspnea and leg fatigue were measured with the Borg scale. Results: In both groups, walking speed was constant during the SMWT and V. O2 showed a plateau after the 3rd minute. When comparing SMWT (6th min) and peak CPET, patients with FEV1 ≥50% showed a greater V. O2, but lower values of V. O2,VE, HR, dyspnea, leg fatigue, and SpO2 during walking. In contrast, in those with FEV1 <50% predicted values were similar. Distance walked during the SMWT strongly correlated with V. O2 at peak CPET (r=0.78; P=0.0001). Conclusion: The SMWT is a constant load exercise in COPD patients, regardless of disease severity. It imposes high metabolic, ventilatory and cardiovascular requirements, which were closer to those of CPET in severe COPD. These findings may explain the close correlation between distance walked and peak CPET V. O2.

Prueba de marcha de 6 min y ejercicio máximo en cicloergómetro en la enfermedad pulmonar obstructiva crónica, ¿son sus demandas fisiológicas equivalentes?

BACKGROUND AND OBJECTIVES The physiological load imposed by the six minute walk test (SMWT) in chronic obstructive pulmonary disease (COPD) patients come from small studies where the influence of disease severity has not been assessed. The aim of the present study was to compare the SMWT with an incremental cardiopulmonary exercise test (CPET) in patients classified by disease severity according to FEV(1) (cutoff 50% predicted). PATIENTS AND METHODS Eighty-one COPD patients (53 with FEV(1) > or =50%) performed both tests on two consecutive days. Oxygen consumption (VO(2)), carbon dioxide production (VCO(2)), minute ventilation (V(E)), heart rate (HR) and pulse oximetry (SpO(2)) were measured during SMWT and CPET using portable equipment. Dyspnea and leg fatigue were measured with the Borg scale. RESULTS In both groups, walking speed was constant during the SMWT and VO(2) showed a plateau after the 3rd minute. When comparing SMWT (6th min) and peak CPET, patients with FEV(1) > or =50% showed a greater VO(2), but lower values of VCO(2),V(E), HR, dyspnea, leg fatigue, and SpO(2) during walking. In contrast, in those with FEV(1) <50% predicted values were similar. Distance walked during the SMWT strongly correlated with VO(2) at peak CPET (r=0.78; P=0.0001). CONCLUSION The SMWT is a constant load exercise in COPD patients, regardless of disease severity. It imposes high metabolic, ventilatory and cardiovascular requirements, which were closer to those of CPET in severe COPD. These findings may explain the close correlation between distance walked and peak CPET VO(2).

Reducción de la actividad física en pacientes con enfermedad pulmonar obstructiva crónica

BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) decrease their physical activity. However, it is unknown at which stage of the disease the reduction occurs and whether dyspnea is a limiting factor. AIM To compare physical activity between patients with COPD and controls of similar age and to assess its association with disease severity. MATERIAL AND METHODS We studied 112 patients with mild to very severe COPD and 55 controls. Lung function, six-minutes walking test (SMWT), and physical activity through the International Physical Activity Questionnaire (IPAQ) were measured. RESULTS Compared to controls, physical activity was significantly reduced in COPD patients (1823 ± 2598 vs. 2920 ± 3040 METs min/week; p = 0.001). Patients were more frequently sedentary (38 vs. 11%), while controls were more often very active (31 vs. 19%) or moderately active (58 vs. 43%). Physical activity was reduced from Global Initiative for Obstructive Chronic Lung Disease (GOLD) stage 2 and from Modified Medical Research Council (MMRC) dyspnea grade 1. Weak relationships were observed between lung function, SMWT and physical activity. CONCLUSIONS Physical activity decreases early in the course of the disease and when dyspnea is still mild, among patients with COPD.

Diagnóstico y manejo de colitis ulcerosa grave: Una mirada actualizada

Ulcerative Colitis (UC) is a chronic inflammatory disease involving the colon, with alternating periods of remission and activity. Exacerbations can be severe and associated with complications and mortality. Diagnosis of severe UC is based on clinical, biochemical and endoscopic variables. Patients with severe UC must be hospitalized. First line therapy is the use of intravenous corticoids which achieve clinical remission in most patients. However, 25% of patients will be refractory to corticoids, situation that should be evaluated at the third day of therapy. In patients without response, cytomegalovirus infection must be quickly ruled out to escalate to second line therapy with biological drugs or cyclosporine. Total colectomy must not be delayed if there is no response to second line therapy, if there is a contraindication for second line therapies or there are complications such as: megacolon, perforation or massive bleeding. An active management with quick escalation on therapy allows to decrease the prolonged exposure to corticoids, reduce colectomy rates and its perioperative complications.

Obesidad y cáncer: la tormenta perfecta

While some genetic factors may explain the development of cancer, its main causes are related to environmental exposure to carcinogenic agents as well as to the effect of determined lifestyles and habits. Several epidemiological studies have shown a consistent relation between obesity and cancer. In non smokers, obesity is the most relevant risk factor in the development of malignant tumors. There is a clear association between obesity and endometrial cancer, breast cancer in postmenopausal women, pancreatic, esophageal and colon cancer. Sexual steroids, insulin like growth factor axis and adipokines are the three main models to explain the biological basis for the obesity-cancer relationship. However, these models do not explain all the biological mechanisms that link obesity to cancer. There are other factors in play such as chronic inflammation, hypoxia and oxidative stress. Obesity may hamper the screening, diagnosis and treatment of some tumors, increasing mortality rates. Obesity prevention and management, therefore, may be the most important modifiable factor in reducing both incidence and mortality in cancer. New studies are required to quantify the effect of intentional weight reduction on the incidence and relapse of cancer. Considering the efficacy of bariatric surgery for weight reduction, it is an attractive model to study this link.

Proteína C Reactiva en la EPOC y su relación con la gravedad de la enfermedad, las exacerbaciones y las comorbilidades

BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) have elevated serum levels of ultrasensitive C reactive protein (CRPus). This raise may be related directly to COPD and its associated systemic inflammation or secondary to other factors such as smoking status, disease severity, acute exacerbations, or associated complications. AIM To evaluate the potential causes of raised levels of CRPus in stable COPD patients. PATIENTS AND METHODS Cohorts of 133 mild-to-very severe COPD patients (41 current smokers), 31 never-smokers, and 33 current smoker controls were compared. Clinical assessments included body mass index (BMI), fat (FM) and fat-free mass (FFM) measurement by DEXA, forced expiratory volume in one second (FEV1), arterial oxygen tension (PaO2), six-minute walking test (SMWT), emphysema (EMPH) and right thigh muscle cross-sectional area (TMCSA), both quantified by high resolution computed tomography. RESULTS Serum CRPus levels were significantly higher in COPD patients than in controls (7 ± 4.2 and 3.7 ± 2.7 mg/L respectively; p < 0.0001). Being smoker did not influence CRPus levels. These levels were significantly correlated with FM (r = 0.30), BMI (r = 0.21), FEV1 (r = -0.21), number of acute exacerbations of the disease in the last year (r = 0.28), and PaO2 (r = -0.27). Using multivariate analysis FM, PaO2, and number of acute exacerbations of the disease in the last year had the strongest association with CRPus levels. CONCLUSIONS CRPus is elevated in COPD patients, independent of smoking status. It is weakly associated with fat mass, arterial oxygen tension and frequency of exacerbations.Background: Patients with chronic obstructive pulmonary disease (COPD) have elevated serum levels of ultrasensitive C reactive protein (CRPus). This raise may be related directly to COPD and its associated systemic inflammation or secondary to other factors such as smoking status, disease severity, acute exacerbations, or associated complications. Aim: To evaluate the potential causes of raised levels of CRPus in stable COPD patients. Patients and Methods: Cohorts of 133 mild-to-very severe COPD patients (41 current smokers), 31 never-smokers, and 33 current smoker controls were compared. Clinical assessments included body mass index (BMI), fat (FM) and fat-free mass (FFM) measurement by DEXA, forced expiratory volume in one second (FEV1), arterial oxygen tension (PaO2), six-minute walking test (SMWT), emphysema (EMPH) and right thigh muscle cross-sectional area (TMCSA), both quantified by high resolution computed tomography. Results: Serum CRPus levels were significantly higher in COPD patients than in controls (7 ± 4.2 and 3.7 ± 2.7 mg/L respectively; p < 0.0001). Being smoker did not influence CRPus levels. These levels were significantly correlated with FM (r = 0.30), BMI (r = 0.21), FEV1 (r = -0.21), number of acute exacerbations of the disease in the last year (r = 0.28), and PaO2 (r = -0.27). Using multivariate analysis FM, PaO2, and number of acute exacerbations of the disease in the last year had the strongest association with CRPus levels. Conclusions: CRPus is elevated in COPD patients, independent of smoking status. It is weakly associated with fat mass, arterial oxygen tension and frequency of exacerbations.

Insuficiencia intestinal secundaria a síndrome de intestino corto: resultados de un programa multidisciplinario de rehabilitación intestinal

BACKGROUND In patients suffering intestinal failure due to short bowel, the goal of an Intestinal Rehabilitation Program is to optimize and tailor all aspects of clinical management, and eventually, wean patients off lifelong parenteral nutrition. AIM To report the results of our program in patients suffering intestinal failure. PATIENTS AND METHODS A registry of all patients referred to the Intestinal Failure unit between January 2009 and December 2015 was constructed. Initial work up included prior intestinal surgery, blood tests, endoscopic and imaging studies. Also demographic data, medical and surgical management as well as clinical follow-up, were registered. RESULTS Data from 14 consecutive patients aged 26 to 84 years (13 women) was reviewed. Mean length of remnant small bowel was 100 cm and they were on parenteral nutrition for a median of eight months. Seven of 14 patients had short bowel secondary to mesenteric vascular events (embolism/thrombosis). Medical management and autologous reconstruction of the bowel included jejuno-colic anastomosis in six, enterorraphies in three, entero-rectal anastomosis in two, lengthening procedures in two, ileo-colic anastomosis in one and reversal Roux-Y gastric bypass in one. Thirteen of 14 patients were weaned off parenteral nutrition. CONCLUSIONS Our Multidisciplinary Intestinal Rehabilitation Program, allowed weaning most of the studied patients off parenteral nutrition.Background: In patients suffering intestinal failure due to short bowel, the goal of an Intestinal Rehabilitation Program is to optimize and tailor all aspects of clinical management, and eventually, wean patients off lifelong parenteral nutrition. Aim: To report the results of our program in patients suffering intestinal failure. Patients and methods: A registry of all patients referred to the Intestinal Failure unit between January 2009 and December 2015 was constructed. Initial work up included prior intestinal surgery, blood tests, endoscopic and imaging studies. Also demographic data, medical and surgical management as well as clinical follow-up, were registered. Results: Data from 14 consecutive patients aged 26 to 84 years (13 women) was reviewed. Mean length of remnant small bowel was 100 cm and they were on parenteral nutrition for a median of eight months. Seven of 14 patients had short bowel secondary to mesenteric vascular events (embolism/thrombosis). Medical management and autologous reconstruction of the bowel included jejuno-colic anastomosis in six, enterorraphies in three, entero-rectal anastomosis in two, lengthening procedures in two, ileo-colic anastomosis in one and reversal Roux-Y gastric bypass in one. Thirteen of 14 patients were weaned off parenteral nutrition. Conclusions: Our Multidisciplinary Intestinal Rehabilitation Program, allowed weaning most of the studied patients off parenteral nutrition.