Objective: To determine the sensitivity of the scoring system proposed by the Brazilian National Ministry of Health in 2002 for the diagnosis of tuberculosis in children and adolescents suspected of having the disease. Methods: This was a retrospective study of 316 children and adolescents (0-14 years of age) diagnosed with pulmonary tuberculosis between 1997 and 2007 at the Brazilian Institute for Tuberculosis Research, located in the city of Salvador, Brazil. After reviewing the medical charts and chest X-rays of the patients, we calculated the tuberculosis scores. Results: The majority of the subjects (80.4%) had a history of close household contact with an AFB-positive adult within the last two years. The tuberculin test was negative in 11 subjects (3.5%). According to the scoring system, 251 (79.4%) were very likely to have tuberculosis (score, ≥ 40), 63 (19.9%) were moderately likely to have tuberculosis (score, 30-35), and 2 (0.7%) were unlikely to have tuberculosis (score, ≤ 25). When a cut-off score of 30 was used, the sensitivity of this scoring system was 99.3%. Conclusions: In our sample, the sensitivity of this scoring system was high when the selected cut-off score was employed. If a cut-off score of 40 had been used, 20% of the subjects would not have been treated. Therefore, scores between 30 and 35 are critical for diagnostic confirmation. Judicious clinical evaluation should prevail in the decision of treating these patients. When the cut-off score of 30 is used, 30% of individuals with other pathologies will be treated for tuberculosis. This highlights the need for improved diagnostic methods for tuberculosis.

Keywords: Tuberculosis/diagnosis; Epidemiology; Diagnostic techniques and procedures.

Objective: To evaluate chest X-rays of patients with pulmonary tuberculosis and to determine whether the extent of radiographic lesions correlates with bacteriological parameters. Methods: In this retrospective, descriptive study, we evaluated chest X-rays, as well as AFB detection by smear microscopy and culture for Mycobacterium tuberculosis, initially and during the first two months of treatment, in 800 male patients hospitalized between 1995 and the present at a 250-bed hospital in northwestern Turkey. Results: The initial mean ESR was 58 ± 37 mm/h. Initial sputum smears and cultures were positive in 83.8% and 89.5% of the patients, respectively. After the first month of treatment, the proportion of patients with positive sputum culture was higher among those with cavitary tuberculosis than among those with non-cavitary tuberculosis (53.7% vs. 37.7%, p < 0.001). The number of affected zones was not correlated with age, symptom duration, contact with an active tuberculosis patient, or concomitant diabetes (p > 0.05 for all) but was positively correlated with the ESR (r = 0.23, p < 0.001). During the first and second months of treatment, conversion to smear-negative status was less common in patients with bilateral involvement than in those with unilateral involvement (p < 0.001 and p = 0.002 for months 1 and 2, respectively). Disease extent did not correlate with age, symptom duration, contact with an active tuberculosis patient, or concomitant diabetes but did correlate with delayed bacteriological recovery. Conclusions: Chest X-ray and bacteriology are valuable tools for the evaluation of pulmonary tuberculosis

Keywords: Radiography, thoracic; Bacteriology; Tuberculosis, pulmonary/drug therapy.

Objective: To evaluate the accuracy of determining specific IgA to HspX recombinant antigen in pleural fluid and serum samples for the diagnosis of pleural tuberculosis in patients with pleural effusion. Methods: This was a cross-sectional study. Serum and pleural fluid samples of patients with pleural effusion and suspected of having pleural tuberculosis were tested with indirect ELISA in order to determine the optical density of specific IgA to HspX. Results: We evaluated serum and pleural fluid samples from 132 patients: 97 diagnosed with pleural tuberculosis (study group) and 35 diagnosed with pleural effusion due to other causes (control group). The determination of IgA in pleural fluid satisfactorily discriminated between pleural tuberculosis patients and control patients. The sensitivity of the test in pleural fluid and in serum was 69% and 30%, respectively, whereas the specificity was 83% and 84%, respectively. Conclusions: Our data suggest that this test can be used in the diagnosis of pleural tuberculosis. Further studies, involving larger patient samples and different epidemiological scenarios, are warranted.

Keywords: Pleural effusion; Tuberculosis/diagnosis; Enzyme-linked immunosorbent assay.

Objective: To determine the clinical and epidemiological profile of patients who are candidates for TNF-α inhibitor use and are classified as having latent tuberculosis (LTB), as well as to evaluate the outcomes of prophylactic treatment with isoniazid. Methods: A prospective descriptive analysis followed by an analytical, observational, cross-sectional study of the outcomes of prophylactic treatment in a group of 45 candidates for TNF-α inhibitor use. We evaluated the patients through anamnesis, clinical examination, chest X-ray, and tuberculin skin test (TST) using the Mantoux method. Results: The mean age was 45 years, and 56.0% of the patients were female. Chronic rheumatic diseases, chronic dermatological diseases, and Crohn's disease were present in 46.7%, 40.0%, and 13.3% of the patients, respectively. The mean TST induration was 14.6 mm (range: 5-30 mm). The majority (n = 30) of the 45 patients (66.7%) had an induration > 10 mm. In the 16 patients with BCG vaccination scars, the mean induration was 15.7 mm, and 14 of those patients had an induration > 10 mm. Chest X-ray results were considered normal, with minimal alterations, in 64.4% and 35.6% of the patients, respectively. The treatment with isoniazid was abandoned by 1 patient (2.2%) and completed by 41 (91.2%), whereas it was interrupted because of drug-induced hepatitis in 2 (4.4%), and 1 patient (2.2%) was transferred to another hospital. Of those who completed the treatment, 5 experienced mild side effects. Conclusions: Determining the profile of candidates for TNF-α inhibitor use is important for the management of LTB treatment and for the establishment of clinical protocols for the use and monitoring of the use of these medications.

Keywords: Tuberculosis; Latent tuberculosis; Tuberculin test; Isoniazid; Tumor necrosis factor-alpha.

Objective: To determine the impact that an educational intervention employing problem-solving strategies for the environmental control of aeroallergens has on environmental conditions in the households of children with asthma. The intervention was carried out by community health agents. Methods: This was a prospective intervention study. The community health agents visited 95 households in which there were children (2-10 years of age) who had recurrent episodes of wheezing and dyspnea. All of the households investigated were in the city of Iguatu, Brazil. The educational interventions involved focus groups and community health agents. The focus groups were asked to brainstorm the educational measures to be implemented, in order to devise problem-solving strategies. After the intervention, 84 households were revisited and reevaluated. Results: After the intervention, there was a significant decrease in the use of brooms for cleaning the floor (p = 0.02), in the use of coal-burning stoves (p = 0.001), and in the number of stuffed toys (p = 0.05). There was also a significant post-intervention improvement in the environmental control of aeroallergens in the bedrooms of the children (p = 0.003). Conclusions: The educational intervention applied in this study proved to be an important tool for the target population, improving environmental conditions in the households of children with asthma.

Keywords: Asthma; Primary health care; Family health program; Health education.

Objective: To determine the prevalence of asthma in a group of obese adult candidates for bariatric surgery and to evaluate the severity of asthma in this group of patients. Methods: This was a cross-sectional study involving 363 obese adults (body mass index ≥ 35 kg/m2) evaluated by a pulmonologist, using clinical evaluation as a diagnostic tool for asthma. All patients underwent clinical evaluation and spirometry and were divided into two groups (asthma and control). The patients with asthma were stratified by the severity of asthma. Results: The prevalence of asthma in the obese population studied was 18.5% (95% CI: 14.5-22.4). That prevalence was 20.4% (95% CI: 16.2-24.5) and 13.7% (95% CI: 10.1-17.2) in the women and the men, respectively. Asthma symptoms in the last twelve months were present in 8.0% (95% CI: 5.2-10.7), and the initial manifestation of asthma symptoms occurred during childhood/adolescence in 17.4% (95% CI: 13.5-21.3). In the asthma group, intermittent asthma was present in 29 patients (43.3%), mild persistent asthma in 7 (10.4%), moderate asthma in 25 patients (37.3%), and severe persistent asthma in 6 (9.0%). Conclusions: Using clinical evaluation as the diagnostic criterion, we found the prevalence of asthma to be high in this group of obese adults. Asthma was more common in females, and the initial manifestation of asthma symptoms more commonly occurred during childhood/adolescence. The severity of asthma in this group of obese adults was within the range of mean values predicted for the general population. Intermittent asthma, mild persistent asthma, and moderate persistent asthma predominated.

Keywords: Asthma; Cross-sectional studies; Spirometry; Respiratory function tests; Obesity, morbid.

Objective: To assess ICU patients with COPD, in terms of in-hospital characteristics, two-year mortality and two-year functional status of survivors. Methods: A prospective cohort study involving patients with acute exacerbation of COPD admitted to the ICUs of two hospitals in the city of Porto Alegre, Brazil, between July of 2005 and July of 2006. At two years after discharge, survivors were interviewed by telephone in order to determine Karnofsky scores and scores on a scale regarding activities of daily living (ADL). Results: The sample comprised 231 patients. In-hospital mortality was 37.7%, and two-year post-discharge mortality was 30.3%. Of the 74 survivors, 66 were interviewed (89%). The mean age at ICU admission was 74 ± 10 years, and the mean Acute Physiology and Chronic Health Evaluation II score was 18 ± 7. Two or more comorbidities were present in 87.8% of the patients. Of the 66 interviewees, 57 (86.3%) lived at home, 58 (87.8%) were self-sufficient, 12 (18.1%) required oxygen therapy, and 4 (6.1%) still required ventilatory support. There was a significant reduction in the quality of life and autonomy of the survivors, as evidenced by the Karnofsky scores (85 ± 9 vs. 79 ± 11, p = 0.03) and ADL scale scores (29 ± 5 vs. 25 ± 7; p = 0.01), respectively. Conclusions: In this patient sample, two-year mortality was quite high. Although there was a noticeable reduction in the functional status of the survivors, they remained self-sufficient.

Keywords: Pulmonary disease, chronic obstructive/mortality; Quality of life; Intensive care units.

Objective: To determine whether nebulizers are a source of microbial contamination in patients with cystic fibrosis, as well as whether the technique and frequency of disinfection of these devices is appropriate. Methods: This was a cross-sectional, uncontrolled observational study. Samples were collected from 28 patients with cystic fibrosis. Samples were collected at the homes of the patients, who were not previously informed of the purpose of the visit. Three samples were collected from each patient: one from the nebulizer chamber, one from the mask/mouthpiece, and one from the patient (oropharyngeal swab/sputum). The samples were properly stored and taken for analyses. The patients, their parents, or their legal guardians completed a questionnaire regarding nebulizer cleaning and disinfecting methods. Results: We collected 84 samples from the 28 patients. Of those 28 patients, 15 (53.5%) were male. The median age of the patients was 11 years (range, 1-27 years). Of the 28 patients, 15 presented with positive oropharyngeal swab/sputum sample cultures. The most common bacterial isolates were Staphylococcus aureus (in 8 patients) and Pseudomonas aeruginosa (in 4 patients). Although the samples obtained from the nebulizers presented with various pathogens in culture, no specific species predominated. In 27 cases (96.7%), there were no associations between the samples obtained from the nebulizers and those obtained from the patients in terms of the results of the cultures. Cleaning and disinfection of nebulizers were inappropriate in 22 cases (78.6%). Conclusions: In this sample of patients, despite the inappropriate disinfection techniques, nebulizers were not found to be a source of microbial contamination.

Keywords: Cystic fibrosis; Nebulizers and vaporizers; Disinfection.

Objective: To establish reference values for cellularity in induced sputum samples collected from healthy adults. Methods: Induced sputum samples were obtained from 88 healthy adult never-smokers (39 males). The mean age was 36 years (range, 18-68 years). The participants had been residing in the city of Florianópolis, Brazil (a medium-sized non-industrial city) for at least two years. After the samples had been processed, we obtained total and differential cell counts. Results: The mean total cell count was 4.8 ± 4.2 × 106 cells/g. There was a predominance of macrophages (mean, 77.5 ± 14.7%) and neutrophils (mean, 23.4 ± 14.3%). Eosinophils were virtually absent (mean, 0.1 ± 0.3%). Lymphocytes and bronchial epithelial cells were scarce. Neither age nor atopy had any effect on the total or differential cell counts. Conclusions: In the induced sputum of this healthy adult population, macrophages and neutrophils predominated. However, the proportion of neutrophils was lower than that reported in previous studies, which suggests that reference values might vary depending on geographic location.

Keywords: Sputum; Reference values; Brazil.

Objective: Adjuvant chemotherapy is recommended for most patients submitted to resection due to non-small cell lung cancer (NSCLC) staged as II or IIIA. However, although various chemotherapy regimens that include cisplatin have been used in phase III trials, the best choice remains unclear. The objective of this study was to describe the experience of the Instituto Nacional do Câncer (INCA, Brazilian National Cancer Institute), located in the city of Rio de Janeiro, Brazil, with the use of the cisplatin-etoposide combination in such patients, with a special focus on survival data. Methods: We retrospectively evaluated the medical charts of the patients receiving adjuvant therapy for NSCLC at the INCA between 2004 and 2008. Results: We included 51 patients, all of whom were treated with the cisplatin-etoposide combination. The median follow-up period was 31 months, and the median overall survival was 57 months. In the univariate analysis, median survival was lower in the patients submitted to chemotherapy plus radiotherapy than in those submitted to chemotherapy alone (19 vs. 57 months; p < 0.001), and there was a trend toward lower median survival in stage III patients than in stage I-II patients (34 vs. 57 months; p = 0.22). Overall survival was not significantly associated with gender (p = 0.70), histological pattern (p = 0.33), or cisplatin dose (p = 0.13). Conclusions: Our results support the use of adjuvant chemotherapy, and our survival data are similar to those reported in major randomized clinical trials. However, long-term follow-up is warranted in this population.

Keywords: Lung neoplasms; Chemotherapy, adjuvant; Survival analysis.

Objective: To determine the prevalence of smoking and the level of knowledge about smoking among undergraduate health sciences students. Methods: This was a cross-sectional study. A self-administered structured questionnaire was completed in the classroom by senior undergraduate health sciences students in the cities of Cuiabá and Várzea Grande, Brazil. We evaluated students at one public university and two private universities. Five variables were studied: age, gender, type of course, smoking status, and knowledge about smoking. The knowledge variable was divided into five parts: smoking as a disease; smoking/nicotine as a cause of dependence; specific education on smoking; major obstacles to the success of smoking cessation; and forms of smoking treatment. Only the medical students responded to questions related to the last two items. Results: The prevalence of smoking ranged from 9.3% at the public university to 21.1% at one of the two private universities. Approximately 30% of the respondents were unable to identify nicotine as the cause of dependence, 20.8% did not consider smoking a disease, and 47.2% reported that they had never received any instruction on the topic of smoking. The medical students enrolled at the public university showed the highest level of knowledge regarding the various forms of smoking treatment. Conclusions: The prevalence of smoking among the university students in our sample was high. Their knowledge about smoking was insufficient, which suggests inadequacy of the curricula at these universities.

Keywords: Tabagismo/epidemiologia; Estudantes; Questionários.

Objective: To assess mortality and identify mortality risk factors in patients admitted to a thoracic surgery ICU. Methods: We retrospectively evaluated 141 patients admitted to the thoracic surgery ICU of the Denizli State Hospital, located in the city of Denizli, Turkey, between January of 2006 and August of 2008. We collected data regarding gender, age, reason for admission, invasive interventions and operations, invasive mechanical ventilation, infections, and length of ICU stay. Results: Of the 141 patients, 103 (73.0%) were male, and 38 (23.0%) were female. The mean age was 52.1 years (range, 12-92 years), and the mortality rate was 16.3%. The most common reason for admission was trauma. Mortality was found to correlate with advanced age (p < 0.05), requiring invasive mechanical ventilation (OR = 42.375; p < 0.05), prolonged ICU stay (p < 0.05), and specific reasons for admission-trauma, gunshot wound, stab wound, and malignancy (p < 0.05 for all). Conclusions: Among patients in a thoracic surgery ICU, the rates of morbidity and mortality are high. Increased awareness of mortality risk factors can improve the effectiveness of treatment, which should reduce the rates of morbidity and mortality, thereby providing time savings and minimizing costs.

Keywords: Intensive care units; Thoracic surgery/mortality; Hospital mortality; Risk factors.

In the atypical smooth muscle cells that are characteristic of lymphangioleiomyomatosis (LAM), there are estrogen and progesterone receptors. Therefore, anti-hormonal therapy, despite having produced controversial results, can be considered a treatment option. The objective of this retrospective study was to evaluate hormonal and spirometric data for nine women with LAM after one year of treatment with goserelin. The mean increase in FEV1 and FVC was 80 mL and 130 mL, respectively. There was effective blockage of the hormonal axis. It is still not possible to exclude a potential beneficial effect of the use of gonadotropin-releasing hormone analogues in LAM patients, which underscores the need for randomized trials.

Keywords: Lymphangioleiomyomatosis; Spirometry; Goserelin.

O prejuízo funcional parece diferir entre membros superiores e membros inferiores de pacientes com DPOC. Dois possíveis mecanismos explicam os sintomas importantes de dispneia e fadiga relatados pelos pacientes ao executar tarefas com membros superiores não sustentados: a disfunção neuromecânica dos músculos respiratórios e a alteração dos volumes pulmonares durante as atividades realizadas com membros superiores. A disfunção neuromecânica está relacionada à alteração do padrão respiratório e à simultaneidade de estímulos aferentes e eferentes musculares, o que causaria a dissincronia na ação dos músculos respiratórios em pacientes com DPOC durante esse tipo de exercício. Adicionalmente, o aumento da ventilação durante os exercícios com membros superiores em pacientes com DPOC induz à hiperinsuflação dinâmica em diferentes cargas de trabalho. Nos membros inferiores, há redução da força e da endurance muscular do quadríceps femoral nos pacientes com DPOC comparados a indivíduos saudáveis. Uma explicação para essas reduções é a anormalidade no metabolismo muscular (diminuição da capacidade aeróbia), a dependência do metabolismo glicolítico e o acúmulo rápido de lactato durante o exercício. Quando contrastadas as atividades de membros superiores e membros inferiores, os exercícios com membros superiores resultam em maior demanda metabólica e ventilatória com mais intensa sensação de dispneia e fadiga. Devido às diferenças nas adaptações morfofuncionais dos músculos dos membros superiores e membros inferiores em pacientes com DPOC, protocolos específicos de treinamento de força e/ou endurance devem ser desenvolvidos e testados para os grupos musculares desses segmentos corporais.

Keywords: Pulmonary disease, chronic obstructive; Muscle fatigue; Upper extremity; Lower extremity.

Knowledge of the structure and function of pulmonary circulation has evolved considerably in the last few decades. The use of non-invasive imaging techniques to assess the anatomy and function of the pulmonary vessels and heart has taken on added importance with the recent advent of novel therapies. Imaging findings not only constitute a diagnostic tool but have also proven to be essential for prognosis and treatment follow-up. This article reviews the myriad of imaging methods currently available for the assessment of pulmonary circulation, from the simple chest X-ray to techniques that are more complex and promising, such as electrical impedance tomography.

Keywords: Pulmonary circulation; Diagnostic imaging; Hypertension, pulmonary.

A 79 year-old man sought treatment in the emergency room complaining of persistent fever, chest pain, and general fatigue. A chest X-ray showed a giant infectious bulla (24 cm in diameter) in the left lung. The patient had no history of abnormalities on X-rays, and his latest medical check-up, conducted in the preceding year, had produced no abnormal findings. Diagnostic procedures, including bronchoscopy, revealed lung cancer (large cell carcinoma) in the left lower bronchus. The tumor obstructed the airway. Although there have been various reports of giant bullae, their etiology remains unknown. We suggest that an obstruction, such as that caused by the tumor in this case, can lead to air trapping, resulting in the formation of a bulla. In the case of a giant bulla that rapidly increases in size, lung cancer should be included in the differential diagnosis.

Keywords: Lung neoplasms/complications; Infection; Drainage.