Brazilian Journal of Pulmonology

ISSN (on-line): 1806-3756 | ISSN (printed): 1806-3713

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Year 2004 - Volume 30  - Number 1  (January/February)

Editorial

1 - Jornal Brasileiro de Pneumologia

Carlos Alberto de Castro Pereira

J Bras Pneumol.2004;30(1):1

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Upgrading

2 - O JP de cara nova

Geraldo Lorenzi-Filho

J Bras Pneumol.2004;30(1):1

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Original Article

3 - Long-term survival in lung cancer after surgical treatment: is gender a prognostic factor?

Sobrevida de longo prazo em carcinoma brônquico após tratamento cirúrgico: sexo é fator prognóstico?

Carolina Mariante de Abreu, José Miguel Chatkin, Carlos Cezar Fritscher, Mário Bernardes Wagner, José A. L. Figueiredo Pinto

J Bras Pneumol.2004;30(1):2-8

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BACKGROUND: In agreement with other reported studies, wehad previously found a possible association between gender and prognosis in stage I non-small cell lung cancer (NSCLC), showing a higher survival rate among females. OBJECTIVES: The purpose of this study was to further clarify the role of gender as a possible prognostic factor in NSCLC. METHOD: In a retrospective cohort study, we examined the survival of 163 NSCLC patients who underwent curative surgical treatment at the Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS) Hospital between 1990 and 1997. Data was analyzed using Kaplan-Meier plots. Additionally, we used the Mann-Whitney test for comparing group survival rates and the Cox regression model to adjust for potential confounding factors. RESULTS: Were included 124 (76.07%) males and 39 (23.93%) females, whose median survival was of 32.3 and 60.6 months, respectively. The 5-year survival was 38.0% for men and 55.4% for women (P=0.030). Considering only stage I patients, survival rates were 44.4% and 81.8% for men and women, respectively (P=0.009). Effect of gender continued after adjustment for several factors (age, hemoglobin, histology, tumor size, type of surgery and postoperative complications). CONCLUSION: This study confirms our previous findings that women live longer after NSCLC surgery when compared to men. This result is only observed at an early stage and persists after adjustment of several factorsP

 


Keywords: Carcinoma, bronchogenic [surgery]; Carcinoma, bronchogenic [epidemiolgy]; Prognosis; Sex distribution; Disease - free survival.

 

4 - Cystic fibrosis in adults clinical and spirometric aspects

Fibrose cística em adultos: aspectos clínicos e espirométricos

Antônio Carlos M. Lemos; Eliana Matos; Rosana Franco; Pablo Santana; Maria Angélica Santana

J Bras Pneumol.2004;30(1):9-13

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INTRODUCTION: Cystic Fibrosis is usually diagnosed in childhood. In Brazil, few studies have approached CF diagnosed in adulthood. OBJECTIVE:The aim of this study was to describe demographic and clinical characteristics and spirometric data of patients with CF diagnosed in adulthood (over 16 years of age) in Bahia, Brazil. METHODS: Twenty-eight patients with cystic fibrosis diagnosed in adulthood were evaluated at the Reference Center of Cystic Fibrosis of the state of Bahia. Variables of interest were age, gender, race, body mass index (BMI), sputum culture, presence of sinusitis and bronchiectasis, spirometric tests with the best values performed for forced expiratory volume in the first second (FEV1), forced vital capacity (FVC) and response to bronchodilators. RESULTS: Mean age of diagnosis was 31.1 ± 12.4 years. Of the patients, 53.4% were black and mulatto and the mean BMI was 18.7 ± 3.0 kg/m2. P aeruginosa was present in 12 (43%) of the total patients. The mean percentages ± SD of FVC and FEV1 were 58.9 ± 21.6% and 44.1 ± 23%, respectively. In the group of patients with presence of P. aeruginosa in sputum cultures, mean of the spirometry parameters were lower than those of the P. aeruginosa-free group. However, this difference achieved a statistically significant difference (p = 0.0007) only in FVC . CONCLUSIONS: In agreement with many authors, this study strengthen the point of view that CF must be investigated in patients with recurrent infections, sinusitis and bronchiectasis even in adulthood. Values of the percentages of FVC and FEV1 in relation to those foreseen were lower in patients bearers of P. aeruginosa thereby showing a higher deterioration of the pulmonary function.

 


Keywords: Cystic fibrosis/diagnosis. Adult. Spirometry/methods.

 

5 - Influence of ascites in the pulmonary function of patients with portal hypertension

Influência da ascite na avaliação da função pulmonar em portadores de hipertensão portal

Angela Maria Stiefano Nitrini; Roberto Stirbulov; Ernani Geraldo Rolim

J Bras Pneumol.2004;30(1):14-19

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BACKGROUND: Oxygen deficiency in patients with portal hypertension may be secondary to changes in respiratory mechanics due to ascites. OBJECTIVES: Evaluate pulmonary function in patients with portal hypertension before and after reduction of the ascites. METHOD: Fifteen patients with portal hypertension and ascites were submitted to pulmonary function tests, comprising spirometry and arterial blood gas determination, before and after reduction of ascites. The analyzed parameters were: forced vital capacity (FVC); forced expiratory volume in one second (FEV1); forced expiratory flow between 25% - 75% of forced vital capacity (FEF 25-75%); expiratory reserve volume (ERV); FEV1/FVC; arterial oxygen pressure (PaO2); arterial carbon-dioxide pressure (PaCO2) and arterial oxygen saturation (SaO2). RESULTS: There was remarkable improvement in pulmonary volumes after decrease of ascites by treatment with diuretics associated or not to paracentesis. CONCLUSION: We concluded, that in patients with portal hypertension and ascites, there is a decrease of pulmonary volumes compared to predicted values, with significant improvement decrease of ascites. Similarly, an increase of the arterial oxygen pressure and of the arterial oxygen saturation was perceived.

 


Keywords: Ascites/therapy. Hypertension, portal. Respiratory function tests.

 

6 - Post-infectious bronchiolitis obliterans: clinical aspects and complementary tests of 48 children

Bronquiolite obliterante pós-infecciosa: aspectos clínicos e exames complementares de 48 crianças

Rosaly Vieira dos Santos; Nelson A. Rosário; Carlos Antônio Ried

J Bras Pneumol.2004;30(1):20-25

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BACKGROUND: The clinical evaluation of patients with post-infectious bronchiolitis obliterans (BO) is variable. OBJECTIVE: Substantiate the clinical characteristics, the evolution and the complementary tests of 48 patients with post-infectious bronchiolitis obliterans (BO). METHOD: Observational and retrospective study. Diagnosis of BO was based upon clinical criteria, CT scan findings and exclusion of other diseases. History prior to diagnosis and complementary tests were evaluated as well as initial and final values of oxygen saturation. RESULTS: Mean age of patients at the acute stage of the infectious disease was of 9.6. Thirty two of the patients were male. All were hospitalized during the acute stage, 14 of them (29%) in the ICU. Four patients died two years after onset of acute bronchiolitis. During evolution, all required emergency care due to exacerbation of the pulmonary condition and 24 (50%) were hospitalized, 2 of them in the ICU. The majority continued presenting cough, wheezing, crackles and hyperinflation, however to a lesser degree. Mean of initial arterial saturation was of 89% and final of 92%. The most common infectious agents in sputum samples were H. influenzae, S. pneumoniae and M. catarrhalis. Increased serum IgM and IgC were found in 9 and 7 patients, respectively. The most frequent findings at thorax CT scan were mosaic perfusion, bronchiectasis, atelectasis and bronchial wall thickening. CONCLUSION: Post infectious BO is a chronic and severe disease with persistent symptoms that in general affect infants. Positive serum cultures and increased serum immunoglobulins are suggestive of chronic infectious inflammatory condition.

 


Keywords: Bronchiolitis obliterans. Obstructive lung diseases.

 

Year 2004 - Volume 30  - Number 2  (March/April)

Editorial

1 - 

Milton de Arruda Martins

J Bras Pneumol.2004;30(2):-

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2 - 

Thais Helena Abrahão Thomaz Queluz

J Bras Pneumol.2004;30(2):92-

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Original Article

4 - Effect of a clinical protocol on the management of acute asthma in the emergency room of a university hospital

Efeito da implantação de um protocolo assistencial de asma aguda no serviço de emergência de um hospital universitário

Pérsio Mariano da Rocha, Andréia Kist Fernandes, Fernando Nogueira, Deise Marcela Piovesan, Suzie Kang, Eduardo Franciscatto, Thaís Millan, Cristina Hoffmann, Carísi Anne Polanczyk, Sérgio Saldanha Menna Barreto, Paulo de Tarso Roth Dalcin

J Bras Pneumol.2004;30(2):94-101

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Background: There is a wide variability in clinical practice for treating acute asthma (AA) in the emergency room (ER) interfering in the quality of management. Objective: To evaluate the impact of a clinical protocol for care of acute asthma in the ER of the Hospital de Clínicas de Porto Alegre. Method: In this hospital a cross-sectional study was conducted before and after implementation of the protocol, of consecutive patients presenting with acute asthma in the adult ER (age ³ 12 years). The intention was to measure the effect of recommendations on the objective assessment of severity, utilization of diagnostic tools, proposed therapy, not recommended therapy and on the outcomes. Results: The pre-protocol group comprised 108 patients and the protocol group comprised 96 patients. There was a significant increase in the use of pulse oximetry (8% to 77%, p<0.001) and PEFR (5% to 21%, p<0.001). There was an increase in the utilization of radiology (33% to 66%, p<0.001) and in that of blood tests (11% to 25%, p=0.016). There was also an increase in the number of patients receiving the three recommended nebulizations in the first hour (22% to 36%, p=0.04). Although the overall use of corticosteroids did not change, there was a significant increase in the use of oral steroids (8% to 28%, p<0.001). There was no significant difference in the not recommended therapy, time of stay and outcomes. Conclusion: The acute asthma clinical protocol used in the ER was associated to a positive effect on the objective assessment of severity of asthma and on the use of the recommended therapy. No other significant influence on the treatment or on the outcome was perceived.

 


Keywords: Clinical protocols. Asthma. Emergency medicine.

 

5 - Exercise-induced bronchospasm in children and adolescents with a diagnosis of asthma

Broncoespasmo induzido pelo exercício em crianças e adolescentes com diagnóstico de asma

Vitor E. Cassol, Maria E. Trevisna, Eliane Z. C. de Moraes, Luiz O. C. Portela, Sérgio Saldanha Menna Barreto

J Bras Pneumol.2004;30(2):102-108

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Introduction: In asthmatic children and adolescents a high incidence of temporary bronchospasm is perceived after physical exertion. Objective: To investigate incidence and severity of exercise-induced bronchospasm in children and adolescents with a clinical diagnosis of mild, moderate or severe asthma. Method: A descriptive, cross-sectional, not controlled study was carried out. The sample encompassed follow-up of 40 asthmatic patients of both genders, between 7 and 18 years of age who were not regularly using anti-inflammatory medication. A standardized exercise provocation test that consisted of steady running on a treadmill with a 10% inclination was administered Pulmonary function was tested with forced spirometry using six expiratory maneuvers repeated at approximately 1, 5 ,10,15, 20 and 30 minutes after the exercise. The highest of six FEV1 readings was used for analysis. The FEV1 was employed to evaluate the presence and to classify the severity of positive exercise induced bronchospasm (EIB). The asthmatic patients presented adequate clinical and spirometric conditions for testing (FEV1 at least 70 % of the predicted value). A drop of ³ 10% in relation to FEV1 before exercise was adopted as a criterion for (EIB). Results: 26 (65 %) patients developed EIB. The proportion by category was: mild asthma 44%, moderate and severe asthma 100%. There was a significant association between proportion of EIB and severity of asthma (p<0.05), and a significant difference between severity of EIB (confirmed by a recorded decrease in the 1 second forced expiratory volume) and asthma severity (p<0.05). Conclusion: The proportion and severity of EIB were clearly related to the clinical severity of asthma.

 


Keywords: Asthma, exercise-induced/diagnosis. Children. Adolescent. Spirometry/methods.

 

6 - Transbronchial needle aspiration in the diagnosis and staging of lung cancer

Punção aspirativa transbrônquica por agulha no diagnóstico e estadiamento do câncer de pulmão

Mauro Zamboni, Deborah Cordeiro Lannes, Andréia Salarini Monteiro, Marilene S. Nascimento, Edson Toscano, Aureliano Mota de Sousa Cavalcanti, Samuel Z. de Biasi Cordeiro, Paulo de Biasi Cordeiro

J Bras Pneumol.2004;30(2):109-114

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Background: Transbronchial needle aspiration (TBNA) with a flexible bronchoscope has been used for many years in the United States of America to diagnose bronchogenic carcinoma. However little information on the subject is available in Brazil. Objective: Assess the effectiveness of transbronchial needle aspiration for diagnosis and staging of lung cancer. Method: A retrospective review was made of 74 TBNA performed at the National Cancer Institute, in Rio de Janeiro, Brazil. a thoracic computerized tomography had oreviouslbeen made of all patients. Eleven (15%) patients exhibited mediastinal masses and 63 (85%) hilar masses. Seventy six endoscopic alterations were detected: enlargement of the main carina in 44 (59%) patients; enlargement of the secondary carina in 12 (16%); paratracheal compression in 5 (7%); posterior tracheal wall compression in 3 (4%); main bronchus compression in 5 (7%) AND BRONCHOSCOPY was normal in 5 (7%) patients. Results: Specimens were satisfactory for diagnosis in 42 (57%) patients and in 34 (46%) diagnosis was confirmed. Malignancy was confirmed in 30 of 34 patients (88%): as follows: small cell undifferentiated carcinoma in 10 of 30 (33%); squamous cell lung cancer in 7 of 30 (23%); adenocarcinoma 7 of 30 (23%); and non-small cell lung cancer in 6 of 30 (20%). Four of 30 (12%) were diagnosed as bearers of benign disease: tuberculosis 2 of 4 (50%) and sarcoidosis 2 of 4 (50%). No complications related to the method were perceived. Conclusion: This preliminary experience with TBNA in 74 patients indicated that this method is safe, easy to perform with a minimum of complications and useful for the diagnosis and staging of pulmonary neoplasms.

 


Keywords: Bronchoscopy/methods. Carcinoma, bronchogenic/diagnosis. Aspiration/methods.

 

7 - Extended Thymectomy for Treating Patients with Myasthenia Gravis (MG)

Resultado da timectomia ampliada no tratamento de pacientes com Miastenia gravis

Raul Lopes Ruiz Jr, Samuel Marek Reibscheid, Antonio José Maria Cataneo, Luis Aatônio de Lima Rezende

J Bras Pneumol.2004;30(2):115-120

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Background: Extended thymectomy is one of several types of thymectomy. Literature suggests that the outcome and prognosis will be enhanced by performing a more extensive resection of the gland and of the anterior mediastinum tissue. Objective: To retrospectively evaluate response of MG patients to extended thymectomy. Method: From August 1992 to January 2003, forty-six MG patients were submitted to preoperative plasmapheresis and extended thymectomy. According to the time elapsed since onset of symptom they were divided into three groups; < 12 months, 13 to 24 months, and > 25 months. Results: There were 31 female and 15 male patients, mean age 30 years and average evolution time 26.3 months. Outpatient post-operative follow-up was on the average of 26.6 months. Level of response was good, 50% had full remission and a further 39% had good response. There was one death. The most common histopathology finding was thymic hyperplasia. Only 3 patients (6.5%) had benign thymomas; 5 (10.8%) had extra glandular thymic tissue: 2 in the perithymic fat and 3 in the pericardiac fat adjacent to the left phrenic nerve and aortal-pulmonary window. Conclusion: Treatment of MG by extended thymectomy is safe and efficient with high levels of complete remission. Extra glandular thymic tissue was found in some patients. As soon as diagnosis is completed, thymectomy is indicated together with plasmapheresis and medication, independent of age, onset of symptoms, and thymus pathology.

 


Keywords: Thymectomy/methods. Myasthenia gravis/pathology. Neuromuscular diseases/rehabilitation.

 

8 - Six Minutes Walk Test: Study of the Effect of Learning in Chronic Obstructive Pulmonary Disease Patients

Teste de caminhada de seis minutos: estudo do efeito do aprendizado em portadores de doença pulmonar obstrutiva crônica

Sérgio Leite Rodrigues, Hélder Fonseca E Mendes, Carlos Alberto de Assis Viegas

J Bras Pneumol.2004;30(2):121-125

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Background: The six minutes walk test has been increasingly utilized to assess the effectiveness of different clinical and surgical treatment options in pulmonary diseases. However lack of standardization for their performance may influence measurements and jeopardize assessment of the functional capacity of patients with cardiopulmonary disease. Objective: To determine the possible effects of learning on the distance covered during the six minute walk test for bearers of chronic obstructive pulmonary disease. Method: A retrospective analysis of 35 medical records of COPD patients referred to the Pulmonary Rehabilitation Program of the University Hospital of Brasília was carried out. On alternate days these patients had performed two six minutes walk tests, spirometry and arterial blood gas analysis. Clinical and functional diagnosis was based upon the history of exposure to risk factors, mucus production, dyspnea and spirometric dysfunction after use of bronchodilators. The Student test was used for the comparison of results that were different. Results: The distances covered in the second six-minute walk test (515 ± 82 meters) were greater than those covered in the first six-minute walk test (480 ± 85 metros), with statistically significant differences (p<0.05). However measurements of the muscular effort and perception of dyspnea (Borg scale), peripheral blood oxygen saturation (SpO2), respiratory and heart rates did not disclose any statistically significant differences between the two tests (p<0.05). Conclusion: The present study suggests that in order to standardize the six minutes walk test, the procedure should be performed at least twice to better assess the functional capacity of patients, bearers of chronic obstructive pulmonary disease.

 


Keywords: Walking. Effectiveness. Lung diseases, obstrutive.

 

9 - Objective evaluation of clubbing on shadow images of index fingers. A study of patients with pulmonary disease and of normal individuals

Avaliação objetiva do hipocratismo digital em imagens de sombra de dedo indicador; estudo em pacientes pneumopatas e em indivíduos normais

José da Silva Moreira, Nelson da Silva Porto, Ana Luiza Schneider Moreira

J Bras Pneumol.2004;30(2):126-133

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Background: Normal diagnosis of clubbing is clinical; however use of objective criteria may improve the accuracy of findings Objective: To present a simple method of obtaining finger images for the purpose of studying clubbing. Method: Shadow images of the index fingers obtained by projection through a transparent glass plate virtually without distortion and displayed on a common sheet of paper yielded the profile (PA) and hyponychial (HA) angles; as well as the ratio between distal phalangean and interphalangean depths (DPD/IPD). Upon physical examination of 306 adult bearers of pulmonary disease, 116 disclosed presence of clubbing (YES); 126 absence (NO); and 64 were doubtful cases (DBT). Also studied were 452 normal adult individuals. Among these 71.0% of the bearers and 33.4% of the controls were smokers. Results: Values found in normal individuals and in patients bearers of clubbing (YES) were, respectively, 172.8±5.9º vs. 183.4±5.9º for PA, 181.5±5.0º vs. 201.4±6.5º for HA, and 0.904±0.029 vs. 1.014±0.062 for DPD/IPD (significant differences, p<0.001). In the doubtful) cases (DBT) the three values were also higher than in normal controls (p<0.001). Furthermore, it was shown that among controls PA, HA and the DPD/IPD ratios were significantly larger in male smokers (p<0.005) while only the DPD/IPD ratio was larger in female smokers (p<0.05). Conclusions: This is a simple method of obtaining clear index finger images. The hyponychial angle determined on the images was the most useful measurement to discriminate digits clinically with and without clubbing (sensitivity of 76.7%, specificity of 83.2%, predictive positive value of 95.5% and predictive negative value of 96.9%).

 


Keywords: Clubbing, profile angle, hyponychial angle, relation DPD/IPD.

 

10 - Study of bronchoalveolar lavage in leptospirosis patients with pulmonary involvement

Estudo do lavado broncoalveolar em pacientes com comprometimento pulmonar na leptospirose

Jorge Eduardo Manhães de Carvalho, Isabela Nascimento Moraes, Angela Santos Ferreira, Regina Lúcia Caetano Gomes, Marcos Olivier Dalston, João José Pereira da Silva

J Bras Pneumol.2004;30(2):134-139

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Background: Pulmonary involvement is common in leptospirosis and usually characterized by hemoptysis, dyspnea and diffuse bilateral infiltrates in chest X-rays. Such findings may be compatible with alveolar hemorrhage, already described by some authors both in autopsies and bronchoalveolar lavage (BAL). Objective: To evaluate the presence of alveolar hemorrhage, diagnosed through BAL, in bearers of leptospirosis patients with pulmonary involvement emphasizing the method's importance for early detection of this complication. Method: Seven patients with leptospirosis were submitted to BAL. All presented respiratory symptoms and/or infiltrates in the chest X-rays and/or hypoxemia. Alveolar hemorrhage was defined by the following findings in BAL: percentage of siderophages e"20% and/or Golde score >100 and/or hemorrhagic fluid. Culture and direct tests for leptospirosis were performed in BAL. Diagnosis of disease was confirmed by microscopy serum agglutination. Results: The aspect of the bronchoscopy was normal in five patients, showed blood in the bronchial tree in one case and inflammatory manifestations in another. The BAL aspect was hemorrhagic for all patients portraying alveolar hemorrhage. Culture and direct tests were negative for Leptospiras in the BAL. Conclusions: Leptospirosis must be taken into account in the differential diagnosis of alveolar hemorrhage. The BAL was confirmed as an efficient method for detection of alveolar hemorrhage in leptospirosis, to recommend immediate therapy for the purpose of preventing its evolution to massive hemoptysis and respiratory failure.

 


Keywords: Leptospirosis. Bronchoalveolar lavage fluid. Radiography, thoracic.

 

11 - Tuberculosis associated to AIDS: demographic, clinical and laboratory characteristics of patients cared for at a reference center in the south of Brazil.

Tuberculose associada à AIDS: características demográficas, clínicas e laboratoriais de pacientes atendidos em um serviço de referência do sul do Brasil

Maria Marta Santos Boffo, Ivo Gomes de Mattos, Marta Osório Ribeiro, Isabel Cristina de Oliveira Neto

J Bras Pneumol.2004;30(2):140-146

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Background: Synergism between tuberculosis and HIV is responsible for the increased morbidity-mortality rate in AIDS patients. Objective: To delineate the profile of patients with tuberculosis and AIDS in the city of Rio Grande by relating demographic, clinical and laboratory data. Method: The sample comprised all cases of tuberculosis defined by identification of Mycobacterium tuberculosis that occurred in the AIDS Service of the University Hospital/FURG between September, 1997 and December, 2000, which added to a total of 31 patients confirmed as definite cases of AIDS. Using the Ogawa-Kudoh culture method and the Kinyoun bacilloscopy, 33 clinical pulmonary and extrapulmonary specimens were analyzed. Identification of M. tuberculosis was made by the usual phenotype methods. The method of proportions was chosen to establish resistance of isolated strains. Results: The mean age was of 33.8±9.9 years, with a man/woman ratio of 2.87:1 and 80.7% of Caucasians. All patients (n=31) exhibited overall or specific clinical manifestations of turberculosis at the time of suspicion diagnosis. In 20 of the cases risk factors were observed: use of injected drugs, alcoholism, malnutrition, imprisonment. Pulmonary disease occurred in 19 cases, extrapulmonary in 10 and the association of both in two. Lymph node commitment was more frequent among those with extrapulmonary disease. The isolated strains (33) were identified as M. tuberculosis and 28 were tested and showed sensibility to Isoniazid and Rifampin. Conclusion: In AIDS patients, tuberculosis appeared with various clinical manifestations, jeopardizing both men and women of less favored social conditions while at a fully productive stage of their lives.

 


Keywords: Tuberculosis/epidemiology. Tuberculosis/complications. Acquired immunodeficiency syndorme/tuberculosis. Mycobacterium tuberculosis/indicators of morbidity and mortality.

 

Case Report

12 - Hemangioendothelioma: a rare tumor of the mediastinum

Hemangioendotelioma:tumor raro de mediastino

Marcelo Loze de Queiroz, Petrucio Arantes Sarmento de Souza, Carlos Jogi Imaeda, Vicente Forte

J Bras Pneumol.2004;30(2):147-149

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A 30 year old Caucasian male from São Paulo was admitted to the hospital He had been complaining about constant, moderate pain in the anterior and lateral left hemi-thoracic region for the last three months as well as associated great effort dyspnea over the last month.Investigation with chest X-rays, CT scans and MRI revealed a large anterior and medial mediastinal tumor suggesting large vessel invasion. The patient was submitted to a left side parasternal mediastinostomy and a biopsy of the mediastinal mass which was complicated by severe bleeding. An immediate median full sternotomy was elected in addition to a left anterior-lateral thoracotomy for total tumor resection and control of the bleeding. Evolution was good, with hospital discharge on the ninth postoperative day. The anatomical-pathological essay disclosed a hemangioendothelioma of the mediastinum.

 


Keywords: Hemangioendothelioma/diagnosis. Mediastinal neoplasms.

 

13 - Microscopic Polyangiitis with Alveolar Hemorrhage

Poliangeíte microscópica com hemorragia alveolar difusa

José Wellington Alves dos Santos, Gustavo Trindade Michel, Carlos Eurico da Luz Pereira, Vera Luiza Capelozzi, Jader Nascimento Mileto, Cleber Antonio Fiorini

J Bras Pneumol.2004;30(2):150-153

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Microscopic Polyangiitis is a form of Anti-Neutrophil Cytoplasmic Antibody (ANCA)-associated small-vessel vasculitis that preferentially involves venules, capillaries and arterioles and may also involve arteries and veins. It is one of the most common primary systemic small-vessel vasculitis. Its clinical presentation is not distinguishable from the Wegener's granulomatosis (WG) and the Churg-Strauss syndrome (CSS). These types of small-vessel vasculitis are histologically similar and can be differentiated by the presence of granulomatous inflammation in WG or asthma in CSS. The case of a 66-year-old man with microscopic polyangiitis presenting with alveolar hemorrhage is reported with a discussion of the differential diagnosis of other types of pulmonary small-vessel vasculitis.

 


Keywords: Microscopic polyangiitis. Alveolar hemorrhage. Pulmonary vasculitis

 

14 - Bronchiolitis obliterans organizing pneumonia

Bronquiolite obliterante com pneumonia em organização

Gabriela Addor, Andréia Salarini Monteiro, David Henrique Nigri, Wilhermo Torres, Carlos Alberto de Barros Franco

J Bras Pneumol.2004;30(2):154-157

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48 years-old woman, asymptomatic, presented with radiographic findings of patchy airspace consolidation with nodular opacities in the upper right lobe, middle lobe and lingula. The differential diagnoses of neoplasms, sarcoidosis, granulomatous diseases and tuberculosis were considered. Diagnosis of Bronchiolitis obliterans organizing pneumonia was made by means of videothoracoscopy whereupon treatment with corticosteroids was begun. The patient had a positive evolution with resolution of the radiographic finding.

 


Keywords: bronchiolitis obliterans organizing pneumonia, bronchiolitis obliterans

 

Review Article

15 - Biomass burning and health effects

Queima de biomassa e efeitos sobre a saúde

Marcos Abdo Arbex, José Eduardo Delfini Cançado, Luiz Alberto Amador Pereira, Alfésio Luís Ferreira Braga, Paulo Hilário do Nascimento Saldiva

J Bras Pneumol.2004;30(2):158-175

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The first thought that comes to mind concerning air pollution is related to urban centers where automotive exhausts and the industrial chimneys are the most important sources of atmospheric pollutants. However a significant portion of the earth's population is exposed to still another source of air pollution, the burning of biomass that primarily affects developing countries. This review article calls the attention of lung specialists, public authorities and the community in general to the health risks entailed in the burning of biomass, be it indoors or outdoors to which the population is exposed. This review describes the main conditions that lead to the burning of biomass and how the literature has recorded its effects on human health discussing the psychopathological mechanisms. Finally two recent studies are presented that emphasize an important type of biomass burning that of the sugar cane straw. This is a common practice in several regions of Brazil changing the respiratory morbidity standards of the population exposed.

 


Keywords: air pollution, biomass, sugar cane, smoke, vegetation fires, respiratory disease.

 

16 - Smoking and its peculiarities during pregnancy: a critical review

Tabagismo e suas peculiaridades durante a gestação: uma revisão crítica

Waldir Leopércio, Analice Gigliotti

J Bras Pneumol.2004;30(2):176-185

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Pregnancy is a special occasion to promote the end of the smoking habit. Concern with health of the fetus brings about an extraordinary motivation for the pregnant woman. Results and cost-effectiveness of interventions are better in this group than in the overall population and the advantages extrapolate the benefits to the woman's health as they also allow for the development of a healthy fetus. Knowledge of the peculiarities of smoking during pregnancy is fundamental for a directed approach which adds to a probability of greater success. This review investigates the extent of the harm of tobacco for the pregnant woman as well as for the fetus. As such it, it encourages the use of appropriate techniques to urge pregnant women to stop smoking.

 


Keywords: Smoking/adverse effects. Tobacco use cessation/methods. Pregnancy.

 

Letters to the Editor

17 - Atividade bactericida precoce: uma metodologia segura e necessária

Moises Palaci, David Jamil Hadad, Valdério do Valle Dettoni, Reynaldo Dietze

J Bras Pneumol.2004;30(2):189-191

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18 - Carta ao Editor

Sergio Pripas

J Bras Pneumol.2004;30(2):192-

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Year 2004 - Volume 30  - Number 3  (May/June)

Editorial

1 - Biomass burning and its effects on health

Biomass burning and its effects on health

C. Arden Pope III

J Bras Pneumol.2004;30(3):193-

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2 - Smoking in health professionals

Smoking in health professionals

J Bras Pneumol.2004;30(3):194-

PDF EN


Original Article

3 - Effects of salbutamol delivered by dry-powder inhaler on methacholine-induced bronchoconstriction

Efeito do salbutamol liberado através de inalador de pó seco sobre o broncoespasmo induzido por metacolina

Adalberto Sperb Rubin, Liliana G Pelegrin,Christiano Perin, Maurício Roux Leite, Luiz Carlos Corrêa da Silva

J Bras Pneumol.2004;30(3):195-200

Abstract PDF PT

Background: Short-acting b2 agonists delivered by metered-dose inhaler (MDIs) are the drugs usually used for the reversal of methacholine-induced bronchoconstriction. The b2 agonists that are delivered by dry-powder inhaler (DPI) can be an efficacious option. Objective: To evaluate the effectiveness and speed of action of salbutamol delivered by DPI (Pulvinal; Butoventâ), in comparison to salbutamol delivered by MDI, in reversing methacholine-induced bronchoconstriction. Method: Sixty successive methacholine-induced bronchoconstriction patients who presented a decrease of at least 20% in forced expiratory volume (FEV1) were evaluated prospectively. Of these 60 patients, we randomized 30 (first group) to receive 200 mcg of salbutamol by MDI and 30 (second group) to receive 200 mcg of salbutamol by DPI (Pulvinal). Both drugs were administered with the objective of reversing bronchoconstriction during the final phase of a bronchoprovocation test. The FEV1 values obtained at 1 and 5 minutes after bronchodilator administration were evaluated. Results: The groups were comparable in gender distribution, age, weight, dose level provoking a 20% drop in FEV1 (first group: 1.3 mg; second group: 1.19 mg; p = 0.79) and post-methacholine FEV1 (first group: 2.03 l; second group: 1.99 l; p = 0.87), with no statistically significant differences between the two groups. In the first group (MDI), the mean increase in FEV1 was 16.2% (at 1 minute) and 22.2% (at 5 minutes), and in the second group (DPI) it was 17% (at 1 minute) and 23.6% (at 5 minutes). There was no statistically significant difference between the groups (p = 0.8). Conclusion: The b2-agonists delivered by DPI (Pulvinal) present the same bronchodilator efficacy and speed of action as do those delivered by the more traditional MDI method.

 


Keywords: Asthma. Bronchodilator agents/administration & dosage. Albuterol/administration & dosage. Methacholine chloride/administration & dosage. Respiratory therapy/methods. Administration, inhalation/methods. Prospective studies.

 

4 - Immunoglobulins, complements and autoantibodies in 58 workers exposed to silica

Estudo de imunoglobulinas, complementos e auto-anticorpos em 58 trabalhadores expostos à sílica

Hermano Albuquerque de Castro, Carolina Gimenes da Silva, Alfred Lemle

J Bras Pneumol.2004;30(3):201-206

Abstract PDF PT

Background: The primary work-related lung disease in Brazil is silicosis. Its pathogenic agent is the dust of crystalline free silica (SiO2; silicon dioxide). The inflammatory process of silicosis is not yet well understood. Objective: To analyze, through immunologic laboratory evaluation, including nonspecific and specific immunity, the profile of IgG, IgM, IgA, C3, C4 and autoantibodies in the serum of workers, with or without silicosis, exposed to silica. Methods: Fifty-eight male workers were studied. All had been exposed to silica. Immunologic, radiologic and functional evaluations were made. The immunoglobulins IgG, IgA, and IgM, the complement system components C3 and C4, and the autoantibodies were assessed. Results: Chest X-rays were normal in 20 of the 58 workers and compatible with silicosis in 38. Among the 38 who were positive, IgG values were, on average, higher than in the group with normal X-rays (p < 0.05). There were no significant differences in average values of IgA, IgM, C3 or C4 (p > 0.05). The percentage of autoantibody positivity was higher in the silicosis group than in the group with normal X-rays. Conclusion: The increased levels of IgG in patients with silicosis constitutes an important discovery. It may represent continuity of the granulomatous reaction, even when the individual is no longer being exposed to silica. However, further studies are necessary in order to increase understanding of the mechanism involved in the silicosis immunologic process.

 


Keywords: Lung diseases. Silicosis. Occupational diseases. Immunoglobulins

 

5 - Influence of general clinical parameters on the quality of life of chronic obstructive pulmonary disease patients

Influência de características gerais na qualidade de vida de pacientes com doença pulmonar obstrutiva crônica

Victor Zuniga Dourado, Letícia Cláudia de Oliveira Antunes, Lídia Raquel de Carvalho, Irma Godoy

J Bras Pneumol.2004;30(3):207-214

Abstract PDF PT Portuguese Text

Background: There is currently no consensus regarding which factors influence the quality of life of patients suffering from chronic obstructive pulmonary disease (COPD). However, identifying such factors could orient approaches to improving the quality of the lives of these patients. Objective: To evaluate factors that can interfere with quality of life in COPD patients selected for pulmonary rehabilitation. Methods: Twenty-one patients with moderate to severe COPD were evaluated. Maximal inspiratory pressure (MIP), 6-minute walk test (6MWT), body mass index (BMI), pulmonary function, blood gases, grip strength (measured with a dynamometer), quadriceps strength and St. George's Respiratory Questionnaire (SGRQ) scores were assessed. Results: Statistically significant negative correlations with quality of life were found for the following factors: "impact" scores of: forced expiratory volume in one second (FEV1) (r = -0.68; p = 0.004), FEV1 to forced vital capacity ratio (FEV1/FVC) (r = -0.61; p = 0.014), peak expiratory flow (PEF) (r = -0.53 (p = 0.015), 6MWT (r = -0.63; p = 0.001) and BMI (r = -0.64; p = 0.002); "activity" scores for: MIP (r = -0.57; p = 0.007), baseline arterial oxygen saturation by pulse oximetry (SpO2) (r = -0.52; p = 0.018) and 6MWT (r = -0.58; p = 0.007); "symptom" score for: BMI (r = -0.60; p = 0.005); and "total" scores for: FEV1 (r = -0.64; p = 0.01), PEF (r = -0.47; p = 0.033) and BMI (r = -0.57; p = 0.009). Multiple linear regression revealed the primary factors influencing quality of life to be: BMI, which presented a significant influence on "symptom", "impact" and "total" scores (p = 0.002, p = 0.009 and p = 0.024, respectively); and 6MWT, which had a significant influence on "activity" and "impact" scores (p = 0.048 and p = 0.010, respectively). Conclusions: The BMI and 6MWT were shown to have an influence on quality of life in the COPD patients studied. Therefore, therapeutic approaches to improving the quality of life of COPD patients should take these indices into consideration.

 


Keywords: Lung diseases, obstructive/rehabilitation. Quality of life

 

6 - Treatment of empyema using thoracentesis with irrigation and intrapleural application of an antimicrobial agent

Toracocentese esvaziadora com irrigação e uso de antimicrobiano intrapleural no tratamento do empiema

Liana Peres Duailibe, Maria Ilizabeti Donatti, Paulo de Tarso Müller, Pedro Nango Dobashi

J Bras Pneumol.2004;30(3):215-222

Abstract PDF PT

Background: Empyema is a serious disease classically characterized by purulence within the pleural cavity. Early diagnosis demands immediate treatment, although there is still great controversy surrounding the question of what is the best therapy. Objective: To analyze the method of using thoracentesis and pleural irrigation, combined with the intrapleural application of an antimicrobial agent, to treat empyema - and to compare this method with others described in the literature. Method: Between January 1999 and May 2000, 17 patients diagnosed with loculated or diffuse pleural empyema were submitted to thoracentesis, followed by thorough washing of the pleural cavity with isotonic solution and intrapleural administration of a non-irritating antimicrobial agent to the pleura. Results: The group of patients studied consisted of 15 men and 2 women, and the average age was 44. The most common clinical symptoms were fever, productive cough, chest pain and dyspnea, and the most common cause was pneumonia. Macroscopically, 12 patients presented obviously purulent pleural fluid. In 4 (26.67%) of the patients, the etiological agent was identified, the most frequent being Staphylococcus sp. Pulmonary decortication was indicated in 2 cases, and those 2 patients were therefore excluded. The average length of hospitalization was 17.1 days, although 3 patients received the treatment as outpatients. No recurrence or mortality was observed with the use of this methodology. Conclusion: This approach reduced the need for invasive procedures, proving to be safe and efficient, with lower rates of morbidity and mortality than other modalities of treatment.

 


Keywords: Empyema/Pleural, Pleura/Blood Supply, Treatment Outcome, Treatment Effectiveness.

 

7 - Smoking among medical students: temporal trends and related variables

Tabagismo em estudantes de Medicina: tendências temporais e fatores associados

Ana Maria Baptista Menezes, Pedro Curi Hallal, Fernando Silva, Marcos Souza, Luciene Paiva, Aline D'Ávila, Bianca Weber, Viviane Vaz, Fernando Marques, Bernardo L. Horta

J Bras Pneumol.2004;30(3):223-228

Abstract PDF PT

Background: Although the prevalence of smoking among medical students declined steadily between the 1960s and 1980s, it seems to have stabilized in recent years. Objectives: To evaluate temporal trends, over the last 17 years, in the smoking habits of medical students at the Universidade Federal de Pelotas, in the state of Rio Grande do Sul, Brazil, and to identify some possible risk factors for smoking. Method: Cross-sectional surveys with comparable methodologies were conducted in 1986, 1991, 1996 and 2002. Self-administered questionnaires were used. Smokers were defined as those who were smoking at least one cigarette per day for at least one month. Descriptive analyses were carried out, as well as crude evaluations using chi-square tests for heterogeneity and linear trend. In addition, Poisson regression, adjusted for age, was used in order to evaluate the effect of medical school class year on the incidence of smoking. Results: The prevalence of smoking among UFPel medical students was 10.1%, statistically similar to values found in 1991 and 1996. No differences in smoking frequency were found relating to sex, age, or parental smoking. The prevalence of smoking was found to increase progressively over the course of medical school. Conclusions: The downward trend in smoking prevalence among UFPel medical students is being replaced by a stable rate of approximately 10-15%. Anti-smoking campaigns are still necessary in university environments, especially in medical schools.

 


Keywords: Smoking/trends. Smoking/epidemiology. Medical students/tobacco use cessation. Cross-sectional studies. Questionnaires.

 

8 - Community-acquired pneumonia in elderly patients: adherence to Brazilian guidelines for the treatment of pneumonia

Pneumonias adquiridas na comunidade em pacientes idosos: aderência ao Consenso Brasileiro sobre Pneumonias

José Roberto de Almeida, Olavo Franco Ferreira Filho

J Bras Pneumol.2004;30(3):229-236

Abstract PDF PT

Background: Pneumonia is a common disease with a high mortality rate, being the sixth leading cause of death among elderly people in the USA and the fifth among those in Brazil. Initial treatment of pneumonia is usually empirical since the ethiological agent is identified in only approximately 50% of cases. Therefore, several scientific societies have defined some guidelines for initial antimicrobial therapies. Objectives: This study evaluated adherence to the guidelines set forth by the Consenso Brasileiro sobre Pneumonias (Brazilian Consensus on Pneumonia) for treatment of community-acquired pneumonia in hospitalized elderly patients. Method: Fifty-four patients, aged 60 or over, hospitalized at Londrina University Hospital with community-acquired pneumonia between 2 August 1999 and 2 August 2000 were evaluated. Whether their treatment adhered or did not adhere to guidelines, the patients were compared in terms of 30-day mortality, average time for clinical stabilization, average length of hospital stay, cost of treatment and severity score. Results: The average age was 74.1, and 61.1% of the patients were treated in accordance with the Brazilian guidelines for treatment of community-acquired pneumonia. There were no differences in length of hospital stays, cost of treatment, time to clinical stability and severity score between the two groups (adherent and non-adherent). However, there was a difference in mortality. The rate of mortality was higher in patients with pneumonia severity index (PSI) scores of IV or V who were treated according to the guidelines than in those with the same score whose treatment was non-adherent (p = 0.04). In general, PSI score was related to mortality. The mortality rate among patients with scores of II and III was 9.5%, compared with 30.3% in patients with scores of IV and V. Conclusion: Adherence to the Brazilian guidelines for treatment of community-acquired pneumonia in elderly patients was satisfactory, and there was no difference in results between both groups, except for the higher mortality rate found for patients with higher PSI scores who were treated according to the guidelines. A positive correlation was found between PSI score and mortality.

 


Keywords: Pneumonia. Health Planning Guidelines. Community-Acquired Infections. Health Services for the Aged.

 

9 - Percutaneous Tracheostomy in Critically-ill Patients: The Experience of a Medical Intensive Care Unit

Traqueostomia percutânea no doente crítico: a experiência de uma unidade de terapia intensiva clínica

Marcelo Park, Leonardo Brauer, Ricardo Reis Sanga, André Carlos Kajdacsy-Balla Amaral, José Paulo Ladeira, Luciano Cesar Pontes de Azevedo, Leandro Utino Taniguchi, Luiz Monteiro da Cruz-Neto

J Bras Pneumol.2004;30(3):237-242

Abstract PDF PT

Background: Tracheostomy is a procedure commonly required in the intensive care unit. In the last two decades, the use of the percutaneous method has increased in parallel with improvements in the technique. Objective: To describe our experience in employing the percutaneous method over the last 3.5 years. Methods: We created, retrospectively, a database of prospective tracheostomy data related to 78 patients evaluated between January 2000 and July 2003. We used the percutaneous tracheostomy techniques of either progressive dilatation (in 36 patients) or forceps dilatation (in 42 patients). Data are expressed as number of occurrences or median with interquartile ranges. Results: The mean age of the patients was 66 (range, 43-75), and the median APACHE II score was 16 (range, 12-21). The median time spent on mechanical ventilation prior to tracheostomy was 14 days (range, 10-17 days). Of the 78 patients studied, 18 (23%) died while in the intensive care unit. The most common cause of admission was acute central nervous system disturbance (in 45%). Most of the tracheostomies performed were indicated due to difficulty in weaning from mechanical ventilation (in 50%) or to Glasgow Coma scores consistently lower than 8 (in 49%). Bronchoscopy was used in all but 6 of the procedures. There were complications in 33% of the procedures. The most common complication was light bleeding, without need for transfusion. No patient died due to complications arising from the procedure. Conclusion: Percutaneous tracheostomy is reasonable and safe when performed in an intensive care unit.

 


Keywords: Tracheostomy/methods. Respiration, Artificial/methods. Respiratory insufficiency/therapy. Respiratory insufficiency/complications.

 

10 - Clinical and epidemiological characteristics of contagious adult of tuberculosis in children

Características clínicas e epidemiológicas do adulto contagiante da criança com tuberculose

João Ab Lima, Edgar Enrique Sarria Icaza, Beatriz G. Menegotto, Gilberto Bueno Fischer, Sérgio Saldanha Menna Barreto

J Bras Pneumol.2004;30(3):243-252

Abstract PDF PT

Background: Tuberculosis in children generally occurs as a direct result of cohabitation with a contagious adult. Objective: To create a profile of a typical adult with contagious tuberculosis (as identified through the public health system) living with a child who has been diagnosed with tuberculosis. Method: Case study. Children younger than 14 years of age who were diagnosed with tuberculosis were included. Parents were interviewed using structured questionnaires. Means and standard deviations were analyzed using the Student's t-test. Fisher's exact test or the Dz test was used for comparisons. Results: Fifty children, representing 96% of those diagnosed with tuberculosis in the Porto Alegre health care system between July 20, 2001 and August 10, 2002, were included. The mean age was 76 months, and 60% were girls. The classic forms of pulmonary presentation (consolidation or cavitation) were seen in 38%. The majority of the children were diagnosed in the hospital and came from homes in which there were (a mean of) 6 cohabitants and a total family income less than 2 times the local minimum wage. Using ELISA, HIV co-infection was identified in 25% (although not all were tested). The children regularly visited places other than their homes. In 78% of cases, the contagious adult was identified. These contagious adults were mostly males (56%), and the mean age was 32. In most cases (79%), the contagious adult was a relative, usually a parent. Within this group of adults with contagious tuberculosis, HIV co-infection was identified in 43% of those tested. Conclusions: Adults with contagious tuberculosis living in the home continue to be the most likely source of tuberculosis infection in children. Co-infection with HIV in these pediatric patients, as well as in the cohabiting adults with contagious tuberculosis, is a significant finding. It must be emphasized that the possibility of contact with contagious individuals in the home should be explored in every diagnosed case of pediatric tuberculosis.

 


Keywords: Tuberculosis/epidemiology. Children. Communicable diseases/etiology.

 

Upgrading

11 - Pulmonary Medicine residency in Brazil

A residência médica em Pneumologia no Brasil

Evandro Guimarães de Sousa

J Bras Pneumol.2004;30(3):253-259

Abstract PDF PT

Background: A residency in Pulmonary Medicine represents the best source of training for those who wish to specialize in the area. In Brazil, the Comissão Nacional de Residência Médica (National Committee of Medical Residency) regulates such programs. Objective: To analyze the number of programs and their levels state of accreditation, the number of residents and the distribution of these programs and residents among the various institutions throughout Brazil. Methods: The list of programs furnished by the National Committee of Medical Residency in April 2003 was analyzed, and the basic criteria for accreditation in the area (according to the legislation currently in effect) were reviewed. Results: Of the 58 accredited programs, 35 are offered in hospitals in the southeastern region of Brazil, and 133 of the residents are also there. In contrast, there is only 1 accredited program, and there are only 3 residents enrolled in that program. Conclusion: Although all 58 programs are accredited, most are clustered in the southeastern region. It is therefore necessary that the Comissão Nacional de Residência Médica and the Sociedade Brasileira de Pneumologia e Tisiologia (Brazilian Society of Pulmonology and Phthisiology) begin a joint project in order to manage the creation of new programs. Thus, the number of programs and residents required for each of the various regions could be determined.

 


Keywords: Residency/Medical, Pulmonary Disease (Specialty), Internship and Residency

 

Case Report

12 - Shrinking lung syndrome in systemic lupus erythematosus

Síndrome do pulmão encolhido no lúpus eritematoso sistêmico

Cíntia Andrade Costa, Dálvaro Oliveira de Castro Jr., Sérgio Jezler, Mettermayer Santiago

J Bras Pneumol.2004;30(3):260-263

Abstract PDF PT

Systemic lupus erythematosus (SLE) may involve the respiratory tract in several ways, such as through pleuritis, pneumonitis, interstitial disease or pulmonary hypertension. In rare cases, SLE patients present a syndrome characterized by dyspnea, chest pain and abnormalities in pulmonary function testing, although there may be no evidence of major parenchymal lung disease on computerized tomography scans. This condition has come to be known as shrinking lung syndrome. We report a case that meets these diagnostic criteria, emphasizing the pathogenesis proposed, as well as the therapeutic options available.

 


Keywords: Lupus Erythematosus/Systemic, Respiratory System, Shrinking Lung Syndrome

 

13 - Severe form of hantavirus cardiopulmonary syndrome managed with continuous positive airway plessure through facial mask

Forma grave da síndrome pulmonar e cardiovascular por hantavírus tratada com pressurização positiva através de máscara facial

Mariangela Pimentel Pincelli, Carlos Roberto Ribeiro de Carvalho, Luis Tadeu Moraes Figueiredo, Antônio Delfino de Oliveira Júnior, Ana Lúcia Bernardo Soares, Carmen Sílvia Valente Barbas

J Bras Pneumol.2004;30(3):264-269

Abstract PDF PT

In 1993 the first Brazilian cluster of Hantavirus Cardiopulmonary Syndrome (HCPS) was described in Juquitiba, SP. Since then, there have been descriptions of new cases specially on the southeast and south states of Brazil. Only in 2002 there were observed the first three cases of HCPS in our city: São Carlos. One of our patients was successfully supported with CPAP through facial mask. This is the first severe case of acute respiratory failure induced by Hantavirus that was successfully managed with this kind of respiratory strategy.

 


Keywords: Noninvasive Ventilation, CPAP, Hantavirus Pulmonary and Cardiovascular Syndrome, Acute Hipoxemic Respiratory Failure.

 

14 - Acute disseminated histoplasmosis in an immunocompetent patient

Histoplasmose disseminada aguda em indivíduo imunocompetente

Simone Castelo Branco Fortaleza, Silvia Karine de Albuquerque Lopes, Tereza de Jesus Bandeira, Teresa Neuma Albuquerque Gomes Nogueira, Marcelo Alcântata Holanda

J Bras Pneumol.2004;30(3):270-273

Abstract PDF PT

Histoplasmosis is a fungal disease caused by inhalation of Histoplasma capsulatum fungus. The disease does not normally affect immunocompetent individuals after a single, transient inhalation exposure. However, longer exposure may cause chronic or disseminated acute pulmonary infection. In immunocompromised patients, the infection is disseminated and severe. We report the case of a 13-year-old immunocompetent patient, presenting with fever, cough and dyspnea for one month. The chest X-ray and computed tomography scan revealed interstitial infiltrate and diffuse micronodules. The patient reported having had close and prolonged contact with birds. He was submitted to an open lung biopsy and the tissue culture was positive for Histoplasma capsulatum sp. He was treated with amphotericin B for 28 days, followed by treatment with itraconazole for 6 months, and there was complete resolution of the disease.

 


Keywords: Histoplasmosis, Immunocompetence, Birds.

 

Review Article

15 - Economic evaluation of the impact of chronic obstructive pulmonary disease and its acute exacerbations on Latin America

Avaliação econômica da doença pulmonar obstrutiva crônica e de suas agudizações. Aplicação na América Latina

Marc Miravitlles

J Bras Pneumol.2004;30(3):274-285

Abstract PDF PT

Chronic obstructive pulmonary disease is highly prevalent the world over. An estimated 7% to 10% of the global adult population is affected. In Brazil, the incidence of chronic bronchitis is 12.7% among individuals over the age of 40. Economic studies have great relevance in devising policies for dealing with diseases of such high prevalence. The majority of data related to the costs of chronic obstructive pulmonary disease is culled from national health databases. There have been only a few studies evaluating the direct public health costs of the disease. In analyzing those studies, one can conclude that a chronic obstructive pulmonary disease patient generates a direct annual expenditure of 1200 to 1800 USD. However, the cost is correlated with the severity of the disease. Patients suffering from the more severe forms can require as much as double that expenditure, and early diagnosis is therefore vital. The most cost-effective strategy is early detection of the disease, in concert with anti-smoking campaigns. In the most advanced stages of the disease, the greatest costs are incurred due to hospitalization. In such cases, correct treatment of the acute exacerbations of the disease is crucial to minimizing costs. The average cost of a hospital stay in Brazil is 2761 Brazilian reals, which is equal to that of one full year of outpatient treatment. Antibiotic therapy accounts for only a small fraction of the total cost of treating such acute exacerbations. The use of more efficacious antibiotics may represent a more cost-effective strategy for reducing the rate of treatment failure. Economic analysis should allow for the identification and implementation of the most cost-effective strategies for treating this disease.

 


Keywords: Smoking/adverse effects. Tobacco use cessation/methods. Pregnancy.

 

16 - Critical analysis of scoring systems used in the assessment of Cystic Fibrosis severity: State of the art

Análise crítica dos escores de avaliação de gravidade da fibrose cística: Estado da arte

Camila Isabel da Silva Santos, José Dirceu Ribeiro, Antônio Fernando Ribeiro, Gabriel Hessel

J Bras Pneumol.2004;30(3):286-

Abstract PDF PT

This study carries out a descriptive and comparative analysis of the various types of cystic fibrosis severity scores described in the literature and contextualizes the origin and objective of each. A total of 16 scoring systems were found: 8 are used predominantly for clinical evaluation, 5 for radiographic findings, 2 for tomographic findings and 1 for scintigraphic findings. Despite the criticism and controversy regarding these instruments of assessment, they have contributed to a better understanding of the disease and to the development of more effective therapeutic procedures.

 


Keywords: Severity of illness index. Cystic fibrosis. Review literature.

 

Year 2004 - Volume 30  - Number 4  (July/August)

Editorial

1 - Participation of researchers from the Brazilian Network of Tuberculosis Research in the activities of the Brazilian Journal of Pulmonology, official publication of the Brazilian Society of Pulmonology and Phthisiology

Incorporação de atores da Rede Brasileira de Pesquisa em TB nas atividades do Jornal Brasileiro de Pneumologia da Sociedade Brasileira de Pneumologia e Tisiologia

Afrânio Lineu Kritski

J Bras Pneumol.2004;30(4):394-397

PDF PT PDF EN Portuguese Text


2 - Tuberculosis load: reflections on a theme

Carga da tuberculose: reflexões sobre o tema

Antonio Ruffino Netto

J Bras Pneumol.2004;30(4):398-400

PDF PT PDF EN Portuguese Text


3 - Another milestone for the Brazilian Journal of Pulmonology

Um novo marco no Jornal Brasileiro de Pneumologia

Geraldo Lorenzi Filho

J Bras Pneumol.2004;30(4):401

PDF PT PDF EN Portuguese Text


Original Article

4 - Occurrence of active tuberculosis in households inhabited by patients with susceptible and multidrug-resistant tuberculosis

Ocorrência de tuberculose doença entre contatos de tuberculose sensível e multirresistente

Elizabeth Clara Barroso; Rosa Maria Salani Mota; Valéria Góes Ferreira Pinheiro; Creusa Lima Campelo; Jorge Luis Nobre Rodrigues

J Bras Pneumol.2004;30(4):401-408

Abstract PDF PT PDF EN

Background: Since the first years of antituberculosis chemotherapy, there has been controversy regarding the transmissibility, infectiousness, virulence and pathogenicity of susceptible and drug-resistant strains of Mycobacterium tuberculosis. Objective: To determine the incidence of active tuberculosis (TB) among individuals cohabiting with patients infected with susceptible and multidrug-resistant tuberculosis (MDR-TB). Methods: A case-control study was conducted. Cases of MDR-TB were defined as those infected with M. tuberculosis strains resistant to at least rifampin and isoniazid. Susceptible TB cases (controls) were defined as those first treated at approximately the same time as the first treatment of the MDR-TB cases - and cured by the time of the interview. Study cases were selected on the basis of the results of susceptibility tests, using the proportion method, carried out at the Central Laboratory of Public Health of the State of Ceará. The control group consisted of patients enrolled in the Tuberculosis Control Program between 1990 and 1999. Results: We evaluated 126 patients and 176 controls. The number of individuals sharing the household with patients was 557 in the MDR-TB group and 752 in the controls. The average number of exposed individuals per index case was 4.42 and 4.27 among patients and controls, respectively. Of the 557 MDR-TB-exposed individuals, 4.49% (25)received antituberculosis treatment after the respective index case had begun treatment, compared to 5.45% (41/752) among the controls ( p = 0.4468). Microepidemics of MDRTB were confirmed in eight families. Conclusion: Our results suggest that the incidence of active TB is comparable between households inhabited by MDRTB patients and those inhabited by susceptible-TB patients.

 


Keywords: Tuberculosis, multidrug-resistant/epidemiology. Tuberculosis/trasmission.

 

5 - Efficiency of clinical, radiological and laboratory testing in the diagnosis of pleural tuberculosis

Rendimento de variáveis clínicas, radiológicas e laboratoriais para o diagnóstico da tuberculose pleural

Denise Duprat Neves; Ricardo Marques Dias; Antônio José Ledo Alves da Cunha; Antonio Monteiro da Silva Chibante

J Bras Pneumol.2004;30(4):409-416

Abstract PDF PT PDF EN

Background: In Brazil, tuberculosis is the major cause of pleural effusion. In more than 50% of cases, treatment has been initiated prior to confirmation of the diagnosis. Our objective was to identify factors that can contribute to the diagnosis. Method: We studied 215 consecutive patients with pleural effusion: 104 from tuberculosis (TB) and 111 from other causes (41 were from malignancies, 29 involved transudation, 28 were parapneumonic and 13 were from other etiologies). Clinical, radiological and laboratorial variables were evaluated for differences between the two groups, individually or in combination. Results: Male gender and PPD > 10 mm were significantly more frequent in the tuberculosis group. Radiological features were similar in both groups. Among the continuous variables, adenosine deaminase (ADA), percentile of cells, protein and age performed better as isolated diagnostic criteria. Between the group with tuberculosis and that with pleural effusion from other causes, no significant differences were found in Lactate dehydrogenase, total leukocytes or duration of disease. The correlation of ADA with any other welldeveloped continuous variable showed an LR+ > 10 and an LR- < 0.1, which effectively confirmed or ruled out a diagnosis of tuberculous pleural effusion. Conclusions: In patients with ADA levels > 39 at 95% sensitivity, the specificity can be improved to more than 90% if we consider non purulent effusion or effusion with a predominance of lymphocytes (> 50%).

 


Keywords: Tuberculosis, pleural/diagnosis. Adenosine deaminase/diagnosis use. Sensitivity and specificity.

 

6 - Deaths attributed to tuberculosis in the state of Rio de Janeiro

Óbitos atribuídos à tuberculose no Estado do Rio de Janeiro

Lia Selig; Márcia Belo; Antônio Jose Ledo Alves da Cunha; Eleny Guimarães Teixeira; Rossana Brito; Ana Lucia Luna; Anete Trajman

J Bras Pneumol.2004;30(4):417-424

Abstract PDF PT PDF EN

Background: In 1998, tuberculosis incidence and mortality rates in the state of Rio de Janeiro (RJ) were the highest in Brazil. However, the RJ tuberculosis database (SINAN-TBRJ) has proven unreliable. Objective: To evaluate the current tuberculosis control program by analyzing tuberculosis-attributed deaths. Methods: Descriptive studies of the SINAN-TB-RJ and tuberculosis mortality (SIM-TB-RJ) databases were carried out. Both databases were linked using the Reclink program. A study based on medical records was performed in the five hospitals where the greatest numbers of tuberculosis deaths occurred. Results: In the SINAN-TB-RJ database, 16,567 cases were registered in adults (> 14 years of age). Pulmonary disease was present in 13,989 (84.5%), of whom 8223 (56.8%) presented sputum smears that were positive for acid fast bacilli. Anti-HIV testing, recommended for all patients with tuberculosis, was performed in only 4141 (25%) of tuberculosis cases. The SIM-TB-RJ database showed 1146 deaths that were attributed to tuberculosis. Only 478 (41.7%) of those had been reported to the health care system (SINAN-TB-RJ). Among the 302 medical records analyzed, 154 (50.9%)recorded hospitalizations of up to 10 days and 143 (47.3%) had respiratory symptoms for more than 60 days before diagnosis. Among 125 cases of retreatment, the RHZE regimen recommended by the Brazilian Ministry of Health was prescribed for only 43 (34.4%). Conclusion: This study demonstrates weakness in the RJ tuberculosis control program, characterized by delayed diagnosis, limited use of the recommended tests, poor reporting, and non-compliance with the Ministry of Health guidelines.

 


Keywords: Tuberculosis. Epidemiology. Program Evaluation

 

7 - Drug-resistant Mycobacterium tuberculosis strains isolated at an AIDS reference center general hospital in Rio de Janeiro

Resistência aos medicamentos anti-tuberculose de cepas de Mycobacterium tuberculosis isoladas de pacientes atendidos em hospital geral de referência para tratamento de AIDS no Rio de Janeiro

Rossana Coimbra Brito; Celine Gounder; Dirce Bonfim de Lima; Hélio Siqueira; Hebe Rodrigues Cavalcanti; Maracy Marques Pereira; Afrânio Lineu Kritski

J Bras Pneumol.2004;30(4):425-432

Abstract PDF PT PDF EN

Background: Tuberculosis become important challenge to health care settings. Brazil has high prevalence of the disease and Rio de Janeiro has high incidence rates with 30% of cases notified at hospitals. Objective: To evaluate prevalence of initial and acquired drug resistance at a general hospital, reference for aids treatment in Rio de Janeiro and to identify associated factors. Methods: Mycobacterium tuberculosis strains from 165 patients were analyzed, between August 1996 and February 1998. Results: Twenty per cent (33/165) were resistant to at least one drug; 13% (12/165) to isoniazid; 3.64% (6/ 165) to rifampin and 3.64% (6/165) to both. Among HIV seropositive subjects (52/165); 28.85% (15/52) were resistant to at least one drug. Acquired resistance occurred in 15.79% of 19 patients that mentioned previous antiTB treatment. Association statistically significant was found with non cavitation on X-ray in bivariate analyses ( P=0.05). Eighty four patients refereed no previous treatment (NPT). Resistance to 1 or more drugs was found in 28.57% (24/84) of NPT patients. Association statistically significant with initial resistance was found with health care workers (P=0.004), unemployment (P=0.03), and diarrhea (P=0.01) in bivariate analyses. On multivariate analyses, health care workers ( P=0.002) remained significantly associated with initial resistance. Conclusions: High resistance rates was found. It corroborates that hospitals needs attention for TB control especially which concerns to health care works infection.

 


Keywords: Mycobacterium tuberculosis. Drug resistance. Disease transmission, patient to professional. Hospitals.

 

8 - Analysis of different primers used in the PCR method: diagnosis of tuberculosis in the state of Amazonas, Brazil

Análise de diferentes primers utilizados na PCR visando ao diagnóstico da tuberculose no Estado do Amazonas

Mauricio Morishi Ogusku; Julia Ignez Salem

J Bras Pneumol.2004;30(4):433-439

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Background: Various primers are being tested for the detection of Mycobacterium tuberculosis DNA. The accuracy of the polymerase chain reaction (PCR) depends on the target sequence used and whether the test will be performed in culture or in clinical specimens. Objectives: To identify DNA sequences, specifically those commonly reported as targets for diagnosis of tuberculosis (TB), in clinical samples of M. tuberculosis strains. Method: Eighty-one clinical samples from suspected TB patients were initially processed and submitted to bacilloscopy (smear) and culture, and PCR was performed with specific primers for the following targets: IS 6110, 65 kDa, 38 kDa and MPB64. Results: Smear and culture results were negative in 24 samples, as was the PCR. The 19 samples testing smear positive, as well as the isolated strains, were 100% positive on PCR, with the exception of the 89.4% result from PCR with MPB64 primers. In the 38 smear negative and culture positive samples, PCR results were inconsistent. The primers specific for amplifying the 123 bp IS 6110 fragment gave the highest positivity (92.1%), diagnostic agreement (0.9143), co-positivity (94.7%) and co-negativity (100%). Conclusion: The IS 6110, 38 kDa, MPB64 and 65 kDa sequences were found in the genome of all M. tuberculosis strains isolated in patients from the state of Amazonas. The protocol for processing the clinical samples prior to PCR analysis and the specific primers used to amplify the 123bp IS 6110 fragment showed a greater efficiency in diagnosing pulmonary (paucibacillary) tuberculosis in comparison to published data.

 


Keywords: Primers/PCR. Diagnosis/Tuberculosis. Mycobacterium tuberculosis.

 

9 - Prevalence of tuberculin skin testing among medical students in Campos School of Medicine, Rio de Janeiro

Prevalência da prova tuberculínica positiva entre alunos da Faculdade de Medicina de Campos (RJ)

Luiz Clovis Parente Soares; Fernanda C. Queiroz Mello; Afrânio Lineu Kritski

J Bras Pneumol.2004;30(4):440-447

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Background: The Hospital Ferreira Machado, utilized, in part, as a clinical training center for graduate students from the Faculdade de Medicina de Campos, admitted 65 tuberculosis (TB) patients in 2001. Objective: To estimate the prevalence of positive tuberculin skin tests (TST) among medical students during distinct periods of their training and to identify and analyze correlated factors. To compare positivity rates, taking into account the booster effect, and estimate incidence of positive TST by class year. Methods: A cross-sectional study was conducted among 500 students registered in the first semester of 2002. Using a structured and validated questionnaire, data regarding demographics, BCG vaccination and potential exposure to TB patients were obtained. A professional licensed by the Health Department administered the TSTs, and the twostep Mantoux method (PPD Rt23) was used. Results: Of the 500 eligible subjects, 316 (63.2%) were excluded. Analysis showed increasing two-step TST positivity rates corresponding to extent of clinical experience (4%, 6.4% and 13.1%) and a tendency toward correlation with professional level. The highest percentage of positive TSTs was found during the period of clinical training, which corresponded to the time of greatest exposure to patients (1000 hours). Conclusions: a) the TST positivity rate was high (7.9%) among students; b) TST was correlated with in-hospital training stage; c) evaluation of the booster effect lead us to highly recommended boosters in order to reduce the number of false-negative TST results.

 


Keywords: Tuberculin. Tuberculin test. Tuberculosis. Students/Medical. Cross-sectional studies.

 

10 - Molecular analysis of Mycobacterium tuberculosis strains from an outpatient clinic in Porto Alegre, (RS)

Análise molecular de cepas de Mycobacterium tuberculosis provenientes de um centro de saúde ambulatorial em Porto Alegre, (RS)

Michele Borges; Patrícia Izquierdo Cafrune; Lia Gonçalves Possuelo; Andréia Rosane de Moura Valim; Marta Osório Ribeiro; Maria Lucia Rosa Rossetti

J Bras Pneumol.2004;30(4):448-454

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Background: Tuberculosis is an ancient disease, which still remains one of the major ills faced by mankind in the 21st century. In recent decades, new technologies employing the knowledge gained from molecular biology studies have allowed for more accurate detection of tuberculosis and increased investigation of the etiology and epidemiology of the disease. Aim: Evaluating the degree of similarity among strains of Mycobacterium tuberculosis provided by the Phthisiology Sector of Centro de Saúde Navegantes (Navegantes Health Clinic) in Porto Alegre, RS, Brazil. Method: A retrospective study was performed involving RFLP typing of 55 sputum samples from outpatients examined at the Centro de Saúde Navegantes. The results of the genotyping were correlated to the conventional epidemiology data. Results: A single pattern was seen in 39 (70.9%) of the isolates, whereas 16 isolates (29.1%) showed clustering patterns and were grouped into 8 clusters of 2 patients each. An epidemiological link was found for 6 (37.5%) of the 16 patients in the clusters. Conclusion: The appropriate combination of conventional epidemiology and genotyping of M. tuberculosis contributes to a better understanding of the dynamics of tuberculosis transmission even when such a study is performed in a single, isolated health clinic.

 


Keywords: Mycobacterium tuberculosis. Transmission. Polymorphism, Restriction Fragment Length. Epidemiology.

 

11 - Evaluation of rapid microplate assays using cellular-viability indicators to determine patterns of susceptibility to isoniazid and rifampin in Mycobacterium tuberculosis strains

Avaliação de testes rápidos em microplacas usando indicadores de viabilidade celular para determinação da susceptibilidade de cepas de Mycobacterium tuberculosis à isoniazida e rifampicina

Marta Osório Ribeiro; Marlei da Silva Gomes; Simone Gonçalves Senna; Maria Lucia Rosa Rossetti; Leila de Souza Fonseca

J Bras Pneumol.2004;30(4):455-460

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Background: Knowledge of the rates of drug resistance is one of the pillars of tuberculosis control program evaluation. Data from low-resource countries are scarce and results are delayed due to the techniques employed. There is therefore an urgent need for evaluation of faster and less onerous testing methods. Objective: To compare the performance of rapid colorimetric assays for phenotyping that employ oxidationreduction indicators to determine the susceptibility profile of Mycobacterium tuberculosis with the gold-standard proportion method on Lowenstein-Jensen Medium. Method: We analyzed 166 M. tuberculosis strains of known susceptibility. Minimal inhibition concentrations for isoniazid and rifampicin were determined in microplates, using a liquid medium and Alamar Blue and tetrazolium bromide indicators. To measure agreement the Kappa value was used. Cutoff values between sensitive and resistant strains were defined as 0.2µg/mL and 1.0µg/mL for isoniazid and rifampicin, respectively. Results: There was 100% concordance between Alamar Blue and tetrazolium bromide methods in the determination of minimal inhibition concentrations. Agreement between the colorimetric method and the Lowenstein-Jensen was 95% for isoniazid and rifampicin. Using the colorimetric method, results were obtained within 7 days, in contrast to the 28 days required for the conventional method. Conclusions: Assays to determine minimal inhibition concentrations in liquid medium and employing oxidationreduction indicators proved to be rapid and inexpensive. This method has the potential to become a faster, alternative method for determining susceptibility of M. tuberculosis strains in developing countries.

 


Keywords: Mycobacterium tubercolis. Disease susceptibility. Isoniazid/therapeutic use. Rifampin/therapeutic use.

 

12 - Single Nucleotide Polymorphisms (SNPs) of the TNF-á (-238/-308) gene among TB and nom TB patients: Susceptibility markers of TB occurrence?

Distribuição de Polimorfismos de Base única (SNPs) no gene de TNF-a (-238/-308) entre pacientes com TB e outras pneumopatias: marcadores genéticos de susceptibilidade a ocorrência de TB?

Martha Maria de Oliveira; Jocilea C. S. da Silva; Joseane F. Costa; Lúcia Helena Amim; Carla C. S. Loredo; Hedi Melo; Luiz F. Queiroz; Fernanda C. Q. Mello; José Roberto Lapa e Silva; Afrânio Lineu Kritski; Adalberto Rezende Santos

J Bras Pneumol.2004;30(4):461-467

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Background: Host genetic factors may play a role in the susceptibility to active tuberculosis (TB), and several polymorphisms in different cytokine coding genes have been described and associated with diseases to date. Objectives: To investigate whether polymorphisms within the promoter region of the TNF-á (-238/-308) coding genes are associated to the occurrence of active TB. Methods: SNPs within the TNF-á gene were analyzed by PCR-RFLP among two groups of individuals: patients with TB (n = 234, and patients non TB (n = 113). Results: In this study, the presence of the -238A allele was associated with susceptibility to TB disease occurrence and severity (p = 0,00002; OR = 0,15; IC = 0,06-0,36. On the contrary, the -308A allele was associated with protection to the occurrence of another pulmonary diseases. Conclusions: These results suggest the importance of genetics studies on TB occurrence. Further studies are needed pursuing a better understanding of the human pathogenesis of M. tb.

 


Keywords: Tuberculosis/genetics. Polymorphism, single nucleotide/genetics. Tumor necrosis factor/genetics. Alleles. Genotype. Lung diseases.

 

Review Article

13 - Could a DNA vaccine be useful in the control of tuberculosis?

É possível uma vacina gênica auxiliar no controle da tuberculose?

José Maciel Rodrigues Júnior; Karla de Melo Lima; Arlete Aparecida Martins Coelho Castelo; Vânia Luiza Deperon Bonato Martins; Sandra Aparecida dos Santos; Lucia Helena Faccioli; Célio Lopes Silva

J Bras Pneumol.2004;30(4):468-477

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The DNA vaccines currently under pre-clinical and clinical development may prove to be important tools in combating infectious diseases, such as tuberculosis, for which no safe and effective form of prevention has yet been developed. In recent years, several studies have aimed to develop a DNA vaccine encoding mycobacterial proteins such as antigen 85 (Ag85) and the 65-kDa mycobacterial heat shock protein (hsp65). The latter is protective against virulent infection with Mycobacterium tuberculosis (including multidrugresistant strains). The hsp65 DNA vaccine, currently under clinical evaluation in Brazil for cancer therapy, is able to induce the secretion of Th1 cytokines, such as gamma-interferon, associated with disease control. Furthermore, this vaccine stimulates cytotoxic CD8 and CD4 T-cell clones that can be characterized as memory cells, which are responsible for effective and longlasting immunity against tuberculosis. When used as a therapeutic agent in inoculated mice, the hsp65 DNA vaccine promotes changes in the immunity profile, triggering the secretion of Th1 cytokines and establishing a favorable environment for the elimination of bacilli. The results also demonstrate that the route of administration, as well as the formulation in which the vaccine is administered, fundamentally influence the pattern and duration of the immune response induced. Taking all currently available data into account, we can conclude that a DNA vaccine against tuberculosis could contribute significantly to the control of the disease.

 


Keywords: Tuberculosis/epidemiology. Vaccines, DNA/therapeutic use. Heat shock proteins. Auto-immunity.

 

14 - The resurgence of tuberculosis and the impact of the study of pulmonary immunopathogenesis

O ressurgimento da tuberculose e o impacto do estudo da imunopatogenia pulmonar

José Roberto Lapa e SilvaI; Neio BoéchatII

J Bras Pneumol.2004;30(4):478-484

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The resurgence of tuberculosis as one of the most important infectious diseases to affect mankind came after the illusion that the disease was under control and would be eradicated before the end of the 20th Century. Over the last 10 years, in association with American and European research centers, our group at the Universidade Federal do Rio de Janeiro has been dedicated to investigating the pathogenic mechanisms involved in pulmonary tuberculosis. Due to its frequency and role in transmission, pulmonary tuberculosis is the most serious form of the disease. Our hypothesis is that the establishment of latent infection and its progression to active disease depend on an imbalance between activating and deactivating cytokines at the disease site. Despite the presence of protective mechanisms such as the macrophage expression of phenotypes (denoting cellular and molecular activation of agents involved in protection, such as nitric oxide and interferon-ã), tuberculosis progresses. A possible explanation for this is the concomitant presence at the site of infection of molecules such as interleukin-10 and TGF-â, which are able to deactivate previously activated macrophages. Recent data suggest that mycobacteria secrete proteins capable of inducing interleukin-10, thus contributing to overcoming host protective mechanisms. Susceptible individuals would be more able to produce larger amounts of these molecules due to genetic polymorphisms that facilitate interleukin-10 production at infection onset. The understanding of these mechanisms could advance the prevention and discovery of new therapeutic targets for the control of tuberculosis.

 


Keywords: Tuberculosis/ethiology. Tuberculosis pulmonary/pathology.

 

15 - Chemoprophylaxis in the prevention of tberculosis

Quimioprofilaxia na prevenção da tuberculose

Norma I Soza Pineda; Susan M. Pereira; Eliana Dias Matos; Mauricio L Barreto

J Bras Pneumol.2004;30(4):485-495

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Tuberculosis chemoprophylaxis is a therapeutic measure for the prevention of infection by Mycobacterium tuberculosis or to avoid development of the disease in individuals already infected with it. Isoniazid is the most commonly used therapy; however, the use of rifampicin and pyrazinamide has recently been introduced. The objectives of this study were to review the results of the principal studies evaluating the indications for chemoprophylaxis with isoniazid alone and in association with other drugs, its efficacy in the prevention of tuberculosis with respect to the different risk groups and the alternative regimens available. A systematic revision of the medical literature was carried out with particular emphasis on clinical trials and meta-analyses. Official records were also consulted. Those studies involving randomized clinical trials on the use of isoniazid, rifampicin or pyrazinamide in HIV-positive or negative patients were selected. Isoniazid continues to be effective for the prevention of tuberculosis in populations of both HIV-negative and HIV-positive individuals. The standard dose of 5-15 mg/kg/day has shown similar protection over treatment periods ranging from six to twelve months. The risk of developing hepatitis was less than 1%; however monitoring during treatment is recommended in patients over 35 years of age and in users of alcohol. Studies involving treatment regimens with other forms of medication were inconclusive and new studies would have to be performed to evaluate the efficacy of these regimens in populations at high risk of developing tuberculosis.

 


Keywords: Tuberculosis. Chemoprophylaxis. Isoniazid.

 

Letters to the Editor

16 - Limitations of the use of the mtp40 fragment as a marker of differentiation between Mycobacterium tuberculosis and M. bovis

Limitações do uso do fragmento mtp40 como marcador de diferenciação entre Mycobacterium tuberculosis e M. bovis

Cristina Viana-Niero; Sylvia Cardoso Leão

J Bras Pneumol.2004;30(4):496-500

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Year 2004 - Volume 30  - Number 5  (September/October)

Editorial

1 - Uma realidade

Sérgio Saldanha Menna Barreto

J Bras Pneumol.2004;30(5):411-412

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Original Article

3 - Acceptability, preference, tolerance and clinical efficacy of dipropionate beclomethasone delivered by two inhalation devices in chronic asthma patients: Clenil pulvinal® versus Miflasona Aerolizer®

Avaliação da eficácia clínica, aceitabilidade e preferência de dois sistemas inalatórios de beclometasona no tratamento da asma : Pulvinal versus Aeroliser.

Jussara Fiterman, Waldo Mattos, Alberto Cukier, Márcia Pizzichinni, Rodnei Frare e Silva, Fabiane Kahan, José Roberto Jardim, Armando Brancatelli

J Bras Pneumol.2004;30(5):413-418

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Acceptability, preference, tolerance and clinical efficacy of dipropionate beclomethasone delivered by two inhalation devices in chronic asthma patients: Clenil pulvinal versus Miflasona Aerolizer Background: Approximately half of all asthmatic patients adhere to their prescribed treatment regimen, which makes noncompliance with treatment one of the main problems associated with the disease. It is possible that inhalation devices combining technological advances with comfort and simplicity of use could increase treatment compliance. Objective: To compare the acceptability of and preference for two inhalation devices (Pulvinal and Aerolizer), as well as to evaluate the efficacy of and tolerance for beclomethasone dipropionate when delivered by these two systems. Method: A multicenter, randomized, crossover parallel study was carried out involving 83 patients with stable asthma. Patients received 500-1000 g/day of beclomethasone dipropionate. After a 2-week run in, the patients were randomized to begin a 4-week crossover treatment period with equivalent doses of Clenil Pulvinal (CP) or Miflasona Aerolizer (MA). Results: Both groups showed improvement in dyspnea and FEV1, and acceptability was considered good or excellent in both groups. Of the patients studied, 50.6% preferred CP, and 39% preferred MA. In their future treatment regimes, 54.5% would choose the CP and 37.7% the MA. Conclusion: Clinical efficacy and acceptability were comparable between CP and MA.

 


Keywords: Asthma/therapy. Beclomethasone/ administration & dosage. Randomized controlled trials. Treatment Outcome.

 

4 - Bronchoscopy in Brazil

Broncoscopia no Brasil

Mauro Zamboni, Andréia Salarini Monteiro

J Bras Pneumol.2004;30(5):419-425

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Background: During recent years, bronchoscopy has evolved considerably. Numerous clinical investigations, symposia, congresses and training courses have demonstrated the renewed interest in respiratory endoscopy. However, it is unknown whether this has modified bronchoscopy practice. Objective: Obtain information regarding the opinions and practices of pulmonologists who perform diagnostic and therapeutic bronchoscopy in Brazil. Methods: A survey consisting of 56 questions was mailed to 576 pulmonologists associated with the SBPT-DER. Results: A total of 111 questionnaires (19.2%) were returned and analyzed. All respondents were familiar with flexible fiberoptic bronchoscopy, but only 45% had performed rigid bronchoscopy. Less than 15% of the responders had performed any therapeutic bronchoscopic procedure. Conclusions: The majority of respondents (87.3%) thought that pulmonary societies and specialized training centers should initiate and disseminate informative materials and programs to optimize and perfect the practice of respiratory endoscopy, including therapeutic bronchoscopy, in Brazil.

 


Keywords: Bronchoscopy. Survey. Bronchoscopy practice.

 

5 - Clinicopathological findings in pulmonary thromboembolism: a 24-year autopsy study

Achados clínicopatológicos na tromboembolia pulmonar: estudo de 24 anos de autópsias

Hugo Hyung Bok Yoo, Fabiana Guandalini Mendes, Christine Elisabete Rubio Alem, Alexandre Todorovic Fabro, José Eduardo Corrente, Thaís Thomaz Queluz

J Bras Pneumol.2004;30(5):426-432

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Background: Pulmonary thromboembolism (PTE) is still an enigmatic disorder in many epidemiological and clinical features, remaining one of the most commonly misdiagnosed disorders. Objective: To describe the prevalence and pathological findings of PTE in a series of autopsies, to correlate these findings with underlying diseases, and to verify the frequency of PTE clinically suspected before death. Method: The reports on 5261 consecutive autopsies performed from 1979 to 2002 in a Brazilian tertiary referral medical school were reviewed for a retrospective study. From the medical records and autopsy reports of the patients found with macroscopically and/or microscopically documented PTE, were gathered data on demographics, underlying diseases, antemortem suspicion of PTE, and probable PTE site of origin. Results: The autopsy rate was 42.0% and PTE was found in 544 patients. In 225 cases, PTE was the main cause of death (fatal PTE). Infections (p=0.0003) were associated with nonfatal PTE and trauma (p=0.007) with fatal PTE. The rate of antemortem unsuspected PTE was 84.6% and 40.0% of these patients presented fatal PTE. Diseases of the circulatory system (p=0.0001), infections (p<0.0001), diseases of the digestive system (p=0.0001), neoplasia (p=0.024) and trauma (p=0.005) were associated with unsuspected PTE. The most frequent PTE site of origin was the lower limbs (48.9%). Probable PTE sites of origin such as right-sided cardiac chambers (p=0.012) and pelvic veins (p=0.015) were associated with fatal PTE. Conclusion: A large number of cases do not have antemortem suspicion of PTE. Special attention should be paid to the possibility of PTE in patients with diseases of the circulatory system, infections, diseases of the digestive system, neoplasia, and trauma.

 


Keywords: Autopsy. Epidemiology. Pulmonary Thromboembolism.

 

6 - Comparative study evaluating outcomes of lobectomy and extended segmentectomy used in the treatment of primary non-small cell bronchial carcinoma

Estudo comparativo entre lobectomia e segmentectomia estendida para o tratamento do carcinoma brônquico não de pequenas células em estágios iniciais

Airton Schneider, Paulo Roberto Kriese, Luiz Augusto Lopes da Costa, Tiago José Refosco, Caroline Buzzatti

J Bras Pneumol.2004;30(5):433-438

Abstract PDF PT PDF EN

Background: Lobectomy is still considered the most effective method of controlling primary lung tumors. Method: During the period from 1995 to 2000, 733 cases of non-small cell bronchial carcinoma. After clinical evaluation and surgical staging, 191 patients were submitted to surgical resection. Of those 191 surgeries, 63 were for locally advanced tumors and 128 (69 segmentectomies and 59 lobectomies) for primary tumors. Post-operative FEV1 of at least 800 ml was used as a measure of surgical success. Extended segmentectomies, in which the resection passes the intersegmental line, including the parenchyma of the adjoining segment, were used. Results: Among the 128 patients with primary tumors, there were 3 deaths and 10 patients fell out of contact. Therefore, 62 segmentectomies and 53 lobectomies were evaluated. There were 72 adenocarcinomas and 43 epidermoid carcinomas. The 5-year survival of lobectomy patients was 80% (T1N0), 72.7% (T2N0), 50% (T1N1) and 31.8% (T2N1), whereas that of segmentectomy patients was 80% (T1N0), 66.6% (T2N0), 41.1% (T1N1) and 30% (T2N1) (p > 0.05). Tumor size and enlarged interlobar lymph nodes were prognostically significant (p < 0.001), although method of resection influenced neither survival nor local or remote recurrence (p > 0.05). Conclusion: Extended segmentectomy represents an alternative treatment for primary tumors in patients with limited lung reserve.

 


Keywords: Lung Neoplasms, surgery. Pulmonary Surgical Procedures. Carcinoma, Non-Small-Cell Lung.

 

7 - Influence of pulmonary rehabilitation on the sleep patterns of patients with chronic obstructive pulmonary disease

Influência da reabilitação pulmonar sobre o padrão de sono de pacientes portadores de doença pulmonar obstrutiva crônica

Renata Cláudia Zanchet, Carlos Alberto de Assis Viegas, Terezinha do Socorro Macêdo Lima

J Bras Pneumol.2004;30(5):439-444

Abstract PDF PT PDF EN

Background: Pulmonary Rehabilitation (PR) improves the quality of life of chronic obstructive pulmonary disease (COPD) patients. However, the influence of PR on the sleep pattern of these patients is unknown. Objective: To evaluate the influence of PR on the sleep patterns of patients with COPD. Method: A total of 27 patients (22 men/5 women) were submitted to polysomnographic, gasometric and anthropometric studies before and after six weeks of PR and were evaluated using the Epworth Sleepiness Scale. The results were analyzed using paired Student's t-test, ANOVA and Newman-Keuls multiple comparison test. Results: Mean age was 63.3 5.3 years, mean FEV1 was 54.8 25.4% of predicted, mean FEV1/FVC was 49.9 12.0% of predicted, mean resting PaO2 was 69.7 7.3 mmHg, and mean resting SaO2 was 93.7 2.1%. Polysomnography revealed sleep patterns to be fragmented, with frequent waking and reduced slow-wave sleep, as well as oxygen desaturation. The most significant drops in oxygen saturation occurred during rapid eye movement sleep. No significant differences were observed between pre- and post-PR values for the other variables studied (p > 0.05).Conclusion: In the group of patients studied, PR did not alter sleep patterns.

 


Keywords: Sleep. Pulmonary Disease. Chronic Obstructive. Lung Diseases, rehabilitation.

 

9 - Induced sputum for the diagnosis of lung disease in HIV-positive patients

O escarro induzido no diagnóstico das doenças pulmonares em pacientes positivos ao vírus da imunodeficiência humana

Rosemeri Maurice da Silva, Paulo José Zimermann Teixeira, José da Silva Moreira

J Bras Pneumol.2004;30(5):452-458

Abstract PDF PT PDF EN

Background: Induced sputum is widely used in assessing airway inflammation. However, its utility as a diagnostic tool in the diagnosis of lung disease in immunosuppressed patients merits further investigation. Objectives: To determinate the diagnostic yield of sputum induction in the diagnosis of lung diseases in HIV-positive patients. Method: Subjects were selected from among HIV-positive patients older than 14 years who were evaluated at a reference hospital between January 2001 and September 2002. Those with respiratory symptoms for 7 days or longer with normal or abnormal chest X-rays, as well as those without respiratory symptoms but with abnormal chest X-rays, were included. All subjects were submitted to clinical examination, radiologic evaluation, sputum induction and laboratory testing. Subsequently, flexible fiberoptic bronchoscopy, bronchoalveolar lavage and transbronchial lung biopsy were performed. Samples were processed for Gram and Ziehl-Neelsen staining, quantitative culture for pyogenic bacteria, direct staining for fungi, culture for mycobacteria and fungi, silver stain for Pneumocystis jiroveci, as well as for total and differential cellularity determination. Results: A total of 54 patients were included. Upon testing negative for any etiologic agent, 7 patients were excluded, resulting in a total of 54 patients studied. A total of 60 infectious agents were isolated. Among the etiologic agents isolated, 46.7% were P. jiroveci, 33.5 were pyogenic bacteria and 16.7% were Mycobacterium tuberculosis. Sputum induction presented 57.5% sensitivity, 42.9% specificity, 87.1% predictive positive value, 13% predictive negative value and 55.6% overall accuracy. Conclusions: In this population, sputum induction proved to be a technique that is safe and easily performed, with a good diagnostic yield.

 


Keywords: HIV, Acquired Immunodeficiency Syndrome, Bronchoscopy, Sputum, Lung Disease/diagnosi.

 

10 - Risk for Mycobacterium tuberculosis infection among medical students at the Universidade Federal do Rio de Janeiro Faculdade de Medicina

Risco de infecção pelo Mycobacterium tuberculosis entre alunos da Faculdade de Medicina da Universidade Federal do Rio de Janeiro

Vania Maria Carneiro da Silva, Antônio José Ledo Alves da Cunha, Afrânio Lineu Kritski

J Bras Pneumol.2004;30(5):459-466

Abstract PDF PT PDF EN

Introduction: There have been few Latin American studies investigating the fact that the rate of tuberculosis (TB) infection among medical students is higher than the 1.3% rate seen in the population at large. Objective: To describe the cumulative incidence and the relative risk for TB infection among medical students. Method: In 1998, a prospective cohort study was conducted involving medical students at the Universidade Federal do Rio de Janeiro Faculdade de Medicina who tested negative (induration <10 mm) on the tuberculin skin test (TST). Students were tested using the two-step TST method and were retested one year later. The students tested were at two different stages in their training: pre-clinical (no contact with patients) and final year (contact with patients). Information about demographic characteristics, BCG vaccination history, and instances of potential exposure to Mycobacterium tuberculosis were obtained using a standardized questionnaire. Of the 575 students initially enrolled, 72% (414) completed the study. Results: The TSTs of 16 (3.9%) of the 414 students converted, representing a cumulative incidence of 3.9% (95% confidence interval = 1.06 to 12.1). Senior medical students were at an almost fourfold higher risk for M. tuberculosis infection than were those in pre-clinical training. Conclusion: The risk for TST conversion is very high in this population.

 


Keywords: PPD. Tuberculosis-infection. Tuberculin conversion. Medical students

 

Upgrading

11 - How to Access the Biomedical Literature and Bridge the "Digital Divide" in Pulmonology

Como acessar a literatura biomédica e cruzar o "divisor de águas digital" em Pneumologia

João Carlos Prolla

J Bras Pneumol.2004;30(5):467-473

Abstract PDF PT PDF EN Portuguese Text

In poor and underdeveloped countries, including Brazil, pulmonologists have great difficulty in maintaining a level of service that keeps pace with advances in current knowledge, in keeping up to date with newly developed techniques, and in pursuing research. Due to the rising costs of scientific journal subscriptions, one of the main problems is lack of access to the scientific literature. The term "digital divide" refers to the gap between those who can and those who cannot effectively use new information technology and tools such as the Internet to communicate within and between countries. In this report, we call attention to some solutions to this situation. In particular, the SciELO Project, the CAPES Periodicals portal and the HINARI project, as well as several others, provide access at little or no cost. These options are explained in detail herein.

 


Keywords: Pulmonary Disease (Specialty), Internet. Bibliography. Resource Guides.

 

Review Article

12 - Imaging of acute pulmonary thromboembolism

Diagnóstico por imagem do tromboembolismo pulmonar agudo

Isabela S. Silva, Nestor L. Müller

J Bras Pneumol.2004;30(5):474-479

Abstract PDF PT PDF EN

The diagnosis of acute pulmonary thromboembolism is based on the clinical probability, use of D-dimer (when available) and imaging. The main imaging modalities used in the diagnosis are ventilation-perfusion (V/Q), angiography, and computed tomography (CT). In the last decade several studies have demonstrated that spiral CT has a high sensitivity and specificity in the diagnosis of acute pulmonary thromboembolism. The evaluation of the pulmonary arteries has further improved with the recent introduction of multidetector spiral CT scanners. Various investigators have suggested that spiral CT pulmonary angiography should replace scintigraphy in the assessment of patients whose symptoms are suggestive of acute PE. This article discusses the role of the various imaging modalities in the diagnosis of acute pulmonary thromboembolism with emphasis on the role of spiral CT.

 


Keywords: Diagnostic imaging. Pulmonary embolism./diagnosis. Angiography. Lung diseases/radionuclide imaging. Tomography, emission-computed single-photon/methods.

 

13 - Thromboprofilaxis for videolaparoscopic cholecystectomy

Tromboprofilaxia na colecistectomia videolaparoscópica

Renato Maciel, Sérgio Saldanha Menna Barreto

J Bras Pneumol.2004;30(5):480-484

Abstract PDF PT PDF EN

Based in a case of a patient who developed pulmonary embolism three days after a laparoscopic cholecystectomy in spite of using unfrationated heparin starting before surgery and mantained in the first 24hs postoperatively. The authors have analysed the risk factors and the rate of VTE in laparoscopic cholecystectomy , the use of thromboprofilaxis and suggested procedures that should be adopted

 


Keywords: Cholecystectomy. Video laparoscopy. Pneumoperitoneum

 

Case Report

14 - 80 year old man thromboendarterectomy Pulmonary thromboendarterectomy in an 80-year-old patient

Tromboendarterectomia pulmonar em paciente com 80 anos de idade

Mário Terra-Filho, Sabrina Correia da Costa Ribeiro, Rogério de Souza, Fábio Biscegli Jatene

J Bras Pneumol.2004;30(5):485-487

Abstract PDF PT PDF EN

Pulmonary hypertension secondary to thromboembolism is a serious and debilitating disease. It occurs in approximately 0.5-1.0% of patients who survive an episode of acute thromboembolism. This is the first reported case of successful thromboendarterectomy performed in an elderly patient in Brazil. The patient, an 80-year-old man, presented favorable postoperative evolution. The authors believe this surgical procedure is a viable option for treatment of this type of pulmonary hypertension even in patients of advanced age, providing that there are no comorbidities.

 


Keywords: Thromboendarterectomy/methods. Hypertension pulmonary/surgery. Clinical evolution.

 

15 - Carcinoid tumor of the skin involving the sternum: Resection and reconstruction

Tumor carcinóide de pele envolvendo o esterno. Ressecção e reconstrução

Samuel Zuínglio de Biase Cordeiro, Paulo Leal, Mauro Zamboni, Emanuel Torquato, Paulo de Biasi Cordeiro

J Bras Pneumol.2004;30(5):488-491

Abstract PDF PT PDF EN

Carcinoid tumor of the skin, which is a malignant neoplasm originating in the neuroendocrine system and having its pathological substrate in the Merkel cells, is a rare occurrence. It is most frequently seen on the skin around the neck and head and is more common in the elderly. This study relates the case of a 35-year-old woman presenting with a visible and palpable tumor covering the upper third of the sternum. Resection of the tumor was indicated because the patient had experienced two significant episodes of bleeding and osseous invasion had occurred. Penetration of the full thickness of the chest wall at the sternum notch necessitated the implantation of a rigid prosthesis. The definitive histopathological diagnosis was made only through postoperative analysis of the excised section. Reconstruction using a surgical cement plate and interposition of a myocutaneous flap proved its usefulness as an alternative when resection is performed in an area important to the postoperative respiratory dynamic, a situation that typically requires a ventilatory prosthesis for up to 6 days. The stability of the chest wall, together with viability of the flap and the recuperation of pulmonary function, allowed the patient to be discharged after 18 days.

 


Keywords: Carcinoma, Merkel cell/surgery. Carcinoid tumor/ diagnosis. Carcinoid tumor/surgery. Immunohistochemistry. Sternun/surgery. Neoplasm metastasis.

 

16 - Digestive Chagas disease with concomitant lipoid pneumonia

Pneumonia lipoídica associada à forma digestiva da doença de Chagas

Marcelo Fernando Ranzani, Nilson Sebastião Miranda, Ulisses Frederigue Júnior, Sérgio Marrone Ribeiro, Jussara Marcondes Machado

J Bras Pneumol.2004;30(5):492-495

Abstract PDF PT PDF EN

A 50-year-old woman with chagasic esophageal achalasia and megacolon presented with nonproductive cough, chest pain and dyspnea. A chest X-ray showed bilateral opacity suggestive of lobar pneumonia. Open lung biopsy revealed lipoid pneumonia resulting from aspiration of mineral oil from a mineral oil-based laxative that the patient had been taking regularly for the last three years. The authors discuss concomitance of chagasic megacolon and esophageal achalasia with lipoid pneumonia and make recommendations regarding the use of mineral oil-based products by these patients.

 


Keywords: Pneumonia, aspirtion/etiology. Pneumonia, lipid/etiology. Esophageal achalasia/pathology. Chagas disease/complications.

 

Year 2004 - Volume 30  - Number 6  (November/December)

Editorial

1 - Thirty years of the Brazilian Journal of Pulmonology: 100% growth in 2 years points to a promising future

Trinta anos de Jornal Brasileiro de Pneumologia: Crescimento de 100% em 2 anos apontam futuro promissor

Geraldo Lorenzi-Filho

J Bras Pneumol.2004;30(6):499

Abstract PDF PT PDF EN Portuguese Text

This will be my last editorial as the editor of the Jornal Brasileiro de Pneumologia (JBP, Brazilian Journal of Pulmonology).

 


2 - The SBPT and conflicts of interest

A SBPT e os conflitos de interesse

Carlos AC Pereira

J Bras Pneumol.2004;30(6):500

PDF PT PDF EN Portuguese Text

Resumo

Dados norte-americanos mostram que no ano de 2000, a indústria de medicamentos financiou mais de 314.000 eventos para médicos, desde jantares até finais de semana em lugares interessantes, ao custo de quase dois bilhões de dólares. Isto levanta a questão do conflito de interesse (COI).

 


Original Article

3 - Anthropometric index for quantitative assessment of pectus excavatum

Índice antropométrico para classificação quantitativa do pectus excavatum*

Eduardo B. Rebeis, Marcos N. Samano, Carlos T. Santos Dias, Ângelo Fernandez, José R. M. Campos, Fábio B. Jatene, Sérgio A. Oliveira

J Bras Pneumol.2004;30(6):501-507

Abstract PDF PT PDF EN

Background: Pectus excavatum is characterized by concave growth of costal cartilage and depression of the lower sternum. Clinical means of classifying these malformations are few and difficult to apply. Objective: To devise clinical tools for quantifying the deformity and comparing preoperative and postoperative findings. Method: A total of 10 pectus excavatum patients who underwent surgery in which the modified Robicsek technique was used by the Thoracic Surgery Group of the Hospital das Clínicas of the University of São Paulo School of Medicine, were clinically and radiologically evaluated in the preoperative and postoperative periods. Ten control individuals, presenting no thoracic or radiological abnormalities, were submitted to identical evaluations. Deformities at the sternum notch level and at the point of maximum deformity were assessed using the anthropometric index and the Haller index. Results: Multivariate analysis of anthropometric index means revealed significant differences between preoperative and control values and between preoperative and postoperative values, as well as a non-significant difference between postoperative and control values. The same results were obtained when Haller index means were analyzed. A paired comparison of preoperative and postoperative means showed two distinct groups. An 86% canonical correlation was found between the anthropometric index and the Haller index. Conclusion: Patients with pectus excavatum can be quantitatively assessed in the preoperative and postoperative periods through the use of the anthropometric index, which allows objective, comparative evaluation of the results and is easily performed.

 


Keywords: Funnel Chest. Anthropometry/methods.

 

4 - Evaluation of Pulmonary Function in Class I and II Obesity

Avaliação da função pulmonar na obesidade graus I e II

Zied Rasslan, Roberto Saad Junior, Roberto Stirbulov, Renato Moraes Alves Fabbri, Carlos Alberto da Conceição Lima

J Bras Pneumol.2004;30(6):508-514

Abstract PDF PT PDF EN

Background: Obesity can effect the thorax, diphragm and abdominal muscles, thereby resulting in altered respiratory function. Objective: To evaluate the effects of obesity and to determine whether body mass index (BMI) and waist circumference correlate with spirometry values in obese individuals. Method: We studied 96 non-smokers of both sexes, 48 suffering from class I and class II obesity and ranging in age rom 18 to 75. All participants presented a BMI between 30 kg/m2 and 40 kg/m2 and none had a history of morbidity. Spirometry was performed, and waist circumferences were measured. Results: No significant differences were found between the spirometric values of men with class I or II obesity and those of non-obese men. In obese women, forced vital capacity and forced expiratory volume in one second (FEV1) were significantly lower than in women who were not obese. Obese individuals of both sexes presented significantly lower expiratory reserve volume (ERV) than did non-obese individuals. Although inspiratory capacity was greater in obese men and women, the difference was significant only for the men. In obese men, there was a significant negative correlation, not seen in the women, between waist circumference and FEV1. Conclusion: Pulmonary function is altered in women suffering from class I and II obesity. In obese men, although pulmonary function is unaffected by BMI, we observed a significant negative correlation between BMI and ERV. We can conclude that pulmonary function is influenced by waist circumference in men suffering from class I and II obesity.

 


Keywords: Respiratory function tests. Spirometry. Body mass index. Obesity.

 

5 - Maximal respiratory pressures and vital capacity: comparison mouthpiece and face-mask evaluation methods

Pressões respiratórias máximas e capacidade vital: comparação entre avaliações através de bocal e de máscara facial

Julio Flavio Fiore Junior, Denise de Morais Paisani, Juliana Franceschini, Luciana Dias Chiavegato, Sonia Maria Faresin

J Bras Pneumol.2004;30(6):515-520

Abstract PDF PT PDF EN

Background: Measurement of maximal respiratory pressures and vital capacity are essential in evaluating respiratory function. However, methodological variations may interfere with the interpretation of results. Objective: To compare values obtained using mouthpiece and face-mask evaluation methods in the measurement of maximal respiratory pressures and vital capacity. Method: We studied 30 patients (16 male), with a mean age of 55.9 ± 15.7, in the preoperative phase of abdominal surgery. Maximal inspiratory pressure and maximal expiratory pressure, as well as vital capacity, were evaluated using either a rigid flanged mouthpiece or a face mask, in randomized order. Results: Evaluation with a face mask did not significantly alter vital capacity and maximal inspiratory pressure values, although maximal expiratory pressure values were significantly lower than when measured using a rigid mouthpiece. During measurement of maximal expiratory pressure, air leakage from around the mask was observed in 60% of cases. When maximal expiratory pressure measurements in which there was no such leakage were considered in isolation, face-mask values were higher than those obtained with the moutpiece. Conclusion: With a face mask, maximal inspiratory pressure and vital capacity can be accurately evaluated. Maximal expiratory pressure can also be adequately evaluated using a face mask, provided that air leakage from the mask edges can be avoided. However, such leakage and the consequent reduction in the values obtained are common and limit the use of this method of evaluation.

 


Keywords: Respiratory function tests. Maximal voluntary ventilation. Respiratory muscles.

 

6 - Polymerase chain reaction used to detect Streptococcus pneumoniae resistance to penicillin

A reação em cadeia da polimerase na detecção da resistência à penicilina em Streptococcus pneumoniae

Eduardo Walker Zettler, Rosane M. Scheibe, Cícero A.G. Dias, Patricia Santafé, José da Silva Moreira, Diógenes S. Santos, Carlos Cezar Fritscher

J Bras Pneumol.2004;30(6):521-527

Abstract PDF PT PDF EN

Background: Streptococcus pneumoniae is the most common etiologic agent of community-acquired respiratory infections. In recent years, S. pneumoniae resistance to antimicrobial agents has increased. Minimum inhibitory concentration (MIC) is routinely used to determine resistance. Polymerase chain reaction (PCR) detects the genes responsible for Streptococcus pneumoniae resistance to penicillin within approximately 8 hours. Objective: To compare the PCR and MIC methods in determining Streptococcus pneumoniae resistance to penicillin. Method: A total of 153 Streptococcus pneumoniae samples, isolated from various anatomical sites, were evaluated in order to detect mutations in the genes encoding pbp1a, pbp2a and pbp2x, which are responsible for Streptococcus pneumoniae penicillin resistance. A correlation was found between mutations and penicillin MIP, as determined by the agar diffusion method. Results: Overal Streptococcus pneumoniae resistance to penicillin was 22.8% (16.3% intermediate resistance and 6.5% high resistance). In a statistically significant finding, we observed no mutations in the penicillin-sensitive samples and only one mutation, typically in the gene encoding pbp2x, among the samples with intermediate resistance, whereas mutations in all three genes studied were observed in the high-resistance samples. Conclusion: For determining Streptococcus pneumoniae resistance to penicillin, PCR is a rapid method of detection that could well be used in clinical practice.

 


Keywords: Streptococcus pneumoniae. Penicillin resistance. Polymerase chain reaction/methods.

 

7 - Chronic Dyspnea and Altered Respiratory Function in Former Workers with Asbestosis Evaluated to Determine Benefits

Dispnéia crônica e alterações funcionais respiratórias em ex-trabalhadores com asbestose avaliados para concessão de benefício

Lara M. Nápolis, Andréa Ap. Sette, Ericson Bagatin, Mário Terra Filho, Reynaldo T. Rodrigues, Jorge Issamu Kavakama, José Alberto Neder, Luiz Eduardo Nery

J Bras Pneumol.2004;30(6):528-534

Abstract PDF PT PDF EN

Background: Dyspnea is a symptom that is difficult to evaluate, especially in occupational diseases. Objective: To evaluate the relationship between chronic dyspnea, in its varying degrees of severity, and the functional repercussions for dysfunction or incapacitation in former workers with asbestosis. Method: A total of 40 former workers diagnosed with asbestosis were evaluated. Dyspnea scores were determined using the modified Medical Research Council scale, the 1984 and 1993 American Medical Association scales, and the Baseline Dyspnea Index. Spirometry, measurement of diffusion capacity for carbon monoxide and cardiopulmonary exercise tests (incremental and submaximal) were also performed. Results: Based on scores obtained using the Medical Research Council and 1984 American Medical Association scales, respectively, 72.5% and 67.5% of the subjects were classified as dyspneic, compared with 37.5% and 31.6%, respectively, using the 1993 American Medical Association and Baseline Dyspnea Index scales. There was greater concordance between the Medical Research Council and 1993 American Medical Association scales, as well as between the 1984 and 1993 American Medical Association scales, when the categories of "absent" and "mild" were grouped. No significant relation was found between dyspnea, as determined by each of the scales, and functional abnormalities - either at rest or during exercise. Conclusion: In individuals with asbestosis, the degree of concordance among the available dyspnea scales varies significantly. There is a real need for dyspnea indices that evaluate respiratory dysfunction at rest and during exercise.

 


Keywords: Asbestosis/diagnosis. Dyspnea/physiopathology. Spirometry/methods.

 

8 - Effects of continuos positive airway pressure on nasal and pharyngeal symptoms in patients with obstructive sleep apnea

Efeitos da pressão positiva contínua em vias aéreas sobre os sintomas nasofaríngeos em pacientes com a síndrome da apnéia obstrutiva do sono

Adelaide Cristina de Figueiredo, Maria Cecília Lorenzi, Simone Prezzoti, Marília Montenegro Cabral, Luiz Ubirajara Sennes, Geraldo Lorenzi-Filho

J Bras Pneumol.2004;30(6):535-539

Abstract PDF PT PDF EN

Background: Nasal and pharyngeal symptoms are common in patients with obstructive sleep apnoea (OSA) treated with nasal continuous positive airway pressure (CPAP). However, these symptoms are common in OSA patients even before the treatment. Objectives: Determine the impact of nasal CPAP on nasal and pharyngeal symptoms in OSA patients. Method: Thirty-five adult patients (28 males), age 54±10 years old, with OSA diagnosed by polissonography. All patients answered to a questionnaire about the presence and quantification of sneezing, rhinorrhea, nasal pruritus, obstruction and bleeding, nasal and pharyngeal dryness. The questionnaire was answered before and after at least three months of CPAP therapy. Results: The apnea-hypopnea index was 50±25 events per hour. Twenty six patients (74%) presented at least one naso-pharingeal symptom before treatment. Nasal obstruction was the most common symptom, being referred by 18 patients (51%). Among the patients that were initially assymptomatic (n=9), 78% developed adverse nasal reactions to CPAP. In contrast, among the patients that presented nasal symptoms before treatment, there was a significant reduction in nasal obstruction, nasal and throat dryness scores as well as nasal bleeding after CPAP therapy. Conclusions: Nasal na pharyngeal symptoms are frequent in OSAS patients. CPAP therapy may originate nasal symptoms in patients previously assymptomatic, as well as reduce the intensity of these symptoms in patients that are previously symptomatic.

 


Keywords: Obstructive sleep apnea syndrome. Nasal obstruction. Continuous positive airway pressure, compliance.

 

9 - Ventilator-associated pneumonia: impact of bacterial multidrug-resistance on morbidity and mortality

Pneumonia associada à ventilação mecânica: impacto da multirresistência bacteriana na morbidade e mortalidade

Paulo José Zimermann Teixeira, Felipe Teixeira Hertz, Dennis Baroni Cruz, Fernanda Caraver, Ronaldo Campos Hallal, José da Silva Moreira

J Bras Pneumol.2004;30(6):540-548

Abstract PDF PT PDF EN

Background: Ventilator-associated pneumonia is the most common nosocomial infection occurring in intensive care units. Objective: To determinate the impact of multidrug-resistant bacteria on morbidity and mortality in patients with ventilator-associated pneumonia. Method: Retrospective cohort study. Over 40 consecutive months, 91 patients on mechanical ventilation developed pneumonia. Cases were grouped into those caused by multidrug-resistant microorganisms and those caused by drug-sensitive microorganisms. Results: Multidrug-resistant bacteria were isolated in 75 cases (82.4%) and drug-sensitive bacteria in 16 (17.6%). Clinical and epidemiological characteristics were not statistically different between the groups. Staphylococcus aureus was responsible for 27.5% of ventilator-associated pneumonia episodes and Pseudomonas aeruginosa for 17.6%. Early-onset ventilator-associated pneumonia occurred in 33 patients (36.3%) and late-onset in 58 (63.7%). Time on mechanical ventilation, length of intensive care unit stay and overall length of hospital stay were not statistically different between groups. Empirical treatment was considered inadequate in 42 patients with pneumonia caused by multidrug-resistant microorganisms (56%) and in 4 with pneumonia caused by drug-sensitive microorganisms (25%) (p = 0.02). Death occurred in 46 patients with pneumonia caused by multidrug-resistant microorganisms (61.3%) and in 4 with pneumonia caused by drug-sensitive microorganisms (25%) (p = 0.008). Conclusion: Bacterial multidrug-resistance had no impact on morbidity but was associated with higher mortality.

 


Keywords: Pneumonia bacterial/etiology. Respiration artificial/complications. Indicators of morbidity and mortality.

 

10 - Pleural fluid adenosine deaminase detection for the diagnosis of pleural tuberculosis

Dosagem da atividade da adenosina deaminase no líquido pleural para o diagnóstico da tuberculose pleural

Morrys Casagrande Kaisemann, Afrânio Lineu Kritski, Maria de Fátima C Pereira, Anete Trajman

J Bras Pneumol.2004;30(6):549-556

Abstract PDF PT PDF EN

Background: The diagnosis of pleural tuberculosis continues to be a challenge due to the low sensitivity of traditional diagnostic methods. Histopathological examination of pleural tissue is the most accurate method, with a sensitivity of up to 80%. Determination of adenosine deaminase levels is a recently introduced method, although its usefulness in the diagnosis of pleural tuberculosis in Brazil has yet to better elucidated. Objective: To verify the sensitivity and specificity of an experimental method of measuring adenosine deaminase activity in pleural fluid in a series of patients with pleural effusion patients evaluated between August 1998 and November 2002 in Rio de Janeiro (RJ). Results: Out of 137 cases, 111 pleural fluid samples were available. Of those, 83 were from pleural tuberculosis patients. Among the 67 pleural tuberculosis patients tested, 10 (14.9%) presented human immunodeficiency virus. The adenosine deaminase cutoff value of 35U/L was determined by a receiver operator characteristic curve. The sensitivity, specificity and likelihood ratios (positive and negative) were 92.8%, 93.3%, 25.8 and 13.9, respectively. Mean adenosine deaminase in the pleural tuberculosis group was 84.7 ± 43.1 U/L, versus 15.9 ± 11.1 U/L in the group with other diseases. There was no significant difference in adenosine deaminase activity between patients with and without human immunodeficiency virus co-infection. Conclusions: Adenosine deaminase measurement in pleural fluid is a sensitive and specific method for the diagnosis of pleural tuberculosis and its use can preclude the need for pleural biopsy in the initial workup of pleural effusion patients. An adenosine deaminase cutoff value of 35U/L is recommended.

 


Keywords: Pleural fluid. Adenosine deaminase. Diagnosis. Tuberculosis. HIV

 

Review Article

11 - Smoke inhalation injury

Lesão por inalação de fumaça

Rogério Souza, Carlos Jardim, João Marcos Salge, Carlos Roberto Ribeiro Carvalho

J Bras Pneumol.2004;30(6):557-565

Abstract PDF PT PDF EN

Inhalation injury is the main cause of death in burn patients and has therefore, understandably, been the subject of numerous published studies. The pathogenesis of inhalation injury involves both local and systemic mechanisms, thereby increasing the repercussions of the injury. The search for tools that would allow earlier diagnosis of inhalation injury and for treatment strategies to lessen its deleterious effects is ongoing. In this review, we describe the physiopathological mechanisms of inhalation injury, as well as the current diagnostic tools and treatment strategies used in patients suffering from inhalation injury. We also attempt to put experimental therapeutic approaches into perspective.

 


Keywords: Smoke inhalation injury/diagnosis. Smoke inhalation injury/pathophysiology. Smoke inhalation injury/ complications. Burns, inhalation/therapy. Review literature. Carbon monoxide. Poisoning/complications.

 

12 - Physiopathology and clinical management of one-lung ventilation

Fisiopatologia e manejo clínico da ventilação seletiva

Halina Cidrini Ferreira, Walter Araújo Zin, Patrícia Rieken Macedo Rocco

J Bras Pneumol.2004;30(6):566-573

Abstract PDF PT PDF EN

During one-lung ventilation, the nonventilated lung is excluded from the ventilation, with all tidal volume directed into the ventilated lung. This technique facilitates viewing of intrathoracic structures, thereby providing optimal surgical conditions. However, this procedure has been associated with reduced arterial oxygen tension, principally in patients with a previous history of lung disease, since it reduces the surface area available for gas exchange and causes a loss of normal autonomic respiratory regulation. Therefore, maintaining sufficient oxygenation and elimination of carbon dioxide is the greatest challenge in the management of the one-lung ventilation. It is recommend that the tidal volume administrated to the ventilated lung be similar to that used during conventional mechanical ventilation and that high fractions of inspired oxygen be used. However, several alternative methods have been proposed in order to minimize hypoxemia during one-lung ventilation, including the correct positioning of the double-lumen tube, the use of positive end-expiratory pressure or continuous positive airway pressure, nitric oxide administration, and alveolar recruitment. The management of one-lung ventilation continues to be a challenge in clinical practice.

 


Keywords: tidal volume, hypoxemia, ventilatory management, mechanical ventilation

 

Case Report

13 - Respiratory bronchilitis-associated interstitial lung disease

Doença pulmonar intersticial associada a bronquiolite respiratória

Silvia CS. Rodrigues, Mauri M. Rodrigues, Ester MC Colleta, Nailê S Rocha, Carlos AC Pereira

J Bras Pneumol.2004;30(6):574-580

Abstract PDF PT PDF EN

Respiratory bronchiolitis-associated interstitial lung disease is one of many within the spectrum of smoking-related diffuse infiltrative lung diseases. The clinical and functional characteristics are typically subtle. Herein, we describe two cases of diagnosed through open-lung biopsy, and characterized by insidious evolution of dyspnea, digital clubbing, cystic lesions on computed tomography scans, and hipoxemia upon exertion. We emphasize that, when smokers are evaluated, it is imprtant to consider a diagnosis of respiratory bronchiolitis-associated interstitial lung disease in the context of interstitial cystitis, as well as in that of lymphangioleiomyomatosis, eosinophilic granuloma and idiophatic pulmonary fibrosis.

 


Keywords: Smoking. Interstitial lung diseases. Bronchiolitis.

 

14 - Tracheobronchial amyloidosis

Amiloidose traqueobrônquica

Luciano Müller Corrêa da Silva, Jamila Bellicanta, Renata Diniz Marques, Luiz Carlos Corrêa da Silva

J Bras Pneumol.2004;30(6):581-584

Abstract PDF PT PDF EN

Amyloidosis is a disease characterized by extracellular deposition of pathologic fibrillar protein in organs and tissues. Diffuse primary tracheobronchial amyloidosis is rare. Herein, we report a case of a male patient with diffuse tracheobronchial amyloidosis, initially diagnosed as bronchial asthma.

 


Keywords: Asthma/pathology. Amyloidosis/diagnosis. Trachea/pathology.

 

15 - Infiltration of old scars: a manifestation of sarcoidosis

Lesões sobre cicatrizes, uma das manifestações da sarcoidose

Paulo Ricardo Martins Souza, Rodrigo Pereira Duquia, Gerson Vetoratto, Hiram Larangeira de Almeida Junior

J Bras Pneumol.2004;30(6):585-587

Abstract PDF PT PDF EN

We report the case of a 41 year-old black woman who presented a sudden infiltration of old scars of her face. These scars were from a car accident 10 years prior. Histological analysis of a skin biopsy revealed non-caseous granulomas consistent with sarcoidosis, and computed tomography of the thorax revealed enlarged mediastinal lymph nodes. The lesions regressed spontaneously and no treatment was required.

 


Keywords: Sarcoidosis/complications. Cicatrix/ethiology. Granuloma/complications.

 

Letters to the Editor

16 - Escarro induzido, recomendações do Programa de Controle de Tuberculose do Estado do Rio de Janeiro*

Marneili Martins, Eliane Dale Sucupira, Lísia M. R. de Freitas, Lia Selig, Eduardo Pamplona Bethlem Rodrigo Siqueira Batista

J Bras Pneumol.2004;30(6):591-592

PDF PT Portuguese Text


17 - 

Miguel Lia Tedde, Fabio Biscegli Jatene

J Bras Pneumol.2004;30(6):593-594

PDF PT Portuguese Text


18 - 

Paulo de Tarso G. Muller, Liana Peres Duailibe

J Bras Pneumol.2004;30(6):595

PDF PT Portuguese Text


19 - 

Marcelo Park, Luciano C. P. Azevedo

J Bras Pneumol.2004;30(6):596

PDF PT Portuguese Text


 


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