Brazilian Journal of Pulmonology

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


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Year 2013 - Volume 39  - Number 5  (September/October)


Original Article

2 - Level of asthma control and its impact on activities of daily living in asthma patients in Brazil

Nível de controle da asma e seu impacto nas atividades de vida diária em asmáticos no Brasil

Mariana Rodrigues Gazzotti, Oliver Augusto Nascimento, Federico Montealegre, James Fish, José Roberto Jardim

J Bras Pneumol.2013;39(5):532-538

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the impact of asthma on activities of daily living and on health status in patients with controlled, partially controlled, or uncontrolled asthma in Brazil. Methods: We used data related to 400 patients in four Brazilian cities (São Paulo, Rio de Janeiro, Salvador, and Curitiba), obtained in a survey conducted throughout Latin America in 2011. All study subjects were > 12 years of age and completed a standardized questionnaire in face-to-face interviews. The questions addressed asthma control, hospitalizations, emergency room visits, and school/work absenteeism, as well as the impact of asthma on the quality of life, sleep, and leisure. The level of asthma control was determined in accordance with the Global Initiative for Asthma criteria. Results: Among the 400 respondents, asthma was controlled in 37 (9.3%), partially controlled in 226 (56.5%), and uncontrolled in 137 (34.2%). The numbers of patients with uncontrolled or partially controlled asthma who visited the emergency room, who were hospitalized, and who missed school/work were higher than were those of patients with controlled asthma (p = 0.001, p = 0.05, and p = 0.01, respectively). Among those with uncontrolled asthma, the impact of the disease on activities of daily living, sleep, social activities, and normal physical exertion was greater than it was among those with controlled or partially controlled asthma (p < 0.001). Conclusions: In Brazil, asthma treatment should be monitored more closely in order to increase treatment adherence and, consequently, the level of asthma control, which can improve patient quality of life and minimize the negative impact of the disease.


3 - Delayed diagnosis of sarcoidosis is common in Brazil

Diagnóstico tardio da sarcoidose é comum no Brasil

Mauri Monteiro Rodrigues, Ester Nei Aparecida Martins Coletta, Rimarcs Gomes Ferreira, Carlos Alberto de Castro Pereira

J Bras Pneumol.2013;39(5):539-546

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the frequency of and the factors related to delayed diagnosis of sarcoidosis in Brazil. Methods: We evaluated patients with a biopsy-proven diagnosis of sarcoidosis, using a questionnaire that addressed the following: time since symptom onset and since the first medical visit; and the number and specialty of the physicians visited. We divided the patients by the timeliness of the diagnosis-timely (< 6 months) and delayed ( 6 months)-comparing the two groups in terms of systemic and pulmonary symptoms; extrathoracic involvement; spirometric data; radiological staging; level of education; income; and tuberculosis (diagnosis and treatment). Results: We evaluated 100 patients. The median number of physicians consulted was 3 (range, 1-14). In 11 cases, sarcoidosis was diagnosed at the first visit. In 54, the first physician seen was a general practitioner. The diagnosis of sarcoidosis was timely in 41 patients and delayed in 59. The groups did not differ in terms of gender; race; type of health insurance; level of education; income; respiratory/systemic symptoms; extrathoracic involvement; and radiological staging. In the delayed diagnosis group, FVC was lower (80.3 ± 20.4% vs. 90.5 ± 17.1%; p = 0.010), as was FEV1 (77.3 ± 19.9% vs. 86.4 ± 19.5%; p = 0.024), misdiagnosis with and treatment for tuberculosis ( 3 months) also being more common (24% vs. 7%, p = 0.032, and 20% vs. 0%; p = 0.002, respectively). Conclusions: The diagnosis of sarcoidosis is often delayed, even when the imaging is suggestive of sarcoidosis. Delayed diagnosis is associated with impaired lung function at the time of diagnosis. Many sarcoidosis patients are misdiagnosed with and treated for tuberculosis.


Keywords: Sarcoidosis; Sarcoidosis, pulmonary/diagnosis; Tuberculosis.


4 - Validation and development of an immunonephelometric assay for the determination of alpha-1 antitrypsin levels in dried blood spots from patients with COPD

Desenvolvimento e validação de um método de imunonefelometria em amostras de sangue em papel-filtro para a dosagem da alfa-1 antitripsina em pacientes com DPOC

Laura Russo Zillmer, Rodrigo Russo, Beatriz Martins Manzano, Ivan Ivanaga, Oliver Augusto Nascimento, Altay Alves Lino de Souza, Gildo Santos Júnior, Francisco Rodriguez, Marc Miravitlles, José Roberto Jardim

J Bras Pneumol.2013;39(5):547-554

Abstract PDF PT PDF EN Portuguese Text

Objective: To validate and develop an immunonephelometric assay for the determination of alpha-1 antitrypsin (AAT) levels in dried blood spots from COPD patients in Brazil. Methods: We determined AAT levels in serum samples and dried blood spots from 192 COPD patients. For the preparation of dried blood spots, a disk (diameter, 6 mm) was placed into a tube, eluted with 200 µL of PBS, and stored overnight at 4°C. All of the samples were analyzed by immunonephelometry in duplicate. We used the bootstrap resampling method in order to determine a cut-off point for AAT levels in dried blood spots. Results: The correlation coefficient between the AAT levels in serum samples and those in dried blood spots was r = 0.45. For dried blood spots, the cut-off value was 2.02 mg/dL (97% CI: 1.45-2.64 mg/dL), with a sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 95.7%, 27.2%, and 100%, respectively. Conclusions: This method for the determination of AAT levels in dried blood spots appears to be a reliable screening tool for patients with AAT deficiency.


5 - Cystic fibrosis transmembrane conductance regulator mutations at a referral center for cystic fibrosis

Mutações no gene cystic fibrosis transmembrane conductance regulator em um centro de referência para a fibrose cística

Cyntia Arivabeni de Araújo Correia Coutinho, Fernando Augusto de Lima Marson, Antônio Fernando Ribeiro, José Dirceu Ribeiro, Carmen Silvia Bertuzzo

J Bras Pneumol.2013;39(5):555-561

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the frequency of six mutations (F508del, G542X, G551D, R553X, R1162X, and N1303K) in patients with cystic fibrosis (CF) diagnosed, at a referral center, on the basis of abnormal results in two determinations of sweat sodium and chloride concentrations. Methods: This was a cross-sectional study involving 70 patients with CF. The mean age of the patients was 12.38 ± 9.00 years, 51.43% were female, and 94.29% were White. Mutation screening was performed with polymerase chain reaction (for F508del), followed by enzymatic digestion (for other mutations). Clinical analysis was performed on the basis of gender, age, ethnicity, pulmonary/gastrointestinal symptoms, and Shwachman-Kulczycki (SK) score. Results: All of the patients showed pulmonary symptoms, and 8 had no gastrointestinal symptoms. On the basis of the SK scores, CF was determined to be mild, moderate, and severe in 22 (42.3%), 17 (32.7%), and 13 (25.0%) of the patients, respectively. There was no association between F508del mutation and disease severity by SK score. Of the 140 alleles analyzed, F508del mutation was identified in 70 (50%). Other mutations (G542X, G551D, R553X, R1162X, and N1303K) were identified in 12 (7.93%) of the alleles studied. In F508del homozygous patients with severe disease, the OR was 0.124 (95% CI: 0.005-0.826). Conclusions: In 50% of the alleles studied, the molecular diagnosis of CF was confirmed by identifying a single mutation (F508del). If we consider the analysis of the six most common mutations in the Brazilian population (including F508del), the molecular diagnosis was confirmed in 58.57% of the alleles studied.


6 - The influence of leptin on Th1/Th2 balance in obese children with asthma

Influência da leptina no equilíbrio Th1/Th2 em crianças asmáticas obesas

Doaa Mohammed Youssef, Rabab Mohamed Elbehidy, Dina Mahamoud Shokry, Eman Mohamed Elbehidy

J Bras Pneumol.2013;39(5):562-568

Abstract PDF PT PDF EN Portuguese Text

Objective: In individuals with asthma, obesity induces the production of leptin and is associated with disease severity. Our objective was to evaluate the levels of serum leptin and their effect on Th1/Th2 balance in obese and non-obese children with asthma, as well as to investigate the association between serum leptin levels and clinical outcomes. Methods: We evaluated 50 atopic children with physician-diagnosed moderate-to-severe persistent asthma and 20 controls. The children with asthma were divided into two groups, by body mass index percentile: obese (n = 25) and non-obese (n = 25). From all subjects, we collected peripheral blood samples in order to determine the levels of leptin, IFN-, and IL-4. Asthma severity was assessed by an asthma symptom score, and the results were correlated with the parameters studied. Results: Serum leptin levels were significantly higher in the obese asthma group than in the non-obese asthma group, as well as being significantly higher in the children with asthma than in the controls, whereas IFN- levels were significantly higher and IL-4 levels were significantly lower in the obese asthma group than in the non-obese asthma group. In addition, the obese asthma group showed higher asthma symptom scores and significantly lower FEV1 (% of predicted) than did the non-obese asthma group. There was a significant positive correlation between leptin and IFN- levels only in the obese asthma group. Conclusions: Although leptin is involved in the pathogenesis of asthma in obese and non-obese children, its effect is more pronounced in the former. In the presence of high leptin levels, only obese children with asthma exhibited Th1 polarization, with higher IFN- levels and greater asthma severity.


7 - Diagnostic criteria and follow-up in neuroendocrine cell hyperplasia of infancy: a case series

Critérios diagnósticos e seguimento em hiperplasia de células neuroendócrinas do lactente: uma série de casos

Vivianne Calheiros Chaves Gomes, Mara Cristina Coelho Silva, José Holanda Maia Filho, Pedro Daltro, Simone Gusmão Ramos, Alan S. Brody, Edson Marchiori

J Bras Pneumol.2013;39(5):569-578

Abstract PDF PT PDF EN Portuguese Text

Objective: Neuroendocrine cell hyperplasia of infancy (NEHI) is a form of childhood interstitial lung disease characterized by tachypnea, retractions, crackles, and hypoxia. The aim of this study was to report and discuss the clinical, imaging, and histopathological findings in a series of NEHI cases at a tertiary pediatric hospital, with an emphasis on diagnostic criteria and clinical outcomes. Methods: Between 2003 and 2011, 12 full-term infants were diagnosed with NEHI, based on clinical and tomographic findings. Those infants were followed for 1-91 months. Four infants were biopsied, and the histopathological specimens were stained with bombesin antibody. Results: In this case series, symptoms appeared at birth in 6 infants and by 3 months of age in the remaining 6. In all of the cases, NEHI was associated with acute respiratory infection. The most common initial chest HRCT findings were ground-glass opacities that were in the middle lobe/lingula in 12 patients and in other medullary areas in 10. Air trapping was the second most common finding, being observed in 7 patients. Follow-up HRCT scans (performed in 10 patients) revealed normal results in 1 patient and improvement in 9. The biopsy findings were nonspecific, and the staining was positive for bombesin in all samples. Confirmation of NEHI was primarily based on clinical and tomographic findings. Symptoms improved during the follow-up period (mean, 41 months). A clinical cure was achieved in 4 patients. Conclusions: In this sample of patients, the diagnosis of NEHI was made on the basis of the clinical and tomographic findings, independent of the lung biopsy results. Most of the patients showed clinical improvement and persistent tomographic changes during the follow-up period, regardless of the initial severity of the disease or type of treatment.


Keywords: Lung diseases, interstitial/diagnosis; Lung diseases, interstitial/treatment; Tomography, X-ray computed.


8 - Prevalence of and factors influencing smoking among medical and non-medical students in Tbilisi, Georgia

Prevalência de tabagismo e fatores que o influenciam em estudantes de medicina e outros universitários em Tbilisi, Geórgia

Ivane Chkhaidze, Nino Maglakelidze, Tamaz Maglakelidze, Nikolai Khaltaev

J Bras Pneumol.2013;39(5):579-584

Abstract PDF PT PDF EN Portuguese Text

Objective: Smoking is a serious problem that has a devastating impact on health. The objective of this study was to describe the prevalence of and factors influencing smoking among medical and non-medical students in Tbilisi, Georgia, as well as to determine whether medical education has an impact on smoking. Methods: A cross-sectional study was carried out at Tbilisi State Medical University and Tbilisi State University, both of which are located in Tbilisi, Georgia. A total of 400 4th-year students (200 students at each university) were asked to complete standardized questionnaires. Results: Of the sample as a whole, 48.75% were identified as smokers and 51.25% were identified as nonsmokers. The mean age was 20.24 years among smokers and 20.26 years among nonsmokers. Of the medical students, 49.5% were smokers, as were 48.0% of the non-medical students. The male-to-female ratio in the study population was 0.9:1.1. Smoking was found to have a strong relationship with gender, males accounting for 65% of all smokers. Of the smokers, 56.9% stated that they would like to quit smoking (for health or financial reasons). Of the medical students, 59.5% expressed a willingness to quit smoking, as did 54.2% of the non-medical students. Conclusions: There is a need to improve smoking education for undergraduate students. Special attention should be given to the inclusion of anti-smoking education in undergraduate curricula, as well as to the implementation of smoking prevention campaigns at institutions of higher education. However, such measures will be effective only if tobacco control policies are strictly enforced on the national level as well.


9 - The outcome of tuberculosis treatment in subjects with chronic kidney disease in Brazil: a multinomial analysis

Desfecho do tratamento da tuberculose em indivíduos com doença renal crônica no Brasil: uma análise multinomial

Barbara Reis-Santos, Teresa Gomes, Bernardo Lessa Horta, Ethel Leonor Noia Maciel

J Bras Pneumol.2013;39(5):585-594

Abstract PDF PT PDF EN Portuguese Text

Objective: To analyze the association between clinical/epidemiological characteristics and outcomes of tuberculosis treatment in patients with concomitant tuberculosis and chronic kidney disease (CKD) in Brazil. Methods: We used the Brazilian Ministry of Health National Case Registry Database to identify patients with tuberculosis and CKD, treated between 2007 and 2011. The tuberculosis treatment outcomes were compared with epidemiological and clinical characteristics of the subjects using a hierarchical multinomial logistic regression model, in which cure was the reference outcome. Results: The prevalence of CKD among patients with tuberculosis was 0.4% (95% CI: 0.37-0.42%). The sample comprised 1,077 subjects. The outcomes were cure, in 58%; treatment abandonment, in 7%; death from tuberculosis, in 13%; and death from other causes, in 22%. The characteristics that differentiated the ORs for treatment abandonment or death were age; alcoholism; AIDS; previous noncompliance with treatment; transfer to another facility; suspected tuberculosis on chest X-ray; positive results in the first smear microscopy; and indications for/use of directly observed treatment, short-course strategy. Conclusions: Our data indicate the importance of sociodemographic characteristics for the diagnosis of tuberculosis in patients with CKD and underscore the need for tuberculosis control strategies targeting patients with chronic noncommunicable diseases, such as CKD.


Keywords: Tuberculosis/epidemiology; Renal insufficiency, chronic/epidemiology; Risk factors; Logistic models.


10 - Evaluation of manual resuscitators used in ICUs in Brazil

Avaliação de reanimadores manuais utilizados em UTIs brasileiras

Tatiana de Arruda Ortiz, Germano Forti Junior, Márcia Souza Volpe, Marcelo do Amaral Beraldo, Marcelo Britto Passos Amato, Carlos Roberto Ribeiro Carvalho, Mauro Roberto Tucci

J Bras Pneumol.2013;39(5):595-603

Abstract PDF PT PDF EN Portuguese Text Appendix

Objective: To analyze psychological morbidity as a moderator of the relationship between smoking representations and quality of life in smokers and former smokers, as well as to determine which psychological variables discriminate between smokers with and without the intention to quit smoking. Methods: This was a quantitative, correlational cross-sectional study involving a convenience sample of 224 smokers and 169 former smokers. Results: In smokers and former smokers, psychological morbidity had a moderating effect on the relationship between mental/physical quality of life and smoking representations (cognitive representations, emotional representations, and comprehensibility). Smokers with the intention to quit smoking more often presented with low comprehensibility, threatening emotional representations, behavioral beliefs, and perceived behavioral control, as well as with normative/control beliefs, than did those without the intention to quit. Conclusions: The results of this study underscore the importance of the moderating effect exerted by psychological morbidity, as well as that of sociocognitive variables, among smokers who have the intention to quit smoking.


Review Article

11 - Obstructive sleep apnea and asthma

Apneia obstrutiva do sono e asma

Cristina Salles, Regina Terse-Ramos, Adelmir Sousa-Machado, Álvaro A Cruz

J Bras Pneumol.2013;39(5):604-612

Abstract PDF PT PDF EN Portuguese Text

Symptoms of sleep-disordered breathing, especially obstructive sleep apnea syndrome (OSAS), are common in asthma patients and have been associated with asthma severity. It is known that asthma symptoms tend to be more severe at night and that asthma-related deaths are most likely to occur during the night or early morning. Nocturnal symptoms occur in 60-74% of asthma patients and are markers of inadequate control of the disease. Various pathophysiological mechanisms are related to the worsening of asthma symptoms, OSAS being one of the most important factors. In patients with asthma, OSAS should be investigated whenever there is inadequate control of symptoms of nocturnal asthma despite the treatment recommended by guidelines having been administered. There is evidence in the literature that the use of continuous positive airway pressure contributes to asthma control in asthma patients with obstructive sleep apnea and uncontrolled asthma.


Case Report

12 - Pneumomediastinum, subcutaneous emphysema, and pneumothorax after a pulmonary function testing in a patient with bleomycin-induced interstitial pneumonitis

Pneumomediastino, enfisema subcutâneo e pneumotórax após prova de função pulmonar em paciente com pneumopatia intersticial por bleomicina

Mariana Sponholz Araujo, Frederico Leon Arrabal Fernandes, Fernando Uliana Kay, Carlos Roberto Ribeiro Carvalho

J Bras Pneumol.2013;39(5):613-619

Abstract PDF PT PDF EN Portuguese Text

Spontaneous pneumomediastinum is an uncommon event, the clinical picture of which includes retrosternal chest pain, subcutaneous emphysema, dyspnea, and dysphonia. The pathophysiological mechanism involved is the emergence of a pressure gradient between the alveoli and surrounding structures, causing alveolar rupture with subsequent dissection of the peribronchovascular sheath and infiltration of the mediastinum and subcutaneous tissue with air. Known triggers include acute exacerbations of asthma and situations that require the Valsalva maneuver. We described and documented with HRCT scans the occurrence of pneumomediastinum after a patient with bleomycin-induced interstitial lung disease underwent pulmonary function testing. Although uncommon, the association between pulmonary function testing and air leak syndromes has been increasingly reported in the literature, and lung diseases, such as interstitial lung diseases, include structural changes that facilitate the occurrence of this complication.


Keywords: Mediastinal emphysema; Subcutaneous emphysema; Spirometry; Bleomycin.


13 - Cryptococcosis, silicosis, and tuberculous pseudotumor in the same pulmonary lobe

Tuberculose pseudotumoral, criptococose e silicose no mesmo lobo pulmonar

Geruza Alves da Silva, Daniel Ferracioli Brandão, Elcio Oliveira Vianna, João Batista Carlos de Sá Filho, José Baddini-Martinez

J Bras Pneumol.2013;39(5):620-626

Abstract PDF PT PDF EN Portuguese Text

Tuberculosis and cryptococcosis are infectious diseases that can result in the formation of single or multiple nodules in immunocompetent patients. Exposure to silica is known to raise the risk of infection with Mycobacterium tuberculosis. We report the case of an elderly man with no history of opportunistic infections and no clinical evidence of immunodeficiency but with a six-month history of dry cough and nocturnal wheezing. A chest X-ray revealed a mass measuring 5.0 × 3.5 cm in the right upper lobe. The diagnostic approach of the mass revealed tuberculosis. The histopathological analysis of the surrounding parenchyma reveled silicosis and cryptococcosis. Cryptococcosis was also found in masses identified in the mediastinal lymph nodes. The surgical approach was indicated because of the degree of pleuropulmonary involvement, the inconclusive results obtained with the invasive and noninvasive methods applied, and the possibility of malignancy. This case illustrates the difficulty inherent to the assessment of infectious or inflammatory pulmonary pseudotumors, the differential diagnosis of which occasionally requires a radical surgical approach. Despite the presence of respiratory symptoms for six months, the first chest X-ray was performed only at the end of that period. We discuss the possible pathogenic mechanisms that might have led to the combination of three types of granulomatous lesions in the same lobe, and we emphasize the need for greater awareness of atypical presentations of pulmonary tuberculosis.


Letters to the Editor

14 - Epipericardial fat necrosis: an unusual cause of chest pain

Necrose da gordura epipericárdica: uma causa incomum de dor torácica

Karina de Souza Giassi, André Nathan Costa, André Apanavicius, Guilherme Hipólito Bachion, Rafael Silva Musolino, Ronaldo Adib Kairalla

J Bras Pneumol.2013;39(5):627-629

PDF PT PDF EN Portuguese Text

17 - Mediastinal cyst as a cause of severe airway compression and dysphonia

Cisto mediastinal como causa de grave compressão da via aérea central e disfonia

Vanessa Costa Menezes, Paulo Francisco Guerreiro Cardoso, Hélio Minamoto, Márcia Jacomelli, Paulo Sampaio Gutierrez, Fabio Biscegli Jatene

J Bras Pneumol.2013;39(5):636-640

PDF PT PDF EN Portuguese Text


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