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.

A visita domiciliar como instrumento de intervenção na oxigenoterapia domiciliar prolongada / Home visit as an intervention instrument in extended home oxygen therapy / La visita domiciliaria como instrumento de intervención en la oxigenoterapia domiciliar prolongada

Objetivo: verificar a contribuição da visita domiciliar como instrumento para avaliar as condições de uso da oxigenoterapia domiciliar. Método: estudo transversal descritivo, com abordagem quantitativa, no qual foram visitados 54 pacientes com DPOC de um programa de oxigenoterapia domiciliar na cidade de Bauru/SP/Brasil. Os dados foram coletados com um formulário, analisados pelo Statistical Analysis System (SAS) v.9.3 e apresentados em frequência simples. Resultados: os pacientes tinham idade média de 67.9 anos, sendo 51.9% do sexo masculino. O tabagismo ativo foi relatado por 14.8%. A maioria 66.6% utilizava O2 apenas no período noturno. O tempo médio de uso do O2 foi 14.6 h/dia. Conclusão: a visita domiciliar identificou inadequações no uso de oxigênio que interferem no tratamento.(AU)

Objective: to verify the contribution of home visits as a tool to evaluate the conditions of using home oxygen therapy. Method: a descriptive and cross-sectional study with a quantitative approach, visiting 54 patients with COPD of a home oxygen therapy program in the city of Bauru/SP/Brazil. Data were collected with a form, analyzed by the Statistical Analysis System (SAS) v.9.3, presented in a single frequency. Results: the patients had a mean age of 67.9 years old, 51.9% male. Active smoking was reported by 14.8% of patients. Most of them, 66.6% used O2 only at night. The average time of use O2 was 14.6 hours/day. Conclusion: home visits identified inadequacies in the use of oxygen that interferes with treatment.(AU)

Objetivo: verificar la contribución de la visita domiciliaria como instrumento para evaluar las condiciones de uso de la oxigenoterapia domiciliaria. Método: estudio transversal descriptivo, con enfoque cuantitativo, en el cual fueron visitados 54 pacientes con DPOC de un programa de oxigenoterapia domiciliaria en la ciudad de Bauru/SP/Brasil. Los datos fueron recogidos con un formulario, analizados por Statistical Analysis System (SAS) v.9.3, presentados en frecuencia simple. Resultados: los pacientes tenían edad media de 67.9 años, siendo 51.9% del sexo masculino. El tabaquismo activo fue relatado por 14.8%. La mayoría 66.6% utilizaba O2 apenas en el período nocturno. El tiempo medio de uso de O2 fue 14.6 h/día. Conclusión: la visita domiciliaria identificó inadecuaciones en el uso de oxígeno que interfieren en el tratamiento.(AU)

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.

Influence of lean body mass on cardiopulmonary repercussions during the six-minute walk test in patients with COPD.

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.