Exclusively Tracheobronchial Paracoccidioidomycosis: A Rare Presentation.

Paracoccidioidomycosis (PCM), or blastomycosis in South America, is a systemic granulomatous mycosis related to activities associated with soil management, especially agriculture. PCM restricted to tracheobronchial tree region has not yet been reported.

Evaluation of the preference, satisfaction and correct use of Breezhaler® and Respimat® inhalers in patients with chronic obstructive pulmonary disease - INHALATOR study.

The INHALATOR study was a randomized, multicentre, open label, two-period of 7 days each, crossover study, with 7 days of washout in-between, aiming to evaluate the correct use, satisfaction and preference between Breezhaler® and Respimat® devices in patients under daily use of open Spiriva® or open Onbrize®, as monotherapy for treatment of mild or moderate COPD. Patients aged ≥40 years with a smoking history of at least 10 pack-year were included in the study. Primary endpoint was the rate of correct use of each device at the first day of treatment after reading the drug leaflet information and was evaluated under the supervision of a trained evaluator. At the end of each treatment phase, the inhaler use was re-evaluated and a satisfaction questionnaire was completed. The patients' preference for the inhaler devices was assessed at the end of the study. After exclusions due to screening failures, 140 patients were randomized: 136 received at least one dose of Breezhaler® and 135 of Respimat®. At treatment start, the rate of correct inhaler use was 40.4% (95%CI: 32.2%-48.7%) for Breezhaler® and 36.3% (95%CI: 28.2%-44.4%) for Respimat® (p = 0.451). After 7 days, the rates were 68.9% (95%CI: 61.1%-76.7%) and 60.4% (95%CI: 52.2%-68.7%), respectively (p = 0.077). According to the Feeling of Satisfaction with Inhaler Questionnaire - FSI 10 patients were more satisfied using Breezhaler® than Respimat® and 57.1% preferred using Breezhaler® (p = 0.001) while 30.1% preferred Respimat® (p < 0.001).

Recommendations for the pharmacological treatment of COPD: questions and answers / Recomendações para o tratamento farmacológico da DPOC: perguntas e respostas

ABSTRACT The treatment of COPD has become increasingly effective. Measures that range from behavioral changes, reduction in exposure to risk factors, education about the disease and its course, rehabilitation, oxygen therapy, management of comorbidities, and surgical and pharmacological treatments to end-of-life care allow health professionals to provide a personalized and effective therapy. The pharmacological treatment of COPD is one of the cornerstones of COPD management, and there have been many advances in this area in recent years. Given the greater availability of drugs and therapeutic combinations, it has become increasingly challenging to know the indications for, limitations of, and potential risks and benefits of each treatment modality. In order to critically evaluate recent evidence and systematize the major questions regarding the pharmacological treatment of COPD, 24 specialists from all over Brazil gathered to develop the present recommendations. A visual guide was developed for the classification and treatment of COPD, both of which were adapted to fit the situation in Brazil. Ten questions were selected on the basis of their relevance in clinical practice. They address the classification, definitions, treatment, and evidence available for each drug or drug combination. Each question was answered by two specialists, and then the answers were consolidated in two phases: review and consensus by all participants. The questions answered are practical questions and help select from among the many options the best treatment for each patient and his/her peculiarities.

RESUMO O tratamento da DPOC vem se tornando cada vez mais eficaz. Medidas que envolvem desde mudanças comportamentais, redução de exposições a fatores de risco, educação sobre a doença e seu curso, reabilitação, oxigenoterapia, manejo de comorbidades, tratamentos cirúrgicos e farmacológicos até os cuidados de fim de vida permitem ao profissional oferecer uma terapêutica personalizada e efetiva. O tratamento farmacológico da DPOC constitui um dos principais pilares desse manejo, e muitos avanços têm sido atingidos na área nos últimos anos. Com a maior disponibilidade de medicações e combinações terapêuticas fica cada vez mais desafiador conhecer as indicações, limitações, potenciais riscos e benefícios de cada tratamento. Com o intuito de avaliar criticamente a evidência recente e sistematizar as principais dúvidas referentes ao tratamento farmacológico da DPOC, foram reunidos 24 especialistas de todo o Brasil para elaborar a presente recomendação. Foi elaborado um guia visual para a classificação e tratamento adaptados à nossa realidade. Dez perguntas foram selecionadas pela relevância na prática clínica. Abordam a classificação, definições, tratamento e evidências disponíveis para cada medicação ou combinação. Cada pergunta foi respondida por dois especialistas e depois consolidadas em duas fases: revisão e consenso entre todos os participantes. As questões respondidas são dúvidas práticas e ajudam a selecionar qual o melhor tratamento, entre as muitas opções, para cada paciente com suas particularidades.

Recommendations for the pharmacological treatment of COPD: questions and answers.

The treatment of COPD has become increasingly effective. Measures that range from behavioral changes, reduction in exposure to risk factors, education about the disease and its course, rehabilitation, oxygen therapy, management of comorbidities, and surgical and pharmacological treatments to end-of-life care allow health professionals to provide a personalized and effective therapy. The pharmacological treatment of COPD is one of the cornerstones of COPD management, and there have been many advances in this area in recent years. Given the greater availability of drugs and therapeutic combinations, it has become increasingly challenging to know the indications for, limitations of, and potential risks and benefits of each treatment modality. In order to critically evaluate recent evidence and systematize the major questions regarding the pharmacological treatment of COPD, 24 specialists from all over Brazil gathered to develop the present recommendations. A visual guide was developed for the classification and treatment of COPD, both of which were adapted to fit the situation in Brazil. Ten questions were selected on the basis of their relevance in clinical practice. They address the classification, definitions, treatment, and evidence available for each drug or drug combination. Each question was answered by two specialists, and then the answers were consolidated in two phases: review and consensus by all participants. The questions answered are practical questions and help select from among the many options the best treatment for each patient and his/her peculiarities.

PET/CT imaging in lung cancer: indications and findings.

The use of PET/CT imaging in the work-up and management of patients with lung cancer has greatly increased in recent decades. The ability to combine functional and anatomical information has equipped PET/CT to look into various aspects of lung cancer, allowing more precise disease staging and providing useful data during the characterization of indeterminate pulmonary nodules. In addition, the accuracy of PET/CT has been shown to be greater than is that of conventional modalities in some scenarios, making PET/CT a valuable noninvasive method for the investigation of lung cancer. However, the interpretation of PET/CT findings presents numerous pitfalls and potential confounders. Therefore, it is imperative for pulmonologists and radiologists to familiarize themselves with the most relevant indications for and limitations of PET/CT, seeking to protect their patients from unnecessary radiation exposure and inappropriate treatment. This review article aimed to summarize the basic principles, indications, cancer staging considerations, and future applications related to the use of PET/CT in lung cancer.

PET/CT imaging in lung cancer: indications and findings / PET/TC em câncer de pulmão: indicações e achados

The use of PET/CT imaging in the work-up and management of patients with lung cancer has greatly increased in recent decades. The ability to combine functional and anatomical information has equipped PET/CT to look into various aspects of lung cancer, allowing more precise disease staging and providing useful data during the characterization of indeterminate pulmonary nodules. In addition, the accuracy of PET/CT has been shown to be greater than is that of conventional modalities in some scenarios, making PET/CT a valuable noninvasive method for the investigation of lung cancer. However, the interpretation of PET/CT findings presents numerous pitfalls and potential confounders. Therefore, it is imperative for pulmonologists and radiologists to familiarize themselves with the most relevant indications for and limitations of PET/CT, seeking to protect their patients from unnecessary radiation exposure and inappropriate treatment. This review article aimed to summarize the basic principles, indications, cancer staging considerations, and future applications related to the use of PET/CT in lung cancer.

O uso de PET/TC na avaliação e manejo de pacientes com câncer de pulmão aumentou substantivamente durante as últimas décadas. A capacidade de combinar informações funcionais e anatômicas permite a PET/TC analisar diversos aspectos do câncer de pulmão, desde um estadiamento mais preciso da doença até a capacidade de prover dados úteis na caracterização de nódulos pulmonares indeterminados. Além disso, a acurácia de PET/TC tem se demonstrado maior do que a de modalidades convencionais em alguns cenários, tornando a PET/CT um valioso método não invasivo para a investigação de câncer de pulmão. Entretanto, a interpretação dos achados de PET/TC apresenta numerosas armadilhas e potenciais fatores de confusão. Portanto, é imperativo que pneumologistas e radiologistas familiarizem-se com as principais indicações e limitações desse método, com o intuito de proteger os pacientes da exposição desnecessária à radiação e de terapias inapropriadas. Este artigo de revisão objetivou sumarizar os princípios básicos, indicações, considerações sobre o estadiamento tumoral e futuras aplicações de PET/TC em câncer de pulmão.

The prevalence of asthma and atopy in schoolchildren from Porto Alegre, Brazil, has plateaued.

OBJECTIVE: A significant increase in the prevalence of asthma and atopy was observed in epidemiological studies conducted in 1980, 1989 and 1998, with schoolchildren of Porto Alegre. The present study aims to determine changes in the prevalence of symptoms of current and lifetime asthma and also to document the prevalence of atopy in schoolchildren from a region of Porto Alegre. METHODS: This was a cross-sectional study in which schoolchildren from 5th to 8th grade (10-18 years), from four schools located in the same geographic area were interviewed. The questionnaire covered symptoms suggestive of lifetime or current asthma (at some point in life or in the last twelve months, respectively). In addition, skin tests were performed in a subset of 241 schoolchildren. RESULTS: 964 students were interviewed from a total of 1195 registered. The prevalence of lifetime asthma symptoms was found to be 41.7%, symptoms of current asthma 14.9% and atopy 52.7%. Compared to previous studies, the prevalence of lifetime asthma and atopy has stabilized while the prevalence of current asthma fell from 22% to 14.9% (P < 0.001). CONCLUSIONS: In the last decade the prevalence of atopy and lifetime asthma has plateaued, while the prevalence of current asthma fell.

Once-daily indacaterol versus tiotropium for patients with severe chronic obstructive pulmonary disease (INVIGORATE): a randomised, blinded, parallel-group study.

BACKGROUND: We compared the efficacy and safety of indacaterol and tiotropium in patients with severe chronic obstructive pulmonary disease (COPD) and a history of at least one moderate to severe exacerbation in the previous 12 months. METHODS: In this multicentre, randomised, blinded, double-dummy, parallel group study, we enrolled patients aged 40 years or older with severe COPD and at least one exacerbation within the previous year. We used a computer-generated sequence to randomly allocate patients (1:1; stratified by baseline inhaled corticosteroid use, with the balance of treatments maintained at country level) to receive either indacaterol (150 µg) or tiotropium (18 µg) once-daily for 52 weeks. Our primary and key secondary objectives were to investigate whether indacaterol was non-inferior to tiotropium for trough forced expiratory volume in 1 s (FEV1) at week 12 (primary endpoint), and for rate of exacerbations at week 52 (secondary endpoint). Analysis populations for the primary and key secondary endpoints were per-protocol sets. The safety set included all patients who received at least one dose of study drug. This study is registered with ClinicalTrials.gov, number NCT00845728. FINDINGS: Between March 16, 2009, and July 5, 2012, we enrolled and randomly allocated 3444 patients: 1723 to indacaterol and 1721 to tiotropium. At week 12, the estimated least squares mean trough FEV1 difference between the groups was -0.011 L (least squares mean with indacaterol [n=1450] 1.134 L [SE 0.008] vs tiotropium [n=1467] 1.145 L [0.008]; one-sided 97.5% CI lower limit -0.026 L; p<0.0001). The lower limit of the 97.5% CI was above the prespecified non-inferiority margin of -0.055 L, suggesting that indacaterol was non-inferior to tiotropium. Indacaterol did not show non-inferiority in terms of annualised exacerbation rates: 0.79 (indacaterol, n=1529) versus 0.61 (tiotropium, n=1543); ratio 1.29 (one-sided 97.5% CI upper limit 1.44). In the safety set, we recorded no between-group difference in the number of patients who had adverse events (indacaterol 1119 [65%] of 1721 patients vs tiotropium 1065 [62%] of 1718 patients) or serious adverse events (indacaterol, 263 [15%] of 1721 patients vs tiotropium, 255 [15%] of 1718 patients). Respiratory disorders, particularly worsening of COPD, were the most common adverse events (COPD: indacaterol, 747 [43%] of 1721 patients and tiotropium, 665 [39%] of 1718 patients) and serious adverse events (COPD: indacaterol, 147 [9%] of 1721 patients and tiotropium, 121 [7%] of 1718 patients). INTERPRETATION: Indacaterol and tiotropium provided clinically relevant improvements in lung function with comparable safety profiles. Tiotropium afforded greater protection from exacerbations, although the absolute number of events was small and the difference between treatments is of uncertain clinical importance. The present data offer evidence consistent with current guidelines. FUNDING: Novartis Pharma AG.

Evaluation of the efficacy and safety of a fixed-dose, single-capsule budesonide-formoterol combination in uncontrolled asthma: a randomized, double-blind, multicenter, controlled clinical trial.

OBJECTIVE: To evaluate the efficacy and safety of a fixed-dose, single-capsule budesonide-formoterol combination, in comparison with budesonide alone, in patients with uncontrolled asthma. METHODS: This was a randomized, double-blind, multicenter, phase III, parallel clinical trial, comparing the short-term efficacy and safety of the combination of budesonide (400 µg) and formoterol (12 µg), with those of budesonide alone (400 µg), both delivered via a dry powder inhaler, in 181 patients with uncontrolled asthma. The age of the patients ranged from 18 to 77 years. After a run-in period of 4 weeks, during which all of the patients received budesonide twice a day, they were randomized into one of the treatment groups. for 12 weeks. The treatment consisted of the administration of the medications twice a day for 12 weeks. The primary outcome measures were FEV1, FVC, and morning PEF. We performed an intention-to-treat analysis of the data. RESULTS: In comparison with the budesonide-only group patients, those treated with the budesonide-formoterol combination showed a significant improvement in FEV1 (0.12 L vs. 0.02 L; p = 0.0129) and morning PEF (30.2 L/min vs. 6.3 L/min; p = 0.0004). These effects were accompanied by good tolerability and safety, as demonstrated by the low frequency of adverse events, only minor adverse events having occurred. CONCLUSIONS: The single-capsule combination of budesonide and formoterol appears to be efficacious and safe. Our results indicate that this formulation is a valid therapeutic option for obtaining and maintaining asthma control. (ClinicalTrials.gov Identifier: NCT01676987 [http://www.clinicaltrials.gov/]).

Avaliação da eficácia e segurança da associação de budesonida e formoterol em dose fixa e cápsula única no tratamento de asma não controlada: ensaio clínico randomizado, duplo-cego, multicêntrico e controlado / Evaluation of the efficacy and safety of a fixed-dose, single-capsule budesonide-formoterol combination in uncontrolled asthma: a randomized, double-blind, multicenter, controlled clinical trial

OBJETIVO: Avaliar a eficácia e a segurança da associação de budesonida e formoterol em dose fixa e cápsula única, em comparação ao uso de budesonida isolada em pacientes com asma não controlada. MÉTODOS: Ensaio clínico randomizado, duplo-cego, multicêntrico, de fase III, com grupos paralelos, comparando a eficácia de curto prazo e a segurança da formulação em pó de budesonida (400 µg) e formoterol (12 µg) com a formulação em pó de budesonida (400 µg) em 181 participantes com asma não totalmente controlada. A idade dos participantes variou de 18-77 anos. Após um período de run-in de 4 semanas, durante o qual todos os participantes receberam budesonida duas vezes por dia, houve a randomização para um dos tratamentos do estudo. O tratamento foi administrado duas vezes ao dia por 12 semanas. Os principais desfechos foram VEF1, CVF e PFE matinal. Os dados foram analisados por intenção de tratar. RESULTADOS: O grupo tratado com a associação, quando comparado ao grupo budesonida isolado, teve uma melhora significativa no VEF1 (0,12 L vs. 0,02 L; p = 0.0129) e no PFE matinal (30,2 L/min vs. 6,3 L/min; p = 0,0004). Esses efeitos foram acompanhados por boa tolerabilidade e segurança, como demonstrado pela baixa frequência de eventos adversos menores. CONCLUSÕES: A associação em cápsula única de budesonida e formoterol mostrou ser eficaz e segura. Os resultados demonstram que essa formulação é uma opção terapêutica válida para a obtenção e manutenção do controle da asma.

OBJECTIVE: To evaluate the efficacy and safety of a fixed-dose, single-capsule budesonide-formoterol combination, in comparison with budesonide alone, in patients with uncontrolled asthma. METHODS: This was a randomized, double-blind, multicenter, phase III, parallel clinical trial, comparing the short-term efficacy and safety of the combination of budesonide (400 µg) and formoterol (12 µg), with those of budesonide alone (400 µg), both delivered via a dry powder inhaler, in 181 patients with uncontrolled asthma. The age of the patients ranged from 18 to 77 years. After a run-in period of 4 weeks, during which all of the patients received budesonide twice a day, they were randomized into one of the treatment groups. for 12 weeks. The treatment consisted of the administration of the medications twice a day for 12 weeks. The primary outcome measures were FEV1, FVC, and morning PEF. We performed an intention-to-treat analysis of the data. RESULTS: In comparison with the budesonide-only group patients, those treated with the budesonide-formoterol combination showed a significant improvement in FEV1 (0.12 L vs. 0.02 L; p = 0.0129) and morning PEF (30.2 L/min vs. 6.3 L/min; p = 0.0004). These effects were accompanied by good tolerability and safety, as demonstrated by the low frequency of adverse events, only minor adverse events having occurred. CONCLUSIONS: The single-capsule combination of budesonide and formoterol appears to be efficacious and safe. Our results indicate that this formulation is a valid therapeutic option for obtaining and maintaining asthma control. (ClinicalTrials.gov Identifier: NCT01676987 [http://www.clinicaltrials.gov/]).

Nontuberculous mycobacterial infection as a cause of difficult-to-control asthma: a case-control study.

BACKGROUND: Symptomatic disease due to nontuberculous mycobacteria (NTM) is known to occur commonly in the presence of structural lung disease, but is not described in association with asthma. METHODS: This was a case-control study nested in a cohort. We identified 22 patients with difficult asthma referred to a tertiary academic referral center and subsequently found to have infection with NTM. We matched each case with two control subjects (next two consecutive patients referred for asthma management). RESULTS: It took on average 2.1 years from the onset of new or worsening symptoms to NTM diagnosis. The most common symptoms were worsening cough (77%), sputum production (40.9%), and frequent exacerbations (31.8%). Mycobacterium avium complex accounted for 63.6% of the infections, Mycobacterium xenopi the balance. Case subjects were older (59.8 ± 8.9 vs 42.6 ± 18 years; P < .001) and had more severe airflow obstruction (FEV(1), 57% [40%-74%] vs 89.5% [80%-98%]; P < .001). There was no difference between case and control subjects in the proportion using inhaled corticosteroids (ICS) or the average daily dose at the time of presentation, but case subjects had used ICS for a longer period (17 [6.2-20] vs 4 [0.75-6.0] years; P=.002). Six subjects with NTM were being treated with daily oral steroids, whereas none of the control subjects was. Of the 22 cases, 10 were treated with antibiotics for NTM, seven demonstrating clinical improvement or resolution of the presenting symptoms. CONCLUSIONS: NTM infection can be associated with asthma and should be considered in difficult-to-treat disease, especially in older individuals with more severe airflow obstruction and greater exposure to inhaled or systemic corticosteroids.

The role of breastfeeding, diet and nutritional status in the development of asthma and atopy.

In many populations, the prevalence of asthma and atopy has increased in recent years. As a result, both conditions have become major public health problems. The possible influence of nutrition-related factors has been demonstrated in an increasing number of studies. Information regarding the role of breastfeeding, diet, nutritional status (obesity in particular), as well as regarding the immunologic responses triggered, helps to improve our understanding of the correlation between oxidative stress, bronchial inflammation, and the development of atopic and asthma symptoms. The article presents a review of the published literature on the relationships established between and among nutrition, asthma, and atopy over the last two decades.

Bariatric surgery in the treatment of obstructive sleep apnea in morbidly obese patients.

BACKGROUND: Weight loss has been shown effective in the treatment of the obstructive sleep apnea-hypopnea syndrome. Regrettably, many obese patients are unable to achieve sustained and useful weight loss by dietary means. Recently, bariatric surgery has emerged as an alternative to treat obesity and many of its comorbidities, although its role for sleep apnea treatment is still not defined. OBJECTIVES: To evaluate the impact of bariatric surgery on obstructive sleep apnea in morbidly obese patients. METHODS: In this cohort study, polysomnography, Epworth Sleepiness Scale questionnaire and clinical assessment were performed in 12 of 13 morbidly obese patients with moderate to severe obstructive sleep apnea treated with bariatric surgery through Roux-en-Y gastric bypass procedure after a minimum of 18 months post surgery. RESULTS: The mean (+/-SD) loss of excess body weight was 70.5 +/- 24%. The mean level obtained in the Epworth Scale was 4.8. There was a significant reduction in the apnea-hypopnea index, from a median of 46.5 (range: 33-140) to 16 (range: 0.9-87) events per hour (p < 0.05), an improvement in mean oxygen saturation from 85.7 +/- 5.1 to 94.5 +/- 3.6% (p < 0.05) and in minimum oxygen saturation from 64.7 +/- 13.4 to 78.7 +/- 13.7% (p < 0.05). The magnitude of the weight loss and the improvements in mean and minimum oxygen saturation were positively correlated, (r = 0.76; p

O papel do aleitamento materno, da dieta e do estado nutricional no desenvolvimento de asma e atopia / The role of breastfeeding, diet and nutritional status in the development of asthma and atopy

O aumento na prevalência da asma e atopia, observado em diversas populações nos anos recentes, contribui para torná-las importantes problemas de saúde pública. A possível influência de fatores relacionados à nutrição humana tem sido demonstrada em crescente número de estudos. O entendimento do papel do aleitamento materno, da dieta, e do estado nutricional, particularmente da obesidade, assim como as respostas imunológicas desencadeadas, ajuda a melhorar a compreensão sobre a relação entre estresse oxidativo, inflamação brônquica, e o desenvolvimento de sintomas asmáticos e atópicos. Este artigo apresenta uma revisão da literatura publicada sobre os aspectos da relação entre nutrição, asma, e atopia, nas duas últimas décadas.

In many populations, the prevalence of asthma and atopy has increased in recent years. As a result, both conditions have become major public health problems. The possible influence of nutrition-related factors has been demonstrated in an increasing number of studies. Information regarding the role of breastfeeding, diet, nutritional status (obesity in particular), as well as regarding the immunologic responses triggered, helps to improve our understanding of the correlation between oxidative stress, bronchial inflammation, and the development of atopic and asthma symptoms. The article presents a review of the published literature on the relationships established between and among nutrition, asthma, and atopy over the last two decades.

Futilidade terapêutica e insuficiência respiratória: realização de um estudo de coorte prospectiva / Medical futility and respiratory failure: a prospective cohort study

JUSTIFICATIVA E OBJETIVOS: A necessidade de reformular as metas dos cuidados intensivos, partindo muitas vezes da cura para o conforto, torna-se necessário nos dias atuais. O médico intensivista, freqüentemente está diante da decisão de suspender ou não oferecer determinado tratamento, apesar de ele estar disponível. O objetivo deste estudo foi estimar o risco evolutivo de probabilidade de morte individual para pacientes internados com insuficiência respiratória na unidade de terapia intensiva (UTI), identificar quais os tratamentos mantenedores da vida foram administrados, o tempo de internação e o desfecho, comparar o desfecho "morte" em relação aos modelos UNICAMP II e APACHE II, bem como verificar se os tratamentos mantenedores da vida podem ser limitados ou suspensos. MÉTODO: Trata-se de um estudo de coorte prospectiva, observacional envolvendo 150 pacientes com insuficiência respiratória internados na unidade de tratamento intensivo. A análise estatística foi realizada por meio dos Modelos Lineares Generalizados. RESULTADOS: Idade, sexo, raça ou morbidade não mostrou estatística significativa para predizer o desfecho. Essa predição foi mais bem averiguada por meio da evolução do índice prognóstico individual nos primeiros sete dias de internação na UTI. A piora do prognóstico em 10 por cento para pacientes com risco inicial entre 70 por cento e 80 por cento, utilizando o modelo UNICAMP II, mostrou especificidade de 97,4 por cento a 98,6 por cento. CONCLUSÕES: A evolução prognóstica dos pacientes, nos primeiros sete dias de internação na UTI, é de grande auxílio do ponto de vista objetivo para a tomada de decisões éticas em torno da não-oferta de novos tratamentos mantenedores da vida.

BACKGROUND AND OBJECTIV, ES: Currently, the reformulation of intensive care goals, often shifting from the search for a cure to offering comfort, has become more and more necessary. The intensivist is frequently confronted with the decision to suspend or not offer a specific therapy, despite its availability. The objective of this study was to estimate the developing risk of probability of death for individual ICU patients with respiratory failure, identify which life-sustaining therapies were administered, time of internment and outcome. Compare the death outcome in relation to UNICAMP II and APACHE II models, as well as verify if the life-sustaining therapies may be limited or suspended. METHODS: It is the observational, prospective cohort study of 150 patients with respiratory failure confined to the intensive care unit. Statistical analysis was carried out using Generalized Linear Models. RESULTS: Age, sex, race or morbidity did not reveal statistical significance in predicting outcome. This prediction was confirmed more accurately by means of changes in the individual prognostic index of death probability during the first seven days of ICU internment. A 10 percent worsening prognosis in patients who presented initial death risk of 70 percent to 80 percent, utilizing the UNICAMP II Model, showed a specificity of 97.4 percent - 98.6 percent. CONCLUSIONS: Prognostic changes in patients during the first seven days of ICU internment are of great aid, from an objective point of view, for ethical decision-making in relation to not-offering new life-sustaining therapies.

Asthma mortality in southern Brazil: is there a changing trend?

BACKGROUND: Mortality from asthma increased during the last decades but is now declining in some countries. Little is known about this trend in Brazil. OBJECTIVE: The objective of the study was to determine the trends in asthma mortality in Southern Brazil. METHODS: We reviewed death certificates of 566 people in the state of Rio Grande do Sul, Brazil, between 5 and 39 years of age in whom asthma was reported to be the underlying cause of death during the period of 1981-2003. Population data were available in 5-year age groups. Mortality rates were submitted to linear and quadratic regression procedures. RESULTS: Among children and teenagers (5-19 years), there were 170 asthma deaths, ranging from 4 to 13 deaths each year with rates of 0.154/100,000 to 0.481/100,000. In young adults (20-39 years), 396 asthma deaths occurred, ranging from 9 to 32 each year, with rates from 0.276/100,000 to 1.034/100,000. There was an initial increase in rates, with later stabilization, and then the start of a decline beginning in the late 1990s and the early part of this decade. This trend occurred in both age subgroups examined but was more evident in males. CONCLUSIONS: Asthma mortality in southern Brazil remains low and appears to be decreasing after reaching a peak in the mid-1990s. The reason for these trends remains unknown.

Microscopic pulmonary neoplastic emboli: report of a case with respiratory failure but normal imaging.

Pulmonary tumour microembolism is a recognised cause of respiratory failure in patients with cancer, but is frequently under recognised. We report the case of a 42-year-old female patient admitted because of rapidly progressive severe dyspnoea with a normal chest X-ray (CXR). Initial investigation and imaging was inconclusive, with normal computerised tomography (CT) scans and pulmonary angiotomography. Videothoracoscopic biopsy was performed. Microscopic examination revealed metastatic adenocarcinoma in the lungs, with pulmonary vasculature showing numerous microemboli in small arterioles. The site of origin was consistent with a primary breast adenocarcinoma resected three years previously. Despite treatment in the Intensive Care Unit, the patient died 72 hours after admission. Active consideration and investigation for malignancy should always be considered in the differential diagnosis of patients with severe unexplained dyspnoea.

Exhaled carbon monoxide as a marker for evaluating smoking abstinence in a Brazilian population sample.

BACKGROUND: Exhaled carbon monoxide (CO(Exh)) measurement is used to confirm smoking status in smoking cessation programs, but the cut-off level is still a matter for discussion. The objective of this study was to compare CO(Exh) levels in smokers and non-smokers to validate the method in a Brazilian population and to estimate the probability of the patient still smoking according to different cut-off points. METHODS: In this cross-sectional study we studied non-atopic Caucasian volunteers with no respiratory infection or steroid therapy in the preceding four weeks. Exclusion criteria were: pregnancy; breast feeding; age<18 and >65 years old; and subjects not signing informed consent. Participants filled out a questionnaire and had their CO(Exh) levels measured. Bayes' theorem was used to calculate the posttest probabilities. RESULTS: We included 393 subjects of whom 239 (61%) were smokers. The mean CO(Exh) was 14.7 +/- 9.4 ppm and 4.3 +/- 2.5 ppm (p<0.001) in smokers and nonsmokers, respectively. Patients with CO(Exh) below 8 ppm had a likelihood ratio below 1 of still smoking. The levels 9 ppm and 10 ppm provided likelihood ratios of 1.50 and 1.93, respectively. Better discriminant power was obtained at >11 ppm, when the likelihood ratio became 63.80 (95%CI 16.1-253.1). CONCLUSIONS: In smoking cessation practice, a likelihood ratio approach may be useful to determine the probability that an individual is still smoking according to various CO(Exh) cut-off points instead of using a fixed value for all patients.

[Medical futility and respiratory failure: a prospective cohort study]. / Futilidade terapêutica e insuficiência respiratória: realização de um estudo de coorte prospectiva.

BACKGROUND AND OBJECTIVES: Currently, the reformulation of intensive care goals, often shifting from the search for a cure to offering comfort, has become more and more necessary. The intensivist is frequently confronted with the decision to suspend or not offer a specific therapy, despite its availability. The objective of this study was to estimate the developing risk of probability of death for individual ICU patients with respiratory failure, identify which life-sustaining therapies were administered, time of internment and outcome. Compare the death outcome in relation to UNICAMP II and APACHE II models, as well as verify if the life-sustaining therapies may be limited or suspended. METHODS: It is the observational, prospective cohort study of 150 patients with respiratory failure confined to the intensive care unit. Statistical analysis was carried out using Generalized Linear Models. RESULTS: Age, sex, race or morbidity did not reveal statistical significance in predicting outcome. This prediction was confirmed more accurately by means of changes in the individual prognostic index of death probability during the first seven days of ICU internment. A 10% worsening prognosis in patients who presented initial death risk of 70% to 80%, utilizing the UNICAMP II Model, showed a specificity of 97.4% - 98.6%. CONCLUSIONS: Prognostic changes in patients during the first seven days of ICU internment are of great aid, from an objective point of view, for ethical decision-making in relation to not-offering new life-sustaining therapies.

Adesão ao tratamento de manutenção em asma (estudo ADERE) / Compliance with maintenance treatment of asthma (ADERE study)

OBJETIVO: Avaliar a adesão ao tratamento preventivo de asma persistente moderada e grave. MÉTODOS: Médicos de vários Estados do país foram contactados para selecionar asmáticos persistentes moderados ou graves, maiores de doze anos. Os pacientes receberam salmeterol/fluticasona 50/250 µg diskus durante 90 dias (sendo orientados a retornarem as embalagens ao final do estudo para conferência da dosagem total utilizada). Receberam telefonemas da equipe do estudo no início e ao final de 90 dias para que fosse avaliada a adesão. Foi considerado como aderente ao tratamento o asmático que utilizou no mínimo 85 por cento das doses prescritas. As variáveis estudadas foram sexo, idade, cor, estado civil, escolaridade, tabagismo atual, outras atopias, co-morbidades, gravidade da asma, uso de outras medicações e número de hospitalizações por asma. RESULTADOS: Foram incluídos 131 pacientes oriundos de quinze estados, com taxa geral de adesão de 51,9 por cento. Houve diferença significativa na adesão quanto à gravidade da asma (maior adesão nos casos graves; p = 0,02). Não houve diferença estatisticamente significativa nas demais variáveis. CONCLUSÃO: A taxa geral de adesão ao tratamento de manutenção da asma foi baixa.

OBJECTIVE: To determine the rate of compliance with preventive treatment of moderate and severe persistent asthma. METHODS: Physicians at various medical centers across the country were invited to nominate patients for participation in the study. Inclusion criteria were being over the age of 12 and presenting moderate or severe persistent asthma. Participating patients received salmeterol/fluticasone 50/250 µg by dry powder inhaler for 90 days and were instructed to return the empty packages at the end of the study as a means of determining the total quantity used. In order to evaluate compliance, a member of the research team contacted each patient via telephone at the study outset and again at the end of the 90-day study period. Asthma patients were considered compliant with the treatment if they used at least 85 percent of the prescribed dose. The following variables were studied: gender, age, race, marital status, years of schooling, smoking habits, other atopic conditions, comorbidities, asthma severity, use of other medication and number of hospital admissions for asthma. RESULTS: A total of 131 patients from fifteen states were included. The overall rate of compliance was found to be 51.9 percent. There was a significant difference in compliance in relation to asthma severity: compliance was greater among patients with severe persistent asthma than among those with moderate persistent asthma (p = 0.02). There were no statistically significant differences among any of the other variables. CONCLUSION: The overall rate of compliance with maintenance treatment of asthma was low.