Lung cancer screening in Brazil: recommendations from the Brazilian Society of Thoracic Surgery, Brazilian Thoracic Association, and Brazilian College of Radiology and Diagnostic Imaging.

Although lung cancer (LC) is one of the most common and lethal tumors, only 15% of patients are diagnosed at an early stage. Smoking is still responsible for more than 85% of cases. Lung cancer screening (LCS) with low-dose CT (LDCT) reduces LC-related mortality by 20%, and that reduction reaches 38% when LCS by LDCT is combined with smoking cessation. In the last decade, a number of countries have adopted population-based LCS as a public health recommendation. Albeit still incipient, discussion on this topic in Brazil is becoming increasingly broad and necessary. With the aim of increasing knowledge and stimulating debate on LCS, the Brazilian Society of Thoracic Surgery, the Brazilian Thoracic Association, and the Brazilian College of Radiology and Diagnostic Imaging convened a panel of experts to prepare recommendations for LCS in Brazil. The recommendations presented here were based on a narrative review of the literature, with an emphasis on large population-based studies, systematic reviews, and the recommendations of international guidelines, and were developed after extensive discussion by the panel of experts. The following topics were reviewed: reasons for screening; general considerations about smoking; epidemiology of LC; eligibility criteria; incidental findings; granulomatous lesions; probabilistic models; minimum requirements for LDCT; volumetric acquisition; risks of screening; minimum structure and role of the multidisciplinary team; practice according to the Lung CT Screening Reporting and Data System; costs versus benefits of screening; and future perspectives for LCS.

Lung cancer screening in Brazil: recommendations from the Brazilian Society of Thoracic Surgery, Brazilian Thoracic Association, and Brazilian College of Radiology and Diagnostic Imaging / Recomendações da Sociedade Brasileira de Cirurgia Torácica, Sociedade Brasileira de Pneumologia e Tisiologia e Colégio Brasileiro de Radiologia e Diagnóstico por Imagem para o rastreamento do câncer de pulmão no Brasil

ABSTRACT Although lung cancer (LC) is one of the most common and lethal tumors, only 15% of patients are diagnosed at an early stage. Smoking is still responsible for more than 85% of cases. Lung cancer screening (LCS) with low-dose CT (LDCT) reduces LC-related mortality by 20%, and that reduction reaches 38% when LCS by LDCT is combined with smoking cessation. In the last decade, a number of countries have adopted population-based LCS as a public health recommendation. Albeit still incipient, discussion on this topic in Brazil is becoming increasingly broad and necessary. With the aim of increasing knowledge and stimulating debate on LCS, the Brazilian Society of Thoracic Surgery, the Brazilian Thoracic Association, and the Brazilian College of Radiology and Diagnostic Imaging convened a panel of experts to prepare recommendations for LCS in Brazil. The recommendations presented here were based on a narrative review of the literature, with an emphasis on large population-based studies, systematic reviews, and the recommendations of international guidelines, and were developed after extensive discussion by the panel of experts. The following topics were reviewed: reasons for screening; general considerations about smoking; epidemiology of LC; eligibility criteria; incidental findings; granulomatous lesions; probabilistic models; minimum requirements for LDCT; volumetric acquisition; risks of screening; minimum structure and role of the multidisciplinary team; practice according to the Lung CT Screening Reporting and Data System; costs versus benefits of screening; and future perspectives for LCS.

RESUMO O câncer de pulmão (CP) é uma das neoplasias mais comuns e letais no Brasil, e apenas 15% dos pacientes são diagnosticados nos estágios iniciais. O tabagismo persiste como o responsável por mais de 85% de todos os casos. O rastreamento do CP (RCP) por meio da TC de baixa dosagem de radiação (TCBD) reduz a mortalidade do CP em 20%, e, quando combinado com a cessação do tabagismo, essa redução chega a 38%. Na última década, diversos países adotaram o RCP como recomendação de saúde populacional. No Brasil, embora ainda incipiente, a discussão sobre o tema é cada vez mais ampla e necessária. Com o intuito de aumentar o conhecimento e estimular o debate sobre o RCP, a Sociedade Brasileira de Cirurgia Torácica, a Sociedade Brasileira de Pneumologia e Tisiologia e o Colégio Brasileiro de Radiologia e Diagnóstico por Imagem constituíram um painel de especialistas para elaborar as recomendações para o RCP. As recomendações aqui apresentadas foram baseadas em revisão narrativa da literatura, com ênfase em grandes estudos populacionais, em revisões sistemáticas e em recomendações de diretrizes internacionais, sendo construídas após ampla discussão pelo grupo de especialistas. Os temas revisados foram os seguintes: porque rastrear, considerações gerais sobre tabagismo, epidemiologia do CP, critérios de elegibilidade, achados incidentais, lesões granulomatosas, modelos probabilísticos, requisitos mínimos da TCBD, aquisições volumétricas, riscos do rastreamento, estrutura mínima e papel da equipe multidisciplinar, conduta segundo o Lung CT Screening Reporting and Data System (Lung-RADS), custos vs. benefícios e perspectivas do rastreamento.

Symptom variability over the course of the day in patients with stable COPD in Brazil: a real-world observational study.

OBJECTIVE: To analyze symptoms at different times of day in patients with COPD. METHODS: This was a multicenter, cross-sectional observational study conducted at eight centers in Brazil. We evaluated morning, daytime, and nighttime symptoms in patients with stable COPD. RESULTS: We included 593 patients under regular treatment, of whom 309 (52.1%) were male and 92 (15.5%) were active smokers. The mean age was 67.7 years, and the mean FEV1 was 49.4% of the predicted value. In comparison with the patients who had mild or moderate symptoms, the 183 (30.8%) with severe symptoms were less physically active (p = 0.002), had greater airflow limitation (p < 0.001), had more outpatient exacerbations (p = 0.002) and more inpatient exacerbations (p = 0.043), as well as scoring worse on specific instruments. The most common morning and nighttime symptoms were dyspnea (in 45.2% and 33.1%, respectively), cough (in 37.5% and 33.3%, respectively), and wheezing (in 24.4% and 27.0%, respectively). The intensity of daytime symptoms correlated strongly with that of morning symptoms (r = 0.65, p < 0.001) and that of nighttime symptoms (r = 0.60, p < 0.001), as well as with the COPD Assessment Test score (r = 0.62; p < 0.001), although it showed only a weak correlation with FEV1 (r = -0.205; p < 0.001). CONCLUSIONS: Dyspnea was more common in the morning than at night. Having morning or nighttime symptoms was associated with greater daytime symptom severity. Symptom intensity was strongly associated with poor quality of life and with the frequency of exacerbations, although it was weakly associated with airflow limitation.

Update on the approach to smoking in patients with respiratory diseases.

Smoking is the leading cause of respiratory disease (RD). The harmful effects of smoking on the respiratory system begin in utero and influence immune responses throughout childhood and adult life. In comparison with "healthy" smokers, smokers with RD have peculiarities that can impede smoking cessation, such as a higher level of nicotine dependence; nicotine withdrawal; higher levels of exhaled carbon monoxide; low motivation and low self-efficacy; greater concern about weight gain; and a high prevalence of anxiety and depression. In addition, they require more intensive, prolonged treatment. It is always necessary to educate such individuals about the fact that quitting smoking is the only measure that will reduce the progression of RD and improve their quality of life, regardless of the duration and severity of the disease. Physicians should always offer smoking cessation treatment. Outpatient or inpatient smoking cessation treatment should be multidisciplinary, based on behavioral interventions and pharmacotherapy. It will thus be more effective and cost-effective, doubling the chances of success.

Update on the approach to smoking in patients with respiratory diseases / Atualização na abordagem do tabagismo em pacientes com doenças respiratórias

ABSTRACT Smoking is the leading cause of respiratory disease (RD). The harmful effects of smoking on the respiratory system begin in utero and influence immune responses throughout childhood and adult life. In comparison with "healthy" smokers, smokers with RD have peculiarities that can impede smoking cessation, such as a higher level of nicotine dependence; nicotine withdrawal; higher levels of exhaled carbon monoxide; low motivation and low self-efficacy; greater concern about weight gain; and a high prevalence of anxiety and depression. In addition, they require more intensive, prolonged treatment. It is always necessary to educate such individuals about the fact that quitting smoking is the only measure that will reduce the progression of RD and improve their quality of life, regardless of the duration and severity of the disease. Physicians should always offer smoking cessation treatment. Outpatient or inpatient smoking cessation treatment should be multidisciplinary, based on behavioral interventions and pharmacotherapy. It will thus be more effective and cost-effective, doubling the chances of success.

RESUMO O tabagismo é o maior responsável pelas doenças respiratórias (DR). Os efeitos nocivos do tabaco sobre o aparelho respiratório se iniciam ainda intraútero e influenciam as respostas imunológicas ao longo da infância e vida adulta. Os tabagistas com DR possuem peculiaridades que podem dificultar a cessação tabágica, tais como maior grau de dependência e de abstinência de nicotina; níveis mais elevados de monóxido de carbono exalado; motivação e autoeficácia baixas; maior preocupação com ganho ponderal; e elevada prevalência de ansiedade e depressão. Além disso, requerem tratamento mais intensivo e prolongado. É necessário esclarecer sempre o paciente sobre o fato de que parar de fumar será a única medida que irá reduzir a progressão das DR e melhorar sua qualidade de vida, independentemente do tempo e da gravidade da doença. Os médicos devem sempre oferecer o tratamento de cessação tabágica. O tratamento ambulatorial ou hospitalar deve ser multidisciplinar, baseado em intervenções comportamentais e farmacoterapia, sendo eficaz e custo-efetivo, dobrando as chances de sucesso.

Vitamin D role in smoking women and cardiac remodeling

Background: The objective of the study is to evaluate the influence of serum vitamin D concentrations and smoking status in cardiac structure and function. Methods: The participants of this study were healthy women smokers (n = 18, mean age 52.8 years), ex-smokers ( n = 18, mean age 51.7 years), and never smokers ( n = 19, mean age 44.4 years). All participants underwent assessment of body composition, dietary intake, sun exposure frequency, vitamin D serum determination, and echocardiographic assessment. All data underwent statistical analysis. Results: The three groups were classified as overweight. The group of ex-smokers showed significantly higher vitamin D serum concentrations. Smoker group showed a higher posterior wall thickness (PW), left ventricular mass, and left ventricular mass index (LVMI). We identified positive correlations between LVMI and smoking history, PW and vitamin D serum, and body mass index and time of smoking history. Multiple linear regressions showed positive association of smoking history and LVMI and PW, also that serum vitamin D has a positive association with PW. PW was associated with smoking history and serum vitamin D, showing a deleterious effect on the heart of both variables. Conclusions: Smoking habit in adult women was associated with cardiac remodeling, and excess of vitamin Dis associated with the action of smoking on cardiac variables. Thus, higher serum vitamin D values have a deleterious effect on the heart in this model.

Doença pulmonar obstrutiva crônica / Chronic obstructive pulmonary disease

A doença pulmonar obstrutiva crônica (DPOC) será abordada quanto ao quadro clínico, critérios diagnósticos e tratamento. Serão ainda discutidas as principais manifestações sistêmicas da doença, bem como a importância da identificação e tratamento destas no seguimento de pacientes portadores de DPOC.

Asma na mulher / Asthma in woman

A asma é doença inflamatória crônica de alta prevalência e com alta morbidade se não tratada. Algumas diferenças são notadas entre homens e mulheres, principalmente na manifestação da doença, porém diagnóstico e tratamento não diferem entre os gêneros. Algumas peculiaridades da asma na mulher serão discutidas nesta revisão, bem como o tratamento da gestante asmática.

Pneumonias / Pneumonia

As pneumonias constituem grupo de doenças infecciosas de grande morbidade e mortalidade em todo o mundo. Com base nos consensos atuais, este artigo abordará as principais questões da prática diária tais como agentes etiológicos, quadro clínico, ferramentas diagnósticas e tratamentos para pneumonia adquirida na comunidade (PAC) em adultos imunocompetentes e para pneumonias associadas aos cuidados de saúde.

Doença pulmonar obstrutiva crônica / Chronic obstrutive pulmonary disease

A doença pulmonar obstrutiva crônica (DPOC) será abordada quanto ao quadro clínico, critérios diagnósticos e tratamento. Serão, ainda, discutidas as principais manifestações sistêmicas da doença, bem como a importância da identificação e tratamento destas no seguimento de pacientes portadores de DPOC.

Characteristics of smokers enrolled in a public smoking cessation program.

OBJECTIVE: To evaluate the characteristics of smokers seeking treatment in a public smoking cessation program. METHODS: This was a retrospective evaluation of data collected during the interview for enrollment in the smoking cessation program of the Smoking Outpatient Clinic of the Paulista State University School of Medicine in the city of Botucatu, Brazil, between April of 2003 and April of 2007. Demographic variables; previous use of the behavioral approach, medications or alternative treatments for smoking cessation; degree of nicotine dependence; and history of comorbidities were evaluated in 387 smokers. RESULTS: In our sample, 63% of the smokers were female. The mean age of the subjects was 50 + or - 25 years. More than half of the subjects (61%) had up to eight years of schooling, and 66% had a monthly income of less than twice the national minimum wage. The degree of nicotine dependence was high/very high in 59%, medium in 17% and low/very low in 24% of the subjects. Although 95% of the patients presented comorbidities, only 35% had been referred to the program by a physician. More than half of the subjects (68%) had made at least one smoking-cessation attempt, 83% of whom did so without the help of a structured program. CONCLUSIONS: Smokers seeking assistance for smoking cessation were socially disadvantaged, presented a high degree of nicotine dependence and had previously made smoking-cessation attempts without the benefit of a structured program. Therefore, in order to be effective, smoking control interventions should take into consideration the general characteristics of the smokers treated via the public health care system.

Perfil de fumantes atendidos em serviço público para tratamento do tabagismo / Characteristics of smokers enrolled in a public smoking cessation program

OBJETIVO: Avaliar o perfil dos fumantes que procuraram serviço público de cessação do tabagismo. MÉTODOS: Foram avaliados retrospectivamente os dados coletados durante a avaliação para a admissão no programa de cessação do tabagismo do Ambulatório de Tabagismo da Faculdade de Medicina de Botucatu/Universidade Estadual Paulista, na cidade de Botucatu (SP) entre abril de 2003 e abril de 2007. Variáveis demográficas, uso prévio de abordagem comportamental e/ou farmacológica e/ou tratamentos alternativos para o tabagismo, grau de dependência à nicotina e comorbidades foram avaliados em 387 fumantes. RESULTADOS: Em nossa casuística, 63 por cento dos tabagistas eram do sexo feminino. A idade média dos sujeitos foi de 50 ± 25 anos. Mais da metade dos fumantes (61 por cento) não tinha cursado o ensino médio, e 66 por cento tinham renda mensal menor que dois salários mínimos. O grau de dependência foi elevado/muito elevado em 59 por cento, médio em 17 por cento e baixo/muito baixo em 24 por cento. Embora 95 por cento dos pacientes apresentavam comorbidades, apenas 35 por cento foram encaminhados ao programa por um médico. Mais da metade (68 por cento) tinha feito pelo menos uma tentativa de cessação, 83 por cento sem um programa de tratamento estruturado. CONCLUSÕES: Os tabagistas que procuraram assistência para cessar o tabagismo apresentaram desvantagem social, dependência à nicotina alta e tentativas anteriores de cessação sem tratamento estruturado. Portanto, a intervenção para o controle do tabagismo deve contemplar as características gerais dos fumantes nos serviços públicos para que seja eficaz.

OBJECTIVE: To evaluate the characteristics of smokers seeking treatment in a public smoking cessation program. METHODS: This was a retrospective evaluation of data collected during the interview for enrollment in the smoking cessation program of the Smoking Outpatient Clinic of the Paulista State University School of Medicine in the city of Botucatu, Brazil, between April of 2003 and April of 2007. Demographic variables; previous use of the behavioral approach, medications or alternative treatments for smoking cessation; degree of nicotine dependence; and history of comorbidities were evaluated in 387 smokers. RESULTS: In our sample, 63 percent of the smokers were female. The mean age of the subjects was 50 ± 25 years. More than half of the subjects (61 percent) had up to eight years of schooling, and 66 percent had a monthly income of less than twice the national minimum wage. The degree of nicotine dependence was high/very high in 59 percent, medium in 17 percent and low/very low in 24 percent of the subjects. Although 95 percent of the patients presented comorbidities, only 35 percent had been referred to the program by a physician. More than half of the subjects (68 percent) had made at least one smoking-cessation attempt, 83 percent of whom did so without the help of a structured program. CONCLUSIONS: Smokers seeking assistance for smoking cessation were socially disadvantaged, presented a high degree of nicotine dependence and had previously made smoking-cessation attempts without the benefit of a structured program. Therefore, in order to be effective, smoking control interventions should take into consideration the general characteristics of the smokers treated via the public health care system.

Influência da massa magra corporal nas repercussões cardiopulmonares durante o teste de caminhada de seis minutos em pacientes com DPOC / Influence of lean body mass on cardiopulmonary repercussions during the six-minute walk test in patients with COPD

OBJETIVO: A massa magra corporal (MMC) tem sido associada à mortalidade em pacientes com DPOC, mas seu impacto na limitação funcional é pouco conhecido. O objetivo deste trabalho foi analisar as variáveis cardiopulmonares em pacientes com DPOC, com ou sem depleção da MMC, antes e após a realização do teste de caminhada de seis minutos (TC6). MÉTODOS: Foram avaliados pacientes com DPOC, 36 sem depleção de MMC e 32 com depleção de MMC. Todos os pacientes foram submetidos à avaliação clínica, espirometria, avaliação da composição da massa corpórea e TC6 e responderam a questionários de qualidade de vida e de percepção de dispnéia. RESULTADOS: Não foram observadas diferenças significativas na gravidade de obstrução das vias aéreas, na percepção da dispnéia e na qualidade de vida entre os grupos. A distância percorrida no TC6 foi similar nos pacientes com DPOC com e sem depleção de MMC (470,3 ± 68,5 m vs. 448,2 ± 89,2 m). Entretanto, durante a realização do teste, os pacientes com depleção de MMC apresentaram aumento significativamente maior na diferença entre os valores final e basal da frequência cardíaca e do índice da escala de Borg para cansaço dos membros inferiores. A distância percorrida no TC6 apresentou correlação significativa positiva com o VEF1 (r = 0,381; p = 0,01). CONCLUSÕES: Não houve influência da depleção da MMC na capacidade funcional de exercício e na qualidade de vida dos pacientes estudados. Entretanto, os pacientes com depleção de MMC apresentam sintomas de fadiga dos membros inferiores mais acentuados durante o TC6, o que reforça a importância da avaliação e tratamento das manifestações sistêmicas da DPOC.

OBJECTIVE: Although lean body mass (LBM) has been associated with mortality in patients with COPD, its influence on functional limitation is not clear. The objective of this study was to analyze the cardiopulmonary variables in COPD patients with or without LBM depletion, prior to and after the six-minute walk test (6MWT). METHODS: We evaluated COPD patients, 32 with LBM depletion and 36 without. All patients underwent clinical evaluation, spirometry, evaluation of body mass composition and 6MWT, as well as completing questionnaires related to quality of life and perception of dyspnea. RESULTS: No significant differences in the severity of airway obstruction, perception of dyspnea and quality of life scores were found between the groups. The distance covered on the 6MWT was similar in COPD patients with and without LBM depletion (470.3 ± 68.5 m vs. 448.2 ± 89.2 m). However, patients with LBM depletion presented significantly greater differences between baseline and final values in terms of heart rate and Borg scale index for lower limb fatigue. There was a significant positive correlation between distance covered on the 6MWT and FEV1 (r = 0.381, p = 0.01). CONCLUSIONS: In the patients studied, functional exercise tolerance and quality of life were unaffected by LBM depletion. However, the patients with LBM depletion presented more pronounced lower limb fatigue during the 6MWT, which underscores the importance of the evaluation and treatment of systemic manifestations in COPD patients.

Relação entre o índice de massa corporal e a gravidade da asma em adultos / Relationship between body mass index and asthma severity in adults

OBJETIVO: O aumento do índice de massa corporal (IMC) tem sido associado a uma maior prevalência da asma em adultos. O presente estudo tem o objetivo de avaliar a associação entre a prevalência da obesidade e a gravidade da asma. MÉTODOS: Prontuários de duzentos asmáticos acima dos 20 anos de idade foram avaliados retrospectivamente. A asma foi classificada quanto à gravidade através da história clínica e do diagnóstico registrados, dos resultados da espirometria e da medicação prescrita. O IMC foi calculado e foram considerados obesos os pacientes com IMC > 30 kg/m². RESULTADOS: 23 por cento dos pacientes apresentavam asma intermitente, 25,5 por cento, asma persistente leve, 24 por cento, asma persistente moderada e 27,5 por cento, asma persistente grave. O IMC < 29,9 kg/m² foi observado em 68 por cento dos pacientes e em 32 por cento o IMC foi > 30 kg/m². O odds ratio da relação entre a obesidade e a gravidade da asma foi de 1,17 (CI95 por cento: 0,90-1,53; p > 0,05). CONCLUSÕES: Na amostra estudada não foi encontrada correlação entre a obesidade e a gravidade da asma nem no sexo masculino, nem no feminino.

OBJECTIVE: Elevated values of body mass index (BMI) have been associated with higher prevalence of asthma in adults. The aim of the present study is to evaluate the association between obesity and asthma severity. METHODS: Medical records of two hundred patients older than 20 years of age were evaluated retrospectively. Asthma severity was established after the evaluation of the medical history and diagnosis recorded, spirometry results and the medicines prescribed. BMI was calculated and patients were classified as obese when the BMI was > 30 kg/m². RESULTS: 23 percent of the patients presented intermittent asthma, 25.5 percent presented mild persistent asthma, 24 percent presented moderate persistent asthma, and 27.5 percent presented severe persistent asthma. Values of BMI < 29.9 kg/m² were observed in 68 percent of the patients and in 32 percent the BMI was > 30 kg/m². The odds ratio of the correlation between obesity and asthma severity was 1.17 (95 percent CI: 0.90-1.53; p > 0.05). CONCLUSIONS: In the sample evaluated in this study no correlation between obesity and asthma severity was found for either gender.

Alterações musculares na doença pulmonar obstrutiva crônica / Skeletal muscle dysfunction in chronic obstrutive pulmonary disease

Aumentou recentemente o interesse da comunidade científica nas causas da intolerância ao exercício em pacientes com doença pulmonar obstrutiva crônica (DPOC). além do desuso importo principalmente pela inatividade física, há evidências de alterações no músculo esquelético do portador de DPOC. Esta revisão expõe sucintamente as pricipais alterações muscuosqueléticas encontradas nos portadores de DPOC...

Intolerance to exercise in chronic obstructuve pulnmonar disease (COPD) patients has recently drawn increased attention, as muscular changes have been suggested to be the main factor responsible for the physical impairmnet. In addition to the decontinioning related to physical inactivity, there are evidences of skeletal muscle changes in these patients...