Artículo
Comprando el artículo el PDF del mismo podrá ser descargado
Precio 19,34 €
Comprar ahora
array:20 [ "pii" => "13075090" "issn" => "00257753" "doi" => "10.1157/13075090" "estado" => "S300" "fechaPublicacion" => "2005-05-14" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Med Clin. 2005;124:686-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2789 "formatos" => array:3 [ "EPUB" => 9 "HTML" => 2466 "PDF" => 314 ] ] "itemSiguiente" => array:16 [ "pii" => "13075091" "issn" => "00257753" "doi" => "10.1157/13075091" "estado" => "S300" "fechaPublicacion" => "2005-05-14" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Med Clin. 2005;124:690-1" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2273 "formatos" => array:3 [ "EPUB" => 9 "HTML" => 2100 "PDF" => 164 ] ] "es" => array:10 [ "idiomaDefecto" => true "titulo" => "Suplementos de hierro oral y ácido fólico en un programa de transfusión autóloga con predepósito: estudio aleatorizado" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "690" "paginaFinal" => "691" ] ] "contieneResumen" => array:1 [ "es" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Joan Cid, Xavier Ortín, Enric Contreras, Enric Elies" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Joan" "apellidos" => "Cid" ] 1 => array:2 [ "nombre" => "Xavier" "apellidos" => "Ortín" ] 2 => array:2 [ "nombre" => "Enric" "apellidos" => "Contreras" ] 3 => array:2 [ "nombre" => "Enric" "apellidos" => "Elies" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13075091?idApp=UINPBA00004N" "url" => "/00257753/0000012400000018/v0_201307291959/13075091/v0_201307292000/es/main.assets" ] "itemAnterior" => array:16 [ "pii" => "13075089" "issn" => "00257753" "doi" => "10.1157/13075089" "estado" => "S300" "fechaPublicacion" => "2005-05-14" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Med Clin. 2005;124:681-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 3198 "formatos" => array:3 [ "EPUB" => 7 "HTML" => 2924 "PDF" => 267 ] ] "es" => array:11 [ "idiomaDefecto" => true "titulo" => "Infección previa por <span class="elsevierStyleItalic">Chlamydia pneumoniae</span> y pronóstico a largo plazo en pacientes con síndrome coronario agudo sin elevación del segmento ST" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "681" "paginaFinal" => "685" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Previous infection with <span class="elsevierStyleItalic">Chlamydia pneumoniae</span> and long-term prognosis in patients acute coronary syndrome and with non-ST segment elevation" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Alessandro Sionis, Xavier Bosch, José L Marín, Ignaci Anguera, Marta Hage, Emiliano Bórquez, Fernando Verbal, Josep Vidal" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Alessandro" "apellidos" => "Sionis" ] 1 => array:2 [ "nombre" => "Xavier" "apellidos" => "Bosch" ] 2 => array:2 [ "nombre" => "José L" "apellidos" => "Marín" ] 3 => array:2 [ "nombre" => "Ignaci" "apellidos" => "Anguera" ] 4 => array:2 [ "nombre" => "Marta" "apellidos" => "Hage" ] 5 => array:2 [ "nombre" => "Emiliano" "apellidos" => "Bórquez" ] 6 => array:2 [ "nombre" => "Fernando" "apellidos" => "Verbal" ] 7 => array:2 [ "nombre" => "Josep" "apellidos" => "Vidal" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13075089?idApp=UINPBA00004N" "url" => "/00257753/0000012400000018/v0_201307291959/13075089/v0_201307292000/es/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "titulo" => "Exercise capacity in sarcoidosis. Study of 29 patients" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "686" "paginaFinal" => "689" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Öznuc Akkoca, Gökhan Celik, Füsun Ulger, Peri Arbak, Sevgi Saryal, Gülseren Karabykoglu, Doganay Alper" "autores" => array:7 [ 0 => array:3 [ "nombre" => "Öznuc" "apellidos" => "Akkoca" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "nombre" => "Gökhan" "apellidos" => "Celik" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "nombre" => "Füsun" "apellidos" => "Ulger" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "nombre" => "Peri" "apellidos" => "Arbak" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 4 => array:3 [ "nombre" => "Sevgi" "apellidos" => "Saryal" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 5 => array:3 [ "nombre" => "Gülseren" "apellidos" => "Karabykoglu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 6 => array:3 [ "nombre" => "Doganay" "apellidos" => "Alper" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Ankara University. Faculty of Medicine. Department of Chest Diseases. Cebeci Hospital. Ankara. Turkey." "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Abant Ízzet Baysal University. Düzce Faculty of Medicine. Department of Chest Diseases. Düzce. Turkey." "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Capacidad de ejercicio en la sarcoidosis. Estudio de 29 pacientes" ] ] "textoCompleto" => "<p class="elsevierStylePara">Sarcoidosis, a systemic granulomatous disease of unknown etiology characterized by the formation of epithelioid cell granuloma without caseation, primarily affects the lungs and lymphatic system. The incidence rates are higher among young to middle-aged adults and women.</p><p class="elsevierStylePara">The lungs are affected in more than 90% of patients with sarcodosis. Exertional dyspnea, dry cough and altered exercise tolerance occur in one-half of all patients<span class="elsevierStyleSup">1,2</span>. Although symptomatic muscle involvement is rare (1-2%), asymptomatic muscle involvement is believed to occur in 50-80% of patients. Muscle involvement, systemic and metabolic factors, and decreased lung volume may contribute to diminished inspiratory and expiratory muscle strength<span class="elsevierStyleSup">1,3</span>.</p><p class="elsevierStylePara">The extent of pulmonary parenchymal disease and detection of progressive functional impairment during the course of the disease is important for the diagnosis and management of sarcoidosis patients; yet there is no true non-invasive 'gold standard' for measuring the extent of disease in patients with pulmonary sarcoidosis. Pulmonary function tests in sarcoidosis typically reveal a restrictive pattern with a reduction in carbon monoxide diffusion capacity (DLCO). In rare studies, it is reported that airflow limitation may be observed at the initial diagnosis<span class="elsevierStyleSup">4,5</span>.</p><p class="elsevierStylePara">On the other hand, cardiopulmonary exercise testing has been used more commonly in early diagnosis of interstitial lung diseases during the last decade; since it offers a sensitive mean to evaluate ventilatory, cardiovascular and metabolic functions. In early studies, it has been showed that the exercise intolerance in patients with sarcoidosis may be attributed to a 25-30% reduction in maximal aerobic capacity compared to healthy age-matched controls<span class="elsevierStyleSup">6,7</span>.</p><p class="elsevierStylePara">There is a limited number of studies concerning the exercise response of patients with sarcoidosis. The aims of the present study were <span class="elsevierStyleItalic">1)</span> to evaluate the degree of impairment in pulmonary function tests, arterial blood gas analysis, respiratory muscle strength, exercise capacity and correlation of these parameters with radiological stages of sarcoidosis; <span class="elsevierStyleItalic">2)</span> to further evaluate the use of cardiopulmonary exercise testing in assessing the of extent of pulmonary disease; and <span class="elsevierStyleItalic">3)</span> to discuss the pathophysiologic mechanisms of limitation in exercise capacity in patients with sarcoidosis.</p><p class="elsevierStylePara">Patients and method</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Subjects</span></p><p class="elsevierStylePara">In this prospective study, 29 patients with the diagnosis of biopsy specimen-proven sarcoidosis, according to the criteria of American Thoracic Society (ATS) were included<span class="elsevierStyleSup">1</span>. All of the patients were newly-diagnosed, untreated and non-smokers.</p><p class="elsevierStylePara">The diagnosis of sarcoidosis was based on clinical features, radiological findings and histological evidence of non-caseating granulomata<span class="elsevierStyleSup">1,8</span>. Chest radiographs were examined by three pulmonologists: stage 0, no radiographic abnormalities; stage l, bilateral hilar adenopathy without parenchymal abnormalities; stage ll, bilateral hilar adenopathy with interstitial parenchymal infiltrates; stage lll, interstitial parenchymal infiltrates without hilar adenopathy; and stage lV, cicatricial changes<span class="elsevierStyleSup">1</span>.</p><p class="elsevierStylePara">All of the patients were diagnosed and studied at the Chest Diseases Department and Pulmonary Physiology Laboratory of the same department. Patients with accompanying disease; such as cardiac, other respiratory or neuromuscular disorders, were not enrolled in the study.</p><p class="elsevierStylePara">Cases were grouped according to their radiological stages: (stage I, group 1; stage II, group 2; stage III, group 3). There were no stage 0 and stage IV patients included. Groups 1, 2 and 3 included 11, 13 and 5 patients, respectively.</p><p class="elsevierStylePara">Physical examination of all patients was performed and past medical history was noted. Complete blood count and serum chemistry was done; and serum angiotensin-converting enzyme (SACE) levels were measured. Pulmonary function tests, cardiopulmonary exercise testing and arterial blood gas analysis were performed for each patient.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Pulmonary function tests (PFT)</span></p><p class="elsevierStylePara">PFT, including ventilatory tests, carbon monoxide diffusing capacity (DLCO), lung volumes, mouth inspiratory and expiratory pressures were measured at rest using V<span class="elsevierStyleInf">max</span> 229 Pulmonary Function/Cardiopulmonary Exercise Testing Instruments (Sensor Medics, Bilthoven, The Netherlands). All of the tests were performed in sitting position and the best of three attempts was evaluated. The tests were compatible with the American Thoracic Society (ATS) criteria<span class="elsevierStyleSup">9</span>. Predicted values were calculated using European Community for Steel and Coal (ECCS) reference values<span class="elsevierStyleSup">10</span>.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Respiratory muscle strength</span></p><p class="elsevierStylePara">Inspiratory muscle strength (PI<span class="elsevierStyleInf">max</span>) was measured near residual volume (RV) and expiratory muscle strength (PE<span class="elsevierStyleInf">max</span>) was measured near total lung capacity (TLC). Percentage PI<span class="elsevierStyleInf">max</span> and PE<span class="elsevierStyleInf">max</span> were calculated according to Black and Hyatt's reference values<span class="elsevierStyleSup">11</span>.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Exercise testing</span></p><p class="elsevierStylePara">Progressive cycle exercise tests to symptom limitation were conducted on an electronically braked cycle ergometer (V<span class="elsevierStyleInf">max</span> 229 Pulmonary Function/Cardiopulmonary Exercise Testing Instruments, Sensor Medics, Bilthoven, The Netherlands)<span class="elsevierStyleSup">12</span>. All of the patients were monitorized, throughout the testing, in terms of electrocardiography (ECG), arterial pressure and oxygen saturation. After the initial evaluation, subjects began cycling at a pedalling rate of 50-60 rpm/min for three minutes and afterwards the work was increased by 15-25 watts every minute. The patients were strongly encouraged to perform maximally. The test was terminated at the point of symptom limitation. Peak work rate (watt), peak oxygen consumption (VO<span class="elsevierStyleInf">2</span>), peak oxygen consumption/kg (VO<span class="elsevierStyleInf">2</span>/kg), peak carbon dioxide production (VCO<span class="elsevierStyleInf">2</span>), gas exchange ratio (R, VCO<span class="elsevierStyleInf">2</span>/VO<span class="elsevierStyleInf">2</span>), minute ventilation (VE), respiratory rate (f), breathing reserve (BR), heart rate (HR), heart rate reserve (HRR), O<span class="elsevierStyleInf">2</span> pulse and oxygen uptake/work rate ratio (VO<span class="elsevierStyleInf">2</span>/WR) were recorded. Metabolic parameters of the exercise test (VO<span class="elsevierStyleInf">2</span> and VCO<span class="elsevierStyleInf">2</span>) were compared with predicted normal values of Jones et al<span class="elsevierStyleSup">13</span>. Dead space to tidal volume ratio (Vd/Vt) was calculated (Vd/Vt = (PaCO<span class="elsevierStyleInf">2</span>-PECO<span class="elsevierStyleInf">2</span>)/PaCO<span class="elsevierStyleInf">2</span>). Anaerobic threshold (AT) was determined by V-slope method and reported as the percentage of predicted VO<span class="elsevierStyleInf">2</span> peak.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Arterial blood gas analysis (ABG)</span></p><p class="elsevierStylePara">ABG was performed at rest and at peak performance with a Rapidlab 348 pH/Blood Gas Analyser (Chiron Diagnostics Ltd., Essex, UK); pH, PaO<span class="elsevierStyleInf">2</span>, PaCO<span class="elsevierStyleInf">2</span>, and SaO<span class="elsevierStyleInf">2</span> were measured. An alveolar-arterial oxygen pressure gradient (P[A-a]O<span class="elsevierStyleInf">2</span>) was calculated for each arterial blood sample using measured respiratory quotients.</p><p class="elsevierStylePara">The change in VO<span class="elsevierStyleInf">2</span> (VO<span class="elsevierStyleInf">2</span>) was calculated as the difference in oxygen uptake between peak exercise and resting measurements of oxygen consumption. PaO<span class="elsevierStyleInf">2</span> was calculated as the difference in arterial oxygen tension between peak exercise and resting measurements. P(A-a)O<span class="elsevierStyleInf">2</span> was expressed as the difference between peak exercise and resting measurements. BR was calculated as difference between measured resting MVV and peak exercise ventilation. HRR was calculated as the difference between peak and resting heart rate.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Statistical Analysis</span></p><p class="elsevierStylePara">Statistical analysis was performed through SPSS (SPSS, Inc., Chicago, IL, USA).</p><p class="elsevierStylePara">For all variables, descriptive statistics were generated as mean ± standard deviation (SD). Data of groups were compared using Kruskal-Wallis one way analysis of variance. In case of unequal averages Mann-Whitney U test was used to assess the differences between groups. Due to the exploratory nature of this study, correction for p-values was not performed.</p><p class="elsevierStylePara">Spearman's rank correlation test was performed to reveal relationships between measured physiological parameters and radiological stages. All significance tests were two tailed and p-values lower than 0.05 were considered to be significant.</p><p class="elsevierStylePara">Results</p><p class="elsevierStylePara">Twenty-nine (biopsy specimen-proven) untreated patients were included, 20 of them were females. Mean age was 42.50 ± 9.80 years. There were no differences between groups with regard to age and gender.</p><p class="elsevierStylePara">Fatigue and generalized weakness were most common symptoms, expressed by 6 of 29 patients. They were radiological stage II and III, 2 and 4 patients, respectively. Dyspnea on exertion was the complaint of 5 patients, 4 of them were radiological stage III.</p><p class="elsevierStylePara">Mean SACE level was 98.26 ± 114.16 IU. Although there was no significant difference between groups, higher serum levels of SACE were measured in advanced stages.</p><p class="elsevierStylePara">Results of pulmonary function tests and respiratory muscle strength of the patients are seen in table 1.</p><p class="elsevierStylePara"><img src="2v124n18-13075090tab01.gif"></img></p><p class="elsevierStylePara">Evaluation of all patients showed a mild decrease in DLCO, while PFT parameters were normal. According to radiological stages, a mild and moderate decrease in DLCO was found in stage II and III, respectively. Significant difference in DLCO was assessed between stages I and III. Although inspiratory and expiratory muscle strength was within normal limits, an insignificant decrease was observed in higher radiological stage (table 1).</p><p class="elsevierStylePara">Progressive cycle exercise tests to symptom limitation were conducted for 6-10 min duration. Mean duration was 7.91 ± 1.07 min. Anaerobic threshold (AT) was not determined in 6 of the cases (20%). In the rest of the patients, AT, found by V-Slope method, was 44% of the predicted peak VO<span class="elsevierStyleInf">2</span>. A significant decrement was observed in terms of VO<span class="elsevierStyleInf">2</span> and VO<span class="elsevierStyleInf">2</span>/kg, with increasing radiological stage (p < 0.05). Peak metabolic and ventilatory parameters of patients during the cardiopulmonary exercise testing, and arterial blood gas parameters at rest and at peak exercise are shown in table 2. It was observed that VO<span class="elsevierStyleInf">2</span> in group 3 was lower than that of group 1 (p < 0.05). A decrease in PaO<span class="elsevierStyleInf">2</span> during exercise was only seen in stage III patients (­1.20 mmHg). P(A-a)O<span class="elsevierStyleInf">2</span> was found to increase with exercise in groups 2 and 3; but differences between groups were insignificant. In addition, decrement in O<span class="elsevierStyleInf">2</span> pulse (64%) and oxygen uptake/work rate ratio (VO<span class="elsevierStyleInf">2</span>/WR) (62%) was significant in stage III.</p><p class="elsevierStylePara"><img src="2v124n18-13075090tab02.gif"></img></p><p class="elsevierStylePara">The correlation between peak VO<span class="elsevierStyleInf">2</span> and other parameters are seen in table 3. Significant correlations were found between peak VO<span class="elsevierStyleInf">2</span> and DLCO, VE, O<span class="elsevierStyleInf">2</span> pulse and VO<span class="elsevierStyleInf">2</span>/WR (p < 0.01).</p><p class="elsevierStylePara"><img src="2v124n18-13075090tab03.gif"></img></p><p class="elsevierStylePara">There was a significant correlation between radiological stages and physiological parameters (table 4). Exercise capacity was found to decrease with radiological extension of the disease (r = ­0.43; p < 0.05). DLCO, PaO<span class="elsevierStyleInf">2</span> at rest and during exercise, SaO<span class="elsevierStyleInf">2</span> at rest and during exercise, changes in P(A-a) O<span class="elsevierStyleInf">2</span>, O<span class="elsevierStyleInf">2</span> pulse and VO<span class="elsevierStyleInf">2</span>/WR were also correlated with radiological stage.</p><p class="elsevierStylePara"><img src="2v124n18-13075090tab04.gif"></img></p><p class="elsevierStylePara">Discussion</p><p class="elsevierStylePara">The major finding from the present prospective study is a significant limitation in exercise capacity in patients with sarcoidosis, which showed a significant correlation with radiological stages of diseases, diffusing capacity and some functional parameters (FEV<span class="elsevierStyleInf">1</span>, FEV<span class="elsevierStyleInf">1</span>/FVC). Especially in patients with stage l disease exercise capacity was limited although they had completely normal spirometry.</p><p class="elsevierStylePara">It has been previously postulated that maximal oxygen consumption decreases in sarcoidosis. Matthews and Hooper showed a limitation on progressive incremental exercise tests in 12 of 31 sarcoid patients, 11 of them had abnormal PFT<span class="elsevierStyleSup">14</span>. Sietsema et al. also declared that eleven of 20 sarcoid patients had failed to reach the predicted percent of maximum VO<span class="elsevierStyleInf">2</span><span class="elsevierStyleSup">15</span>. These studies emphasize the partial effect of ventilatory limitation on decreased exercise capacity. In our study, slight decrease in DLCO with normal PFT (TLC, VC, FEV<span class="elsevierStyleInf">1</span>) was found conflicting with the results mentioned above.</p><p class="elsevierStylePara">In the study of Miller et al, 56% of the patients with normal spirometry and decreased diffusion capacity reached the predicted maximal VO<span class="elsevierStyleInf">2</span>, while only 14% of the patients with normal spirometry and DLCO had limited exercise capacity. Patients with normal pulmonary function, in the study of Delobbe, exhibited a 30% lower maximal workload and/or VO<span class="elsevierStyleInf">2max</span> than controls<span class="elsevierStyleSup">2</span>. In our study, we did not determine any decrease in respiratory reserve despite decreased maximal minute ventilation. In addition, peak VO<span class="elsevierStyleInf">2</span> was significantly correlated with DLCO (r = 0.52, p < 0.01), while no correlation was found with breathing reserve (r = 0.28, p > 0.05). Considering all the patients, it was thought that ventilation limitation had little effect on exercise capacity.</p><p class="elsevierStylePara">In patients with severe parenchymal disease, impaired exercise capacity may reflect a limitation by ventilatory mechanics<span class="elsevierStyleSup">15,16</span>. Athos et al. have proven that chest radiograph is the best overall predictor of exercise performance and found evident ventilatory and gas exchange abnormalities in stage II and III patients<span class="elsevierStyleSup">16</span>. We found a significant decrease in FEV<span class="elsevierStyleInf">1</span> together with a decrease in maximal minute ventilation, in stage III patients. An insignificant decrease in TLC and VC was also demonstrated. These results made us think that ventilatory performance has a clear effect on exercise capacity, especially in advanced radiological stages of disease.</p><p class="elsevierStylePara">Pulmonary gas exchange impairment was postulated as another limiting factor that has an effect on exercise capacity<span class="elsevierStyleSup">4,14-17</span>. Abnormal gas exchange can be documented by demonstrating the decrease in PaO<span class="elsevierStyleInf">2</span> and rise in P(A-a)O<span class="elsevierStyleInf">2</span> at maximal exercise, in sarcoidosis. Medinger has claimed that the change in alveolar-arterial oxygen pressure gradient at rest and exercise is the most important physiological parameter, especially in early radiological stages of disease, and P(A-a)O<span class="elsevierStyleInf">2</span>/VO<span class="elsevierStyleInf">2</span> was emphasized to show disease severity and progression<span class="elsevierStyleSup">4</span>. Besides, Medinger also has shown that Vd/Vt and P(a-et)CO<span class="elsevierStyleInf">2</span> are correlated across all radiographic stages of sarcoidosis<span class="elsevierStyleSup">18</span>. Athos et al. have stated that changes in PaO<span class="elsevierStyleInf">2</span> and P(A-a)O<span class="elsevierStyleInf">2</span> are important factors in exercise limitation of advanced stages<span class="elsevierStyleSup">16</span>. In our study, stage III patients had lower PaO<span class="elsevierStyleInf">2</span> and higher P(A-a)O<span class="elsevierStyleInf">2</span> than earlier stages, at rest. There was no significant change in PaO<span class="elsevierStyleInf">2</span> and P(A-a)O<span class="elsevierStyleInf">2</span> and no significant correlation between peak VO<span class="elsevierStyleInf">2</span>% and arterial blood gas levels. Insignificant decrease in PaO<span class="elsevierStyleInf">2</span> and increase in P(A-a) O<span class="elsevierStyleInf">2</span> with exercise, together with the correlation between VO<span class="elsevierStyleInf">2</span> and Vd/Vt resulted in a limitation effect of gas exchange impairment on exercise capacity, especially in advanced radiological stages of disease.</p><p class="elsevierStylePara">Although clinical evidence of myocardial involvement is only present in about 5% of patients with sarcoidosis, unsuspected cardiac involvement may be found in as many as 10-15% of patients<span class="elsevierStyleSup">1,14,15</span>. Left heart failure may appear because of cardiac involvement; in addition, cor pulmonale may develop due to pulmonary vascular disease in sarcoidosis<span class="elsevierStyleSup">15</span>. Moreover, the impaired heart rate response to exercise in sarcoidosis could be related to sinus and/or atrio-ventricular conduction dysfunction secondary to myocardial conducting system infiltration with sarcoid granulomas<span class="elsevierStyleSup">2,19</span>. Ventricular dysfunction because of myocardial involvement and subclinical cardiac dysfunction due to granulomatous infiltration of sinus nodosum may also develop<span class="elsevierStyleSup">19</span>.</p><p class="elsevierStylePara">In the present study, patients could not reach the predicted maximum heart rate, in spite of reached maximal efforts shown by pH values and R values; and heart rate reserve was observed to increase (31.65 ± 11.72/min). No electrocardiographic change was seen. Decreased heart rate response to exercise in sarcoidosis may account at least in part for the observed maximal exercise limitation.</p><p class="elsevierStylePara">Exercise intolerance due to circulatory impairment was thought to develop in our cases, since we have observed a decrease in O<span class="elsevierStyleInf">2</span> pulse and oxygen uptake / work rate ratio. In addition, a significant correlation was found between peak VO<span class="elsevierStyleInf">2</span> and two parameters mentioned above (p < 0.01). None of the patients had pulmonary thromboembolism, coronary heart disease and/or cardiac failure. Complete blood count and serum chemistry was within normal limits.</p><p class="elsevierStylePara">Hansen and Wasserman<span class="elsevierStyleSup">17</span> have concluded that the pathophysiology of the pulmonary circulation is usually more important than ventilatory mechanics in limiting exercise in patients with interstitial pulmonary disease such as asbestosis, pulmonary alveolar proteinosis and sarcoidosis. Many investigators stressed on the importance of pulmonary vascular disease and pulmonary hypertension in interstitial pulmonary processes and emphasized their effects on morbidity .</p><p class="elsevierStylePara">Respiratory muscle strength and respiratory muscle endurance are reduced in sarcoidosis due to involvement of respiratory muscles. Systemic or metabolic factors and decreased lung volumes may also contribute to the decrease in respiratory muscle strength<span class="elsevierStyleSup">3,20</span>. Reduced respiratory muscle strength in the presence of sarcoidosis may aggravate the exercise intolerance independent of ventilatory function impairment<span class="elsevierStyleSup">20</span>. In patients with cardiopulmonary disorders, respiratory muscle strength is a significant contributor to work capacity in addition to any contribution from ventilatory, circulatory and gas exchange impairment<span class="elsevierStyleSup">21</span>. Decrease in respiratory muscle strength in our cases was not observed. This should be related with uninvolved respiratory muscles and normal lung volumes. Therefore respiratory muscle effect on exercise tolerance was not thought as one of the reasons of impairment.</p><p class="elsevierStylePara">In the present study, a correlation between radiological stages and physiological parameters (DLCO, DLCO/VA, PaO<span class="elsevierStyleInf">2</span>, P[A-a]O<span class="elsevierStyleInf">2</span> and exercise time) was revealed (p < 0.01). A negative correlation was found between radiological stage and peak VO<span class="elsevierStyleInf">2</span> (p < 0.05), suggesting that the radiographic stage is a good predictor of exercise performance as in the study of Athos<span class="elsevierStyleSup">16</span>.</p><p class="elsevierStylePara">Exercise capacity is impaired in early stages of sarcoidosis. Moreover, it was found to be the earliest impaired physiological parameter in patients with sarcoidosis. Exercise intolerance, having mutifactorial basis, is correlated with radiological stages. Circulatory impairment and impaired heart rate response to exercise have effects on decreased exercise capacity. Especially in advanced radiological stages of disease, ventilatory and gas exchange impairment also seems to be effective on limiting exercise capacity. Prospective clinical studies with larger series of all stages are needed to define mechanisms of exercise intolerance in sarcoidosis.</p>" "pdfFichero" => "2v124n18a13075090pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec223568" "palabras" => array:3 [ 0 => "Sarcoidosis" 1 => "Capacidad de ejercicio" 2 => "Pruebas de función respiratoria" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec223567" "palabras" => array:3 [ 0 => "Sarcoidosis" 1 => "Exercise capacity" 2 => "Pulmonary function tests" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "Background and objective: Sarcoidosis is a systemic granulomatous disease of unknown etiology. Aims of this prospective study are to evaluate degree of impairment in pulmonary function tests (PFT), arterial blood gas analysis (ABG), respiratory muscle strength, exercise capacity and correlation of these parameters with radiological stages; to further evaluate the use of cardiopulmonary exercise testing in assessment of extent of pulmonary disease; and to discuss the pathophysiologic mechanisms of limitation in exercise capacity in patients with sarcoidosis. Patients and method: 29 patients with sarcoidosis were grouped according to their radiological stages (stage I: group 1; stage II, group 2; stage III, group 3). Groups 1, 2 and 3 included 11, 13 and 5 patients, respectively. PFT, cardiopulmonary exercise testing and ABG were performed for each patient. Results: Evaluation of all patients showed a significant decrement in exercise capacity. Patients in stage III had decreased diffusing capacity and exercise capacity. There was limitation in exercise capacity in stage I patients who had completely normal spirometry and diffusing capacity. We also found a correlation between radiological stages of the disease and exercise capacity, diffusing capacity and ABG. Conclusions: Exercise capacity is impaired also in early stages of sarcoidosis and it was found to be the earliest impaired physiological parameter in sarcoid patients. Exercise intolerance, having mutifactorial basis, is correlated with radiological stages. Circulatory impairment and impaired heart rate response to exercise have effects on limitation in exercise capacity. Especially in advanced radiological stages of disease, ventilatory and gas exchange impairment also seems to be effective on limiting exercise in patients with sarcoidosis." ] "es" => array:1 [ "resumen" => "Fundamento y objetivo: La sarcoidosis es una enfermedad sistémica granulomatosa de etiología desconocida. Los objetivos de este estudio prospectivo fueron evaluar el grado de deterioro de las pruebas funcionales respiratorias, la gasometría arterial, la fuerza de la musculatura respiratoria y la capacidad de ejercicio, así como la correlación de estos parámetros con los estadios radiológicos. Además, se decidió evaluar la utilización de las pruebas de ejercicio cardiorrespiratorio en la valoración de la extensión de la enfermedad pulmonar y, por último, discutir los mecanismos fisiopatológicos de limitación de la capacidad de ejercicio en los pacientes con sarcoidosis. Pacientes y método: Se incluyó a 29 pacientes, que fueron agrupados según sus estadios radiológicos (estadio I, grupo 1; estadio II, grupo 2; estadio III, grupo 3). Los grupos 1, 2 y 3 incluyeron 11, 13 y 5 pacientes, respectivamente. En cada paciente se realizaron pruebas de funcionalismo respiratorio, pruebas de ejercicio cardiorrespiratorio y gasometría arterial. Resultados: Se observó una disminución significativa de la capacidad de ejercicio. Los pacientes del estadio III tenían una disminución de las capacidades de difusión y de ejercicio. Se observó una limitación de la capacidad de ejercicio en los pacientes del estadio I que, por otra parte, mostraron una capacidad de difusión y espirometría normales. También observamos una correlación entre los estadios radiológicos de la enfermedad y la capacidad de ejercicio, capacidad de difusión y gasometría arterial. Conclusiones: La capacidad de ejercicio está deteriorada en los estadios iniciales de la sarcoidosis y éste fue el parámetro fisiológico más precozmente deteriorado en estos pacientes. La intolerancia al ejercicio, con una base multifactorial, se correlaciona con los estadios radiológicos. La afección circulatoria y la respuesta alterada de la frecuencia cardíaca al ejercicio tienen efectos sobre la limitación de la capacidad de ejercicio. Especialmente en los estadios radiológicos avanzados de la enfermedad, el deterioro ventilatorio y del intercambio gaseoso parecen tener asimismo influencia sobre la limitación del ejercicio en pacientes con sarcoidosis." ] ] "multimedia" => array:8 [ 0 => array:6 [ "identificador" => "tbl1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "2v124n18-13075090tab01.gif" "imagenAlto" => 292 "imagenAncho" => 432 "imagenTamanyo" => 18757 ] ] ] ] ] ] 1 => array:6 [ "identificador" => "tbl2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "2v124n18-13075090tab02.gif" "imagenAlto" => 353 "imagenAncho" => 430 "imagenTamanyo" => 23653 ] ] ] ] ] ] 2 => array:6 [ "identificador" => "tbl3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "2v124n18-13075090tab03.gif" "imagenAlto" => 325 "imagenAncho" => 218 "imagenTamanyo" => 11492 ] ] ] ] ] ] 3 => array:6 [ "identificador" => "tbl4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "2v124n18-13075090tab04.gif" "imagenAlto" => 393 "imagenAncho" => 216 "imagenTamanyo" => 14505 ] ] ] ] ] ] 4 => array:5 [ "identificador" => "tbl5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 5 => array:5 [ "identificador" => "tbl6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 6 => array:5 [ "identificador" => "tbl7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 7 => array:5 [ "identificador" => "tbl8" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Statement on Sarcoidosis." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "American Thoracic Society Medical Section of the American Lung Association." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/ajrccm.160.2.ats4-99" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "1999" "volumen" => "160" "paginaInicial" => "736" "paginaFinal" => "55" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10430755" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Impaired exercise response in sarcoid patients with normal pulmonary function." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "Delobbe A" 1 => "Perrault H" 2 => "Maitre J" 3 => "Robin S" 4 => "Hossein-Foucher C Wallaert B" 5 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Sarcoidosis Vasc Diffuse Lung Dis" "fecha" => "2002" "volumen" => "19" "paginaInicial" => "148" "paginaFinal" => "53" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12102611" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Respiratory muscle strength, Lung function, and dyspnea in patients with sarcoidosis." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Baydur A" 1 => "Alsalek M" 2 => "Louire SG" 3 => "Sharma OP." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2001" "volumen" => "120" "paginaInicial" => "102" "paginaFinal" => "8" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11451823" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Sarcoidosis. The value of exercise testing." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Medinger AE" 1 => "Khouri S" 2 => "Rohatgi PK." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2001" "volumen" => "120" "paginaInicial" => "93" "paginaFinal" => "101" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11451822" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Pulmonary function tests in interstitial lung disease." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Alhamad EH" 1 => "Lynch JP" 2 => "Martínez FJ." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "What role do they have? Clin Chest Med" "fecha" => "2001" "volumen" => "22" "paginaInicial" => "715" "paginaFinal" => "50" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Exercise and resting pulmonary function in sarcoidosis." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Karetzky M" 1 => "McDonough M." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Sarcoidosis Vasc Diffuse Lung Dis" "fecha" => "1996" "volumen" => "13" "paginaInicial" => "43" "paginaFinal" => "9" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8865409" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Cardiorespiratory responses to incremental exercise in sarcoidosis patients with normal spirometry." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Miller A" 1 => "Brown LK" 2 => "Sloane MF" 3 => "Bhuptani A" 4 => "Teirstein AS." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "1995" "volumen" => "107" "paginaInicial" => "323" "paginaFinal" => "9" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7842755" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Top ten list in sarcoidosis." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Agostini C." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2001" "volumen" => "119" "paginaInicial" => "1930" "paginaFinal" => "2" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11399725" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Standardization of spirometry (1994 Update)." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "American Thoracic Society." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/ajrccm.152.3.7663792" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "1995" "volumen" => "152" "paginaInicial" => "1107" "paginaFinal" => "36" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7663792" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "referenciaCompleta" => "Standardised lung function testing; lung volumes and forced ventilatory flows. Report Working Party Standardization of Lung Function Tests, European Community for Steel and Coal. Official Statement of the European Respiratory Society. Eur Respir J. 1993;6 Suppl 16:5-40." "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Standardised lung function testing; lung volumes and forced ventilatory flows. Report Working Party Standardization of Lung Function Tests, European Community for Steel and Coal. Official Statement of the European Respiratory Society. Eur Respir J. 1993;6 Suppl 16:5-40." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "Quanjer P" 1 => "Tammeling FJ" 2 => "Cotes JE" 3 => "Pedersen OF" 4 => "Peslin R" 5 => "Yernault JC." ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Maximal respiratory pressures: normal values and relationship to age and sex." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Black LF" 1 => "Hyatt RE." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/arrd.1969.99.5.696" "Revista" => array:6 [ "tituloSerie" => "Am Rev Respir Dis" "fecha" => "1969" "volumen" => "99" "paginaInicial" => "696" "paginaFinal" => "702" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/5772056" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "ATS/ACCP Statement on cardiopulmonary exercise testing." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "American Thoracic Society/American College of Chest Physicians." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.167.2.211" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2003" "volumen" => "167" "paginaInicial" => "211" "paginaFinal" => "77" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12524257" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Normal standards for an incremental progressive cycle ergometer test." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Jones NL" 1 => "Makrides L" 2 => "Hitchcock C" 3 => "Chypchar T" 4 => "McCartney N." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/arrd.1985.131.5.700" "Revista" => array:6 [ "tituloSerie" => "Am Rev Respir Dis" "fecha" => "1985" "volumen" => "131" "paginaInicial" => "700" "paginaFinal" => "8" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3923878" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Exercise testing in pulmonary sarcoidosis." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Matthews JI" 1 => "Hooper RG." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "1983" "volumen" => "83" "paginaInicial" => "75" "paginaFinal" => "81" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6848336" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib15" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Abnormal oxygen uptake responses to exercise in patients with mild pulmonary sarcoidosis." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Sietsema KE" 1 => "Kraft M" 2 => "Ginzton L" 3 => "Sharma OP." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "1992" "volumen" => "102" "paginaInicial" => "838" "paginaFinal" => "45" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1516412" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib16" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Exercise testing in the physiologic assessment of sarcoidosis." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Athos L" 1 => "Mohler JG" 2 => "Sharma OP." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann NY Acad Sci" "fecha" => "1989" "volumen" => "465" "paginaInicial" => "491" "paginaFinal" => "501" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3460390" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib17" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Pathophisiology of activity limitation in patients with interstitial lung disease." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Hansen JE" 1 => "Wasserman K." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "1996" "volumen" => "109" "paginaInicial" => "1566" "paginaFinal" => "76" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8769513" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib18" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Sarcoidosis and gas exchange measures [to the Editor]." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Hansen JE." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2002" "volumen" => "121" "paginaInicial" => "1004" "paginaFinal" => "5" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11888995" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib19" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Myocardial sarcoidosis." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Sharma OP" 1 => "Maheshwari A" 2 => "Thaker K." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "1993" "volumen" => "103" "paginaInicial" => "253" "paginaFinal" => "8" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8417889" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib20" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Relationship between respiratory muscle function and quality of life in sarcoidosis." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Wirnsberger RM" 1 => "Drent M" 2 => "Hekelaar N" 3 => "Breteler MH.M" 4 => "Drent S" 5 => "Wouters EF.M" 6 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "1997" "volumen" => "10" "paginaInicial" => "1450" "paginaFinal" => "5" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9230229" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib21" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Muscle strength, symptom intensity and exercise capacity in patients with cardiorespiratory disorders." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Hamilton AL" 1 => "Killian KJ" 2 => "Summer E" 3 => "Jones NL." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "1995" "volumen" => "152" "paginaInicial" => "2028" "paginaFinal" => "31" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00257753/0000012400000018/v0_201307291959/13075090/v0_201307292000/en/main.assets" "Apartado" => array:4 [ "identificador" => "24087" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Original breve" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00257753/0000012400000018/v0_201307291959/13075090/v0_201307292000/en/2v124n18a13075090pdf001.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13075090?idApp=UINPBA00004N" ]
Consulte los artículos y contenidos publicados en este medio, además de los e-sumarios de las revistas científicas en el mismo momento de publicación
Esté informado en todo momento gracias a las alertas y novedades
Acceda a promociones exclusivas en suscripciones, lanzamientos y cursos acreditados
Medicina Clínica, fundada en 1943, es la única publicación semanal de contenido clínico que se edita en España y constituye el máximo exponente de la calidad y pujanza de la medicina española. Son características fundamentales de esta publicación el rigor científico y metodológico de sus artículos, la actualidad de los temas y, sobre todo, su sentido práctico, buscando siempre que la información sea de la mayor utilidad en la práctica clínica. Los contenidos de Medicina Clínica abarcan dos frentes: trabajos de investigación original rigurosamente seleccionados atendiendo a su calidad, originalidad e interés, y trabajos orientados a la formación continuada, encomendados por la revista a autores relevantes (Editoriales, Revisiones, Conferencias clínicas y clínico-patológicas, Diagnóstico y Tratamiento). En estos artículos se ponen al día aspectos de destacado interés clínico o conceptual en la medicina actual. Medicina Clínica es un vehículo de información científica de reconocida calidad, como demuestra su inclusión en los más prestigiosos y selectivos índices bibliográficos del mundo.
Current Contents/Clinical Medicine, Journal Citation Reports, SCI-Expanded, Index Medicus/Medline, Excerpta Medica/EMBASE, IBECS, IME, MEDES, PASCAL, SCOPUS, ScienceDirect
Ver másEl factor de impacto mide la media del número de citaciones recibidas en un año por trabajos publicados en la publicación durante los dos años anteriores.
© Clarivate Analytics, Journal Citation Reports 2022
SJR es una prestigiosa métrica basada en la idea de que todas las citaciones no son iguales. SJR usa un algoritmo similar al page rank de Google; es una medida cuantitativa y cualitativa al impacto de una publicación.
Ver másSNIP permite comparar el impacto de revistas de diferentes campos temáticos, corrigiendo las diferencias en la probabilidad de ser citado que existe entre revistas de distintas materias.
Ver másMedicina Clínica sigue las recomendaciones para la preparación, presentación y publicación de trabajos académicos en revistas biomédicas
¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?
Are you a health professional able to prescribe or dispense drugs?
Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos