Obstructive sleep apnoea predicts the development of preproliferative and proliferative retinopathy in patients with type 2 diabetes:a longitudinal analysis

Background and aims: Diabetic Retinopathy (DR) is a leading cause of blindness. OSA is associated with increased oxidative and nitrosative stress and endothelial dysfunction in patients with type 2 diabetes (T2DM). Hence, it is plausible that OSA can promote the development and progression of DR. Materials and methods: An observational longitudinal study in adults with T2DM. Patients with pre-existing OSA, end-stage renal disease and non-diabetic retinopathy were excluded. OSA (apnoea hypopnea index ≥ 5 events/hour) was assessed by a single overnight home-based cardio-respiratory monitoring (Alice PDX, etc.). DR was assesses using retinal images between 2007 and 2012. Sight threatening retinopathy (STR) was defined as pre-proliferative or proliferative DR, maculopathy or photocoagulation. Advanced DR was defined as pre-proliferative or proliferative DR. Results: 199 patients were included (57.3% men, 47.7% White Europeans). STR and OSA prevalence were 38.7 % and 62.8% respectively. STR preva-lence was higher in patients with OSA (OSA+) compared to those with-out (OSA-) [48.8% vs. 21.6%, p <0.001]. After adjustment for confounders, OSA remained independently associated with STR (OR 3.7, 95%CI 1.6-8.9, p=0.006, maculopathy (OR 4.5, 1.8-11.4, p=0.002) and advanced DR (OR 3.9, 1.02-15.3, p=0.047). Over 4.4±1 years, more OSA+ patients progressed from no or background DR to advanced DR (15.3% vs. 3%, p=0.01). OSA was an independent predictor of advanced DR development after adjustment (OR 6.6, 95%CI 1.2-35.1, p=0.03). OSA did not predict the development of maculopathy. Patients received continuous positive airway pressure treatment were less likely to develop advanced DR. Conclusion: OSA is independently associated with STR and predicts the development of preproliferative and proliferative DR. Interventional studies are needed to assess the impact of OSA treatment on DR.Supported by: NIHR (UK) and The UK Novo Nordisk Research Foundation.

Évolution des aptitudes physiques et motrices d’élèves-athlètes inscrits dans un programme de spécialisation sportive et d’élèves-athlètes inscrits dans un programme de diversification sportive.

Résumé : L’entrainement sportif est « un processus de perfectionnement de l’athlète dirigé selon des principes scientifiques et qui, par des influences planifiées et systématiques (charges) sur la capacité de performance, vise à mener le sportif vers des performances élevées et supérieures dans un sport ou une discipline sportive » (Harre, 1982). Un entrainement sportif approprié devrait commencer dès l’enfance. Ainsi, le jeune sportif pourrait progressivement et systématiquement développer son corps et son esprit afin d’atteindre l’excellence sportive (Bompa, 2000; Weineck, 1997). Or plusieurs entraineurs, dans leur tentative de parvenir à des résultats de haut niveau rapidement, exposent les jeunes athlètes à une formation sportive très spécifique et rigoureuse, sans prendre le temps de développer convenablement les aptitudes physiques et motrices et les habiletés motrices fondamentales sous-jacentes aux habiletés sportives spécifiques (Bompa, 2000), d’où l’appellation « spécialisation hâtive ». Afin de contrer les conséquences néfastes de la spécialisation hâtive, de nouvelles approches d’entrainement ont été proposées. Une des façons d’y arriver consisterait notamment à pratiquer différents sports en bas âge (Fraser-Thomas, Côté et Deakin, 2008; Gould et Carson, 2004; Judge et Gilreath, 2009; LeBlanc et Dickson, 1997; Mostafavifar, Best et Myer, 2013), d’où l’appellation « diversification sportive ». Plusieurs organisations sportives et professionnelles ont décidé de valoriser et de mettre en place des programmes basés sur la diversification sportive (Kaleth et Mikesky, 2010). C’est donc à la suite d’une prise de conscience des effets néfastes de la spécialisation hâtive que des professionnels de l’activité physique d’une école secondaire du Québec (éducateur physique, kinésiologue et agent de développement sportif) ont mis en place un programme multisports-études novateur au premier cycle du secondaire, inspiré des sciences du sport et des lignes directrices du modèle de développement à long terme de l’athlète (DLTA) (Balyi, Cardinal, Higgs, Norris et Way, 2005). Le présent projet de recherche porte sur le développement des aptitudes physiques et motrices chez de jeunes sportifs inscrits à un programme de spécialisation sportive et de jeunes sportifs inscrits à un programme de diversification sportive à l’étape « S’entrainer à s’entrainer » (12 à 16 ans) du modèle de développement à long terme de l’athlète (Balyi et al., 2005). L’objectif principal de cette étude est de rendre compte de l’évolution des aptitudes physiques et motrices de jeunes élèves-athlètes inscrits, d’une part, à un programme sport-études soccer (spécialisation) et, d’autre part, à un programme multisports-études (diversification). Plus spécifiquement, cette étude tente de (a) dresser un portrait détaillé de l’évolution des aptitudes physiques et motrices des élèves-athlètes de chaque programme et de faire un parallèle avec la planification annuelle de chaque programme sportif et (b) de rendre compte des différences d’aptitudes physiques et motrices observées entre les deux programmes. Le projet de recherche a été réalisé dans une école secondaire de la province de Québec. Au total, 53 élèves-athlètes de première secondaire ont été retenus pour le projet de recherche selon leur volonté de participer à l’étude, soit 23 élèves-athlètes de première secondaire inscrits au programme sport-études soccer et 30 élèves-athlètes de première secondaire inscrits au programme multisports-études. Les élèves-athlètes étaient tous âgés de 11 à 13 ans. Treize épreuves standardisées d’aptitudes physiques et motrices ont été administrées aux élèves-athlètes des deux programmes sportifs en début, en milieu et en fin d’année scolaire. Le traitement des données s’est effectué à l’aide de statistiques descriptives et d’une analyse de variance à mesures répétées. Les résultats révèlent que (a) l’ensemble des aptitudes physiques et motrices des élèves-athlètes des deux programmes sportifs se sont améliorées au cours de l’année scolaire, (b) il est relativement facile de faire un parallèle entre l’évolution des aptitudes physiques et motrices des élèves-athlètes et la planification annuelle de chaque programme sportif, (c) les élèves-athlètes du programme multisports-études ont, en général, des performances semblables à celles des élèves-athlètes du programme sport-études soccer et (d) les élèves-athlètes du programme sport-études soccer ont, au cours de l’année scolaire, amélioré davantage leur endurance cardiorespiratoire, alors que ceux du programme multisports-études ont amélioré davantage (a) leur vitesse segmentaire des bras, (b) leur agilité à l’épreuve de course en cercle et (c) leur puissance musculaire des membres inférieurs, confirmant ainsi que les aptitudes physiques et motrices développées chez de jeunes athlètes qui se spécialisent tôt sont plutôt spécifiques au sport pratiqué (Balyi et al., 2005; Bompa, 1999; Cloes, Delfosse, Ledent et Piéron, 1994; Mattson et Richards, 2010), alors que celles développées à travers la diversification sportive sont davantage diversifiées (Coakley, 2010; Gould et Carson, 2004; White et Oatman, 2009). Ces résultats peuvent s’expliquer par (a) la spécificité ou la diversité des tâches proposées durant les séances d’entrainement, (b) le temps consacré à chacune de ces tâches et (c) les exigences reliées à la pratique du soccer comparativement aux exigences reliées à la pratique de plusieurs disciplines sportives. Toutefois, les résultats obtenus restent complexes à interpréter en raison de différents biais : (a) la maturation physique, (b) le nombre d’heures d’entrainement effectué au cours de l’année scolaire précédente, (c) le nombre d’heures d’entrainement offert par les deux programmes sportifs à l’étude et (d) les activités physiques et sportives pratiquées à l’extérieur de l’école. De plus, cette étude ne permet pas d’évaluer la qualité des interventions et des exercices proposés lors des entrainements ni la motivation des élèves-athlètes à prendre part aux séances d’entrainement ou aux épreuves physiques et motrices. Finalement, il serait intéressant de reprendre la présente étude auprès de disciplines sportives différentes et de mettre en évidence les contributions particulières de chaque discipline sportive sur le développement des aptitudes physiques et motrices de jeunes athlètes.

Importância da avaliação da aptidão física : avaliação da aptidão cardiorrespiratória no Virgin Active Oeiras

O presente relatório diz respeito às atividades realizadas no âmbito de um estágio no Health Club Virgin Active Oeiras (VAO), com incidência sobre a importância da avaliação da aptidão física aos utentes. Este estágio decorreu ao longo do 2º ano de Mestrado em Exercício e Saúde da Faculdade de Motricidade Humana. Para além de uma descrição e reflexão sobre os métodos e procedimentos adotados no decorrer do estágio, este relatório tem como objetivo principal explorar questões relacionadas com a metodologia de avaliação física aos utentes neste clube de saúde, com vista à sua otimização. Perante isto, foram estudados os meios disponíveis para a operacionalização de um protocolo de avaliação que englobasse todas as componentes da aptidão física segundo as recomendações atuais, incluindo a vertente cardiorrespiratória que não era usualmente avaliada no clube. De forma a atingir os objetivos pretendidos, o processo de sensibilização da direção do Clube foi realizado através da avaliação da aptidão cardiorrespiratória a 100 utentes iniciantes. Esta abordagem mostrou que 47% dos utentes iniciantes possuía uma aptidão cardiorrespiratória abaixo do razoável. Uma vez que esta análise era limitada, tendo em conta a elevada população que frequenta o clube, foram ainda abordados 150 utentes não iniciantes, através de uma campanha denominada “coração saudável”, na qual constou incluiu um “vale” para a realização de uma avaliação da aptidão cardiorrespiratória e um questionário. Este questionário refletiu que aproximadamente 70% dos utentes nunca tinha sido sujeito a uma prova de esforço já tendo frequentado outros clubes de saúde. Outras abordagens aos utentes foram realizadas durante este processo, nomeadamente, a promoção de atividades de cariz cardiorrespiratório e a disponibilização e instrução quanto ao uso do cardio-frequêncimetro. Este relatório refletiu a necessidade de um clube de saúde diferenciar-se não só pelas infraestruturas e atividades oferecidas, mas também pela informação e educação dos utentes relativamente à aptidão física relacionada com a saúde e ao impacto do exercício físico na qualidade de vida de quem o pratica.

Preoperative respiratory muscle dysfunction is a predictor of prolonged invasive mechanical ventilation in cardiorespiratory complications after heart valve surgery

Objective: To verify whether preoperative respiratory muscle strength and ventilometric parameters, among other clinically relevant factors, are associated with the need for prolonged invasive mechanical ventilation (PIMV) due to cardiorespiratory complications following heart valve surgery. Methods: Demographics, preoperative ventilometric and manometric data, and the hospital course of 171 patients, who had undergone heart valve surgery at Hospital das Clinicas da Faculdade de Medicina de Ribeirao Preto, were prospectively collected and subjected to univariate analysis for identifying the risk factors for PIMV. Results: The hospital mortality was 7%. About 6% of the patients, who had undergone heart valve surgery required PIMV because of postoperative cardiorespiratory dysfunction. Their hospital mortality was 60% (vs 4%, p < 0.001). Univariate analysis revealed that preoperative respiratory muscle dysfunction, characterized by maximal inspiratory and expiratory pressure below 70% of the predicted values combined with respiratory rate above 15 rpm during ventilometry, was associated with postoperative PIMV (p = 0.030, odds ratio: 50, 95% confidence interval (CI): 1.2-18). Postoperative PIMV was also associated with: (1) body mass index (BMI) < 18.5 (odds ratio: 7.2, 95% CI: 1.5-32), (2) body weight < 50 kg (odds ratio: 6.5, 95% CI: 1.6-25), (3) valve operation due to acute endocarditis (odds ratio: 5.5, 95% CI: 0.98-30), and (4) concomitant operation for mitral and tricuspid valve dysfunction (p = 0.047, odds ratio: 5.0, 95% CI: 1.1-22). Conclusion: Our results have demonstrated that respiratory muscle dysfunction, among other clinical factors, is associated with the need for PIMV due to cardiovascular or pulmonary dysfunction after heart valve surgery. (C) 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B. V. All rights reserved.

Cardio-pulmonary interaction in premature newborn with nasal continuous positive airways pressure (n-CPAP) respiratory assistance evaluated with echocardiography

Introduction: Nasal continuous positive airways pressure (n-CPAP) is an effective treatment in premature infants with respiratory distress. The cardio-pulmonary interactions secondary to n-CPAP are well studied in adults, but less well described in premature infants. We postulated that there could be important interactions with regard to the patent ductus arteriosus (PDA). Methods: Prospective study, approved by the local ethic committee. Premature infants less than 32 weeks gestation, _7 days-old, needing n-CPAP for respiratory distress, but without the need of additional oxygen were included in the study. Every patient had a first echocardiography with n-CPAP and then n-CPAP was retrieved. 3 hours later the echocardiography was repeated by the same investigator and then the patient replaced on n-CPAP. Results: 14 premature newborn were included, mean gestational age of 28 _ 2 weeks, mean weight 1.1 _ 0.3 Kg and height 39 _ 3 cm. Echocardiographic measurements are depicted in Table 1. Significant finding were observed between measurement on n- CPAP or without n-CPAP: on end diastolic left ventricular diameter (12.8 _ 1.6 mm vs. 13.5 _ 2 mm), on end systolic left ventricular diameter (8.4 _ 1.3 mm vs. 9.1 _ 1.5 mm), left atrium diameter (8.9 _ 2.2 mm vs. 10.4 _ 2.5 mm), maximal velocity on tricuspid valve (46 _ 10 cm/s vs. 51 _ 9 cm/s), calculated Qp (3.7 _ 0.8 L/min/m2 vs. 4.3 _ 0.8 L/min/m2). Only three patients have demonstrated a PDA during the study. Conclusion: Positive end expiratory pressure (Peep) has hemodynamic effects which are: reduction of systemic and pulmonary venous return as shown by the changes on tricuspid valve inflow,on the calculated Qp and finally on the diameter of the left atrium and left ventricle.We found in premature infants the same hemodynamic effects than those described in adults but with lower Peep values. This could be due to the particular elasticity and weakness of the thoracic wall of premature infants. Interestingly the flow through a PDA seems also to be diminished with Peep, but the number of patients is insufficient to conclude. Further investigation will be needed to better understand these interactions. Table 1. Echocardiographic measurement (mean (SD)). With n-CPAP Without n-CPAP p value RV ED diameter (mm) 6.3 (1.7) 6.04 (1.1) NS LV ED diameter (mm) 12.8 (1.6) 13.5 (2.0) _0.05 LV ES diameter (mm) 8.4 (1.3) 9.1 (1.5) _0.05 SF (%) 34 (5) 33 (6) NS Ao valve diameter (mm) 7.4 (1.3) 7.4 (1.2) NS LA diameter (mm) 8.9 (2.2) 10.4 (2.5) _0.05 Vmax Ao (cm/s) 70 (16) 71 (18) NS Vmax PV (cm/s) 69 (15) 72 (16) NS Vmax TV (cm/s) 46 (10) 51 (9) _0.05 Vmax MV (cm/s) 53 (17) 54 (18) NS Qp (L/min/m2) 3.7 (0.8) 4.3 (0.8) _0.05 Qs (L/min/m2) 4.0 (0.8) 4.0 (0.7) NS Qp/Qs 0.92 (0.14) 1.09 (0.23) _0.05 RV: right ventricle, LV: left ventricle, ED: end diastolic, ES: end systolic, SF: shortening fraction,Ao: aortic valve, LA: left atrium,Vmax: maximum Doppler Velocity, Qp: pulmonary output, Qs: systemic output, NS: non significant.

Cardiovascular risk and mortality in end-stage renal disease patients undergoing dialysis: sleep study, pulmonary function, respiratory mechanics, upper airway collapsibility, autonomic nervous activity, depression, anxiety, stress and quality of life: a prospective, double blind, randomized controlled clinical trial

Background: Chronic kidney disease (CKD) is one of the most serious public health problems. The increasing prevalence of CKD in developed and developing countries has led to a global epidemic. The hypothesis proposed is that patients undergoing dialysis would experience a marked negative influence on physiological variables of sleep and autonomic nervous system activity, compromising quality of life.Methods/Design: A prospective, consecutive, double blind, randomized controlled clinical trial is proposed to address the effect of dialysis on sleep, pulmonary function, respiratory mechanics, upper airway collapsibility, autonomic nervous activity, depression, anxiety, stress and quality of life in patients with CKD. The measurement protocol will include body weight (kg); height (cm); body mass index calculated as weight/height(2); circumferences (cm) of the neck, waist, and hip; heart and respiratory rates; blood pressures; Mallampati index; tonsil index; heart rate variability; maximum ventilatory pressures; negative expiratory pressure test, and polysomnography (sleep study), as well as the administration of specific questionnaires addressing sleep apnea, excessive daytime sleepiness, depression, anxiety, stress, and quality of life.Discussion: CKD is a major public health problem worldwide, and its incidence has increased in part by the increased life expectancy and increasing number of cases of diabetes mellitus and hypertension. Sleep disorders are common in patients with renal insufficiency. Our hypothesis is that the weather weight gain due to volume overload observed during interdialytic period will influence the degree of collapsibility of the upper airway due to narrowing and predispose to upper airway occlusion during sleep, and to investigate the negative influences of haemodialysis in the physiological variables of sleep, and autonomic nervous system, and respiratory mechanics and thereby compromise the quality of life of patients.

Comparisons of Mortality and Pre-discharge Respiratory Outcomes in Small-for-gestational-age and Appropriate-for-gestational-age Premature Infants.

BACKGROUND: There are differences in the literature regarding outcomes of premature small-for-gestational-age (SGA) and appropriate-for gestational-age (AGA) infants, possibly due to failure to take into account gestational age at birth. OBJECTIVE: To compare mortality and respiratory morbidity of SGA and AGA premature newborn infants. DESIGN/METHODS: A retrospective study was done of the 2,487 infants born without congenital anomalies at RESULTS: Controlling for GA, premature SGA infants were at a higher risk for mortality (Odds ratio 3.1, P = 0.001) and at lower risk of respiratory distress syndrome (OR = 0.71, p = 0.02) than AGA infants. However multivariate logistic regression modeling found that the odds of having respiratory distress syndrome (RDS) varied between SGA and AGA infants by GA. There was no change in RDS risk in SGA infants at GA 32 wk (OR = 0.41, 95% CI 0.27 - 0.63; p < 0.01). After controlling for GA, SGA infants were observed to be at a significantly higher risk for developing chronic lung disease as compared to AGA infants (OR = 2.2, 95% CI = 1.2 - 3.9, P = 0.01). There was no significant difference between SGA and AGA infants in total days on ventilator. Among infants who survived, mean length of hospital stay was significantly higher in SGA infants born between 26-36 wks GA than AGA infants. CONCLUSIONS: Premature SGA infants have significantly higher mortality, significantly higher risk of developing chronic lung disease and longer hospital stay as compared to premature AGA infants. Even the reduced risk of RDS in infants born at >/=32 wk GA, (conferred possibly by intra-uterine stress leading to accelerated lung maturation) appears to be of transient effect and is counterbalanced by adverse effects of poor intrauterine growth on long term pulmonary outcomes such as chronic lung disease.

Mortality from respiratory system cancer among Illinois residents, 1969-71 and 1979-81 : a vital statistics special report /

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Recent trends in mortality from respiratory system cancer among Illinois residents : a vital statistics special report.

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Hypothermia And Early Neonatal Mortality In Preterm Infants.

To evaluate intervention practices associated with hypothermia at both 5 minutes after birth and at neonatal intensive care unit (NICU) admission and to determine whether hypothermia at NICU admission is associated with early neonatal death in preterm infants. This prospective cohort included 1764 inborn neonates of 22-33 weeks without malformations admitted to 9 university NICUs from August 2010 through April 2012. All centers followed neonatal International Liaison Committee on Resuscitation recommendations for the stabilization and resuscitation in the delivery room (DR). Variables associated with hypothermia (axillary temperature <36.0 °C) 5 minutes after birth and at NICU admission, as well as those associated with early death, were analyzed by logistic regression. Hypothermia 5 minutes after birth and at NICU admission was noted in 44% and 51%, respectively, with 6% of early neonatal deaths. Adjusted for confounding variables, practices associated with hypothermia at 5 minutes after birth were DR temperature <25 °C (OR 2.13, 95% CI 1.67-2.28), maternal temperature at delivery <36.0 °C (OR 1.93, 95% CI 1.49-2.51), and use of plastic bag/wrap (OR 0.53, 95% CI 0.40-0.70). The variables associated with hypothermia at NICU admission were DR temperature <25 °C (OR 1.44, 95% CI 1.10-1.88), respiratory support with cold air in the DR (OR 1.40, 95% CI 1.03-1.88) and during transport to NICU (OR 1.51, 95% CI 1.08-2.13), and cap use (OR 0.55, 95% CI 0.39-0.78). Hypothermia at NICU admission increased the chance of early neonatal death by 1.64-fold (95% CI 1.03-2.61). Simple interventions, such as maintaining DR temperature >25 °C, reducing maternal hypothermia prior to delivery, providing plastic bags/wraps and caps for the newly born infants, and using warm resuscitation gases, may decrease hypothermia at NICU admission and improve early neonatal survival.

Adaptações cardio-respiratorias em atletas : estudo em diferentes fases do treinamento fisico

Universidade Estadual de Campinas. Faculdade de Educação Física

Trends in dermatomyositis- and polymyositis-related mortality in the state of Sao Paulo, Brazil, 1985-2007: multiple cause-of-death analysis

Background: Dermatomyositis (DM) and polymyositis (PM) are rare systemic autoimmune rheumatic diseases with high fatality rates. There have been few population-based mortality studies of dermatomyositis and polymyositis in the world, and none have been conducted in Brazil. The objective of the present study was to employ multiple-cause of-death methodology in the analysis of trends in mortality related to dermatomyositis and polymyositis in the state of Sao Paulo, Brazil, between 1985 and 2007. Methods: We analyzed mortality data from the Sao Paulo State Data Analysis System, selecting all death certificates on which DM or PM was listed as a cause of death. The variables sex, age and underlying, associated or total mentions of causes of death were studied using mortality rates, proportions and historical trends. Statistical analysis were performed by chi-square and H Kruskal-Wallis tests, variance analysis and linear regression. A p value less than 0.05 was regarded as significant. Results: Over a 23-year period, there were 318 DM-related deaths and 316 PM-related deaths. Overall, DM/PM was designated as an underlying cause in 55.2% and as an associated cause in 44.8%; among 634 total deaths females accounted for 71.5%. During the study period, age-and gender-adjusted DM mortality rates did not change significantly, although PM as an underlying cause and total mentions of PM trended lower (p < 0.05). The mean ages at death were 47.76 +/- 20.81 years for DM and 54.24 +/- 17.94 years for PM (p = 0.0003). For DM/PM, respectively, as underlying causes, the principal associated causes of death were as follows: pneumonia (in 43.8%/33.5%); respiratory failure (in 34.4%/32.3%); interstitial pulmonary diseases and other pulmonary conditions (in 28.9%/17.6%); and septicemia (in 22.8%/15.9%). For DM/PM, respectively, as associated causes, the following were the principal underlying causes of death: respiratory disorders (in 28.3%/26.0%); circulatory disorders (in 17.4%/20.5%); neoplasms (in 16.7%/13.7%); infectious and parasitic diseases (in 11.6%/9.6%); and gastrointestinal disorders (in 8.0%/4.8%). Of the 318 DM-related deaths, 36 involved neoplasms, compared with 20 of the 316 PM-related deaths (p = 0.03). Conclusions: Our study using multiple cause of deaths found that DM/PM were identified as the underlying cause of death in only 55.2% of the deaths, indicating that both diseases were underestimated in the primary mortality statistics. We observed a predominance of deaths in women and in older individuals, as well as a trend toward stability in the mortality rates. We have confirmed that the risk of death is greater when either disease is accompanied by neoplasm, albeit to lesser degree in individuals with PM. The investigation of the underlying and associated causes of death related to DM/PM broaden the knowledge of the natural history of both diseases and could help integrate mortality data for use in the evaluation of control measures for DM/PM.

Chronic obstructive pulmonary disease in Brazil: mortality and hospitalization trends and rates, 1996-2008

SETTING: Chronic obstructive pulmonary disease (COPD) is the third leading cause of death among adults in Brazil. OBJECTIVE: To evaluate the mortality and hospitalisation trends in Brazil caused by COPD during the period 1996-2008. DESIGN: We used the health official statistics system to obtain data about mortality (1996-2008) and morbidity (1998-2008) due to COPD and all respiratory diseases (tuberculosis: codes A15-16; lung cancer: code C34, and all diseases coded from J40 to 47 in the 10th Revision of the International Classification of Diseases) as the underlying cause, in persons aged 45-74 years. We used the Joinpoint Regression Program log-linear model using Poisson regression that creates a Monte Carlo permutation test to identify points where trend lines change significantly in magnitude/direction to verify peaks and trends. RESULTS: The annual per cent change in age-adjusted death rates due to COPD declined by 2.7% in men (95%CI -3.6 to -1.8) and -2.0% (95%CI -2.9 to -1.0) in women; and due to all respiratory causes it declined by -1.7% (95%CI 2.4 to -1.0) in men and -1.1% (95%CI -1.8 to -0.3) in women. Although hospitalisation rates for COPD are declining, the hospital admission fatality rate increased in both sexes. CONCLUSION: COPD is still a leading cause of mortality in Brazil despite the observed decline in the mortality/hospitalisation rates for both sexes.

Impact of number of vessels disease on outcome of patients with stable coronary artery disease: 5-year follow-up of the medical, angioplasty, and bypass surgery study (MASS)

Objective: To evaluate whether the number of vessels disease has an impact on clinical outcomes as well as on therapeutic results accordingly to medical, percutaneous, or surgery treatment in chronic coronary artery disease. Methods: We evaluated 825 individuals enrolled in MASS study, a randomized study to compare treatment options for single or multivessel coronary artery disease with preserved left ventricular function, prospectively followed during 5 years. The incidence of overall mortality and the composite end-point of death, myocardial infarction, and refractory angina were compared in three groups: single vessel disease (SVD n = 214), two-vessel disease (2VD n = 253) and three-vessel disease (3VD n = 358). The relationship between baseline variables and the composite end-point was assessed using a Cox proportional hazards survival model. Results: Most baseline characteristics were similar among groups, except age (younger in SVD and older in 3VD, p < 0.001), lower incidence of hypertension in SVD (p < 0.0001), and lower levels of total and LDL-cholesterol in 3VD (p = 0.004 and p = 0.005, respectively). There were no statistical differences in composite end-point in 5 years among groups independent of the kind of treatment; however, there was a higher mortality rate in 3VD (p < 0.001). When we stratified our analysis for each treatment option, bypass surgery was associated with a tower number of composite end-point in all groups (SVD p < 0.001, 2VD p = 0.002, 3VD p < 0.001). In multivariate analysis, we found higher mortality risk in 3VD comparing to SVD (p = 0.005, HR 3.14, 95%Cl 1.4-7.0). Conclusion: Three-vessel disease was associated with worse prognosis compared to single-or two-vessel disease in patients with stable coronary disease and preserved ventricular function at 5-year follow-up. In addition, event-free survival rates were higher after bypass surgery, independent of the number of vessels diseased in these subsets of patients. (c) 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.