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Lara de Souza Dias,1 Anna Carolina Galvão Ferreira,1 José Laerte Rodrigues da Silva Junior,2 Marcus Barreto Conte,3 Marcelo Fouad Rabahi1 1Faculdade de Medicina, Universidade Federal de Goiás, Goiânia, Goiás, Brasil; 2Faculdade de Medicina, Universidade de Rio Verde, Aparecida de Goiânia, Goiás, Brasil; 3Faculdade de Medicina, Faculdade Arthur Sá Earp Neto, Petrópolis, Rio de Janeiro, BrasilCorrespondence: Lara de Souza Dias Viela Gabriela Augusta Nascimento Qd.B Lt.7H Centro, CEP:75640-000, Piracanjuba, Goiás, BrasilEmail laradias_1@hotmail.comRationale: Frailty in chronic obstructive pulmonary disease (COPD) patients has been associated with a higher rate of incidents, longer duration of hospitalization, poorer quality of life, and higher mortality.Objective: To measure the prevalence of frailty among COPD patients and to evaluate associated variables.Methods: A cross-sectional study. Subjects who visited a State Center for High-Cost Medicines to obtain free monthly COPD medicines were considered eligible. Individuals ≥ 40 years old who had a FEV1/FVC ratio of < 0.7 post-bronchodilation were enrolled. The Fatigue, Resistance, Ambulation, Illnesses, and Loss of weight (FRAIL) scale, Medical Research Council dyspnea scale (MRC), COPD Assessment Test (CAT), a combination of CAT/MRC [(CAT/8)+MRC], and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) severity scale were used to evaluate the enrolled subjects. Variables associated with frailty were analyzed using an ordered logistic regression and a multivariate logistic regression.Results: The prevalence of frailty and pre-frailty among the 153 COPD subjects enrolled was 50.3% (77/153) and 35.3% (54/153), respectively. Frailty scores were correlated with CAT (correlation coefficient [cc]: 0.52, p < 0.001) and MRC (cc: 0.48, p < 0.001). Ordinal regression models showed that MRC and CAT were associated with fragility (p < 0.0001 for both models). Higher odds of frailty were observed in GOLD groups B (p = 0.04) and D (p = 0.02). Multiple logistic regression revealed that the combination CAT/MRC≥ 5.5 was associated with frailty (OR 6.73; p < 0.0001) and had a specificity of 80.3%, sensitivity of 62.3%, and positive and negative predictive values of 76.2% and67.8%, respectively.Conclusion: Frailty prevalence was high and was correlated with higher MRC and CAT scores. The CAT/MRC combination [(CAT/8)+MRC] ≥ 5.5 was highly associated with frailty, suggesting that an additional specific evaluation for the presence of frailty is indicated.Keywords: frailty, pulmonary disease, chronic obstructive more...

Daniela Graner Schuwartz Tannus-Silva,1 João Batista Masson-Silva,1 Lays Silva Ribeiro,1 Marcus Barreto Conde,2,3 Marcelo Fouad Rabahi1 1Faculty of Medicine, Federal University of Goias, Goiânia, Goiás, 2Instituto de Doenças do Tórax da Universidade Federal do Rio de Janeiro, Rio de Janeiro, 3Faculdade de Medicina de Petrópolis, Petrópolis, Rio de Janeiro, Brazil Background and objective: COPD, a systemic illness associated with the impairment of different organs, affects patient prognosis and quality of life. The aim of this study was to evaluate the association between right ventricle (RV) function, the BODE (body mass index, airflow obstruction, dyspnea, and exercise capacity) index (a multifunctional scale for the assessment of mortality risk), and quality of life in patients with COPD. Methods: A cross-sectional study was carried out in 107 outpatients presenting with stable COPD who underwent clinical assessment, spirometry, arterial blood gas analyses, a 6-minute walk test, electrocardiography, and echocardiogram and who responded to the Saint George’s Respiratory Questionnaire (SGRQ). Results: Among the study subjects, 53% (57/107) were males, and the mean age was 65.26±8.81 years. A positive correlation was observed between RV dysfunction measured by the myocardial performance index using tissue Doppler (MPIt) and the BODE index, even after adjustment for age and partial pressure of oxygen (r2=0.47; P more...

Marcelo Fouad Rabahi,1,2 Sheila Alves Pereira,1 José Laerte Rodrigues Silva Júnior,1,2 Aline Pacheco de Rezende,1 Adeliane Castro da Costa,2 Krislainy de Sousa Corrêa,2,3 Marcus Barreto Conde4,5 1School of Medicine, Federal University of Goiás, Goiania, Brazil; 2Clínica do Aparelho Respiratório (CLARE), Goiania, Brazil; 3Pontifical Catholic University of Goiás, Goiania, Brazil; 4Faculdade de Medicina de Petrópolis/FASE, Petrópolis, Brazil; 5Instituto de Doenças do Tórax da Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil Background: The diagnosis of chronic obstructive pulmonary disease (COPD) is often delayed until later stages of the disease. The purpose of the present study was to determine the prevalence of COPD among adults on treatment for systemic arterial hypertension independently of the presence of respiratory symptoms. Methods: This cross-sectional study included adults aged ≥40 years with tobacco/occupational exposure and systemic arterial hypertension diagnosed at three Primary Health Care facilities in Goiania, Brazil. Patients were evaluated using a standardized respiratory questionnaire and spirometry. COPD prevalence was measured considering the value of forced vital capacity and/or forced expiratory volume in 1 second more...

Maria Rosedália de Moraes,1 Adeliane Castro da Costa,2 Krislainy de Sousa Corrêa,2 Ana Paula Junqueira-Kipnis,2 Marcelo Fouad Rabahi3 1Health Sciences of Federal University of Goiás, 2Institute of Tropical Pathology and Public Health, Federal University of Goiás, Goiânia, Goiás, Brazil; 3Faculty of Medicine, Federal University of Goiás, Goiânia, Goiás, Brazil Background: The role of interleukins in the severity and clinical profile of chronic obstructive pulmonary disease (COPD) is not known, but evidence supports the contribution of systemic inflammation to disease pathophysiology. This study evaluated the relationship of serum biomarkers to the severity and clinical parameters of COPD. Methods and findings: Serum levels of high-sensitivity C-reactive protein, interleukin-6 (IL-6), and interleukin-8 (IL-8) were measured in 50 patients with stable COPD and in 16 controls. The levels of these biomarkers were compared with parameters of severity, such as the grading of flow obstruction using the recommendations of the Global initiative for chronic Obstructive Lung Disease, the BMI (body mass index), obstruction, dyspnea, exercise capacity (health index) index, the number of exacerbations within the last year, and peripheral oxygen saturation after the six-minute walk test, and with clinical parameters, such as bronchitis and non-bronchitis phenotypes, the number of associated comorbidities, and the smoking burden. COPD patients exhibited higher levels of IL-6 and IL-8 compared to the control group. Higher levels of IL-6 occurred in COPD groups with body mass index more...

Introduction: The humanization of care can be defined, in a generic way, as the act of making an empathetic and respectful approach to patients. This study proposed to evaluate the perception of attitudes of medical students regarding the doctor-patient relationship, after implementation of teaching a humanized and structured care method., Materials and Methods: Single-blind, randomized controlled experimental study that evaluated medical students in relation to patient care, based on a pre-post design, using the Patient-Practitioner Orientation Scale (PPOS). This scale has been validated to assess patient-centered attitudes, as the prime outcome measure. The intervention, with a group of randomized students, included teaching the structured and humanized method of patient care, denominated the SEAGULL (Subjective, Exams, Analysis, Goal, Ultimate Action), and was carried out at the university outpatient clinic., Results: Fifty-nine medical students participated in the study, with a mean age of 21.3 years (SD = 2.8) and a higher prevalence of female students (71.2%). The increase in the final scores was greater in the intervention group (p = 0.025) when comparing means of the total PPOS scores. The intervention group presented a larger effect size and higher mean scores (d = 0.49, Δ = +0.38, p<0.001) than the control group (d = 0.21, Δ = + 0.10, p = 0.004). It is noteworthy that the analysis of the initial and final means of the PPOS scores of the sharing domain revealed larger effect sizes in the intervention group compared to the control group (Δ = +0.42, d = 0.63; p<0.001)., Discussion and Conclusion: The findings showed that training in the use of the SEAGULL structured method led to a significant increase in PPOS scores related to the humanization of care by these students, with emphasis on the domain of sharing information, power, and responsibility with patients., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2025 Chagas Cardoso et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.) more...

Objective: The aim of this study was to present epidemiological data on hospitalizations and deaths related to asthma in Brazil over the past 11 years., Methods: An ecological study was conducted on asthma-related hospitalizations and mortality in Brazil from 2013 to 2023, using data extracted from the Department of Informatics of the Brazilian Unified Health System and the Mortality Information System., Results: Asthma-related deaths showed an increasing trend during the analyzed period. A surge in deaths was observed in 2022 compared to 2014 (difference between means = 56.08 ± 19.7; 95% CI = 15.2-96.9). The mean number of deaths was higher among females, with their rate remaining stable, while the rate for males increased. Individuals aged >60 years accounted for approximately 65% of all asthma-related deaths from 2013 to 2023, with a strong direct correlation observed between age and the number of deaths, regardless of sex. During the same period, the total number of asthma-related hospitalizations in Brazil showed a declining trend, decreasing from 134,322 in 2013 to 87,707 in 2023., Conclusion: Over the past 11 years, asthma-related deaths have increased in Brazil, with the majority occurring among females. Older individuals accounted for most asthma-related deaths, and a positive correlation was observed between age and the number of deaths. more...

Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with loss of lung function, poor quality of life, loss of exercise capacity, risk of serious cardiovascular events, hospitalization, and death. However, patients underreport exacerbations, and evidence suggests that unreported exacerbations have similar negative health implications for patients as those that are reported. Whilst there is guidance for physicians to identify patients who are at risk of exacerbations, they do not help patients recognise and report them. Newly developed tools, such as the COPD Exacerbation Recognition Tool (CERT) have been designed to achieve this objective. This review focuses on the underreporting of COPD exacerbations by patients, the factors associated with this, the consequences of underreporting, and potential solutions. more...

Objective: To assess prescription patterns for short-acting b2 agonists (SABAs) and other asthma medications in asthma patients treated by specialists and participating in the SABA use IN Asthma (SABINA) study in Brazil., Methods: This was an observational, cross-sectional study conducted at five sites in different regions of Brazil. The primary endpoints were to record SABA prescriptions and obtain data on over-the-counter (OTC) SABA purchases at the pharmacy., Results: Data on 218 asthma patients were analyzed. Of those 218 patients, 80.3% were prescribed SABAs in addition to their maintenance therapy, with a mean of 11.2 SABA canisters in the previous 12 months. Of those patients, 71.4% were prescribed ≥ 3 canisters and 42.2% were prescribed ≥ 10 canisters. None of the patients were prescribed SABA monotherapy. A total of 14.2% of the patients reported purchasing SABAs OTC at a pharmacy without a prescription. Of those, 48.4% purchased ≥ 3 SABA canisters. A fixed-dose combination of an inhaled corticosteroid and a long-acting b2 agonist was prescribed to 95.0% of the patients. In the year before the study visit, 45.0% of the patients received at least one course of oral corticosteroid burst treatment. Asthma was well controlled in 43.1% of the patients, partly controlled in 34.9%, and uncontrolled in 22.0%. Patients reported a mean of 1.1 severe asthma exacerbations, with 49.1% experiencing 1 or more severe exacerbations., Conclusions: Overprescription and OTC purchases of SABAs are common in Brazil, possibly leading to the need for courses of oral corticosteroids. The health care community should collaborate to implement evidence-based recommendations and promote health education to improve asthma management in Brazil. more...

Historically, all efforts against tuberculosis were focused on rapid diagnosis and effective treatment to break the chain of transmission of Mycobacterium tuberculosis. However, in the last few years, more and more evidence has been found on the dramatic consequences of the condition defined as post-tuberculosis lung disease (PTLD). Approximately one third of patients surviving pulmonary tuberculosis face considerable ongoing morbidities, including respiratory impairment, psychosocial challenges, and reduced health-related quality of life after treatment completion. Given the important global and local burden of tuberculosis, as well as the estimated burden of PTLD, the development of a consensus document by a Brazilian scientific society-Sociedade Brasileira de Pneumologia e Tisiologia (SBPT)-was considered urgent for the prevention and management of this condition in order to allocate resources to and within tuberculosis services appropriately and serve as a guide for health care professionals. A team of eleven pulmonologists and one methodologist was created by the SBPT to review the current evidence on PTLD and develop recommendations adapted to the Brazilian context. The expert panel selected the topics on the basis of current evidence and international guidelines. During the first phase, three panel members drafted the recommendations, which were divided into three sections: definition and prevalence of PTLD, assessment of PTLD, and management of PTLD. In the second phase, all panel members reviewed, discussed, and revised the recommendations until a consensus was reached. The document was formally approved by the SBPT in a special session organized during the 2023 SBPT Annual Conference. more...

Introduction: Several polymorphisms altering the NAT2 activity have already been identified. The geographical distribution of NAT2 variants has been extensively studied and has been demonstrated to vary significantly among different ethnic population. Here, we describe the genetic variability of human N-acetyltransferase 2 ( NAT2 ) gene and the predominant genotype-deduced acetylation profiles of Brazilians. Methods: A total of 964 individuals, from five geographical different regions, were genotyped for NAT2 by sequencing the entire coding exon. Results: Twenty-three previously described NAT2 single nucleotide polymorphisms (SNPs) were identified, including the seven most common ones globally (c.191G>A, c.282C>T, c.341T>C, c.481C>T, c.590G>A, c.803A>G and c.857G>A). The main allelic groups were NAT2*5 (36%) and NAT2*6 (18.2%), followed to the reference allele NAT2*4 (20.4%). Combined into genotypes, the most prevalent allelic groups were NAT2*5/*5 (14.6%), NAT2*5/*6 (11.9%) and NAT2*6/*6 (6.2%). The genotype deduced NAT2 slow acetylation phenotype was predominant but showed significant variability between geographical regions. The prevalence of slow acetylation phenotype was higher in the Northeast, North and Midwest (51.3%, 45.5% and 41.5%, respectively) of the country. In the Southeast, the intermediate acetylation phenotype was the most prevalent (40.3%) and, in the South, the prevalence of rapid acetylation phenotype was significantly higher (36.7%), when compared to other Brazilian states ( p < 0.0001). Comparison of the predicted acetylation profile among regions showed homogeneity among the North and Northeast but was significantly different when compared to the Southeast ( p = 0.0396). The Southern region was significantly different from all other regions ( p < 0.0001). Discussion: This study contributes not only to current knowledge of the NAT2 population genetic diversity in different geographical regions of Brazil, but also to the reconstruction of a more accurate phenotypic picture of NAT2 acetylator profiles in those regions., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Lopes, Teixeira, Cabello, Nery, Sales, Nahn J. R., Moreira, Stahlke, Possuelo, Rossetti, Rabahi, Silva, Leme, Woods, Nobre, Oliveira, Narahashi, Cavalcanti, Suffys, Boukouvala, Gallo and Santos.) more...

Sleep is essential for the proper functioning of all individuals. Sleep-disordered breathing can occur at any age and is a common reason for medical visits. The objective of this consensus is to update knowledge about the main causes of sleep-disordered breathing in adult and pediatric populations, with an emphasis on obstructive sleep apnea. Obstructive sleep apnea is an extremely prevalent but often underdiagnosed disease. It is often accompanied by comorbidities, notably cardiovascular, metabolic, and neurocognitive disorders, which have a significant impact on quality of life and mortality rates. Therefore, to create this consensus, the Sleep-Disordered Breathing Department of the Brazilian Thoracic Association brought together 14 experts with recognized, proven experience in sleep-disordered breathing. more...

Objective: To assess the prevalence of the eosinophilic and allergic phenotypes of severe asthma in Brazil, as well as to investigate the clinical characteristics of severe asthma patients in the country., Methods: This was a cross-sectional study of adult patients diagnosed with severe asthma and managed at specialized centers in Brazil. The study was conducted in 2019., Results: A total of 385 patients were included in the study. Of those, 154 had a blood eosinophil count > 300 cells/mm3 and 231 had a blood eosinophil count of ≤ 300 cells/mm3. The median age was 54.0 years, and most of the patients were female, with a BMI of 29.0 kg/m2 and a history of allergy (81.6%). The prevalence of patients with a blood eosinophil count > 300 cells/mm3 was 40.0% (95% CI: 35.1-44.9), and that of those with a blood eosinophil count > 300 cells/mm3 and a history of allergy was 31.9% (95% CI: 27.3-36.6). Age and BMI showed positive associations with a blood eosinophil count > 300 cells/mm3 (OR = 0.97, p < 0.0001; and OR = 0.96, p = 0.0233, respectively), whereas the time elapsed since the onset of asthma symptoms showed an increased association with a blood eosinophil count > 300 cells/mm3 (OR = 1.02, p = 0.0011)., Conclusions: This study allowed us to characterize the population of severe asthma patients in Brazil, showing the prevalence of the eosinophilic phenotype (in 40% of the sample). Our results reveal the relevance of the eosinophilic phenotype of severe asthma at a national level, contributing to increased effectiveness in managing the disease and implementing public health strategies. more...

The Bacillus Calmette-Guérin (BCG) vaccine, which is widely used to protect children against tuberculosis, can also improve immune response against viral infections. This unicentric, randomized-controlled clinical trial assessed the efficacy and safety of revaccination with BCG Moscow in reducing the positivity and symptoms of COVID-19 in health care workers (HCWs) during the COVID-19 pandemic. HCWs who had negative COVID-19 IgM and IgG and who dedicated at least eight hours per week in facilities that attended to individuals suspected of having COVID-19 were included in the study and were followed for 7, 15, 30, 60, and 180 days by telemedicine. The HCWs were randomly allocated to a revaccinated with BCG group, which received the BCG vaccine, or an unvaccinated group. Revaccination with BCG Moscow was found to be safe, and its efficacy ranged from 30.0% (95.0%CI -78.0 to 72.0%) to 31.0% (95.0%CI -74.0 to 74.0%). Mycobacterium bovis BCG Moscow did not induce NK cell activation at 15-20 days post-revaccination. As hypothesized, revaccination with BCG Moscow was associated with a lower incidence of COVID-19 positivity, though the results did not reach statistical significance. Further studies should be carried out to assess whether revaccination with BCG is able to protect HCWs against COVID-19. The protocol of this clinical trial was registered on August 5th, 2020, at REBEC (Registro Brasileiro de Ensaios Clínicos, RBR-4kjqtg - ensaiosclinicos.gov.br/rg/RBR-4kjqtg/1) and the WHO (# U1111-1256-3892). The clinical trial protocol was approved by the Comissão Nacional de ética de pesquisa- CONEP (CAAE 31783720.0.0000.5078)., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 dos Anjos, da Costa, Cardoso, Guimarães, Rodrigues, Ribeiro, Borges, Carvalho, Dias, Rezende, Souza, Ferreira, Saraiva, Barbosa, Vieira, Conte, Rabahi, Kipnis and Junqueira-Kipnis.) more...

Advances in the understanding that severe asthma is a complex and heterogeneous disease and in the knowledge of the pathophysiology of asthma, with the identification of different phenotypes and endotypes, have allowed new approaches for the diagnosis and characterization of the disease and have resulted in relevant changes in pharmacological management. In this context, the definition of severe asthma has been established, being differentiated from difficult-to-control asthma. These recommendations address this topic and review advances in phenotyping, use of biomarkers, and new treatments for severe asthma. Emphasis is given to topics regarding personalized management of the patient and selection of biologicals, as well as the importance of evaluating the response to treatment. These recommendations apply to adults and children with severe asthma and are targeted at physicians involved in asthma treatment. A panel of 17 Brazilian pulmonologists was invited to review recent evidence on the diagnosis and management of severe asthma, adapting it to the Brazilian reality. Each of the experts was responsible for reviewing a topic or question relevant to the topic. In a second phase, four experts discussed and structured the texts produced, and, in the last phase, all experts reviewed and approved the present manuscript and its recommendations. more...

Purpose: This study aims to define which of the right ventricular myocardial deformation indices best correlates with the classic echocardiographic measurements and indices of right ventricular (RV) dysfunction in patients with stable chronic obstructive pulmonary disease (COPD)., Patients and Methods: Ninety-one patients with stable COPD underwent clinical evaluation, spirometry, a 6-minute walk test, and echocardiographic examination. Patients were divided into two groups: "with RV dysfunction" (≥1 classic parameter) and "without RV dysfunction". We used speckle tracking to estimate myocardial deformation. For all analyses, results were considered significant if p < 0.05., Results: The mean age across all participants was 65 ± 9 years, with 53% (48/91) being male. Patients in the group with RV dysfunction were able to walk shorter distances and had higher estimated right ventricular systolic pressure (RVSP) and mean pulmonary arterial pressure (mPAP). The RV free wall longitudinal strain (RVFWLS) was the only deformation indices that showed a significant correlation with all classic measurements and indices in the diagnosis of RV dysfunction (Wald test, 10.24; p < 0.01; odds ratio, 1.61). In the ROC curve analysis, the absolute value <20% was the lowest cut-off point of this index for detection of RV dysfunction (AUC = 0.93, S: 95.8%, and E: 88%)., Conclusion: In COPD patients, RVFWLS is the myocardial deformation index that best correlates with classic echocardiographic parameters for the diagnosis of RV dysfunction using <20% as a cut-off point., Competing Interests: All authors declare no competing financial interests and report no conflicts of interest for this work., (© 2021 Masson Silva et al.) more...

Many conditions result in chronic interstitial lung disease (ILD), being classified as fibrosing ILDs, including idiopathic pulmonary fibrosis, connective tissue diseases, sarcoidosis, and fibrotic hypersensitivity pneumonitis. HRCT plays an important role in the clinical evaluation of fibrosing ILDs. Current treatment perspectives are encouraging and reinforce the need for HRCT scans of adequate technical quality for early detection of fibrosing ILD. Despite efforts in this regard, the significance and management of imaging findings of early interstitial lung abnormalities have yet to be clarified. After identification of CT findings consistent with fibrosing ILD, radiologists must be able to identify characteristic morphological patterns and, in some cases, features of specific clinical entities. In cases in which HRCT features are not sufficiently specific for a definitive diagnosis, HRCT can aid in selecting the best site for surgical lung biopsy. CT follow-up is useful for identifying progressive fibrosing ILDs and detecting complications unrelated to the underlying disease, including infections, acute exacerbations, and neoplasms. Automated quantification tools have clinical applicability and are likely to be available for use in imaging analysis in the near future. In addition, incorporation of CT evaluation into scoring systems based on clinical and functional parameters for staging fibrosing disease is likely to become valuable in determining prognosis. Knowledge of the clinical applications of CT evaluation is essential for specialists managing patients with fibrosing ILD and can have a positive impact on the clinical course of the disease. more...

Early, accurate diagnosis of tuberculosis is one of the major pillars of the control of the disease. The purpose of this consensus statement is to provide health professionals with the most current, useful evidence for the diagnosis of tuberculosis in Brazil. To that end, the Tuberculosis Committee of the Brazilian Thoracic Association brought together 14 members of the Association with recognized expertise in tuberculosis in Brazil to compose the statement. A nonsystematic review of the following topics was carried out: clinical diagnosis, bacteriological diagnosis, radiological diagnosis, histopathological diagnosis, diagnosis of tuberculosis in children, and diagnosis of latent tuberculosis infection. more...

Objective: To evaluate the performance of the No-Apnea score, a simplified screening instrument for obstructive sleep apnea (OSA), by gender., Methods: This was a cross-sectional study including adults undergoing full polysomnography. The No-Apnea model comprises two items (neck circumference and age) with a total score of 0 to 9. The severity of OSA was categorized, on the basis of the apnea-hypopnea index, as any (≥ 5 events/h), moderate-to-severe (≥ 15 events/h), or severe (≥ 30 events/h). The performance of the No-Apnea instrument was assessed by determining the area under the (ROC) curve (AUC) and by constructing contingency tables., Results: We evaluated a total of 6,606 adults (53.8% men). For categorizing the level of OSA severity, the No-Apnea score had a sensitivity of 83.9-93.0% and a specificity of 57.3-35.2%. At all OSA severity levels, the No-Apnea score exhibited higher sensitivity and lower specificity in men than in women. The No-Apnea score proved to be an appropriate screening model for patients in general or when separated by gender or severity of OSA (AUC > 0.7 for all). The discriminatory power of the No-Apnea score to predict any, moderate-to-severe, and severe OSA was similar between genders (p = 0.109, p = 0.698, and p = 0.094, respectively)., Conclusions: In a sample of adults referred to the sleep laboratory, there was no significant difference between men and women in terms of the discriminatory power of the No-Apnea instrument in for screening for OSA severity. more...

The incidence and prevalence of lung disease caused by non-tuberculous mycobacteria (NTM-LD) has increased worldwide and its diagnosis represents a complex challenge. This article aims to review the tomographic findings of NTM-LD in order to facilitate their definitive diagnosis. The search for publications on the subject was performed in PMC and Scielo using the keywords 'non-tuberculous mycobacteria', 'lung disease and computed tomography (CT)' and 'radiological findings'. The radiological findings described by 18 articles on mycobacteriosis were reviewed. In addition, CT images of patients diagnosed with NTM-LD were considered to represent radiological findings. Eighteen publications were used whose main findings were pulmonary cavitation (88.9%), bronchiectasis (77.8%), and pulmonary nodules (55.6%). Despite the overlaps in imaging-related analysis of myocobacterioses with other pulmonary infections, such as tuberculosis, the predominant involvement of the middle lobe and lingula should raise suspicion for NTM-LD. more...

Objective: To determine the prevalence of incidental findings on magnetic resonance imaging (MRI) scans of the cervical, thoracic and lumbar spine in a paediatric population., Materials and Methods: We evaluated 190 spinal MRI examinations of patients aged ≤ 18 years of age. The study included only patients for whom complete medical records were available and who underwent complete MRI examination of the cervical, thoracic or lumbar spine, including whole-spine sagittal T2-weighted sequences. Imaging findings not related to the symptom or indication for MRI were considered incidental findings., Results: Of the 190 MRI examinations evaluated, 110 were in women and 80 were in men. The mean age of the study population was 12.46 ± 3.68 years. The main clinical indications for MRI in the sample were lumbago, scoliosis, dorsalgia and cervicalgia. Incidental findings were detected in the cervical, thoracic and lumbar spine in 40 (21.05%), 26 (13.83%) and 43 (22.63%) of the patients, respectively. The most common were (in the cervical spine) reversal/correction of the normal curvature; (in the thoracic spine) intravertebral disc herniation (Schmorl's node) and disc dehydration; and (in the lumbar spine) disc protrusion (12 cases), Schmorl's node (5 cases) and spondylolysis (4 cases)., Conclusion: Incidental findings on MRI of the spine are less common in the paediatric population than in the adult population. Nevertheless, careful clinical evaluation of paediatric patients with complaints of axial and radiating pain is necessary in order to determine the correlation between symptoms and imaging findings. more...

The pharmacological management of asthma has changed considerably in recent decades, as it has come to be understood that it is a complex, heterogeneous disease with different phenotypes and endotypes. It is now clear that the goal of asthma treatment should be to achieve and maintain control of the disease, as well as to minimize the risks (of exacerbations, disease instability, accelerated loss of lung function, and adverse treatment effects). That requires an approach that is personalized in terms of the pharmacological treatment, patient education, written action plan, training in correct inhaler use, and review of the inhaler technique at each office visit. A panel of 22 pulmonologists was invited to perform a critical review of recent evidence of pharmacological treatment of asthma and to prepare this set of recommendations, a treatment guide tailored to use in Brazil. The topics or questions related to the most significant changes in concepts, and consequently in the management of asthma in clinical practice, were chosen by a panel of experts. To formulate these recommendations, we asked each expert to perform a critical review of a topic or to respond to a question, on the basis of evidence in the literature. In a second phase, three experts discussed and structured all texts submitted by the others. That was followed by a third phase, in which all of the experts reviewed and discussed each recommendation. These recommendations, which are intended for physicians involved in the treatment of asthma, apply to asthma patients of all ages. more...

Objective To verify association between left ventricular (LV) mass and thickness and the presence of significant nocturnal hypoxemia in patients with COPD with mild diurnal hypoxemia. Methods A cross-sectional study carried out in clinically stable outpatients with COPD and mild hypoxemia (oxygen saturation ≥90 to ≤94%, identified by noninvasive oximetry) in a clinic specialized in the treatment of respiratory diseases in Goiânia-GO. All patients were submitted to clinical evaluation, spirometry, polysomnography, echocardiography, arterial blood gas analysis, 6-minute walk test and chest X-ray. Results Patients with significant nocturnal hypoxemia had echocardiographic parameters associated with increase of LV musculature when compared to patients with mild nocturnal hypoxemia. The LV volume/mass ratio was significantly lower in the group with significant nocturnal hypoxemia (ratio 0.64 ± 0.13 versus 0.72 ± 0.12, p = 0.04), the thickness diastolic diameter of the interventricular septum and the diastolic thickness of the LV posterior wall were significantly higher in this group (9.7 ± 0.92 versus 9.1 ± 0.90 p = 0.03), (9.7 ± 1.0 versus 8.9 ± 1.0, p = 0.01. The time in REM sleep with saturation below 85% significantly predicted septum thickness (adjustment for BMI, age and mean blood pressure, r2 = 0.20; p = 0.046). Conclusion We observed association between severe REM sleep hypoxemia and echocardiographic parameters indicating increased LV mass in individuals with COPD and significant nocturnal hypoxemia. This suggests that this subgroup of individuals may benefit from an echocardiographic evaluation of the left ventricle. more...

Objective: To evaluate the disease and treatment information provided to patients with chronic obstructive pulmonary disease at hospital discharge., Methods: This was a cross-sectional study including hospitalized patients with chronic obstructive pulmonary disease at three tertiary hospitals. The study was based on seven items of the Global Initiative for Obstructive Lung Disease (GOLD) discharge guidelines. Two hospitals in this study had a Medical Residency Program in Pulmonology, and one did not have the program., Results: Fifty-four patients were evaluated. Large amounts of information were provided concerning effective pharmacological maintenance (item 1), blood gas evaluation/measurement of oxygen saturation (item 2), assessment of inhalation technique (item 4), and maintenance therapy (item 5). Less information was provided regarding comorbidity management planning (item 3), the completion of antibiotic/corticosteroid therapy (item 6) and follow-up with the attending physician or specialist (item 7) had less information. We observed significant differences between hospitals for items 1, 4 and 7, and better performance in hospitals with medical residency in pulmonology., Conclusion: Hospitalized patients with chronic obstructive pulmonary disease received little to no information about the seven items addressed by GOLD discharge guidelines. This finding suggests that these guidelines should be used more often by clinicians in hospital with or without medical residency in pulmonology. The lack of specialized care resulted in insufficient amount of information for patients with chronic obstructive pulmonary disease at discharge. more...

Objective: Clinical trials have shown that nintedanib 150 mg twice daily (bid) reduces disease progression in patients with idiopathic pulmonary fibrosis (IPF), with an adverse event profile that is manageable for most patients. Prior to the approval of nintedanib as a treatment for IPF in Brazil, an expanded access program (EAP) was initiated to provide early access to treatment and to evaluate the safety and tolerability of nintedanib in this patient population., Methods: Patients with a diagnosis of IPF within the previous five years, forced vital capacity (FVC) ≥ 50% predicted and diffusing capacity of the lungs for carbon monoxide (DLco) 30% to 79% predicted were eligible to participate in the EAP. Patients received nintedanib 150 mg bid open-label. Safety assessments included adverse events leading to permanent discontinuation of nintedanib and serious adverse events., Results: The EAP involved 57 patients at eight centers. Most patients were male (77.2%) and white (87.7%). At baseline, mean (SD) age was 70.7 (7.5) years and FVC was 70.7 (12.5) % predicted. Mean (SD) exposure to nintedanib was 14.4 (6.2) months; maximum exposure was 22.0 months. The most frequently reported adverse events considered by the investigator to be related to nintedanib treatment were diarrhea (45 patients, 78.9%) and nausea (25 patients, 43.9%). Adverse events led to permanent discontinuation of nintedanib in 16 patients (28.1%). Sixteen patients (28.1%) had a serious adverse event., Conclusion: In the Brazilian EAP, nintedanib had an acceptable safety and tolerability profile in patients with IPF, consistent with data from clinical trials. more...

Objective: To evaluate the use of video lessons on the topic of COPD as a training tool for a multidisciplinary team working in the primary health care sector., Methods: This was a quasi-experimental study involving a multidisciplinary team working at a primary health care clinic. The level of knowledge about COPD was measured by applying a specific, 16-item questionnaire - before, immediately after, and three months after the video lessons. In a set of six structured video lessons, the training focused on the prevention, case-finding, treatment, and monitoring of cases of COPD. The data were analyzed with the Friedman test, the Kruskal-Wallis test, Tukey's post hoc test, Dunnett's test, and the Bonferroni test., Results: There was a significant difference between the periods before and immediately after the training in terms of the scores on 15 of the 16 items on the questionnaire regarding the level of knowledge about COPD. The median total score of the participants increased significantly, from 60 points before the training to 77 points immediately thereafter and 3 months thereafter (p < 0.001 for both). Before the training, 23 (63.9%) and 13 (36.1%) of the members of the multidisciplinary team presented strong and very strong levels of agreement, respectively, among the 16 questionnaire items. After the training, 100% of the individuals presented a very strong degree of agreement., Conclusions: Multidisciplinary education through video lessons increased the knowledge of COPD on the part of a primary health care team, and the knowledge acquired was retained for at least three months after the intervention. more...

Introduction and Objective: The main goal of asthma treatment is to achieve and maintain clinical control of the disease. The exhaled fraction nitric oxide (FeNO) level is a biomarker of T-helper cell type 2 (Th2) inflammation of the airways. Our objective was to determine whether the FeNO level can be used to discriminate between patients with controlled, partially controlled, and uncontrolled asthma., Materials and Methods: The FeNO level and asthma control were evaluated in a retrospective and analytic cross-sectional study through data collected from asthmatic patients who were assessed by clinical history, asthma control, physical examination, spirometry, and FeNO level. Asthma control was determined by the criteria of the Global Initiative for Asthma and classified as controlled asthma, partially controlled asthma, and uncontrolled asthma. The FeNO values were classified as low (<25 ppb) or intermediate/high (⩾25 ppb) based on the American Thoracic Society recommendations., Results: The symptoms of 81 asthmatic patients were classified as controlled (34 [42%] patients), partially controlled (27 [33.3%] patients), and uncontrolled (20 [24.7%] patients). The FeNO level discriminated between the uncontrolled and controlled groups ( P  = .01) and between the uncontrolled and partially controlled groups ( P  = .01), but not between the controlled and partially controlled groups ( P  = .98). An FeNO level >30 ppb was associated with uncontrolled asthma ( P  = .0001) with an area under the receiver operating characteristic curve of 0.78 (95% confidence interval = 0.65-0.89)., Conclusions: FeNO level could be helpful in determining asthma control as >30 ppb was associated with uncontrolled asthma., Competing Interests: Declaration of Conflicting Interests:The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. more...

The INHALATOR study was a randomized, multicentre, open label, two-period of 7 days each, crossover study, with 7 days of washout in-between, aiming to evaluate the correct use, satisfaction and preference between Breezhaler ® and Respimat ® devices in patients under daily use of open Spiriva ® or open Onbrize ® , as monotherapy for treatment of mild or moderate COPD. Patients aged ≥40 years with a smoking history of at least 10 pack-year were included in the study. Primary endpoint was the rate of correct use of each device at the first day of treatment after reading the drug leaflet information and was evaluated under the supervision of a trained evaluator. At the end of each treatment phase, the inhaler use was re-evaluated and a satisfaction questionnaire was completed. The patients' preference for the inhaler devices was assessed at the end of the study. After exclusions due to screening failures, 140 patients were randomized: 136 received at least one dose of Breezhaler ® and 135 of Respimat ® . At treatment start, the rate of correct inhaler use was 40.4% (95%CI: 32.2%-48.7%) for Breezhaler ® and 36.3% (95%CI: 28.2%-44.4%) for Respimat ® (p = 0.451). After 7 days, the rates were 68.9% (95%CI: 61.1%-76.7%) and 60.4% (95%CI: 52.2%-68.7%), respectively (p = 0.077). According to the Feeling of Satisfaction with Inhaler Questionnaire - FSI 10 patients were more satisfied using Breezhaler ® than Respimat ® and 57.1% preferred using Breezhaler ® (p = 0.001) while 30.1% preferred Respimat ® (p < 0.001)., (Copyright © 2018. Published by Elsevier Ltd.) more...

Pulmonary fungal infections, which can be opportunistic or endemic, lead to considerable morbidity and mortality. Such infections have multiple clinical presentations and imaging patterns, overlapping with those of various other diseases, complicating the diagnostic approach. Given the immensity of Brazil, knowledge of the epidemiological context of pulmonary fungal infections in the various regions of the country is paramount when considering their differential diagnoses. In addition, defining the patient immunological status will facilitate the identification of opportunistic infections, such as those occurring in patients with AIDS or febrile neutropenia. Histoplasmosis, coccidioidomycosis, and paracoccidioidomycosis usually affect immunocompetent patients, whereas aspergillosis, candidiasis, cryptococcosis, and pneumocystosis tend to affect those who are immunocompromised. Ground-glass opacities, nodules, consolidations, a miliary pattern, cavitary lesions, the halo sign/reversed halo sign, and bronchiectasis are typical imaging patterns in the lungs and will be described individually, as will less common lesions such as pleural effusion, mediastinal lesions, pleural effusion, and chest wall involvement. Interpreting such tomographic patterns/signs on computed tomography scans together with the patient immunological status and epidemiological context can facilitate the differential diagnosis by narrowing the options. more...

Study Objectives: To develop and validate a practical model for obstructive sleep apnea (OSA) screening in adults based on objectively assessed criteria, and then compare it with two widely used tools, namely STOP-BANG and NoSAS., Methods: This is a retrospective study of an existing database of consecutive outpatients who were referred for polysomnography for suspected sleep-disordered breathing by their primary care physicians. Area under the curve (AUC) and 2 × 2 contingency tables were employed to obtain the performance of the new instrument., Results: A total of 4,072 subjects were randomly allocated into two independent cohorts: one for derivation (n = 2,037) and one for validation (n = 2,035). A mnemonic model, named No-Apnea, with two variables (neck circumference and age) was developed (total score: 0-9 points). We used the cutoff ≥ 3 to classify patients at high risk of having OSA. OSA severity was categorized by apnea-hypopnea index (AHI): any OSA (AHI 5 ≥ events/h; OSA-5), moderate/ severe OSA (AHI 15 ≥ events/h; OSA-15); and severe OSA (AHI 30 ≥ events/h; OSA-30). In the derivation cohort, the AUCs for screening of OSA-5, OSA-15, and OSA-30 were: 0.784, 0.758, and 0.754; respectively. The rate of subjects correctly screened was 78.1%, 68.8%, and 54.4%, respectively for OSA-5, OSA-15, and OSA-30. Subsequently, the model was validated confirming its reproducibility. In both cohorts, No-Apnea discrimination was similar to STOP-BANG or NoSAS., Conclusions: The No-Apnea, a 2-item model, appears to be a useful and practical tool for OSA screening, mainly when limited resources constrain referral evaluation. Despite its simplicity when compared to previously validated tools (STOP-BANG and NoSAS), the instrument exhibits similar performance characteristics., (© 2018 American Academy of Sleep Medicine.) more...

Tuberculosis continues to be a major public health problem. Although efforts to control the epidemic have reduced mortality and incidence, there are several predisposing factors that should be modified in order to reduce the burden of the disease. This review article will address some of the risk factors associated with tuberculosis infection and active tuberculosis, including diabetes, smoking, alcohol use, and the use of other drugs, all of which can also contribute to poor tuberculosis treatment results. Tuberculosis can also lead to complications in the course and management of other diseases, such as diabetes. It is therefore important to identify these comorbidities in tuberculosis patients in order to ensure adequate management of both conditions. more...

Objective: To analyze the impact that the 2009 changes in tuberculosis treatment in Brazil had on the rates of cure, tuberculosis recurrence, mortality, treatment abandonment, and multidrug-resistant tuberculosis (MDR-TB)., Methods: An ordinary least squares regression model was used in order to perform an interrupted time series analysis of secondary data collected from the Brazilian Tuberculosis Case Registry Database for the period between January of 2003 and December of 2014., Results: The 2009 changes in tuberculosis treatment in Brazil were found to have no association with reductions in the total number of cases (β = 2.17; 95% CI: -3.80 to 8.14; p = 0.47) and in the number of new cases (β = -0.97; 95% CI: -5.89 to 3.94; p = 0.70), as well as having no association with treatment abandonment rates (β = 0.40; 95% CI: -1.12 to 1.93; p = 0.60). The changes in tuberculosis treatment also showed a trend toward an association with decreased cure rates (β = -4.14; 95% CI: -8.63 to 0.34; p = 0.07), as well as an association with increased mortality from pulmonary tuberculosis (β = 0.77; 95% CI: 0.16 to 1.38; p = 0.01). Although there was a significant increase in MDR-TB before and after the changes (p < 0.0001), there was no association between the intervention (i.e., the changes in tuberculosis treatment) and the increase in MDR-TB cases., Conclusions: The changes in tuberculosis treatment were unable to contain the decrease in cure rates, the increase in treatment abandonment rates, and the increase in MDR-TB rates, being associated with increased mortality from pulmonary tuberculosis during the study period.Keywords: Tuberculosis, pulmonary/epidemiology; Tuberculosis, pulmonary/drug therapy; Tuberculosis, pulmonary/mortality; Interrupted time series analysis; Drug resistance, multiple; Drug compounding. more...

Tuberculosis treatment remains a challenge due to the need to consider, when approaching it, the context of individual and collective health. In addition, social and economic issues have been shown to be variables that need to be considered when it comes to treatment effectiveness. We conducted a critical review of the national and international literature on the treatment of tuberculosis in recent years with the aims of presenting health care workers with recommendations based on the situation in Brazil and better informing decision-making regarding tuberculosis patients so as to minimize morbidity and interrupt disease transmission. more...

Objective: To validate the Portuguese-language version of the STOP-Bang (acronym for Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, and Gender) questionnaire, culturally adapted for use in Brazil, as a means of screening for obstructive sleep apnea (OSA) in adults., Methods: In this validation study, we enrolled patients ≥ 18 years of age, recruited between May of 2015 and November of 2016. All patients completed the STOP-Bang questionnaire and underwent overnight polysomnography. To evaluate the performance of the questionnaire, we used contingency tables and areas under the (receiver operating characteristic) curve (AUCs)., Results: We included 456 patients. The mean age was 43.7 ± 12.5 years, and 291 (63.8%) of the patients were male. On the basis of the apnea-hypopnea index (AHI), we categorized OSA as mild/moderate/severe (any OSA; AHI ≥ 5 events/h), moderate/severe (AHI ≥ 15 events/h), or severe (AHI ≥ 30 events/h). The overall prevalence of OSA was 78.3%, compared with 52.0%, and 28.5% for moderate/severe and severe OSA, respectively. The most common score on the STOP-Bang questionnaire was 4 points (n = 106), followed by 3 points (n = 85) and 5 points (n = 82). An increase in the score was paralleled by a reduction in sensitivity with a corresponding increase in specificity for all AHI cut-off points. The AUCs obtained for the identification of any, moderate/severe, and severe OSA were: 0.743, 0.731, and 0.779, respectively. For any OSA, the score on the questionnaire (cut-off, ≥ 3 points) presented sensitivity, specificity, and accuracy of 83.5%, 45.5%, and 75.2%, respectively., Conclusions: The STOP-Bang questionnaire performed adequately for OSA screening, indicating that it could be used as an effective screening tool for the disorder. more...

Idiopathic pulmonary fibrosis is a severe and progressive chronic fibrosing interstitial lung disease, a definitive diagnosis being established by specific combinations of clinical, radiological, and pathological findings. According to current international guidelines, HRCT plays a key role in establishing a diagnosis of usual interstitial pneumonia (UIP). Current guidelines describe three UIP patterns based on HRCT findings: a typical UIP pattern; a pattern designated "possible UIP"; and a pattern designated "inconsistent with UIP", each pattern having important diagnostic implications. A typical UIP pattern on HRCT is highly accurate for the presence of histopathological UIP, being currently considered to be diagnostic of UIP. The remaining patterns require further diagnostic investigation. Other known causes of a UIP pattern include drug-induced interstitial lung disease, chronic hypersensitivity pneumonitis, occupational diseases (e.g., asbestosis), and connective tissue diseases, all of which should be included in the clinical differential diagnosis. Given the importance of CT studies in establishing a diagnosis and the possibility of interobserver variability, the objective of this pictorial essay was to illustrate all three UIP patterns on HRCT. more...

The treatment of COPD has become increasingly effective. Measures that range from behavioral changes, reduction in exposure to risk factors, education about the disease and its course, rehabilitation, oxygen therapy, management of comorbidities, and surgical and pharmacological treatments to end-of-life care allow health professionals to provide a personalized and effective therapy. The pharmacological treatment of COPD is one of the cornerstones of COPD management, and there have been many advances in this area in recent years. Given the greater availability of drugs and therapeutic combinations, it has become increasingly challenging to know the indications for, limitations of, and potential risks and benefits of each treatment modality. In order to critically evaluate recent evidence and systematize the major questions regarding the pharmacological treatment of COPD, 24 specialists from all over Brazil gathered to develop the present recommendations. A visual guide was developed for the classification and treatment of COPD, both of which were adapted to fit the situation in Brazil. Ten questions were selected on the basis of their relevance in clinical practice. They address the classification, definitions, treatment, and evidence available for each drug or drug combination. Each question was answered by two specialists, and then the answers were consolidated in two phases: review and consensus by all participants. The questions answered are practical questions and help select from among the many options the best treatment for each patient and his/her peculiarities. more...