Aims: LDL oxidation plays an important role in the initiation and progression of atherosclerosis. HDL impedes oxidation, glycation and glycoxidation in vitro and there is evidence to suggest paraoxonase-1 (PON1) plays an important role in this. 1. In patients with dyslipidaemia treated with statins, I assessed the relationship of serum PON1 activity with in vitro HDL antioxidant capacity, susceptibility of LDL to oxidation and the protection offered by HDL. 2. I studied the effect of the presence and severity of obstructive sleep apnoea (OSA) in morbidly obese patients on HDL anti-oxidant and anti-inflammatory functions. 3. I investigated the influence of extended release niacin/ laropiprant (ERN/LRP) versus placebo in patients who had persistent dyslipidaemia despite receiving high doses of potent statins. I assessed the effect of ERN/LRP on mediators of vascular inflammation and HDL's in vitro anti-oxidant function. Methods: 1. LDL isolated from dyslipidemic patients was incubated with and without HDL, in the presence of Cu2+. Similarly isolated HDL was incubated alone. Lipid peroxides (LPO) generated over 3 hours were measured. Patients were divided into 2 groups based on median serum PON1 activity. 2. 41 morbidly obese patients were divided into two groups based on the presence or absence of OSA ("OSA" and "no OSA" group) or on severity of OSA (high or low apnoea-hypoapnoea index (AHI) groups). I studied HDL's ability to protect itself from in vitro oxidation and measured serum PON1 activity, tumor necrosis factor alpha (TNFalpha) and intercellular adhesion molecule 1 (ICAM1). 3. This was a randomised double blind cross over trial, where I studied the effect of ERN/LRP compared to placebo in 27 patients who had high LDL-C inspite of maximum tolerated doses of statins. I measured lipid profile, apolipoproteins, cholesteryl ester transport protein (CETP) activity, paraoxonase 1 activity (PON1), oxidised LDL (oxLDL) and related mediators of vascular inflammation. I also examined the capacity of HDL to protect LDL from in vitro oxidation. Results and conclusion: 1. In statin treated dyslipidemic patients the capacity of HDL to protect itself and LDL from oxidation in vitro is significantly better in individuals with higher serum PON1 activity. 2. The capacity of HDL to protect itself from in vitro oxidation in morbidly obese patients is reduced with onset and severity of OSA. The differences in TNFalpha and ICAM1 levels may suggest endothelial dysfunction due to OSA. Oxidative damage of PON1 attributable to OSA could be a mechanism for HDL and endothelial dysfunction. 3. Treatment with ERN/LRP resulted in a significant improvement in HDL-C but did not affect HDL's in vitro anti-oxidant function in patients who had persistent dyslipidaemia despite high doses of potent statins. For the first time I have shown that ERN/LRP reduces mediators of vascular inflammation.

Childhood OSA is increasingly recognized to be associated with a variety of complications including neurocognitive and cardiovascular diseases. The intermediate link between OSA and end organ damage has been suggested to be inflammation, and both local airway and systemic inflammation have been described in adults with OSA. A non-invasive technique of sputum induction was utilised to show that children with OSA also have airway inflammation, as characterized by a significant increase in neutrophils, and the severity of OSA also correlated significantly with the degree of neutrophilic inflammation (Chapter 7). This finding may lead to research on the use of anti-inflammatory therapeutic agents or antibiotics for the treatment of childhood OSA. Another marker of inflammation, C-reactive protein (CRP) was measured in a cohort of children with OSA before and after treatment (Chapter 8). Children with OSA had higher CRP levels compared to their non-OSA counterparts, and the raised CRP decreased significantly following treatment suggesting that the inflammatory response is potentially reversible. The cardiovascular risk factors of insulin levels and blood pressure (BP) were evaluated and children with OSA had higher serum insulin and greater systolic and diastolic BP compared to healthy controls (Chapters 9 and 10). These findings suggest that children with OSA may be at risk of developing metabolic syndrome and its devastating consequence. (Abstract shortened by UMI.) / The original research studies undertaken were based on nocturnal sleep examinations to explore childhood OSA in two main aspects, namely its assessment, and a better understanding of its complications in children. The gold standard for diagnosing OSA is overnight polysomnography (PSG), which is an expensive investigation that is not routinely available at all public hospitals in Hong Kong. Alternative valid assessment tools for OSA that are more cost-effective are needed. The feasibility of using radiographic techniques to assess severity of OSA was explored, and the size of the upper airway, as reflected by the tonsillar pharyngeal (TP) ratio obtained from lateral neck radiograph, correlated well with the severity of OSA (Chapter 4). A defined TP cutoff could accurately predict moderate-to-severe OSA with high sensitivity and specificity. This method could be used in clinical practice to prioritize patients with suspected OSA for further evaluation. A locally applicable questionnaire scale was examined for its validity and accuracy in diagnosing children with OSA (Chapter 5). The presence of three symptoms (snoring, mouth breathing and nocturnal sweating) was found to have high predictive value in correctly identifying children with the condition. The question of whether a single night PSG study is adequate in diagnosing OSA was examined together with the assessment for the presence of night-to-night variability in PSG and respiratory parameters in childhood sleep (Chapter 6). Forty-four obese children and 43 age and sex-matched healthy controls underwent two consecutive nights PSG examination. Although a first night effect was clearly documented, a single night PSG study would have correctly identified over 80% of children with OSA. This finding has significant resource implications. / Albert Martin Li. / Adviser: Tony Nelson. / Source: Dissertation Abstracts International, Volume: 70-06, Section: B, page: 3420. / Thesis (M.D.)--Chinese University of Hong Kong, 2008. / Includes bibliographical references (leaves xxxv-lxxx). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstract in English only. / School code: 1307.

by Martin Li. / Year shown on spine: 1997. / Thesis (M.Phil.)--Chinese University of Hong Kong, 1996. / Includes bibliographical references (leaves 150-157). / DECLARATION --- p.II / ABSTRACT --- p.III / ACKNOWLEDGEMENTS --- p.VII / CONTENTS --- p.VIII / LIST OF ABBREVIATIONS --- p.XIV / LIST OF TABLES --- p.XVI / LIST OF CHART --- p.XXIII / LIST OF FIGURES --- p.XXIV / Chapter CHAPTER 1 --- OBSTRUCTIVE AIRWAY DISEASE: PUBLIC HEALTH AND CLINICAL ASPECTS --- p.1 / Chapter 1.1. --- Background --- p.1 / Chapter 1.2. --- Magnitude of the problem --- p.2 / Chapter 1.2.1. --- Asthma --- p.2 / Chapter 1.2.2. --- Chronic obstructive pulmonary disease --- p.3 / Chapter 1.2.3. --- Prevalence of osteoporosis in Hong Kong --- p.4 / Chapter 1.2.4. --- History of asthma care --- p.5 / Chapter 1.2.5. --- Treatment of OAD --- p.5 / Chapter 1.3. --- Side effects of Glucocorticoid in OAD patients --- p.6 / Chapter 1.4. --- Side effccts of inhaled corticosteroids in OAD patients --- p.7 / Chapter 1.5. --- Trend of asthma therapy in Hong Kong --- p.8 / Chapter CHAPTER 2: --- OSTEOPOROSIS: PUBLIC HEALTH AND CLINICAL ASPECTS --- p.11 / Chapter 2.1. --- Bone Biology --- p.11 / Chapter 2.2. --- Skeletal Organisation --- p.11 / Chapter 2.3. --- Bone remodelling --- p.12 / Chapter 2.4. --- Effect of corticosteroids on bone remodelling --- p.13 / Chapter 2.5. --- Corticosteroids induccs osteoporosis --- p.13 / Chapter 2.6. --- Factors affecting BMD --- p.14 / Chapter 2.6.1. --- Peak bone mass --- p.14 / Chapter 2.6.2. --- Ethnic factors --- p.14 / Chapter 2.6.3. --- Aging --- p.15 / Chapter 2.6.4. --- Calcium intake --- p.15 / Chapter 2.6.5. --- Oestrogen --- p.16 / Chapter 2.6.6. --- Alcohol consumption --- p.17 / Chapter 2.6.7. --- Cigarette smoking --- p.17 / Chapter 2.7. --- Physical activity and BMD --- p.17 / Chapter 2.8. --- Body composition in Chinese subjects --- p.18 / Chapter CHAPTER 3 --- "PHASE I: BODY COMPOSITION AND BONE MINERAL DENSITY IN OBSTRUCTIVE AIRWAY DISEASE PATIENT AND NORMAL CONTROL SUBJECTS: OBJECTIVES, SUBJECTS AND METHODS" --- p.20 / Chapter 3.1. --- Objectives --- p.20 / Chapter 3.2. --- Subjects and methods --- p.21 / Chapter 3.2.1 --- OAD patients --- p.21 / Chapter 3.2.1.1 --- Disease definition and selection criteria --- p.21 / Chapter 3.2.1.2. --- Normal Control subjects --- p.21 / Chapter 3.3. --- Power of estimation --- p.22 / Chapter 3.4. --- Survey methods --- p.22 / Chapter 3.5. --- Questionnaire --- p.23 / Chapter 3.6. --- Body composition and bone mineral density measurement --- p.23 / Chapter 3.6.1. --- Body composition analysis --- p.24 / Chapter 3.6.2. --- Lumbar spine and proximal hip bone mineral density analysis --- p.24 / Chapter 3.6.3. --- Routine quality control of measurements --- p.24 / Chapter 3.6.4. --- Precision on patient repositioning --- p.25 / Chapter 3.7. --- Statistical methods --- p.25 / Chapter 3.8. --- Bone mineral density of normal control subjects --- p.25 / Chapter CHAPTER 4 --- PHASE II: FLUORIDE IN THE TREATMENT OF OSTEOPOROSIS --- p.27 / Chapter 4.1. --- Introduction --- p.27 / Chapter 4.2. --- Mechanisms of action --- p.28 / Chapter 4.2.1. --- Antiresorptive effect of fluoride --- p.28 / Chapter 4.2.2. --- Force-oriented osteogenic effect of fluoride --- p.28 / Chapter 4.2.3. --- Biochemical osteogenic effect --- p.29 / Chapter 4.3. --- Effect of fluoride salts on BMD: results of clinical trials --- p.29 / Chapter 4.4. --- Effcct of fluoride on bone histomorphology --- p.30 / Chapter 4.5. --- Compliance with sodium fluoride therapy --- p.31 / Chapter 4.6. --- Contradiction of fluoride treatment --- p.31 / Chapter 4.7. --- Sodium monofluorophosphate preparation --- p.32 / Chapter CHAPTER 5 --- PHASE II: THE EFFECTS OF FLUORIDE ON BONE MINERAL DENSITY OF OAD PATIENTS ON STEROID TREATMENT --- p.37 / Chapter 5.1. --- Objectives --- p.37 / Chapter 5.2. --- Subjects and methods --- p.37 / Chapter 5.2.1. --- Power of the study --- p.37 / Chapter 5.2.2. --- Subjects --- p.37 / Chapter 5.2.3. --- Method of randomisation --- p.38 / Chapter 5.2.4. --- Treatment modalities --- p.39 / Chapter 5.2.4.1. --- Treatment group --- p.39 / Chapter 5.2.4.2. --- Control group --- p.39 / Chapter 5.2.5. --- Bone mineral density measurements --- p.39 / Chapter 5.2.6. --- Routine quality control of measurement and precision on patient repositioning --- p.40 / Chapter 5.2.7. --- Methods of monitoring drug compliance --- p.40 / Chapter 5.2.8 --- Statistical methods --- p.40 / Chapter CHAPTER 6 --- RESULTS FOR PHASE I --- p.42 / Chapter 6.1. --- Statistical power of this phase of the study --- p.42 / Chapter 6.2. --- Clinical features of OAD subjects on inhaled steroid --- p.42 / Chapter 6.3. --- Anthropometric measurements and bone mineral density --- p.45 / Chapter 6.4. --- Analysis of covariance for BMDs differences --- p.48 / Chapter 6.5. --- Multiple regression --- p.50 / Chapter 6.6 --- Correlation --- p.51 / Chapter CHAPTER 7 --- RESULTS FOR PHASE II: FLUORIDE AND CALCIUM TRIAL --- p.81 / Chapter 7.1. --- Factors affects the power of studies --- p.81 / Chapter 7.2. --- Clinical findings --- p.82 / Chapter 7.3. --- Body measurements and bone mineral densitometry --- p.85 / Chapter CHAPTER 8: --- DISCUSSION FOR PHASE I --- p.117 / Chapter CHAPTER 9: --- DISCUSSION FOR PHASE II: TRIDIN AND CALCIUM TRIAL --- p.124 / APPENDIX 1: QUESTIONNAIRE FOR OAD BONE MINERAL DENSITY STUDY --- p.132 / APPENDIX 2: BONE SCANS FROM HOLOGIC QDR2000 --- p.137 / APPENDIX 3. TABLES AND REFERENCE CURVES FOR NORMAL HONG KONG CHINESE FEMALE OR MALE BMD --- p.142 / REFERENCE --- p.150

Introdução: Medidas baseadas no relato dos pacientes vêm sendo incorporadas de forma crescente como parâmetros adicionais na avaliação das intervenções e na decisão por modalidades de tratamento. Um dessas medidas é a avaliação da Qualidade de Vida Relacionada à Saúde (QVRS). Nos diversos estudos de QVRS em DPOC constata-se a predominância daqueles que avaliaram a influência de fatores clínicos relacionados à função pulmonar. Objetivos: Avaliar a QVRS de pacientes com DPOC e analisar a influência de fatores clínicos e sóciodemográficos e de bem-estar espiritual, na QVRS desses pacientes. Método: Foram entrevistados 70 pacientes atendidos em um ambulatório de pneumologia. Os dados foram coletados utilizando-se três instrumentos: uma ficha de caracterização dos pacientes, a Escala de Bem Estar Espiritual (EBE), contendo um componente religioso (BER) e um existencial (BEE), e o Saint George Respiratory Questionnaire (SGRQ), composto pelos domínios Sintomas, Atividades e Impactos. A regressão linear múltipla, método backward, foi a estratégia utilizada para identificação dos fatores associados à QVRS. Resultados: Os pacientes eram homens, em sua maioria, tinham em média 64,24 anos (dp =10,22), baixo nível de escolaridade e de renda, católicos, ex-fumantes, com alta carga tabágica e com DPOC grave ou muito grave. Os escores do SGRQ indicaram má QVRS, principalmente em função das limitações na atividade física (média de 72%, dp=15). No domínio Sintomas, a média foi de 65% (dp= 18), de 57% (dp=19) no domínio Impactos e de 63% (dp=15) no escore total. A EBE mostrou um alto nível de bem-estar espiritual, com maior contribuição do componente religioso, o escore total foi de 94,87 (dp= 13,56), 51,50 (dp =8,68) para o domínio religioso e 43,37 (dp=6,76) para o existencial. Nas analises multivariadas, as variáveis de maior influência na QVRS foram: a escolaridade, presente nos modelos finais dos três domínios e no total do SGRQ (valores de -15,15 em sintomas, -10,75 em atividade, -19,33 em impactos e -44,20 no escore total) ; presença de comorbidades ( -9,00) , trabalho atual ( -12,22), BER ( 0,41) e BEE (-0,88) no domínio Atividade; tempo de DPOC ( 0,61) , no domínio Sintomas e carga tabágica ( -0,131) no domínio Impactos, para o escore total, trabalho atual ( -36,59), presença de comorbidades ( -17,88), BER ( 1,30) e BEE ( -1,94). Conclusão: Os resultados deste estudo reforçam a importância de considerar fatores como a escolaridade, o trabalho, a presença de comorbidades, a religiosidade e a espiritualidade na assistência integral aos pacientes com DPOC, visando proporcionar-lhes uma melhor qualidade de vida. / Introduction: Patient Report Outcomes are being increasingly incorporated as additional parameters in the evaluation of interventions and decision for treatment modalities. One of these measures is the evaluation of Health Related Quality of Life (HRQOL). In several studies of HRQOL in COPD patients there is a predominance of evaluating the influence of clinical factors related to lung function. Objectives: This study aimed to evaluate the HRQOL of COPD patients and analyze the influence of sociodemographic, clinical and spiritual well being factors, on patients HRQOL. Method: We interviewed 70 patients treated on a pulmonology outpatient. Data were collected using three instruments: a form of patients characterization, the Saint George Respiratory Questionnaire (SGRQ), comprising Symptoms, Activities and Impacts domains, and Spiritual Well-Being Scale (SWBS), which includes a religious component (RWB) and an existential (EWB). Multiple linear regression, backward method, was the strategy chose to identify associated factors with HRQOL. Results: The patients were majority men, had an average of 64.24 years (SD = 10.22), low education and income, Catholics, former smokers, with high smoking load and severe or very severe COPD. The SGRQ scores indicated poor HRQOL, mainly due to limitations in physical activity (average of 72%, sd = 15). In the Symptoms domain the average was 65% (sd = 18), 57% (sd = 19) in the Impacts domain and of 63% (sd = 15) in the total score. The SWBS showed a high level of spiritual well-being (total score of 94.87, sd = 13.56), with major contribution of religious component, the 51.50 (sd = 8.68) for the religious domain and 43.37 (sd = 6.76) to the existential one. In multivariate analysis, the variables that influenced HRQOL were: schooling, present in the final model of the three domains and SGRQ total (values of -15.15 in Symptoms, -10.75 in Activities, -19 in Impacts, and -44.20 in total score); comorbidities presence ( -9.00), current job ( -12.22), RWB ( 0.41) and EWB (-0, 88) in Activities area; duration of COPD ( 0.61) in Symptoms; tobacco intake ( -0.131) in Impacts and current job ( -36.59), comorbidities presence ( -17.88 ), RWB ( 1.30) and EWB ( -1.94) in total score. Conclusion: The results of this study reinforce the importance of considering factors such as education, employment, presence of comorbidities, religion and spirituality in comprehensive care to patients with COPD in order to provide them a better quality of life.

Submitted by THIAGO DIAS FERNANDES null (thiagodf83@hotmail.com) on 2017-02-03T21:14:57Z No. of bitstreams: 1 TESE PRONTA FINAL.pdf: 8515287 bytes, checksum: dedec31a9ce185e261cf9657fdb3dd34 (MD5) / Approved for entry into archive by LUIZA DE MENEZES ROMANETTO (luizamenezes@reitoria.unesp.br) on 2017-02-07T12:44:46Z (GMT) No. of bitstreams: 1 fernandes_td_dr_bot.pdf: 8515287 bytes, checksum: dedec31a9ce185e261cf9657fdb3dd34 (MD5) / Made available in DSpace on 2017-02-07T12:44:46Z (GMT). No. of bitstreams: 1 fernandes_td_dr_bot.pdf: 8515287 bytes, checksum: dedec31a9ce185e261cf9657fdb3dd34 (MD5) Previous issue date: 2016-12-05 / Introdução: O reflexo trigêmino-facial (RTF) pode ser estudado e mensurado através de técnica eletrofisiológica - o Blink Reflex. As respostas R2 são integradas em nível ponto-bulbar por neurônios que têm relação anatômica e funcional com a formação reticular, por sua vez relacionada à fisiologia do sono e fisiopatologia da Síndrome da Apneia Obstrutiva do Sono (SAOS). Objetivo: Estudar o RTF em pacientes com SAOS e correlacionar os achados com parâmetros polissonográficos. Métodos: Foram estudados 50 pacientes adultos com SAOS, de ambos os sexos, submetidos à polissonografia, estudos de condução nervosa sensitiva e motora nos membros, e estudo do RTF. Resultados: Dos 50 pacientes estudados, 10 preencheram critérios de exclusão. Dentre 40 pacientes analisados, o RTF foi normal em 7, mostrou achados de hiperexcitabilidade em 16 (grande amplitude, longa duração e/ou curta latência) - Grupo 1, e achados de hipoexcitabilidade em 17 (baixa amplitude e/ou latência prolongada ou resposta ausente) - Grupo 2, com diferenças estatisticamente significativas entre os grupos (p < 0.0001). As alterações do RTF não apresentaram correlações estatisticamente significativas com os diferentes parâmetros polissonográficos estudados. Conclusões: A avaliação eletrofisiológica do RTF permitiu separar pacientes com SAOS em 3 grupos (normal, achados de hiperexcitabilidade, achados de hipoexcitabilidade) evidenciando normalidade, disfunção e/ou lesão de grupos neuronais do tronco encefálico. / Background: The Blink Reflex can be evaluated through electrophysiological method. The R2 late responses are mediated by neuronal groups in the pons and medulla with anatomical and physiological relation with the reticular formation, wich is related to sleep physiology and physiopathology of the Obstructive Sleep Apnea (OSA). Objective: To study the Blink Reflex in patients with OSA and to correlate the findings with polysomnographic parameters. Methods: Fifty adult patients with OSA diagnosis were enrolled for polysomnography, limb conduction studies and Blink Reflex. Results: Ten patients fulfilled exclusion criteria. From 40 patients studied, 7 showed normal Blink Reflex, 16 hyperexcitability findings (high amplitude, long duration, and/or short latency response) - Group 1, and 17 hypo excitability findings (low amplitude and/or prolonged latency, or absent response) - Group 2, with significant differences between groups (p < 0.0001). No statistically significant difference was observed between the Blink Reflex abnormalities and the polysomnographic parameters evaluated. Conclusion: The electrophysiological evaluation of the blink reflex afforded to distinguish OSA patients in 3 groups (normal, hyperexcitability findings, hypo excitability findings) related to normality, dysfunction and/or injury of neuronal groups in the brainstem.

Resumo: A Síndrome de Apnéia Hipopnéia Obstrutiva do Sono é um distúrbio caracterizado por episódios repetidos de obstrução parcial ou completa da via aérea superior durante o sono, resultando em hipóxia intermitente, hipercapnia e fragmentação do sono. Afeta 0,7% a 3% das crianças na faixa etária pré-escolar, e está, nas crianças, relacionada com a hipertrofia das tonsilas palatina e/ou faríngeas. Em adultos, a SAHOS foi relacionada como fator de risco para doenças cardiovasculares e distúrbios metabólicos. Em crianças, há poucos relatos de alterações cardíacas como cor pulmonale ou HAS. Porém, as evidências fisiopatológicas da SAHOS permitem suspeitar que haja alterações estruturais e funcionais cardíacas, notadamente do ventrículo direito. Avaliar a função cardíaca de crianças com distúrbios respiratórios obstrutivos por hipertrofia das tonsilas, antes e após a cirurgia de adeno- e/ou tonsilectomia. Foram estudadas 40 crianças, de ambos os sexos, com idade entre 3 a 11 anos, das quais 30 estavam em seguimento no Ambulatório de Distúrbios do Sono, da disciplina de Otorrinolaringologia, FMB - UNESP, aguardando cirurgia de adeno- e/ou tonsilectomia por hipertrofia das tonsilas e distúrbios respiratórios obstrutivos, caracterizados por roncos, pausas respiratórias referidas e sono agitado. As outras 10 crianças eram controles saudáveis, os dois grupos estando homogêneos em relação ao sexo, idade, peso e altura. Todas as 40 crianças foram submetidas a ecocardiograma, visando as 4 câmaras em sístole e diástole... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Obstructive sleep apnea is characterized by intermittent partial or complete obstruction of the upper airway, causing hypoxemia, hypercapnia and sleep fragmentation. It affects 0,7% to 3% of the pre-school children, and in children it is closely related to enlarged tonsils. In adults, sleep apnea has been described as na independent risk factor for cardiovascular disease and metabolic disorders. In children, there a few studies for cardiovascular disfunction, most of them related to cor pulmonale or hypertension. Even though, the pathophysiologic mechanism of OSA permit to suspect of structural and functional cardiac changes, mostly of the right chambers. To study the heart function in children with sleep-related breathing disorders and enlarged tonsils, before and after adeno- and/or tonsillectomy. We studied 40 children, of both genders, aged between 3 and 11 years. Thirty children were at follow-up of Botucatu Medical School - State University of São Paulo due to hypertrophy of the tonsils and clincal complaints of Obstructive Sleep Apnea, as snoring, referred apneas and restless sleep. The other ten children were healthy controls; both groups were homogeneous in gender, age, weight and height. All 40 children were submitted to echocardiogram, analysing the four chambers, in systole and diastole... (Complete abstract click electronic access below) / Orientador: Jair Cortez Montovani / Coorientador: Beatriz Matsubara / Coorientador: José Roberto Fioretto / Doutor

As transformações demográficas e epidemiológicas do século anterior trouxeram significativas modificações sociodemográficas e de saúde, em todo o mundo, com o aumento de idosos na população. Ao processo de envelhecimento pode estar associado às doenças crônicas não transmissíveis, dentre elas a doença pulmonar obstrutiva crônica (DPOC), um problema de saúde pública, parcialmente reversível, progressivo e incapacitante. Assim, os objetivos do estudo foram caracterizar os idosos com diagnóstico de DPOC nos estádios I a IV, atendidos no Ambulatório de Pneumologia Geral do HCFMRP/USP, segundo as variáveis sociodemográficas, história de tabagismo e condição de saúde; identificar o grau de independência funcional; identificar a presença de sintomas de depressão; analisar a correlação entre o grau de independência funcional, idade, número de morbidades, tempo e grau de DPOC e a associação entre a presença de sintomas de depressão, as variáveis sociodemográficas, o grau de DPOC e as comorbidades. Trata-se de um estudo descritivo, transversal e correlacional. A coleta dos dados ocorreu no período de março a maio de 2010. Utilizou-se um instrumento para caracterização da amostra, a Medida da Independência Funcional (MIF) e a Escala de rastreamento de sintomas depressivos (CES-D). Foram estudados 84 idosos, média de idade 70,4 anos (s=7,3); 61,9% homens; 51,2% casados; 36,9% viúvos; 36,9% sabiam ler e escrever informalmente/analfabetos; 82,8% eram aposentados; 73,2% recebiam um salário mínimo; 54,8% moravam com a família; 75% deixaram de fumar, 20,2% ainda fumavam e 4,8% nunca fumaram; a carga tabágica foi superior para os homens, sendo a diferença significativa (p<000,1); 100% tinham DPOC, 51,2% pressão alta, 39,3% problemas para dormir e 33,3 problemas cardíacos; a média de morbidades foi de 3,4(s=2,4); 41,7% referiram internação nos últimos 12 meses; 34,5% por exacerbação da DPOC e 34,3% por pneumonia. Houve predomínio da DPOC nos estádios III (40,5%) e II (35,7%), verificou-se prevalência de homens (79,5%) no estádio III e de mulheres (56,7%) no II; os homens apresentaram níveis de DPOC mais elevados que as mulheres, sendo a diferença estatisticamente significativa (p=0,05); tempo médio de DPOC foi 8,3 anos (s=6,4). O escore médio da MIF total foi 117,0 pontos; 96,4% com nível de Independência completa/modificada; a correlação de Pearson entre número de morbidade e MIF (total e motora) foi inversa e significativa (p=0,02). A CES-D classificou 71,4% com sintomas de depressão. Houve diferenças significativas entre presença de sintomas de depressão e as variáveis, sexo (p=0,01), estado conjugal (p=0,02) e problemas para dormir (p=0,01). O estudo revelou que a maioria dos idosos apresentava independência completa/modificada e presença de sintomas de depressão. Apesar de não ter encontrado diferenças significativas na correlação entre os escores da MIF e as variáveis, idade, tempo e grau de DPOC, bem como entre a associação de sintomas depressivos com idade, grau de DPOC e comorbidades, os resultados são relevantes para discussões entre os profissionais da área da saúde, uma vez que a identificação correta de fatores que podem influenciar no tratamento, reabilitação e qualidade de vida do idoso com DPOC torna efetiva as praticas assistenciais voltadas para as necessidades dos mesmos. / The demographic and epidemiological transformations of the previous century brought significant sociodemographic and health changes, globally, with an increase of the elderly population. The aging process can be associated to non transmissible chronic diseases, among them the chronic obstructive pulmonary disease (COPD), which is a partially reversible, progressive and debilitating public health problem. Thus, this descriptive, cross-sectional and correlational study aimed to characterize the elderly with diagnosis of COPD at stages I to IV, who receive care at the Outpatient Clinic of General Pneumology of the Hospital das Clínicas of the University of São Paulo at Ribeirão Preto Medical School (HCFMRP/USP), according to sociodemographic variables, history of smoking and health conditions; to identify the degree of functional independence; to identify the presence of symptoms of depression; to analyze the correlation among the degree of functional independence, age, number of morbidities, time and stage of COPD and the association between the presence of symptoms of depression, the sociodemographic variables, the stage of COPD and the comorbidities. Data collection was carried out between March and May 2010. An instrument was used for the characterization of the sample, as well as the Measure of Functional Independence (MFI) and the Center for Epidemiologic Studies Depression Scale (CES-D). In total, 84 elderly adults were studied, with average age of 70.4 years (sd=7,3); 61.9% men; 51.2% married; 36.9% widower; 36.9% could read and write and were informally illiterate; 82.8% were retired; 73.2% received one minimum wage monthly; 54.8% lived with the family; 75% quit smoking, 20.2% still smoked and 4.8% never smoked; the tobacco load was higher for men, with significant difference (p<0.001); 100% had COPD, 51.2% had high blood pressure, 39.3% problems to sleep and 33.3 heart problems; the average of reported morbidities was 3.4 (sd=2.4); 41.7% reported being hospitalized in the last 12 months; 34.5% for aggravation of COPD and 34.3% pneumonia. There was predominance of COPD at stages III (40.5%) and stage II (35.7%), with prevalence of men (79.5%) at stage III and women (56.7%) at stage II; men presented higher levels of COPD than women, with statistically significant difference (p=0.05); average time of COPD was 8.3 years (sd=6.4). The average score of total MIF was 117.0 points; 96.4% with level of complete/altered independence; Person correlation between number of morbidity and MIF (total and motor) was inverse and significant (p=0.02). CES-D classified 71.4% of the participants with symptoms of depression. There were significant differences between the presence of symptoms of depression and the variables gender (p=0.01), marital status (p=0.02) and problems to sleep (p=0.01). The study revealed that most elderly adults presented complete/altered independence and presence of symptoms of depression. Although there were no significant differences between the correlation of the scores of MIF and the variables age, time and stage of COPD, as well as the association of depressive symptoms with age, stage of COPD and comorbidities, results are relevant for discussions among health professionals, once the correct identification of factors that can influence on the treatment, rehabilitation and quality of life of the elderly with COPD make care practices targeting the needs of the elderly more effective.

Introdução: Medidas baseadas no relato dos pacientes vêm sendo incorporadas de forma crescente como parâmetros adicionais na avaliação das intervenções e na decisão por modalidades de tratamento. Um dessas medidas é a avaliação da Qualidade de Vida Relacionada à Saúde (QVRS). Nos diversos estudos de QVRS em DPOC constata-se a predominância daqueles que avaliaram a influência de fatores clínicos relacionados à função pulmonar. Objetivos: Avaliar a QVRS de pacientes com DPOC e analisar a influência de fatores clínicos e sóciodemográficos e de bem-estar espiritual, na QVRS desses pacientes. Método: Foram entrevistados 70 pacientes atendidos em um ambulatório de pneumologia. Os dados foram coletados utilizando-se três instrumentos: uma ficha de caracterização dos pacientes, a Escala de Bem Estar Espiritual (EBE), contendo um componente religioso (BER) e um existencial (BEE), e o Saint George Respiratory Questionnaire (SGRQ), composto pelos domínios Sintomas, Atividades e Impactos. A regressão linear múltipla, método backward, foi a estratégia utilizada para identificação dos fatores associados à QVRS. Resultados: Os pacientes eram homens, em sua maioria, tinham em média 64,24 anos (dp =10,22), baixo nível de escolaridade e de renda, católicos, ex-fumantes, com alta carga tabágica e com DPOC grave ou muito grave. Os escores do SGRQ indicaram má QVRS, principalmente em função das limitações na atividade física (média de 72%, dp=15). No domínio Sintomas, a média foi de 65% (dp= 18), de 57% (dp=19) no domínio Impactos e de 63% (dp=15) no escore total. A EBE mostrou um alto nível de bem-estar espiritual, com maior contribuição do componente religioso, o escore total foi de 94,87 (dp= 13,56), 51,50 (dp =8,68) para o domínio religioso e 43,37 (dp=6,76) para o existencial. Nas analises multivariadas, as variáveis de maior influência na QVRS foram: a escolaridade, presente nos modelos finais dos três domínios e no total do SGRQ (valores de -15,15 em sintomas, -10,75 em atividade, -19,33 em impactos e -44,20 no escore total) ; presença de comorbidades ( -9,00) , trabalho atual ( -12,22), BER ( 0,41) e BEE (-0,88) no domínio Atividade; tempo de DPOC ( 0,61) , no domínio Sintomas e carga tabágica ( -0,131) no domínio Impactos, para o escore total, trabalho atual ( -36,59), presença de comorbidades ( -17,88), BER ( 1,30) e BEE ( -1,94). Conclusão: Os resultados deste estudo reforçam a importância de considerar fatores como a escolaridade, o trabalho, a presença de comorbidades, a religiosidade e a espiritualidade na assistência integral aos pacientes com DPOC, visando proporcionar-lhes uma melhor qualidade de vida. / Introduction: Patient Report Outcomes are being increasingly incorporated as additional parameters in the evaluation of interventions and decision for treatment modalities. One of these measures is the evaluation of Health Related Quality of Life (HRQOL). In several studies of HRQOL in COPD patients there is a predominance of evaluating the influence of clinical factors related to lung function. Objectives: This study aimed to evaluate the HRQOL of COPD patients and analyze the influence of sociodemographic, clinical and spiritual well being factors, on patients HRQOL. Method: We interviewed 70 patients treated on a pulmonology outpatient. Data were collected using three instruments: a form of patients characterization, the Saint George Respiratory Questionnaire (SGRQ), comprising Symptoms, Activities and Impacts domains, and Spiritual Well-Being Scale (SWBS), which includes a religious component (RWB) and an existential (EWB). Multiple linear regression, backward method, was the strategy chose to identify associated factors with HRQOL. Results: The patients were majority men, had an average of 64.24 years (SD = 10.22), low education and income, Catholics, former smokers, with high smoking load and severe or very severe COPD. The SGRQ scores indicated poor HRQOL, mainly due to limitations in physical activity (average of 72%, sd = 15). In the Symptoms domain the average was 65% (sd = 18), 57% (sd = 19) in the Impacts domain and of 63% (sd = 15) in the total score. The SWBS showed a high level of spiritual well-being (total score of 94.87, sd = 13.56), with major contribution of religious component, the 51.50 (sd = 8.68) for the religious domain and 43.37 (sd = 6.76) to the existential one. In multivariate analysis, the variables that influenced HRQOL were: schooling, present in the final model of the three domains and SGRQ total (values of -15.15 in Symptoms, -10.75 in Activities, -19 in Impacts, and -44.20 in total score); comorbidities presence ( -9.00), current job ( -12.22), RWB ( 0.41) and EWB (-0, 88) in Activities area; duration of COPD ( 0.61) in Symptoms; tobacco intake ( -0.131) in Impacts and current job ( -36.59), comorbidities presence ( -17.88 ), RWB ( 1.30) and EWB ( -1.94) in total score. Conclusion: The results of this study reinforce the importance of considering factors such as education, employment, presence of comorbidities, religion and spirituality in comprehensive care to patients with COPD in order to provide them a better quality of life.

INTRODUÇÃO: Uma alta prevalência de apnéia obstrutiva do sono (AOS) tem sido relatada em paciente com doença arterial coronária (DAC). Vários mecanismos relacionados à AOS, incluindo dessaturação da oxi-hemoglobina e aumento da demanda de oxigênio, aumento da atividade simpática bem como estado pro trombótico, podem ser perigosos nos pacientes com DAC. Entretanto, a AOS é pouco reconhecida e não é rotineiramente pesquisada nos pacientes admitidos em unidade de cuidados coronários (UCC) com DAC. O padrão ouro para o diagnóstico de AOS é a polissonografia noturna (PSG), método impraticável na UCC, pois implica no deslocamento do paciente para o laboratório de sono. OBJETIVOS: Construir e validar um monitor de oximetria para diagnóstico de AOS em pacientes admitidos na UCC com diagnóstico de DAC aguda. MÉTODOS: Foi inicialmente desenvolvido monitor de oximetria continua que registra os dados derivados dos monitores da UCC e permite a determinação do índice de dessaturação da oxi-hemoglobina (IDO) através de análise visual da curva de oximetria. O monitor foi então utilizado em pacientes consecutivos admitidos na UCC com diagnóstico de DAC aguda. Uma amostra desta população foi também estudada através de PSG, num período máximo de três meses após a alta. RESULTADOS: Trinta e sete pacientes foram estudados através de monitorização de oximetria durante a noite na UCC. PSG foi também realizada em vinte pacientes. AOS, diagnosticada pelo monitor de oximetria contínua (IDO > 5/hora), estava presente em 43% dos pacientes. AOS foi diagnosticada em 45% dos pacientes estudados com PSG (índice de apnéia e hipopnéia > 15 eventos por hora). Houve um bom nível de concordância entre o diagnóstico de AOS pelo monitor de oximetria na UCC e pela polissonografia - kappa = 0.898; p < 0.0001. O IDO determinado pelo monitor se correlacionou de forma significativa com o índice de apnéia e hipopnéia (r = 0.737; p < 0.0001). O diagnóstico de AOS através do monitor demonstrou sensibilidade de 88,9% e especificidade de 100%. CONCLUSÃO: O monitor desenvolvido no presente trabalho, que permite o registro da oximetria contínua a partir de dados que já são habitualmente coletados na UCC, é um método simples e preciso para o diagnóstico de AOS na UCC. / BACKGROND: A high prevalence of Obstructive sleep apnea (OSA) has been reported in patients with coronary artery disease (CAD). Several OSA related mechanisms, such as oxygen desaturation, high sympathetic activity, increased cardiac oxygen demand and a prothrombotic state, may be particularly dangerous in acute CAD patients. Nevertheless, OSA is frequently underdiagnosed and patients with CAD are not routinely screened for OSA when admitted to the Coronary Care Unit (CCU). OBJECTIVES: To build and validate a continuous overnight oximetry, by recording oximetry data derived from the CCU monitor, for the detection of OSA in acute CAD patients. DESIGN: We studied consecutive patients recruited on the basis of the presence of acute CAD requiring CCU, analyzed overnight continuous oximetry data and further compared it with full overnight polysomnography (PSG). RESULTS: Thirty-seven patients underwent overnight oxygen saturation monitoring in the CCU and 20 of these patients were submitted to PSG, performed within 3 months after hospital discharge. OSA was present in 43% and 45% of the patients studied by overnight oxygen saturation monitoring and PSG, respectively. The oxymetry derived oxygen desaturation index and the PSG derived apnea hypopnea index were strongly correlated (r = 0,737; p < 0,0001). There was a good level of agreement between abnormal oxymetric results and abnormal PSG results (kappa = 0.898; p < 0,0001). Overnight oximetry had a sensitivity of 88.9% and a specificity of 100% for OSA diagnosis. CONCLUSIONS: Continuous overnight oximetry derived from monitors that are already present in the CCU is a simple and accurate method for the diagnosis of OSA in the CCU.

A characteristic feature of Chronic Obstructive Pulmonary Disease (COPD) is an abnormal inflammatory response in the lungs to inhaled particles or gases. The ability to assess and monitor this response in the lungs of COPD patients is important for understanding the pathogenic mechanisms, but also provides a measure of the activity of the disease. Disease activity is more likely to relate to lung inflammation rather than the degree of airflow limitation as measured by the FEV1. Preliminary studies have shown the 18F fluorodeoxyglucose positron emission tomography (18F FDG-PET) signal, as a measure of lung inflammation, is quantifiable in the lungs and is increased in COPD patients compared to controls. However, the methodology requires standardisation and any further enhancement of the methodology would improve its application to assess inflammation in the lungs. I investigated various methods of assessing FDG uptake in the lungs and assessed the reproducibility of these methods, and particularly evaluated whether the data was reproducible or not in the COPD patients (smokers and ex-smokers). This data was then compared with a group of healthy controls to assess the role of dynamic 18F FDG-PET scanning as a surrogate marker of lung inflammation. My data showed a good reproducibility of all methods of assessing FDG lung uptake. However, using conventional Patlak analysis, the uptake was not statistically different between COPD and the control group. Encouraging results in favour of COPD patients were nonetheless shown using compartmental methods of assessing the FDG lung uptake, suggesting the need to correct for the effect of air and blood (tissue fraction effect) when assessing this in a highly vascular organ like the lungs. A prospective study analysis involving a bigger cohort of COPD patients would be desirable to investigate this further.