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Descriptive statistics are expressed as frequencies and percentages. The first step was to compare the different variables by univariate analysis, with the use of the Kaplan-Meier method and two-tailed log-rank tests. The second step was to use the Cox regression model for determining which variables were independently associated with mortality.

Therefore, the initial sample consisted of 54 patients, whose clinical characteristics are summarized in Table 1. Of those 4, only the patient who had developed recent airflow obstruction survived. However, by the end of the two-year follow-up period, no new events had occurred. Of the 4 patients who developed recent airflow obstruction, 2 improved during the follow-up period. The mean age of the patients was Table 2 lists the values for the functional parameters, expressed as means and standard deviations.

The baseline pulmonary function values were comparable to those of the general population. Table 3 shows the most common lung diseases, as determined on the basis of spirometry results, lung volume values, and DLCO values. As can be seen, Only 1 patient with pre-HSCT airflow obstruction survived to the end of the two-year post-transplantation follow-up period. Of the 5 patients who were. Table 1 - Clinical and demographic characteristics of the patients submitted to hematopoietic stem cell transplantation. Of those 3 patients, the one who had developed BOOP died, and the other 2 improved as a result of the treatment.

Of the survivors, 7 did not undergo pulmonary function tests at the end of the two-year follow-up period. Of the 54 patients evaluated, 23 Table 4 shows the result of the univariate analysis log-rank test or Cox model comparing variables between the patients who died and those who did not. Table 5 shows the final multivariate regression model. The variable pre-existing lung disease was excluded from this analysis because of its low frequency in the sample only in 1 patient.

In the final model, mortality was not found to be associated with the combination of abnormal spirometry results, abnormal lung volume values, and abnormal DLCO values. Discussion The main results of the present study show that patients with impaired pulmonary function, as assessed by spirometry, and an unrelated donor were the most likely to die after HSCT. However, abnormal spirometry results do not contraindicate the procedure. Table 3 - Lung diseases and abnormal DLCO in the patients submitted to hematopoietic stem cell transplantation, over time.

Table 4 - Results of the univariate analysis of the patients submitted to hematopoietic stem cell transplantation, by outcome death vs. Although there are many studies on this subject in the literature, questions remain about the true usefulness of PFTs. One relevant aspect of the present study was that spirometry results were evaluated together with lung volume values and DLCO values.

This was due to the fact that these variables represent different markers of the physiological status of such patients. Spirometry measures the volume of air inhaled and exhaled, as well as respiratory flows. Table 5 - Results of the final model of the analysis of the patients submitted to hematopoietic stem cell transplantation, adjusted for mortality. It should be highlighted that there were 19 deaths within the first days after HSCT, a fact that prevented the investigation of a possible association between abnormal PFT results after HSCT and mortality.

The investigation of the causes of death after HSCT revealed that mortality was associated with infection in Contrary to expectation, when evaluating abnormal spirometry results together with abnormal lung volume values and abnormal DLCO values, we found no significant association with mortality. The degree of relatedness and the HLA match between donor and receptor play an important role in immune reconstitution after transplantation.

Therefore, recipients of grafts from unrelated or HLA-unmatched donors, or a combination of the two, require stricter control of rejection mechanisms, which might be associated with immunodeficiency states and higher mortality. In the literature, there are studies describing an association between NIPCs and abnormal pulmonary function. In addition, we used the reference equations that best correlate with the different age groups and genders. The increase in the number of autologous HSCTs, rather than in the number of allogenic HSCTs, in the two years when the patients were included also contributed to the smaller final sample size, in addition to complicating comparisons with most other studies, which were retrospective and included recipients of autologous or allogenic transplantation.

Despite the aforementioned restrictions, the results of the present study suggest that performing pre-HSCT spirometry is important because it provides baseline values for future comparisons. In addition, abnormal spirometry values reveal a higher risk of post-HSCT mortality, although such values do not contraindicate the procedure. Given that spirometry is inexpensive and relatively easy to perform, compared with measurement of absolute lung volumes and measurement of DLCO, which are not readily available at most health care facilities in Brazil, it seems reasonable that spirometry alone should be used in pre-HSCT PFTs, the more complex tests being reserved for selected cases.

Appelbaum FR. Hematopoietic-cell transplantation at Pulmonary complications of solid organ and hematopoietic stem cell transplantation. Bronchiolitis obliterans following haematopoietic stem cell transplantation. Afessa B, Peters SG. Chronic lung disease after hematopoietic stem cell transplantation. Clin Chest Med. Pre-operative and post-operative spirometry in bone marrow transplant patients. Long-term pulmonary function abnormalities and survival after allogeneic marrow transplantation.

Bone Marrow Transplant. Pulmonary function abnormalities after allogeneic marrow transplantation: a systematic review and assessment of an existing predictive instrument. Recommended screening and preventive practices for long-term survivors after hematopoietic cell transplantation: joint recommendations of the European Group for Blood and Marrow Transplantation, the Center for International Blood and Marrow Transplant Research, and the American Society of Blood and Marrow Transplantation.

Biol Blood Marrow Transplant. Pulmonary function testing in bone marrow transplantation: a systematic review [Article in Portuguese]. Rev Port Pneumol. Pulmonary function testing prior to hematopoietic stem cell transplantation. Design of Clinical Trials Working Group report. Non-infectious pulmonary complications after the hematopoietic stem cell transplantation [Article in Portuguese]. Sullivan KM. Graft vs. Host Disease. Malden: Blackwell Pub; Vol II.

I Consenso Brasileiro sobre Espirometria. Pulmonary-function testing. Reference values for lung function tests. Static volumes. Attachment for automated single breath diffusing capacity measurement. Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assn. Pretransplant lung function, respiratory failure, and. Effect on survival of the development of late-onset non-infectious pulmonary complications after stem cell transplantation. Transplants of umbilical-cord blood or bone marrow from unrelated donors in adults with acute leukemia.

Late-onset noninfectious pulmonary complications after allogeneic bone marrow transplantation. Br J Haematol. Chronic airflow obstruction in long-term survivors of allogeneic bone marrow transplantation. Implications of early airflow decline after myeloablative allogeneic stem cell transplantation. Associate Professor. Abstract Objective: To develop regression equations for predicting six-minute and incremental shuttle walk distances 6MWD and ISWD, respectively , based on demographic characteristics, anthropometric variables, and grip strength.

Height, weight, and grip strength were also assessed. Results: Age, gender, height, and weight collectively explained Conclusions: Grip strength is a determinant of ISWD and 6MWD; however, it could not improve the power of equations adjusted by demographic and anthropometric variables. The validity of our models including grip strength should be further evaluated in patients with skeletal muscle dysfunction.

Correspondence to: Victor Zuniga Dourado. E-mail: vzdourado yahoo. Submitted: 26 April Accepted, after review: 19 July Introduction Walking tests, such as the six-minute walk test 6MWT and incremental shuttle walk test ISWT , 1,2 are economically accessible and offer the advantage of operational simplicity. These tests are well established and have become widely used measures of exercise capacity in patients with any of a number of chronic diseases.

The 6MWT, which is of a fixed duration, is influenced by external factors, such as motivation and the amount of effort expended. Therefore, the instructions and level of encouragement given should be carefully standardized. Shorter individuals and women have shorter strides and consequently cover less distance. Elderly and obese individuals often have low lean body mass and therefore also cover shorter distances. The 6MWD has been reported to be below average in unmotivated individuals, those with cognitive deficits, and those with arthritis or other musculoskeletal disorders.

Using a predictive model, the authors showed that age, height, weight, and gender collectively explained The assessment of grip strength GS has broad clinical applicability, because it is a low-cost, simple, rapid, and noninvasive method, 12,13 providing an indicator of general health and overall muscle function.

Therefore, the purpose of this study was to develop regression equations for predicting the 6MWD and ISWD, based on demographic characteristics, anthropometric variables, and GS. All of the subjects selected for study were healthy and ambulatory having no cardiorespiratory, metabolic, neuromuscular, or musculoskeletal disease and requiring no walking aids. Subjects with abnormal post-. To verify the reliability of our reference equations, we applied them in the 8 test subjects.

Weight and height were measured by standard techniques, with the subjects wearing light clothing and no shoes. Weight was measured to the nearest 0. Before and after each test, we assessed HR, blood pressure, breathlessness, and leg fatigue. To minimize the learning effect, we allowed an interval of at least 30 min between tests. Walking speed was controlled by a series of sounds indicating the moment the subject should change directions around the cone. Every 60 s, another sound indicated the moment at which the subject should increase the pace.

When the subject was unable to reach the closest cone i. Because the ISWT was developed to assess functional exercise capacity in patients with lung disease, the original. However, because we were applying the test in healthy subjects, we extended it to 15 stages 1, m , in order to avoid the ceiling effect. The dominant hand was defined as that favored in carrying out daily activities. The participants were asked about hand preference for activities such as writing, eating, and carrying objects.

We took three measurements, 30 s apart. The greatest of the three measurements was used in the data analysis. Data are presented as mean and standard deviation or as median and interquartile range. We also used stepwise multiple linear regression analysis to identify the dependent variables that were the best predictors of 6MWD and ISWD. Age, gender, height, and weight were included in the regression models. Alternate models were constructed to include GS. Gender interaction terms were included for age, height, weight, and GS. Sample size was estimated on the basis of the number of variables to be entered into the multiple regression analysis and the minimum number of observations required.

The minimum sample size was calculated to be at least 50 subjects. Results The characteristics of the 90 subjects 40 males are summarized in Table 1. All of the subjects had normal lung function. Age, gender, height, and weight collectively explained In the alternate models, age, height, weight, and GS collectively explained No interactions with gender were detected.

Table 1 - General characteristics of the subjects. The difference between the measured and predicted ISWD. Table 2 - Predictive model for incremental shuttle and six-minute walk distances in healthy subjects, using demographic and anthropometric attributes. Figure 1 - Correlation of grip strength with six-minute walk distance a and incremental shuttle walk distance b.

These results are quite similar to those previously described for older Brazilians adults. The negative influence of advanced age on ISWD might be explained by the gradual reduction in muscle mass, muscle strength, and maximal oxygen uptake that typically occurs in parallel with aging. This could be attributed to the great influence that age, weight, height, and gender has on GS.

However, it is possible that the equations including GS would be more appropriate for the evaluation of patients with muscle depletion. In such cases, muscle strength would be considered, and the predicted performance on the 6MWT and ISWT might more accurately represent the functional capacity of the patients. Further studies are needed in order to assess the validity of these equations in patients who are more debilitated and have skeletal muscle dysfunction, such as those with lung diseases, especially COPD, cystic fibrosis, and bronchiectasis, in which there is typically pronounced muscle loss.

It is likely that individuals walk with intensity above the lactate threshold during a large portion of the test, which results in greater recruitment of glycolytic muscle fibers. Table 3 - Predictive model for the incremental shuttle and six-minute walk distances in healthy subjects using demographic and anthropometric attributes and grip strength. However, during the test, the patients with such depletion presented significantly greater HR and sensation of leg fatigue. Various chronic diseases have systemic manifestations. One major manifestation of such diseases is peripheral skeletal muscle dysfunction.

Although reductions in muscle mass and strength occur in parallel, the correlation between these variables is not linear. Therefore, muscle depletion can occur even in patients with normal body mass and BMI. For example, patients of the same gender with the same anthropometric characteristics would be expected to cover the same distance on field walking tests, after adjustment for anthropometric and demographic attributes, based on reference equations.

However, peripheral muscle strength i. To predict performance on walking tests, muscle strength, widely J Bras Pneumol. Our results have clinical implications. Traditionally, GS has been used in evaluating the physical condition of the upper limbs. However, more recently, GS has been assessed in various clinical situations. The authors found that GS was strongly correlated with mortality. Poorer performance on the timed walk test, as well as diabetes mellitus, hypertension, and cancer, were also found to be significant negative predictors of five-year survival.

Previous studies have demonstrated a significant positive correlation between GS and body cell mass. The authors also showed that lower baseline GS was predictive of an accelerated decline in cognition and in the ability to perform activities of daily living. Therefore, the determination of GS could be useful for identifying elderly patients at risk for such a decline. As an index of general health and muscle strength, GS shows promise. Given the low cost of dynamometry, it is reasonable to include this variable in regression models designed to predict the distance covered on walking tests.

The main limitation of the present study was the use of a convenience sample, which might. However, this type of sample has often been used in studies evaluating reference values for the total distance walked on field walking tests. This might be attributable to the fact that GS was consistently correlated with age, height, and weight, or there might have been multicollinearity among variables in the alternate models, which could also explain that finding.

However, the inclusion of GS did not appreciably improve the power to predict 6MWD and ISWD in comparison with that of equations including only demographic and anthropometric attributes. Nevertheless, reference equations including muscle function could be useful for interpreting the walk performance of patients with skeletal muscle dysfunction.

The 6-min walk test: a quick measure of functional status in elderly adults. Reference values for the 6-min walk test in healthy children aged years. The incremental shuttle walk test in older Brazilian adults. Grip and pinch strength: normative data for adults. Arch Phys Med Rehabil. Rev Bras Ortop. Relationship of upper-limb and thoracic muscle strength to 6-min walk distance in COPD patients.

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Peripheral muscle weakness contributes to exercise limitation in COPD. The contribution of peripheral muscle function to shuttle walking performance in patients with chronic obstructive pulmonary disease. Standardization of Spirometry, Update. American Thoracic Society. The six-minute walk test: effect of pre-test training on test results of chronic obstructive pulmonary disease patients.

J Nutr. Sex modifies the relationship between age and gait: a population-based study of older adults. The 6-minute walk test: normal values for children of years of age. Arch Dis Child. Principles of exercise testing and interpretation. A simple approach to assess VT during a field walk test.

Int J Sports Med. Physiological responses to the 6-min walk test in patients with chronic obstructive pulmonary disease. Influence of lean body mass on. Handgrip strength and mortality in the oldest old population: the Leiden plus study. Handgrip strength and mortality in older Mexican Americans. J Am Geriatr Soc. The Subjective Global Assessment reliably identifies malnutrition-related muscle dysfunction. Clin Nutr. Handgrip strength as a predictor of functional, psychological and social health.

A prospective population-based study among the oldest old. Age Ageing. Adjunct Professor. Abstract Objective: One of the major issues in the use of spirometry is the evaluation of the values obtained in comparison with standardized reference values. Such reference values should be determined by studying populations similar to the population in which they are intended to be used. Considering the anthropometric differences among races and the effect of regional issues, such as climate and air quality, it is recommended that these standards be set and used regionally.

The objective of this study was to measure the spirometric values in residents of the Mazandaran province in Iran, as well as to determine which standardized reference values most closely correlate with the values obtained and to devise predictive equations for the target population. Methods: This was a cross-sectional study of 1, volunteers, from whom demographic and anthropometric data were collected. After having been instructed in the correct procedure, each volunteer underwent spirometry.

From each volunteer, we obtained three spirometry curves that met the acceptability criteria established by the American Thoracic Society. Results: We observed significant correlations between the measured values and the reference values, for both genders. The strongest correlations were with the European Respiratory Society reference values and with the year age bracket.


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The predictive equations devised were based on the regression coefficients obtained and the demographic data collected. Conclusions: Our results show that the European Respiratory Society standard is the most appropriate standard for use in the population studied. Correspondence to: Siavash Etemadinezhad. E-mail: dr.

Submitted: 28 April Accepted, after review: 15 August Introduction Spirometry is one of the best methods of assessing lung function. It is also used in the diagnosis and follow-up of many pulmonary diseases, as well as providing evidence for use in court cases regarding legal compensation for pulmonary impairment. Reference values are based on various factors, including age, gender, height, weight, and race.

To be generalizable, these values must be obtained by studying representative samples of the general population. In Iran, there is a lack of regional and even national spirometric standards, as well as a lack of comprehensive studies on the subject. Therefore, the objective of this study was to determine whether the spirometric values in our population are similar to any of the standard reference values, as well as to use the values obtained in order to devise predictive equations specifically for use in the population of Iran.

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Volunteers were randomly recruited from urban and rural health centers in every city in the province. All volunteers gave written informed consent. Assuming a sample composed of both genders and distributed throughout four age brackets, we calculated the appropriate sample size by using information obtained from previous studies of FVC and FEV1, together with the following formula:. Using these calculations, we estimated the sample size required to be 1, individuals. For the individuals selected, we collected demographic data age and gender using a questionnaire and anthropometric data height and weight through direct measurement with the appropriate tools scale and stadiometer.

After each volunteer had been instructed in the correct procedure, the spirometry tests were conducted with the individual in a standing position. Table 1 - Demographic, anthropometric, and spirometric characteristics of adult residents of the Mazandaran province in Iran, by gender. We applied the following exclusion criteria: having upper or lower respiratory symptoms; having dyspnea; being a smoker or former smoker; being a passive smoker; having been exposed to occupational hazards such as dust and irritating gases; using beta blockers; having heart disease, musculoskeletal disorders, or any other disabling chest disease; being unable or unwilling to participate in the study; and producing spirometry curves that did not meet the acceptability criteria.

It is notable that 39 individuals were excluded because they were uncooperative or produced unacceptable spirometry curves. Results We evaluated 1, individuals males and females , all between 18 and 60 years of. We found that the mean spirometric values were higher in males than in females Table 1. The correlation between spirometric values and weight was weaker but still significant for certain parameters. As was also expected, there was an inverse correlation between age and spirometric values.

We also found that the values obtained for FVC correlated significantly with the established reference values across all age brackets Table 5. On the basis of the regression coefficient values obtained and the demographic data. Table 2 - Correlation coefficients for the parameters measured in adult residents of the Mazandaran province in Iran, by age, height, weight, and gender. Table 3 - Values obtained for adult residents of the Mazandaran province in Iran, together with the corresponding international standards.

Discussion In our sample, the mean spirometric indices were higher in males than in females. This can be attributed, in part, to the influence that height has on these parameters. The authors found that age and height both had a. The results of the present study also show that spirometric indices decrease in parallel with increasing age.

We obtained the highest values for the year age bracket, a finding that differs slightly from those of an earlier study conducted by our group, 8 in which the highest values were obtained for the year age bracket. The authors evaluated the values obtained. Table 4 - Correlation coefficients of the values obtained for adult residents of the Mazandaran province in Iran, in comparison with international standards, by gender. Table 5 - Correlation coefficients of the FVC values obtained for adult residents of the Mazandaran province in Iran, in comparison with international standards, by age and gender.

They showed that the values obtained were most similar to the Brazilian standards, whereas they differed significantly from the Knudson and ECCS standards, which effectively invalidated the use of those standards in Brazil. In another study conducted in Brazil in , 15 the values of FEV1 and FVC were found to exceed those obtained 12 years prior in , a difference that could be attributable to technical factors. In an earlier study conducted in Brazil, spirometric values were obtained in 1, individuals. The predictive equations we have devised make it clear that the values obtained for FVC were most similar to the ERS reference values, for both genders, whereas those obtained for FEV1 were most similar to the ERS reference values in males and to the ITS reference values in females.

On the basis of our results, taken together with those of previous studies, we can recommended the use of our predictive equations in all spirometry tests conducted in the region under study. Acknowledgments We would like to express our appreciation to Mr. Roy T, Edward P. Pulmonary function testing in industry.

In: Zenz C, editor. Occupational Medicine -- Principles and Practical Applications. Louis: Mosby; Garay SM. Pulmonary function testing. Environmental and Occupational Medicine. Philadelphia: Lippincott-Raven; Occupational lung diseases. In: LaDou J, editor. Occupational Environmental Medicine. Mortazavi N. Comparison of spirometric index function with standards in year old male medical students.

J Zanjan Univ Med Sci. Determination of spirometric indices in healthy non-smoking children and youngster in Isfahan. J Kerman Univ Med Sci. Prediction equations for forced spirometry from European origin populations. Spirometric standards for healthy adult lifetime nonsmokers in Australia.

Comparison of measured spirometric values in healthy individuals over 18 years of Sari. J Mazandaran Univ Med Sci. Quality control of spirometry in the elderly. The SA. Repeatability of spirometry in 18, adult patients. Reference spirometric values in healthy Chinese neversmokers in two townships of Taiwan. Chin J Physiol. Prediction equations for normal and low lung function from the Health Survey for England. References values for forced spirometry.

Validation of new Brazilian predicted values for forced spirometry in caucasians and comparison with predicted values obtained using other reference equations. Golshan M, Nematbakhsh M. Prediction equations of ventilatory function in non-smoker adults in Isfahan, Iran.

Iran J Med Sci. Comparing reference spirometric values obtained from Knudson and Pereira equation adults [Article in Portuguese]. J Pneumologia. Evaluation of normal pulmonary function test in people of Kurdistan Province. Abstract Objective: To describe the characteristics of patients with influenza A H1N1 -associated pneumonia treated at two hospitals in the region of Liguria, Italy, as well as to describe their treatment and outcomes.

Methods: This was a prospective observational study including all patients older than 16 years of age with a confirmed diagnosis of influenza A H1N1 who were admitted to Villa Scassi Hospital, in the city of Genoa, Italy, or to the Sestri Levante General Hospital, in the city of Sestri Levante, Italy, between September of and January of The primary outcome measure was mortality within 60 days after diagnosis. Secondary outcome measures were the need for mechanical ventilation and the length of hospital stay.

Results: Of the 40 patients with a confirmed diagnosis of influenza A H1N1 , 27 presented pneumonia during the study period. The mean age of the 27 patients was Of the 27 patients, 20 had respiratory failure, 4 underwent invasive mechanical ventilation, and 5 underwent noninvasive ventilation. One patient had comorbidities, developed multiple organ failure, and died. Conclusions: During the influenza A H1N1 pandemic, the associated mortality rate was lower in Italy than in other countries, and cases reported in the country typically had a milder course than did those reported elsewhere.

Correspondence to: Antonello Nicolini. E-mail: antonello. Submitted: 11 September Accepted, after review, 19 July Introduction New diseases pose a challenge to clinicians. When a novel infectious disease, influenza A H1N1 , became pandemic, it caused severe illness and resulted in significant increases in the utilization of health care services worldwide.

When secondary bacterial pneumonia is suspected, antibiotics must be used. In addition, the demographic profile of influenza A H1N1 infection was younger, and it affected individuals with fewer comorbidities. More severe respiratory involvement was noted, and a greater number of patients were admitted to ICUs with influenza A H1N1 -associated pneumonia. The objective of the present study was to describe the characteristics of the patients with influenza J Bras Pneumol.

A H1N1 -associated pneumonia treated at two hospitals in the region of Liguria, Italy, between September of and January of , as well as to describe their treatment and outcomes. The inclusion criteria were being at least 16 years of age, being diagnosed with influenza A H1N1 infection, and presenting with radiological findings suggestive of pneumonia. The exclusion criteria were being hospitalized in the preceding 10 days and having concurrent lung cancer or tuberculosis.

Secondary outcomes included the use of mechanical ventilation and ICU admission. The study design was approved by the research ethics committees of the institutions. During the study period, 40 patients diagnosed with influenza A H1N1 were admitted to one of the hospitals.

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The diagnosis was confirmed by reverse transcriptase PCR performed at the Institute for Public Health of the Medical University of Genoa, Genoa, Italy , and all tests were carried out using the guidelines recommended by the U. Centers for Disease Control and Prevention. From a patient with suspected oseltamivir-resistant infection, BAL fluid was collected.

Of the 40 patients, 27 presented with pneumonia. Any patient meeting the criteria for influenza A H1N1 infection and evidence of recent pulmonary infiltrate on chest X-rays, without an alternative diagnosis, was classified as having pneumonia. Chest X-rays were independently evaluated by two investigators. We also used an adapted score system chest X-ray score in order to grade the radiological severity of the pulmonary infiltrates.

A chest CT scan was performed in the case of inconclusive chest X-ray findings or in order to evaluate the extent of pneumonia. Statistical analysis was carried out dividing the patients into two groups: patients with mild disease and patients with severe disease. The latter group comprised patients with sepsis, shock, acute lung injury, or ARDS, as well as patients who required intubation or noninvasive mechanical ventilation and patients admitted to the ICU or to the respiratory intermediate care unit. Results Data related to the 27 patients with confirmed influenza A H1N1 -associated pneumonia were analyzed.

Bacterial co-infection with Staphylococcus aureus was found in only 1 patient in a BAL fluid sample. Clinical and laboratory characteristics of the 27 patients are reported in Table 1. The male-to-female ratio was 1. The mean length of hospital stay was During hospitalization,. Of the 9 patients who required mechanical ventilation, 4 received invasive mechanical ventilation. One patient 3. That was the only patient who required extracorporeal membrane oxygenation.

Fifteen patients had underlying medical conditions: bronchial asthma, in 4 Of the patients admitted to the ICU or to the respiratory intermediate care unit, 6 presented with comorbidities: dementia, in 2 The patients with dementia had the worst outcomes: 1 died, and another underwent intubation and had the longest stay in the ICU. The characteristics of the 9 patients admitted to the ICU or to the respiratory intermediate care unit are described in Table 2. In the comparison of the two groups mild disease vs. Discussion When the influenza A H1N1 virus first appeared, it was evident that it could cause severe illness, 6 and this was confirmed in various studies.

Table 1 - Clinical and laboratory characteristics of the 27 patients diagnosed with influenza A H1N1 associated pneumonia, categorized by the severity of the disease. In our study, age and gender distributions were similar to those previously reported. However, the incidence of gastrointestinal symptoms, such as nausea, vomiting, and diarrhea, was much lower than in previous reports. There was. Table 2 - Characteristics of the 9 patients with severe disease admitted to ICUs or respiratory intermediate care units.

Although our data regarding ICU admission are similar to those collected in other countries, 29 mortality was lower in our study. Another study described patients with. The authors found that respiratory and neurocognitive impairment was associated with severe disease and death. In our study, the only patient who died suffered from a neurocognitive disorder. To our knowledge, this association had not been previously described in the literature in English.

Our hospitals are not referral centers for children and pregnant woman infected with influenza A H1N1. Therefore, no children or pregnant women were included in our study. This was an observational study, and participation was voluntary. It included only patients with confirmed influenza A H1N1 infection. Therefore, our sample. Figure 1 - Regression analysis showing the independent variables that were associated with mechanical ventilation requirement and ICU admission, by disease severity.

Finally, the low mortality rate in our sample makes it impossible to compare our study with other studies or countries in terms of this outcome mortality. In conclusion, patients with suspected influenza A H1N1 infection should be moved to negative-pressure isolation rooms as soon as possible to avoid transmission of the infection. They should receive continuous oxygen monitoring. Antiviral treatment should not be delayed. This infection requires proactive management.

Severe respiratory disease concurrent with the circulation of H1N1 influenza. Novel H1N1 virus infection and pregnancy. Postgrad Med. Update on pandemic Influenza A H1N1 virus. Gordon SM. Update on pandemic influenza A H1N1 virus. Cleve Clin J Med. Historical perspective-Emergence of influenza A H1N1 viruses. Pneumonia and respiratory failure from swineorigin influenza A H1N1 in Mexico. Clinical and laboratory features distinguishing pandemic H1N1 influenza-related pneumonia from interpandemic community-acquired pneumonia in adults.

High-resolution computed tomography findings from adult patients with Influenza A H1N1 virus-associated pneumonia. Eur J Radiol. Rapid-test sensitivity for novel swine-origin influenza A H1N1 virus in humans. Cunha BA. Swine Influenza H1N1 pneumonia: clinical considerations.

Infect Dis Clin North Am. Swine flu and antibiotics. J Antimicrob Chemother. Lung pathology in fatal novel human influenza A H1N1 infection. Am J Clin Pathol. Predictors and outcomes of respiratory failure among hospitalized pneumonia patients with H1N1 influenza in Taiwan. J Infect. High mortality in critically ill patients infected with pandemic influenza A H1N1 with pneumonia and acute kidney injury.

Saudi J Kidney Dis Transpl. Correlates of severe disease in patients with pandemic influenza H1N1 virus infection. Emerg Infect Dis. Characteristics of hospitalised patients with H1N1 influenza in Chile. Pandemic influenza A in Argentina: a study of patients on mechanical ventilation. Chin Med J Engl. Clinical characteristics of pneumonia in hospitalized patients with novel influenza A H1N1 in Korea.

Scand J Infect Dis. Factors associated with death or hospitalization due to pandemic influenza A H1N1 infection in California. Crit Care. Arch Pathol Lab Med. Severe H1N1Associated acute respiratory distress syndrome: A case series. Am J Med. Med Clin Barc. Factors associated with death in hospitalized pneumonia. BMC Infect Dis. Risk factors for severe complications of the novel influenza A H1N1 : analysis of patients hospitalized in Italy.

Clin Microbiol Infect. Abstract Objective: To identify mycobacterial species in the sputum of patients suspected of having pulmonary tuberculosis and to determine the impact that the acquisition of this knowledge has on the therapeutic approach. Methods: We evaluated patients suspected of having pulmonary tuberculosis and referred to the pulmonology department of a public hospital in the city of Teresina, Brazil. Morning sputum specimens were evaluated for the presence of mycobacteria by sputum smear microscopy and culture. We used PCR and restriction enzyme analysis of the hsp65 gene PRA-hsp65 to identify the strains of mycobacteria isolated in culture.

Results: A total of sputum samples were analyzed. The PRA-hsp65 method confirmed these data, showing seven band patterns that were able to identify the isolated species of NTM: Mycobacterium kansasii; M. There were two cases of reinfection, initially attributed to M. Conclusions: In immunocompetent patients, NTM can infect the lungs. It is important to identify the specific NTM in order to establish the correct diagnosis and choose the most appropriate therapeutic regimen. The PRA-hsp65 method is useful in identifying NTM species and can be implemented in molecular biology laboratories that do not specialize in the identification of mycobacteria.

Keywords: Tuberculosis; Mycobacteria, atypical; Polymerase chain reaction; Brazil. Resultados: Foram analisadas amostras de escarro. Correspondence to: Semiramis Jamil Hadad do Monte. Fax: 55 86 E-mail: libpi ufpi. Submitted: 6 October Accepted, after review: 29 April Restriction enzyme analysis of the hsp65 gene in clinical isolates from patients suspected of having pulmonary tuberculosis in Teresina, Brazil. Introduction Tuberculosis TB remains one of the main public health problems in most countries.

It is estimated that one third of the world population is infected with Mycobacterium tuberculosis. Some of the cases initially described as TB infection were subsequently recognized as cases of infection with nontuberculous mycobacteria NTM. There is as yet no evidence of animal-to-human transmission of NTM. In humans, NTM disease is assumed to be acquired through exposure to environmental factors, although a specific source has yet to be identified. Accurate diagnosis to the species level can have a direct impact on clinical management because of the different patterns of drug susceptibility.

Therefore, timely, precise identification of the causative agent is. In , one group of authors proposed a molecular method 12 based on PCR and restriction enzyme analysis of the hsp65 gene PRA-hsp65 , a gene found in all mycobacterial species with species-specific nucleotide sequences. An effective, widely used, and easily reproducible method that does not require viable microorganisms, PRA-hsp65 allows the identification of various species of NTM in a single reaction. Based on the hypothesis that PRA-hsp65 is able to differentiate between M. We also attempted to determine the impact that the acquisition of this knowledge has on the therapeutic approach taken.

The inclusion criterion was being able to produce sputum spontaneously. The exclusion criteria were being under treatment with antituberculosis drugs at the time of sputum collection and having been diagnosed with extrapulmonary TB. CAAE All of the patients gave written informed consent. After performing clinical and radiographic evaluations, we collected spontaneous morning sputum samples two from each patient. Laboratory techniques sputum smear microscopy and culture were standardized in accordance with the norms and guidelines described in the Guidebook for Tuberculosis Bacteriology published by the Brazilian National Ministry of Health.

Phenotyping of strains, for presumptive identification, included macroscopic screening colony morphology and pigmentation , microscopic analysis cord factor detection and identification of contaminating microorganisms , and biochemical analysis, the last performed with an M. Strains with pigmented or smooth, fastgrowing, nonphotochromogenic colonies that showed no cord factor under microscopy were presumptively classified as NTM.

After inactivation, the bacteria were centrifuged for 15 min. After a min centrifugation J Bras Pneumol. All centrifugation steps were carried out at 13, rpm in microcentrifuge tubes Eppendorf, Hamburg, Germany. DNA size markers and bp DNA ladders were applied in three lanes two bp lanes at the extremities of the gel and one bp lane in the center.

After electrophoresis, the gels were stained with ethidium bromide, visualized on a UV transilluminator, and photographed. The PRA-hsp65 patterns were interpreted with the aid of previously published tables. The medical charts of the patients were reviewed in order to obtain information regarding previous diagnoses of TB, positive AFB results, and previous isolations of M. For data analysis, we compared the fragments obtained after enzyme treatment of amplicons with the restriction patterns stored in a PRA electronic database, 17 as well as with the HaeIII and BstEII patterns, thus creating an algorithm for differentiating among NTM strains at the species level.

After obtaining the clinical, radiographic, microbiological, and molecular results, we analyzed the data using the Statistical Package for the Social Sciences SPSS Inc. Results Of the patients evaluated, 3 were excluded: 2 because the sputum samples were insufficient for analysis and 1 because of culture contamination. Of the remaining patients, 94 were diagnosed with PTB on the basis of isolation of M. Strains of NTM were isolated from the sputum samples of the remaining 9 patients.

Only 2 patients were classified as cases of reinfection. The mean age was The two most common symptoms were cough and purulent sputum. Table 1 shows the clinical, radiographic, and microbiological features of the patients. The biochemical tests employed proved capable of identifying M. Mean age was significantly higher among the patients in whom NTM were identified than among those in whom M. There were no significant differences between the patients with M. However, all of the patients who presented with NTM also presented with radiological findings of bronchiectasis, AFB-positive smear, and isolation in culture.

Of the isolates submitted to PRA-hsp65, Table 1 - Clinical, radiographic, and microbiological features of patients who were clinically suspected of having pulmonary infection with Mycobacterium tuberculosis or nontuberculous mycobacteria and were treated at a pulmonology referral center in Teresina, Brazil, from January to June of As in the cases of primary infection, M. The standard treatment regimen the rifampin-isoniazid-pyrazinamide combination failed in 2 of the patients under study.

Those 2 patients had previously experienced treatment failure with ethionamide, pyrazinamide, ethambutol, and streptomycin. In addition, both species had been isolated from earlier sputum samples from those patients, supporting the diagnosis. The patient in whom M. Follow-up evaluation showed complete clinical remission. The patient became asymptomatic 1 year after treatment initiation and remained so after clarithromycin discontinuation. The patient remained symptomatic until death, which occurred 5 years after the diagnosis of pulmonary disease caused by NTM.

Although the patient was not hospitalized, empirical treatment with the rifampin-isoniazidpyrazinamide combination was administered for 2 months while we awaited the results of the molecular identification. After 18 months, the patient was asymptomatic and the culture results were negative. Therefore, the treatment was discontinued. Because of socioeconomic factors, the remaining 7 patients suspected of having TB were hospitalized and treated with the rifampinisoniazid-pyrazinamide combination while we awaited the results of the sputum culture. Those patients also remained symptomatic.

The results of molecular identification by the PRA-hsp65 method were as follows: M. Because of operational problems, it was impossible to carry out a sensitivity test; nevertheless, the therapeutic regimen was changed. For the 3 patients in whom M. In the first month, the patients showed significant clinical improvement. Culture results were negative by the sixth month. The treatment lasted 12 months, after which the patients were completely asymptomatic.

Table 2 - Molecular identification, by PCR and restriction enzyme analysis of the hsp65 gene, of species of mycobacteria isolated in culture of clinical samples collected from patients with pulmonary tuberculosis treated at a pulmonology referral center in Teresina, Brazil, from January to June of When PRA-hsp65 revealed the presence of M. The patient achieved complete clinical remission within 1 month after treatment initiation and remained asymptomatic after the discontinuation of clarithromycin. The patients in whom M. All 7 patients achieved complete clinical remission within 1 year after treatment initiation.

We can therefore affirm that all of the patients were infected, rather than colonized, given that they satisfactorily responded to the changes in the therapeutic regimen. The maximum time elapsed between isolation in culture and species identification by PRA-hsp65 was 24 h, which is impossible when growth and chemical tests are used. The time required for those tests to provide definitive species identification ranges from several weeks to as long as 2 months, given that several of those tests require macroscopic growth of colonies in culture in order to be read.

The time required in order to obtain the results was 4 weeks. Studies have identified new species of NTM, and more than species are currently known, the identification of species by conventional techniques being therefore an arduous, timeconsuming task that requires several laboratory tests and highly qualified human resources. In fact, PRA-hsp65 can identify mycobacteria as early as 24 h after isolation in culture.

In contrast, the time required for classical methods to identify mycobacteria after isolation in culture can be as long as 60 days. The actual prevalence of NTM in Brazil has yet to be determined. Therefore, it is mandatory to use criteria in order to differentiate between colonization and infection. Studies have shown that NTM not only colonize but also pervade tissues, eventually causing infection.

The criteria for making this distinction have been standardized by the American Thoracic Society. In our study, species that had previously been identified in the same patients M. It is of note that those patients were female, had not undergone any endoscopic procedure, and presented with bronchiectasis. Good epidemiological control requires rapid and precise identification of the etiological agent.

Therefore, in order to complement the conventional methods, it is crucial to develop new biochemical strategies for the identification of mycobacteria. In this context, PRA-hsp65 is an attractive option because it is fast, accurate, and reproducible. In addition, it can be performed in laboratories set up for microbiology and molecular biology.

These features hasten test results and allow better management. Therefore, PRA-hsp65 can be a valuable addition to the array of diagnostic tests for mycobacterial infections. In this scenario, the incorporation of a molecular biology method to be performed in clinical diagnostic laboratories becomes increasingly relevant. The choice of therapeutic regimen for the treatment of TB should not be based exclusively on AFB smear results, because TB treatment is long and requires microorganism eradication in order to avoid the development and dissemination of multidrug-resistant forms deriving from an inappropriate initial treatment.

However, physicians should be alert to the possibility that there might be no clinical response, given that NTM are common, as shown in the present study. The correct identification of NTM species is crucial, because other, specific antimicrobials will have to be chosen on the basis of identification and susceptibility test results.

In contrast, the time required for the conventional method of identifying the NTM species which is based on growth and chemical properties is over 30 days. Because PRA-hsp65 yields results more rapidly, the appropriate therapeutic regimen can be started more rapidly.

As can be seen, Only 1 patient with pre-HSCT airflow obstruction survived to the end of the two-year post-transplantation follow-up period. Of the 5 patients who were. Table 1 - Clinical and demographic characteristics of the patients submitted to hematopoietic stem cell transplantation. Of those 3 patients, the one who had developed BOOP died, and the other 2 improved as a result of the treatment. Of the survivors, 7 did not undergo pulmonary function tests at the end of the two-year follow-up period.

Of the 54 patients evaluated, 23 Table 4 shows the result of the univariate analysis log-rank test or Cox model comparing variables between the patients who died and those who did not. Table 5 shows the final multivariate regression model. The variable pre-existing lung disease was excluded from this analysis because of its low frequency in the sample only in 1 patient. In the final model, mortality was not found to be associated with the combination of abnormal spirometry results, abnormal lung volume values, and abnormal DLCO values.

Discussion The main results of the present study show that patients with impaired pulmonary function, as assessed by spirometry, and an unrelated donor were the most likely to die after HSCT. However, abnormal spirometry results do not contraindicate the procedure. Table 3 - Lung diseases and abnormal DLCO in the patients submitted to hematopoietic stem cell transplantation, over time. Table 4 - Results of the univariate analysis of the patients submitted to hematopoietic stem cell transplantation, by outcome death vs.

Although there are many studies on this subject in the literature, questions remain about the true usefulness of PFTs. One relevant aspect of the present study was that spirometry results were evaluated together with lung volume values and DLCO values. This was due to the fact that these variables represent different markers of the physiological status of such patients.

Spirometry measures the volume of air inhaled and exhaled, as well as respiratory flows. Table 5 - Results of the final model of the analysis of the patients submitted to hematopoietic stem cell transplantation, adjusted for mortality. It should be highlighted that there were 19 deaths within the first days after HSCT, a fact that prevented the investigation of a possible association between abnormal PFT results after HSCT and mortality.

The investigation of the causes of death after HSCT revealed that mortality was associated with infection in Contrary to expectation, when evaluating abnormal spirometry results together with abnormal lung volume values and abnormal DLCO values, we found no significant association with mortality. The degree of relatedness and the HLA match between donor and receptor play an important role in immune reconstitution after transplantation.

Therefore, recipients of grafts from unrelated or HLA-unmatched donors, or a combination of the two, require stricter control of rejection mechanisms, which might be associated with immunodeficiency states and higher mortality. In the literature, there are studies describing an association between NIPCs and abnormal pulmonary function.

In addition, we used the reference equations that best correlate with the different age groups and genders. The increase in the number of autologous HSCTs, rather than in the number of allogenic HSCTs, in the two years when the patients were included also contributed to the smaller final sample size, in addition to complicating comparisons with most other studies, which were retrospective and included recipients of autologous or allogenic transplantation. Despite the aforementioned restrictions, the results of the present study suggest that performing pre-HSCT spirometry is important because it provides baseline values for future comparisons.

In addition, abnormal spirometry values reveal a higher risk of post-HSCT mortality, although such values do not contraindicate the procedure. Given that spirometry is inexpensive and relatively easy to perform, compared with measurement of absolute lung volumes and measurement of DLCO, which are not readily available at most health care facilities in Brazil, it seems reasonable that spirometry alone should be used in pre-HSCT PFTs, the more complex tests being reserved for selected cases.

Appelbaum FR. Hematopoietic-cell transplantation at Pulmonary complications of solid organ and hematopoietic stem cell transplantation. Bronchiolitis obliterans following haematopoietic stem cell transplantation. Afessa B, Peters SG. Chronic lung disease after hematopoietic stem cell transplantation. Clin Chest Med. Pre-operative and post-operative spirometry in bone marrow transplant patients. Long-term pulmonary function abnormalities and survival after allogeneic marrow transplantation.

Bone Marrow Transplant. Pulmonary function abnormalities after allogeneic marrow transplantation: a systematic review and assessment of an existing predictive instrument. Recommended screening and preventive practices for long-term survivors after hematopoietic cell transplantation: joint recommendations of the European Group for Blood and Marrow Transplantation, the Center for International Blood and Marrow Transplant Research, and the American Society of Blood and Marrow Transplantation.

Biol Blood Marrow Transplant. Pulmonary function testing in bone marrow transplantation: a systematic review [Article in Portuguese]. Rev Port Pneumol. Pulmonary function testing prior to hematopoietic stem cell transplantation. Design of Clinical Trials Working Group report. Non-infectious pulmonary complications after the hematopoietic stem cell transplantation [Article in Portuguese]. Sullivan KM. Graft vs. Host Disease. Malden: Blackwell Pub; Vol II.

I Consenso Brasileiro sobre Espirometria. Pulmonary-function testing. Reference values for lung function tests. Static volumes. Attachment for automated single breath diffusing capacity measurement. Kaplan EL, Meier P. Nonparametric estimation from incomplete observations.

J Am Stat Assn. Pretransplant lung function, respiratory failure, and. Effect on survival of the development of late-onset non-infectious pulmonary complications after stem cell transplantation. Transplants of umbilical-cord blood or bone marrow from unrelated donors in adults with acute leukemia. Late-onset noninfectious pulmonary complications after allogeneic bone marrow transplantation.

Br J Haematol. Chronic airflow obstruction in long-term survivors of allogeneic bone marrow transplantation. Implications of early airflow decline after myeloablative allogeneic stem cell transplantation. Associate Professor. Abstract Objective: To develop regression equations for predicting six-minute and incremental shuttle walk distances 6MWD and ISWD, respectively , based on demographic characteristics, anthropometric variables, and grip strength.

Height, weight, and grip strength were also assessed. Results: Age, gender, height, and weight collectively explained Conclusions: Grip strength is a determinant of ISWD and 6MWD; however, it could not improve the power of equations adjusted by demographic and anthropometric variables.

The validity of our models including grip strength should be further evaluated in patients with skeletal muscle dysfunction. Correspondence to: Victor Zuniga Dourado. E-mail: vzdourado yahoo. Submitted: 26 April Accepted, after review: 19 July Introduction Walking tests, such as the six-minute walk test 6MWT and incremental shuttle walk test ISWT , 1,2 are economically accessible and offer the advantage of operational simplicity.

These tests are well established and have become widely used measures of exercise capacity in patients with any of a number of chronic diseases. The 6MWT, which is of a fixed duration, is influenced by external factors, such as motivation and the amount of effort expended. Therefore, the instructions and level of encouragement given should be carefully standardized. Shorter individuals and women have shorter strides and consequently cover less distance. Elderly and obese individuals often have low lean body mass and therefore also cover shorter distances. The 6MWD has been reported to be below average in unmotivated individuals, those with cognitive deficits, and those with arthritis or other musculoskeletal disorders.

Using a predictive model, the authors showed that age, height, weight, and gender collectively explained The assessment of grip strength GS has broad clinical applicability, because it is a low-cost, simple, rapid, and noninvasive method, 12,13 providing an indicator of general health and overall muscle function. Therefore, the purpose of this study was to develop regression equations for predicting the 6MWD and ISWD, based on demographic characteristics, anthropometric variables, and GS. All of the subjects selected for study were healthy and ambulatory having no cardiorespiratory, metabolic, neuromuscular, or musculoskeletal disease and requiring no walking aids.

Subjects with abnormal post-. To verify the reliability of our reference equations, we applied them in the 8 test subjects. Weight and height were measured by standard techniques, with the subjects wearing light clothing and no shoes. Weight was measured to the nearest 0. Before and after each test, we assessed HR, blood pressure, breathlessness, and leg fatigue. To minimize the learning effect, we allowed an interval of at least 30 min between tests.

Walking speed was controlled by a series of sounds indicating the moment the subject should change directions around the cone. Every 60 s, another sound indicated the moment at which the subject should increase the pace. When the subject was unable to reach the closest cone i. Because the ISWT was developed to assess functional exercise capacity in patients with lung disease, the original. However, because we were applying the test in healthy subjects, we extended it to 15 stages 1, m , in order to avoid the ceiling effect.

The dominant hand was defined as that favored in carrying out daily activities. The participants were asked about hand preference for activities such as writing, eating, and carrying objects. We took three measurements, 30 s apart. The greatest of the three measurements was used in the data analysis. Data are presented as mean and standard deviation or as median and interquartile range.

We also used stepwise multiple linear regression analysis to identify the dependent variables that were the best predictors of 6MWD and ISWD. Age, gender, height, and weight were included in the regression models. Alternate models were constructed to include GS. Gender interaction terms were included for age, height, weight, and GS. Sample size was estimated on the basis of the number of variables to be entered into the multiple regression analysis and the minimum number of observations required. The minimum sample size was calculated to be at least 50 subjects.

Results The characteristics of the 90 subjects 40 males are summarized in Table 1. All of the subjects had normal lung function. Age, gender, height, and weight collectively explained In the alternate models, age, height, weight, and GS collectively explained No interactions with gender were detected. Table 1 - General characteristics of the subjects. The difference between the measured and predicted ISWD. Table 2 - Predictive model for incremental shuttle and six-minute walk distances in healthy subjects, using demographic and anthropometric attributes.

Figure 1 - Correlation of grip strength with six-minute walk distance a and incremental shuttle walk distance b. These results are quite similar to those previously described for older Brazilians adults. The negative influence of advanced age on ISWD might be explained by the gradual reduction in muscle mass, muscle strength, and maximal oxygen uptake that typically occurs in parallel with aging. This could be attributed to the great influence that age, weight, height, and gender has on GS. However, it is possible that the equations including GS would be more appropriate for the evaluation of patients with muscle depletion.

In such cases, muscle strength would be considered, and the predicted performance on the 6MWT and ISWT might more accurately represent the functional capacity of the patients. Further studies are needed in order to assess the validity of these equations in patients who are more debilitated and have skeletal muscle dysfunction, such as those with lung diseases, especially COPD, cystic fibrosis, and bronchiectasis, in which there is typically pronounced muscle loss. It is likely that individuals walk with intensity above the lactate threshold during a large portion of the test, which results in greater recruitment of glycolytic muscle fibers.

Table 3 - Predictive model for the incremental shuttle and six-minute walk distances in healthy subjects using demographic and anthropometric attributes and grip strength. However, during the test, the patients with such depletion presented significantly greater HR and sensation of leg fatigue. Various chronic diseases have systemic manifestations. One major manifestation of such diseases is peripheral skeletal muscle dysfunction.

Although reductions in muscle mass and strength occur in parallel, the correlation between these variables is not linear. Therefore, muscle depletion can occur even in patients with normal body mass and BMI. For example, patients of the same gender with the same anthropometric characteristics would be expected to cover the same distance on field walking tests, after adjustment for anthropometric and demographic attributes, based on reference equations. However, peripheral muscle strength i.

To predict performance on walking tests, muscle strength, widely J Bras Pneumol. Our results have clinical implications. Traditionally, GS has been used in evaluating the physical condition of the upper limbs. However, more recently, GS has been assessed in various clinical situations. The authors found that GS was strongly correlated with mortality. Poorer performance on the timed walk test, as well as diabetes mellitus, hypertension, and cancer, were also found to be significant negative predictors of five-year survival. Previous studies have demonstrated a significant positive correlation between GS and body cell mass.

The authors also showed that lower baseline GS was predictive of an accelerated decline in cognition and in the ability to perform activities of daily living. Therefore, the determination of GS could be useful for identifying elderly patients at risk for such a decline. As an index of general health and muscle strength, GS shows promise. Given the low cost of dynamometry, it is reasonable to include this variable in regression models designed to predict the distance covered on walking tests. The main limitation of the present study was the use of a convenience sample, which might.

However, this type of sample has often been used in studies evaluating reference values for the total distance walked on field walking tests. This might be attributable to the fact that GS was consistently correlated with age, height, and weight, or there might have been multicollinearity among variables in the alternate models, which could also explain that finding. However, the inclusion of GS did not appreciably improve the power to predict 6MWD and ISWD in comparison with that of equations including only demographic and anthropometric attributes.

Nevertheless, reference equations including muscle function could be useful for interpreting the walk performance of patients with skeletal muscle dysfunction. The 6-min walk test: a quick measure of functional status in elderly adults. Reference values for the 6-min walk test in healthy children aged years. The incremental shuttle walk test in older Brazilian adults. Grip and pinch strength: normative data for adults.

Arch Phys Med Rehabil. Rev Bras Ortop. Relationship of upper-limb and thoracic muscle strength to 6-min walk distance in COPD patients. Peripheral muscle weakness contributes to exercise limitation in COPD. The contribution of peripheral muscle function to shuttle walking performance in patients with chronic obstructive pulmonary disease. Standardization of Spirometry, Update. American Thoracic Society. The six-minute walk test: effect of pre-test training on test results of chronic obstructive pulmonary disease patients. J Nutr. Sex modifies the relationship between age and gait: a population-based study of older adults.

The 6-minute walk test: normal values for children of years of age. Arch Dis Child. Principles of exercise testing and interpretation. A simple approach to assess VT during a field walk test. Int J Sports Med. Physiological responses to the 6-min walk test in patients with chronic obstructive pulmonary disease. Influence of lean body mass on. Handgrip strength and mortality in the oldest old population: the Leiden plus study. Handgrip strength and mortality in older Mexican Americans.

J Am Geriatr Soc. The Subjective Global Assessment reliably identifies malnutrition-related muscle dysfunction. Clin Nutr. Handgrip strength as a predictor of functional, psychological and social health. A prospective population-based study among the oldest old. Age Ageing. Adjunct Professor. Abstract Objective: One of the major issues in the use of spirometry is the evaluation of the values obtained in comparison with standardized reference values.

Such reference values should be determined by studying populations similar to the population in which they are intended to be used. Considering the anthropometric differences among races and the effect of regional issues, such as climate and air quality, it is recommended that these standards be set and used regionally.

The objective of this study was to measure the spirometric values in residents of the Mazandaran province in Iran, as well as to determine which standardized reference values most closely correlate with the values obtained and to devise predictive equations for the target population. Methods: This was a cross-sectional study of 1, volunteers, from whom demographic and anthropometric data were collected. After having been instructed in the correct procedure, each volunteer underwent spirometry. From each volunteer, we obtained three spirometry curves that met the acceptability criteria established by the American Thoracic Society.

Results: We observed significant correlations between the measured values and the reference values, for both genders. The strongest correlations were with the European Respiratory Society reference values and with the year age bracket. The predictive equations devised were based on the regression coefficients obtained and the demographic data collected.

Conclusions: Our results show that the European Respiratory Society standard is the most appropriate standard for use in the population studied. Correspondence to: Siavash Etemadinezhad. E-mail: dr. Submitted: 28 April Accepted, after review: 15 August Introduction Spirometry is one of the best methods of assessing lung function. It is also used in the diagnosis and follow-up of many pulmonary diseases, as well as providing evidence for use in court cases regarding legal compensation for pulmonary impairment. Reference values are based on various factors, including age, gender, height, weight, and race.

To be generalizable, these values must be obtained by studying representative samples of the general population. In Iran, there is a lack of regional and even national spirometric standards, as well as a lack of comprehensive studies on the subject. Therefore, the objective of this study was to determine whether the spirometric values in our population are similar to any of the standard reference values, as well as to use the values obtained in order to devise predictive equations specifically for use in the population of Iran.

Volunteers were randomly recruited from urban and rural health centers in every city in the province. All volunteers gave written informed consent. Assuming a sample composed of both genders and distributed throughout four age brackets, we calculated the appropriate sample size by using information obtained from previous studies of FVC and FEV1, together with the following formula:.

Using these calculations, we estimated the sample size required to be 1, individuals. For the individuals selected, we collected demographic data age and gender using a questionnaire and anthropometric data height and weight through direct measurement with the appropriate tools scale and stadiometer.

After each volunteer had been instructed in the correct procedure, the spirometry tests were conducted with the individual in a standing position. Table 1 - Demographic, anthropometric, and spirometric characteristics of adult residents of the Mazandaran province in Iran, by gender. We applied the following exclusion criteria: having upper or lower respiratory symptoms; having dyspnea; being a smoker or former smoker; being a passive smoker; having been exposed to occupational hazards such as dust and irritating gases; using beta blockers; having heart disease, musculoskeletal disorders, or any other disabling chest disease; being unable or unwilling to participate in the study; and producing spirometry curves that did not meet the acceptability criteria.

It is notable that 39 individuals were excluded because they were uncooperative or produced unacceptable spirometry curves. Results We evaluated 1, individuals males and females , all between 18 and 60 years of. We found that the mean spirometric values were higher in males than in females Table 1. The correlation between spirometric values and weight was weaker but still significant for certain parameters.

As was also expected, there was an inverse correlation between age and spirometric values. We also found that the values obtained for FVC correlated significantly with the established reference values across all age brackets Table 5. On the basis of the regression coefficient values obtained and the demographic data. Table 2 - Correlation coefficients for the parameters measured in adult residents of the Mazandaran province in Iran, by age, height, weight, and gender.

Table 3 - Values obtained for adult residents of the Mazandaran province in Iran, together with the corresponding international standards. Discussion In our sample, the mean spirometric indices were higher in males than in females. This can be attributed, in part, to the influence that height has on these parameters.

The authors found that age and height both had a. The results of the present study also show that spirometric indices decrease in parallel with increasing age. We obtained the highest values for the year age bracket, a finding that differs slightly from those of an earlier study conducted by our group, 8 in which the highest values were obtained for the year age bracket. The authors evaluated the values obtained. Table 4 - Correlation coefficients of the values obtained for adult residents of the Mazandaran province in Iran, in comparison with international standards, by gender.

Table 5 - Correlation coefficients of the FVC values obtained for adult residents of the Mazandaran province in Iran, in comparison with international standards, by age and gender. They showed that the values obtained were most similar to the Brazilian standards, whereas they differed significantly from the Knudson and ECCS standards, which effectively invalidated the use of those standards in Brazil. In another study conducted in Brazil in , 15 the values of FEV1 and FVC were found to exceed those obtained 12 years prior in , a difference that could be attributable to technical factors.

In an earlier study conducted in Brazil, spirometric values were obtained in 1, individuals. The predictive equations we have devised make it clear that the values obtained for FVC were most similar to the ERS reference values, for both genders, whereas those obtained for FEV1 were most similar to the ERS reference values in males and to the ITS reference values in females. On the basis of our results, taken together with those of previous studies, we can recommended the use of our predictive equations in all spirometry tests conducted in the region under study.

Acknowledgments We would like to express our appreciation to Mr. Roy T, Edward P. Pulmonary function testing in industry. In: Zenz C, editor. Occupational Medicine -- Principles and Practical Applications. Louis: Mosby; Garay SM. Pulmonary function testing. Environmental and Occupational Medicine. Philadelphia: Lippincott-Raven; Occupational lung diseases.

In: LaDou J, editor. Occupational Environmental Medicine. Mortazavi N. Comparison of spirometric index function with standards in year old male medical students. J Zanjan Univ Med Sci. Determination of spirometric indices in healthy non-smoking children and youngster in Isfahan. J Kerman Univ Med Sci. Prediction equations for forced spirometry from European origin populations. Spirometric standards for healthy adult lifetime nonsmokers in Australia. Comparison of measured spirometric values in healthy individuals over 18 years of Sari. J Mazandaran Univ Med Sci. Quality control of spirometry in the elderly.

The SA. Repeatability of spirometry in 18, adult patients. Reference spirometric values in healthy Chinese neversmokers in two townships of Taiwan. Chin J Physiol. Prediction equations for normal and low lung function from the Health Survey for England. References values for forced spirometry. Validation of new Brazilian predicted values for forced spirometry in caucasians and comparison with predicted values obtained using other reference equations.

Golshan M, Nematbakhsh M. Prediction equations of ventilatory function in non-smoker adults in Isfahan, Iran. Iran J Med Sci. Comparing reference spirometric values obtained from Knudson and Pereira equation adults [Article in Portuguese]. J Pneumologia. Evaluation of normal pulmonary function test in people of Kurdistan Province. Abstract Objective: To describe the characteristics of patients with influenza A H1N1 -associated pneumonia treated at two hospitals in the region of Liguria, Italy, as well as to describe their treatment and outcomes.

Methods: This was a prospective observational study including all patients older than 16 years of age with a confirmed diagnosis of influenza A H1N1 who were admitted to Villa Scassi Hospital, in the city of Genoa, Italy, or to the Sestri Levante General Hospital, in the city of Sestri Levante, Italy, between September of and January of The primary outcome measure was mortality within 60 days after diagnosis. Secondary outcome measures were the need for mechanical ventilation and the length of hospital stay.

Results: Of the 40 patients with a confirmed diagnosis of influenza A H1N1 , 27 presented pneumonia during the study period. The mean age of the 27 patients was Of the 27 patients, 20 had respiratory failure, 4 underwent invasive mechanical ventilation, and 5 underwent noninvasive ventilation. One patient had comorbidities, developed multiple organ failure, and died. Conclusions: During the influenza A H1N1 pandemic, the associated mortality rate was lower in Italy than in other countries, and cases reported in the country typically had a milder course than did those reported elsewhere.

Correspondence to: Antonello Nicolini. E-mail: antonello. Submitted: 11 September Accepted, after review, 19 July Introduction New diseases pose a challenge to clinicians. When a novel infectious disease, influenza A H1N1 , became pandemic, it caused severe illness and resulted in significant increases in the utilization of health care services worldwide.

When secondary bacterial pneumonia is suspected, antibiotics must be used. In addition, the demographic profile of influenza A H1N1 infection was younger, and it affected individuals with fewer comorbidities. More severe respiratory involvement was noted, and a greater number of patients were admitted to ICUs with influenza A H1N1 -associated pneumonia. The objective of the present study was to describe the characteristics of the patients with influenza J Bras Pneumol. A H1N1 -associated pneumonia treated at two hospitals in the region of Liguria, Italy, between September of and January of , as well as to describe their treatment and outcomes.

The inclusion criteria were being at least 16 years of age, being diagnosed with influenza A H1N1 infection, and presenting with radiological findings suggestive of pneumonia. The exclusion criteria were being hospitalized in the preceding 10 days and having concurrent lung cancer or tuberculosis. Secondary outcomes included the use of mechanical ventilation and ICU admission.

The study design was approved by the research ethics committees of the institutions. During the study period, 40 patients diagnosed with influenza A H1N1 were admitted to one of the hospitals. The diagnosis was confirmed by reverse transcriptase PCR performed at the Institute for Public Health of the Medical University of Genoa, Genoa, Italy , and all tests were carried out using the guidelines recommended by the U.

Centers for Disease Control and Prevention. From a patient with suspected oseltamivir-resistant infection, BAL fluid was collected. Of the 40 patients, 27 presented with pneumonia. Any patient meeting the criteria for influenza A H1N1 infection and evidence of recent pulmonary infiltrate on chest X-rays, without an alternative diagnosis, was classified as having pneumonia. Chest X-rays were independently evaluated by two investigators. We also used an adapted score system chest X-ray score in order to grade the radiological severity of the pulmonary infiltrates.

A chest CT scan was performed in the case of inconclusive chest X-ray findings or in order to evaluate the extent of pneumonia. Statistical analysis was carried out dividing the patients into two groups: patients with mild disease and patients with severe disease. The latter group comprised patients with sepsis, shock, acute lung injury, or ARDS, as well as patients who required intubation or noninvasive mechanical ventilation and patients admitted to the ICU or to the respiratory intermediate care unit. Results Data related to the 27 patients with confirmed influenza A H1N1 -associated pneumonia were analyzed.

Bacterial co-infection with Staphylococcus aureus was found in only 1 patient in a BAL fluid sample. Clinical and laboratory characteristics of the 27 patients are reported in Table 1. The male-to-female ratio was 1. The mean length of hospital stay was During hospitalization,. Of the 9 patients who required mechanical ventilation, 4 received invasive mechanical ventilation. One patient 3. That was the only patient who required extracorporeal membrane oxygenation.

Fifteen patients had underlying medical conditions: bronchial asthma, in 4 Of the patients admitted to the ICU or to the respiratory intermediate care unit, 6 presented with comorbidities: dementia, in 2 The patients with dementia had the worst outcomes: 1 died, and another underwent intubation and had the longest stay in the ICU. The characteristics of the 9 patients admitted to the ICU or to the respiratory intermediate care unit are described in Table 2. In the comparison of the two groups mild disease vs. Discussion When the influenza A H1N1 virus first appeared, it was evident that it could cause severe illness, 6 and this was confirmed in various studies.

Table 1 - Clinical and laboratory characteristics of the 27 patients diagnosed with influenza A H1N1 associated pneumonia, categorized by the severity of the disease. In our study, age and gender distributions were similar to those previously reported. However, the incidence of gastrointestinal symptoms, such as nausea, vomiting, and diarrhea, was much lower than in previous reports.

There was. Table 2 - Characteristics of the 9 patients with severe disease admitted to ICUs or respiratory intermediate care units. Although our data regarding ICU admission are similar to those collected in other countries, 29 mortality was lower in our study. Another study described patients with.

The authors found that respiratory and neurocognitive impairment was associated with severe disease and death. In our study, the only patient who died suffered from a neurocognitive disorder. To our knowledge, this association had not been previously described in the literature in English.

Our hospitals are not referral centers for children and pregnant woman infected with influenza A H1N1. Therefore, no children or pregnant women were included in our study. This was an observational study, and participation was voluntary. It included only patients with confirmed influenza A H1N1 infection. Therefore, our sample. Figure 1 - Regression analysis showing the independent variables that were associated with mechanical ventilation requirement and ICU admission, by disease severity.

Finally, the low mortality rate in our sample makes it impossible to compare our study with other studies or countries in terms of this outcome mortality. In conclusion, patients with suspected influenza A H1N1 infection should be moved to negative-pressure isolation rooms as soon as possible to avoid transmission of the infection. They should receive continuous oxygen monitoring.

Antiviral treatment should not be delayed. This infection requires proactive management. Severe respiratory disease concurrent with the circulation of H1N1 influenza. Novel H1N1 virus infection and pregnancy. Postgrad Med. Update on pandemic Influenza A H1N1 virus. Gordon SM. Update on pandemic influenza A H1N1 virus. Cleve Clin J Med.

Historical perspective-Emergence of influenza A H1N1 viruses. Pneumonia and respiratory failure from swineorigin influenza A H1N1 in Mexico. Clinical and laboratory features distinguishing pandemic H1N1 influenza-related pneumonia from interpandemic community-acquired pneumonia in adults. High-resolution computed tomography findings from adult patients with Influenza A H1N1 virus-associated pneumonia.

Eur J Radiol. Rapid-test sensitivity for novel swine-origin influenza A H1N1 virus in humans. Cunha BA. Swine Influenza H1N1 pneumonia: clinical considerations. Infect Dis Clin North Am. Swine flu and antibiotics. J Antimicrob Chemother. Lung pathology in fatal novel human influenza A H1N1 infection. Am J Clin Pathol.

Predictors and outcomes of respiratory failure among hospitalized pneumonia patients with H1N1 influenza in Taiwan. J Infect. High mortality in critically ill patients infected with pandemic influenza A H1N1 with pneumonia and acute kidney injury. Saudi J Kidney Dis Transpl. Correlates of severe disease in patients with pandemic influenza H1N1 virus infection. Emerg Infect Dis.

Characteristics of hospitalised patients with H1N1 influenza in Chile. Pandemic influenza A in Argentina: a study of patients on mechanical ventilation. Chin Med J Engl. Clinical characteristics of pneumonia in hospitalized patients with novel influenza A H1N1 in Korea. Scand J Infect Dis.

Factors associated with death or hospitalization due to pandemic influenza A H1N1 infection in California. Crit Care. Arch Pathol Lab Med. Severe H1N1Associated acute respiratory distress syndrome: A case series. Am J Med. Med Clin Barc. Factors associated with death in hospitalized pneumonia. BMC Infect Dis. Risk factors for severe complications of the novel influenza A H1N1 : analysis of patients hospitalized in Italy. Clin Microbiol Infect. Abstract Objective: To identify mycobacterial species in the sputum of patients suspected of having pulmonary tuberculosis and to determine the impact that the acquisition of this knowledge has on the therapeutic approach.

Methods: We evaluated patients suspected of having pulmonary tuberculosis and referred to the pulmonology department of a public hospital in the city of Teresina, Brazil. Morning sputum specimens were evaluated for the presence of mycobacteria by sputum smear microscopy and culture.

We used PCR and restriction enzyme analysis of the hsp65 gene PRA-hsp65 to identify the strains of mycobacteria isolated in culture. Results: A total of sputum samples were analyzed. The PRA-hsp65 method confirmed these data, showing seven band patterns that were able to identify the isolated species of NTM: Mycobacterium kansasii; M. There were two cases of reinfection, initially attributed to M.

Conclusions: In immunocompetent patients, NTM can infect the lungs. It is important to identify the specific NTM in order to establish the correct diagnosis and choose the most appropriate therapeutic regimen. The PRA-hsp65 method is useful in identifying NTM species and can be implemented in molecular biology laboratories that do not specialize in the identification of mycobacteria. Keywords: Tuberculosis; Mycobacteria, atypical; Polymerase chain reaction; Brazil. Resultados: Foram analisadas amostras de escarro. Correspondence to: Semiramis Jamil Hadad do Monte.

Fax: 55 86 E-mail: libpi ufpi. Submitted: 6 October Accepted, after review: 29 April Restriction enzyme analysis of the hsp65 gene in clinical isolates from patients suspected of having pulmonary tuberculosis in Teresina, Brazil. Introduction Tuberculosis TB remains one of the main public health problems in most countries. It is estimated that one third of the world population is infected with Mycobacterium tuberculosis.

Some of the cases initially described as TB infection were subsequently recognized as cases of infection with nontuberculous mycobacteria NTM. There is as yet no evidence of animal-to-human transmission of NTM. In humans, NTM disease is assumed to be acquired through exposure to environmental factors, although a specific source has yet to be identified.


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  6. Accurate diagnosis to the species level can have a direct impact on clinical management because of the different patterns of drug susceptibility. Therefore, timely, precise identification of the causative agent is. In , one group of authors proposed a molecular method 12 based on PCR and restriction enzyme analysis of the hsp65 gene PRA-hsp65 , a gene found in all mycobacterial species with species-specific nucleotide sequences. An effective, widely used, and easily reproducible method that does not require viable microorganisms, PRA-hsp65 allows the identification of various species of NTM in a single reaction.

    Based on the hypothesis that PRA-hsp65 is able to differentiate between M. We also attempted to determine the impact that the acquisition of this knowledge has on the therapeutic approach taken. The inclusion criterion was being able to produce sputum spontaneously. The exclusion criteria were being under treatment with antituberculosis drugs at the time of sputum collection and having been diagnosed with extrapulmonary TB. CAAE All of the patients gave written informed consent. After performing clinical and radiographic evaluations, we collected spontaneous morning sputum samples two from each patient.

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    Laboratory techniques sputum smear microscopy and culture were standardized in accordance with the norms and guidelines described in the Guidebook for Tuberculosis Bacteriology published by the Brazilian National Ministry of Health. Phenotyping of strains, for presumptive identification, included macroscopic screening colony morphology and pigmentation , microscopic analysis cord factor detection and identification of contaminating microorganisms , and biochemical analysis, the last performed with an M.

    Strains with pigmented or smooth, fastgrowing, nonphotochromogenic colonies that showed no cord factor under microscopy were presumptively classified as NTM. After inactivation, the bacteria were centrifuged for 15 min. After a min centrifugation J Bras Pneumol. All centrifugation steps were carried out at 13, rpm in microcentrifuge tubes Eppendorf, Hamburg, Germany. DNA size markers and bp DNA ladders were applied in three lanes two bp lanes at the extremities of the gel and one bp lane in the center. After electrophoresis, the gels were stained with ethidium bromide, visualized on a UV transilluminator, and photographed.

    The PRA-hsp65 patterns were interpreted with the aid of previously published tables. The medical charts of the patients were reviewed in order to obtain information regarding previous diagnoses of TB, positive AFB results, and previous isolations of M. For data analysis, we compared the fragments obtained after enzyme treatment of amplicons with the restriction patterns stored in a PRA electronic database, 17 as well as with the HaeIII and BstEII patterns, thus creating an algorithm for differentiating among NTM strains at the species level.

    After obtaining the clinical, radiographic, microbiological, and molecular results, we analyzed the data using the Statistical Package for the Social Sciences SPSS Inc. Results Of the patients evaluated, 3 were excluded: 2 because the sputum samples were insufficient for analysis and 1 because of culture contamination. Of the remaining patients, 94 were diagnosed with PTB on the basis of isolation of M. Strains of NTM were isolated from the sputum samples of the remaining 9 patients. Only 2 patients were classified as cases of reinfection. The mean age was The two most common symptoms were cough and purulent sputum.

    Table 1 shows the clinical, radiographic, and microbiological features of the patients. The biochemical tests employed proved capable of identifying M. Mean age was significantly higher among the patients in whom NTM were identified than among those in whom M. There were no significant differences between the patients with M.

    However, all of the patients who presented with NTM also presented with radiological findings of bronchiectasis, AFB-positive smear, and isolation in culture. Of the isolates submitted to PRA-hsp65, Table 1 - Clinical, radiographic, and microbiological features of patients who were clinically suspected of having pulmonary infection with Mycobacterium tuberculosis or nontuberculous mycobacteria and were treated at a pulmonology referral center in Teresina, Brazil, from January to June of As in the cases of primary infection, M.

    The standard treatment regimen the rifampin-isoniazid-pyrazinamide combination failed in 2 of the patients under study. Those 2 patients had previously experienced treatment failure with ethionamide, pyrazinamide, ethambutol, and streptomycin. In addition, both species had been isolated from earlier sputum samples from those patients, supporting the diagnosis.

    The patient in whom M. Follow-up evaluation showed complete clinical remission. The patient became asymptomatic 1 year after treatment initiation and remained so after clarithromycin discontinuation. The patient remained symptomatic until death, which occurred 5 years after the diagnosis of pulmonary disease caused by NTM.

    Although the patient was not hospitalized, empirical treatment with the rifampin-isoniazidpyrazinamide combination was administered for 2 months while we awaited the results of the molecular identification. After 18 months, the patient was asymptomatic and the culture results were negative.

    Therefore, the treatment was discontinued. Because of socioeconomic factors, the remaining 7 patients suspected of having TB were hospitalized and treated with the rifampinisoniazid-pyrazinamide combination while we awaited the results of the sputum culture. Those patients also remained symptomatic. The results of molecular identification by the PRA-hsp65 method were as follows: M.

    Because of operational problems, it was impossible to carry out a sensitivity test; nevertheless, the therapeutic regimen was changed. For the 3 patients in whom M. In the first month, the patients showed significant clinical improvement. Culture results were negative by the sixth month. The treatment lasted 12 months, after which the patients were completely asymptomatic. Table 2 - Molecular identification, by PCR and restriction enzyme analysis of the hsp65 gene, of species of mycobacteria isolated in culture of clinical samples collected from patients with pulmonary tuberculosis treated at a pulmonology referral center in Teresina, Brazil, from January to June of When PRA-hsp65 revealed the presence of M.

    The patient achieved complete clinical remission within 1 month after treatment initiation and remained asymptomatic after the discontinuation of clarithromycin. The patients in whom M. All 7 patients achieved complete clinical remission within 1 year after treatment initiation. We can therefore affirm that all of the patients were infected, rather than colonized, given that they satisfactorily responded to the changes in the therapeutic regimen. The maximum time elapsed between isolation in culture and species identification by PRA-hsp65 was 24 h, which is impossible when growth and chemical tests are used.

    The time required for those tests to provide definitive species identification ranges from several weeks to as long as 2 months, given that several of those tests require macroscopic growth of colonies in culture in order to be read. The time required in order to obtain the results was 4 weeks. Studies have identified new species of NTM, and more than species are currently known, the identification of species by conventional techniques being therefore an arduous, timeconsuming task that requires several laboratory tests and highly qualified human resources.

    In fact, PRA-hsp65 can identify mycobacteria as early as 24 h after isolation in culture. In contrast, the time required for classical methods to identify mycobacteria after isolation in culture can be as long as 60 days. The actual prevalence of NTM in Brazil has yet to be determined. Therefore, it is mandatory to use criteria in order to differentiate between colonization and infection.

    Studies have shown that NTM not only colonize but also pervade tissues, eventually causing infection. The criteria for making this distinction have been standardized by the American Thoracic Society. In our study, species that had previously been identified in the same patients M. It is of note that those patients were female, had not undergone any endoscopic procedure, and presented with bronchiectasis.

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    Good epidemiological control requires rapid and precise identification of the etiological agent. Therefore, in order to complement the conventional methods, it is crucial to develop new biochemical strategies for the identification of mycobacteria. In this context, PRA-hsp65 is an attractive option because it is fast, accurate, and reproducible.

    In addition, it can be performed in laboratories set up for microbiology and molecular biology. These features hasten test results and allow better management. Therefore, PRA-hsp65 can be a valuable addition to the array of diagnostic tests for mycobacterial infections. In this scenario, the incorporation of a molecular biology method to be performed in clinical diagnostic laboratories becomes increasingly relevant.

    The choice of therapeutic regimen for the treatment of TB should not be based exclusively on AFB smear results, because TB treatment is long and requires microorganism eradication in order to avoid the development and dissemination of multidrug-resistant forms deriving from an inappropriate initial treatment. However, physicians should be alert to the possibility that there might be no clinical response, given that NTM are common, as shown in the present study.

    The correct identification of NTM species is crucial, because other, specific antimicrobials will have to be chosen on the basis of identification and susceptibility test results. In contrast, the time required for the conventional method of identifying the NTM species which is based on growth and chemical properties is over 30 days. Because PRA-hsp65 yields results more rapidly, the appropriate therapeutic regimen can be started more rapidly.

    In conclusion, the present study showed that the implementation of PRA-hsp65 for the identification of mycobacteria in a nonspecialized molecular biology laboratory is feasible. Although it is recognized that PRA-hsp65 should not be considered a replacement for other tests that are used in order to diagnose TB, PRA-hsp65 constitutes an additional diagnostic tool to investigate the etiology of the disease, especially in individuals with no clinical response to antituberculosis drugs.

    The method can contribute to a faster identification of mycobacteria in public laboratories, thus optimizing management. We are also grateful to Miguel Pires de Moura for allowing us to conduct the study at the institution; Dr. Geneva: World Health Organization; Maher D, Raviglione M. Global epidemiology of tuberculosis. The impact of comorbidity on mortality following in-hospital diagnosis of tuberculosis. Tuberculosis and gender in a priority city in the state of Rio de Janeiro, Brazil.

    Runyon EH. Anonymous mycobacteria in pulmonary disease.