Under-Report and Underdiagnosis of Chronic Respiratory Diseases in an African Country

BACKGROUND: Chronic respiratory diseases (CRD) are greatly underestimated. The aim of this study was to assess the burden associated with reported CRD and chronic obstructive pulmonary disease, as defined on the basis of various standardized criteria, by estimating their point prevalence in a sample of individuals attending the Primary Health Care (PHC) level and Emergency Room (ER) Departments in Cape Verde (CV) archipelago. The second aim of the study was to identify factors related to airways obstruction and reported CRD in this population. METHODS: A cross-sectional study was carried out in CV during 2 weeks. Outpatients aged more than 20 years seeking care at PHC level and ER answered a standardized questionnaire and were subjected to spirometry, independently of their complaint. Two criteria for airways obstruction were taken into account: forced expiratory volume (FEV(1)) <80% of the predicted value and FEV(1)/forced vital capacity (FVC) ratio <0.70. RESULTS: A total of 274 individuals with a satisfactory spirometry were included. 22% of the individuals had a FEV(1) < 80%. Individuals older than 46 years had a higher risk of having airways obstruction. Asthma diagnosis (11%) had a clear association with airways obstruction. Smoking was a risk factor for a lower FEV(1). Working in a dust place and cooking using an open fire were both related to chronic bronchitis and asthma diagnosis. CONCLUSION: Under-report and underdiagnosis of chronic respiratory conditions seem to be a reality in CV just as in other parts of the world. To improve diagnosis, our results reinforce the need of performing a spirometry

Avaliação Não Invasiva da Pressão Venosa Central por Ecocardiografia em Cuidados Intensivos. Particularidades nos Doentes com Dilatação do Ventículo Direito e Exacerbação de Doença Pulmonar Crónica

Objectivos: Determinar a possibilidade de avaliação não invasiva da pressão venosa central (PVC) através da análise da veia cava inferior (VCI), obtida por ecocardiografia transtorácica (ETT). Desenho: Estudo prospectivo com 3 anos de duração. Local: Unidade de Cuidados Intensivos Polivalente(UCIP) de 16 camas. Métodos: Estudados doentes admitidos numa UCIP nos quais se avaliou a PVC em simultâneo com exame ETT que, para além da visualização da VCI, consistiu na obtenção da dimensão das cavidades cardíacas e função sistólica do ventrículo esquerdo. Para a correlação foram utilizados testes estatísticos paramétricos e não paramétricos. Resultados: Admitidos 560 doentes com registo simultâneo de PVC e ETT e incluídos 477 doentes em que foi possível visualizar a VCI, com idade média de 62,6 ±17,3 anos, média de internamento de 11,9 ± 18,7 dias, um índice APACHE II médio de 23,9 ± 8,9 e SAPS II médio de 55,7 ± 20,4. Por análise de regressão linear verificou-se uma relação entre a PVC e a dimensão máxima da VCI (p=0,013), o índice da VCI (p=0,001) e a presença de ventilação mecânica (p=0,002). A correlação linear entre a PVC e a dimensão máxima da VCI e respectivo índice foi de 0,34 e 0,44. Por teste de qui-quadrado, verificou-se uma relação estatisticamente significativa entre os seguintes intervalos de valores: índice da VCI <25% e PVC> 13mmHg; índice da VCI entre 26 e 50% e PVC entre 8 e 12mmHg; índice da VCI> 51% e PVC> 7mmHg; dimensão máxima da VCI> 20mmHg e PVC> 13 mmHg; dimensão máxima da VCI> 10mm e PVC> 7mmHg. Nos doentes com dilatação do ventrículo direito (VD) observou-se uma relação mais fraca entre a PVC <7mmHg e a dimensão máxima da VCI <10mm; nos doentes admitidos por exacerbação de doença pulmonar crónica verificou-se uma correlação fraca entre a PVC <7mmHg e o índice da VCI> 50%. A dimensão máxima da VCI, mas não o seu índice, correlacionou-se com a dilatação do VD e AD. Conclusões: A análise da VCI por ETT revelou-se útil na avaliação qualitativa da PVC em doentes admitidos numa UCIP. Em doentes com dilatação do VD e admitidos por exacerbação de doença pulmonar crónica, os métodos avaliados não foram fidedignos para valores baixos de PVC. A dilatação da VCI traduz melhor a cronicidade da doença, enquanto o índice da VCI reflecte melhor o estado de volemia.

A Importância da Dispneia no Diagnóstico da Doença Pulmonar Obstrutiva Crónica. Uma Análise Descritiva de uma Coorte Estável em Portugal (Ensaio Clínico SAFE)

Introdução: Este estudo teve como objectivo determinar os principais sintomas percepcionados pelos doentes com doença pulmonar obstrutiva crónica (DPOC) numa coorte de doentes que participaram num grande ensaio clínico, que avaliou o tiotrópio e que decorreu em Portugal. População e métodos: A caracterização dos sintomas, no momento de avaliação basal dos doentes foi efectuada através do recurso a um questionário padronizado. Os doentes foram inquiridos quanto aos principais sintomas que tinham levado ao diagnóstico e também quanto ao sintoma actual mais problemático. Resultados: Os resultados foram obtidos de 298 doentes, maioritariamente masculinos (95%), que apresentavam, uma média (desvio padrão) de volume expiratório forçado no primeiro segundo basal de 1,1 (0,4) L (40,6 [13.3] % do valor preditivo), uma duração média da doença de 14,4 (10,1) anos e uma carga tabágica de 55,1 (25,3) unidades maço ano. A dispneia foi o sintoma mais frequentemente reportado, como tendo sido o sintoma que levou ao diagnóstico da doença (55,0% de doentes), seguindo-se-lhe a tosse (33,2%). A dispneia foi também o sintoma actual mais problemático (82,6%), seguindo-se-lhe também a tosse (8,4%). A presença de dispneia ou tosse foi independente da gravidade da DPOC. As comorbilidades mais frequentemente reportadas foram as doenças cardiovasculares (49% dos doentes), gastrointestinais (20%) e metabólicas (16%), principalmente a diabetes mellitus.

Doença Pulmonar Obstrutiva Crónica em Portugal: Estudo Pneumobil (1995) e Estudo de Prevalência de 2002 Revisitados

Introdução: A doença pulmonar obstrutiva crónica (DPOC) tem sido, ao longo dos anos, uma importante causa de morbilidade e mortalidade no mundo. Em 1995, a implementação de um rastreio da função respiratória pareceu a forma mais adequada para alertar para os sintomas respiratórios negligenciados e sensibilizar para os rastreios espirométricos. Em 2002, foram criadas novas normas consensuais de diagnóstico e o reconhecimento de que a prevalência da DPOC depende dos critérios de definição de obstrução das vias aéreas. O objetivo deste estudo foi revisitar estes 2 estudos e publicar alguns dos resultados e respetivas metodologias. Métodos: Dos 12 684 indivíduos que constavam da base de dados do Pneumobil, apenas os indivíduos com 40 e mais anos (n = 9061) foram considerados para esta análise. No estudo de 2002 foi incluída uma amostra aleatorizada e representativa de 1384 indivíduos, com idades entre os 35 e os 69 anos. Resultados: A prevalência da DPOC foi de 8,96% no estudo Pneumobil e de 5,34% no estudo de 2002. Em ambos os estudos, a presença da DPOC foi superior no sexo masculino, tendo-se verificado uma associação positiva entre a presença da DPOC e os grupos etários mais velhos. Nos fumadores e ex-fumadores encontrou-se maior proporção de casos com DPOC. Conclusões: A prevalência em Portugal é mais baixa do que noutros países europeus, o que pode estar relacionado com uma menor prevalência de tabagismo. De um modo geral, os fatores de risco mais importantes que mostraram a associação com a DPOC foram a idade maior do que 60 anos, o sexo masculino e a exposição tabágica. Todos os aspetos e as limitações que se referem a diferentes critérios de definição e a metodologias de recrutamento realçam a necessidade de métodos padronizados para determinar a prevalência da DPOC e os fatores de risco associados,cujos resultados possam ser comparados entre países, como acontece no projeto BOLD.

A Review of National Guidelines for Management of COPD in Europe

The quality of care can be improved by the development and implementation of evidence-based treatment guidelines. Different national guidelines for chronic obstructive pulmonary disease (COPD) exist in Europe and relevant differences may exist among them.This was an evaluation of COPD treatment guidelines published in Europe and Russia in the past 7 years. Each guideline was reviewed in detail and information about the most important aspects of patient diagnosis, risk stratification and pharmacotherapy was extracted following a standardised process. Guidelines were available from the Czech Republic, England and Wales, Finland, France, Germany, Italy, Poland, Portugal, Russia, Spain and Sweden. The treatment goals, criteria for COPD diagnosis, consideration of comorbidities in treatment selection and support for use of long-acting bronchodilators, were similar across treatment guidelines. There were differences in measures used for stratification of disease severity, consideration of patient phenotypes, criteria for the use of inhaled corticosteroids and recommendations for other medications (e.g. theophylline and mucolytics) in addition to bronchodilators.There is generally good agreement on treatment goals, criteria for diagnosis of COPD and use of long-acting bronchodilators as the cornerstone of treatment among guidelines for COPD management in Europe and Russia. However, there are differences in the definitions of patient subgroups and other recommended treatments.

Understanding COPD: A Vision on Phenotypes, Comorbidities and Treatment Approach

Chronic Obstructive Pulmonary Disease (COPD) phenotypes have become increasingly recognized as important for grouping patients with similar presentation and/or behavior, within the heterogeneity of the disease. The primary aim of identifying phenotypes is to provide patients with the best health care possible, tailoring the therapeutic approach to each patient. However, the identification of specific phenotypes has been hindered by several factors such as which specific attributes are relevant, which discriminant features should be used for assigning patients to specific phenotypes, and how relevant are they to the therapeutic approach, prognostic and clinical outcome. Moreover, the definition of phenotype is still not consensual. Comorbidities, risk factors, modifiable risk factors and disease severity, although not phenotypes, have impact across all COPD phenotypes. Although there are some identified phenotypes that are fairly consensual, many others have been proposed, but currently lack validation. The on-going debate about which instruments and tests should be used in the identification and definition of phenotypes has contributed to this uncertainty. In this paper, the authors review present knowledge regarding COPD phenotyping, discuss the role of phenotypes and comorbidities on the severity of COPD, propose new phenotypes and suggest a phenotype-based pharmacological therapeutic approach. The authors conclude that a patient-tailored treatment approach, which takes into account each patient's specific attributes and specificities, should be pursued.

Three-Dimensional Contrast-Enhanced Magnetic Resonance Pulmonary Angiography in the Study of Pulmonary Vascular Pathology

OBJECTIVES: To assess the feasibility of performing pulmonary angiography using MRI with contrast enhancement in patients with pulmonary vascular disease. METHODS: We present our experience in ten individuals, two controls and eight patients who underwent the exam after injection of a gadolinium-based contrast agent on a 1 Tesla MR scanner using a time-of-flight sequence and breath-holding during injection of contrast. RESULTS: Pathology in the main pulmonary artery and its major branches was detected easily while resolution at the segmental and subsegmental levels was inadequate. CONCLUSION: Contrast-enhanced magnetic resonance pulmonary angiography is feasible on a 1 Tesla MR scanner for the study of pathology of the main pulmonary artery and its major branches, like massive pulmonary embolism. However its ability to detect and define distal vessel pathology as found in chronic thromboembolic pulmonary hypertension and small pulmonary emboli is limited.

Pulmonary Hypertension in Portugal: First Data from a Nationwide Registry

Introduction. Pulmonary arterial hypertension (PAH) is a rare disease that must be managed in specialized centers; therefore, the availability of epidemiological national data is critical. Methods. We conducted a prospective, observational, and multicenter registry with a joint collaboration from five centers from Portugal and included adult incident patients with PAH or chronic thromboembolic pulmonary hypertension (CTEPH). Results. Of the 79 patients enrolled in this study, 46 (58.2%) were classified as PAH and 33 patients (41.8%) as CTEPH. PAH patients had a mean age of 43.4 ± 16.4 years. Idiopathic PAH was the most common etiology (37%). At presentation, PAH patients had elevated right atrial pressure (RAP) (7.7 ± 5.9mmHg) and mean pulmonary vascular resistance (11.4 ± 6.5 Wood units), with a low cardiac index (2.7 ± 1.1 L⋅min−1 m−2); no patient was under selective pulmonary vasodilators; however, at follow-up, most patients were on single (50%), double (28%), or triple (9%) combination vasodilator therapy. One-year survival was 93.5%, similar to CTEPH patients (93.9%), that were older (60.0 ± 12.5 years) and had higher RAP (11.0 ± 5.2mmHg,

Aortic and Tricuspid Endocarditis in Hemodialysis Patient with Systemic and Pulmonary Embolism

This is a case report of a 43-year-old Caucasian male with end-stage renal disease being treated with hemodialysis and infective endocarditis in the aortic and tricuspid valves. The clinical presentation was dominated by neurologic impairment with cerebral embolism and hemorrhagic components. A thoracoabdominal computerized tomography scan revealed septic pulmonary embolus. The patient underwent empirical antibiotherapy with ceftriaxone, gentamicin and vancomycin, and the therapy was changed to flucloxacilin and gentamicin after the isolation of S. aureus in blood cultures. The multidisciplinary team determined that the patient should undergo valve replacement after the stabilization of the intracranial hemorrhage; however, on the 8th day of hospitalization, the patient entered cardiac arrest due to a massive septic pulmonary embolism and died. Despite the risk of aggravation of the hemorrhagic cerebral lesion, early surgical intervention should be considered in high-risk patients.

Impacto do Exercício Físico Combinado na Percepção do Estado de Saúde da Pessoa com Doença Pulmonar Obstrutiva Crónica

AIM: The aim of the study was to evaluate the effectiveness of a 10-week combined training programme (aerobic and strength exercise) compared to an aerobic training programme, and respiratory physiotherapy on COPD patients' health. METHODS: Fifty subjects with moderate to severe COPD were randomly assigned to two groups. Combined group (CG, n=25) who underwent combined training, and aerobic group (AG, n=25) who underwent aerobic training. These were compared with fifty COPD subjects who underwent respiratory physiotherapy, breathing control and bronchial clearance techniques (RP group, n = 50). We evaluated health state through two questionnaires, St. George's Respiratory Questionnaire (SGRQ) and SF-36, at the beginning and at the end of the programme. RESULTS: The CG group showed differences (p<0.0001) in modification rates in state of health compared to the AG and RP groups in the activity (64 ± 9%, 19 ± 7%, 1 ± 15%) , impact (35 ± 5%, 20 ± 18%, 1 ± 14%) and total (41 ± 9%, 26 ± 17%, 1 ± 15%) domains assessed by the SGRQ, and the physical function (109 ± 74%, 22 ± 12%, 0.1 ± 18%), physical role (52 ± 36%, 11 ± 15%, 1.3 ± 21%) and vitality (83 ± 39%, 14 ± 38%) domains assessed by SF-36. CONCLUSION: These results suggest that combined training in subjects with COPD appears to be a more effective method, with better clinical changes, and improvements in health state perception.

Low Dose Thalidomide for Treatment of Resistant Discoid Lupus Erythematosus. A Case Report

Discoid lupus erythematosus (DLE) is a chronic, indolent, disfiguring disease that is characterized by scaly, erythematous, disk-shaped patches and plaques followed by atrophy, scarring and depigmentation. In a small number of patients, it is refractory to standard therapies. In several studies, thalidomide has been reported to be an effective treatment in those cases. The most fearful side effects are teratogenicity and neuropathy. Adequate counseling and vigilance must be given to the patients. We report a 45-year-old Portuguese woman who presented with a 20-year history of severe facial and scalp DLE confirmed by histopathology. For several years, it failed to respond to several therapies, including topical, intralesional and oral corticosteroids, hydroxychloroquine, methotrexate, azathioprine and topical tacrolimus. Thalidomide was initiated at a dosage of 50mg/day and the skin lesions had improved dramatically after three weeks with complete clinical remission. Two months later, the dose was reduced to 50mg, five days per week without disease rebound. The patient´s concomitant medications during the treatment included sunscreen, hydroxycholoroquine, enoxaparin and aspirin to prevent thromboembolic events. Pregnancy testing, routine laboratory and electrocardiography were performed at regular intervals for safety monitoring and the results were within normal limits. Only minor side effects as nausea, constipation and somnolence were noted, however, they improved with dose reduction. Our data confirm that thalidomide therapy is an alternative or adjunctive treatment for patients with severe, chronic DLE that is refractory to standard therapies. In this patient, low-dose thalidomide was an effective treatment with minimal side effects.

Sépsis Materna

Infections during pregnancy are prevalent. A small number of cases, however, may be life-threatening. Sepsis may be associated with multiple organ dysfunction and high mortality and it is one of the most common causes of direct maternal death often associated with the inability to recognize the severity of the illness. Long-term morbidity associated with maternal sepsis is significant and includes chronic pelvic inflammatory disease, chronic pelvic pain, bilateral tubal occlusion and infertility. The impact on neonatal mortality is also substantial, with over one million infection-related neonatal deaths eve - ry year. In the last few years, a vast number of clinical reviews of severe sepsis in pregnancy have been published, focusing on the characteristics of pregnant woman, the establishment of a specific treatment and the relevance of pregnancy surveillance by a multidisciplinary team. The treatment of sepsis is time-critical and requires early diagnosis, aggressive resuscitation, antibiotic administration and source control.

Rhinoscleroma in a 5-year-old Portuguese Child

Rhinoscleroma is a chronic granulomatous infectious disease that is rare in Western Europe. We report the case of a 5-year-old Portuguese boy diagnosed with rhinoscleroma in the context of recurrent epistaxis. He had a 6-month course of antibiotic (amoxicillin plus clavulanate) therapy with full recovery.