Marcelo Basso Gazzana

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.

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.

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.

The electronic cigarette: the new cigarette of the 21st century?

The electronic nicotine delivery system, also known as the electronic cigarette, is generating considerable controversy, not only in the general population but also among health professionals. Smokers the world over have been increasingly using electronic cigarettes as an aid to smoking cessation and as a substitute for conventional cigarettes. There are few available data regarding the safety of electronic cigarettes. There is as yet no evidence that electronic cigarettes are effective in treating nicotine addiction. Some smokers have reported using electronic cigarettes for over a year, often combined with conventional cigarettes, thus prolonging nicotine addiction. In addition, the increasing use of electronic cigarettes by adolescents is a cause for concern. The objective of this study was to describe electronic cigarettes and their components, as well as to review the literature regarding their safety; their impact on smoking initiation and smoking cessation; and regulatory issues related to their use.

Asma aguda em adultos na sala de emergência: o manejo clínico na primeira hora

Asthma is a disease with high prevalence in our country and around the world. Although new therapeutic approaches have been recently developed, there appears to be a worldwide increase in morbidity and mortality from asthma. In many institutions, asthma exacerbation is still a common medical emergency. Clinical evidence demonstrates that the first hour of management of acute asthma in the emergency room entails crucial decisions that could be determinant in the clinical outcome. In this non-systematic review, the authors focus on the first hour assessment and treatment of patients with acute asthma and outline an appropriate strategy for their management. Diagnosis, severity assessment, pharmacological treatment, complications, and the decision regarding the place where additional treatment will take place will be considered. It is reasonable to expect that these recommendations will help physicians make appropriate decisions about the first hour care of acute asthma in the emergency room.

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.

Pneumomediastinum and Subcutaneous Emphysema in Diabetic Ketoacidosis

before or during such an emergency event. Additionally, the Red Cross Service Centers provide case work and referral services after the emergency treatment services obtained at the shelters. The service centers assist with obtaining medical attention, contacting physicians, and paying for medical appointments and any other service that is specifically disaster related. Thus, this emergency assistance initializes the case-work process providing food, clothing, medicine, and other necessities. * Information obtained from the American Red Cross National Office, April 1995.

Valor dos achados clínicos e da avaliação funcional pulmonar pré-operatórios como preditores das complicações pulmonares pós-operatórias

OBJECTIVE: To assess the relationship between clinical and preoperative pulmonary functional evaluation and occurrence of postoperative pulmonary complications. METHODS: We conducted a retrospective cohort study with patients submitted to pulmonary functional evaluation over a period of 5 years. We collected clinical, demographic and spirometric data, also those related to surgical procedures and postoperative pulmonary complications. RESULTS: Medical records of 521 patients were evaluated. Mean age was 59.5 ± 14 years, 65.8% were male, and 93.4% were white. The mean FEV1, was 76.6 ± 24.6% of the predicted. Clinical comorbidities were present in 73.5% of all patients (COPD in 29.8%). The most common surgical sites were thorax (n=122; 23.4%) and upper abdomen (n=117; 22.5%). Postoperative pulmonary complications occurred in 99 patients (19.0%), with respiratory insufficiency as the most common (4.6%). Forty three patients (8.3%) died. The rates of pulmonary complications were higher after thoracic (28.9%), cardiac (28%) and upper abdomen surgery (24.3%) (p 3.5 hours (p 0.05). CONCLUSION: The most important factors associated with postoperative pulmonary complications were surgical site, time of anesthesia, and ASA classification.