PET-CT has low specificity for mediastinal staging of non-small-cell lung cancer in an endemic area for tuberculosis: a diagnostic test study (LACOG 0114).

BACKGROUND: The present study aims to assess the performance of 18F-FDG PET-CT on mediastinal staging of non-small cell lung cancer (NSCLC) in a location with endemic granulomatous infectious disease. METHODS: Diagnostic test study including patients aged 18 years or older with operable stage I-III NSCLC and indication for a mediastinal lymph node biopsy. All patients underwent a 18F-FDG PET-scan before invasive mediastinal staging, either through mediastinoscopy or thoracotomy, which was considered the gold-standard. Surgeons and pathologists were blinded for scan results. Primary endpoint was to evaluate sensitivity, specificity and positive and negative predictive values of PET-CT with images acquired in the 1st hour of the exam protocol, using predefined cutoffs of maximal SUV, on per-patient basis. RESULTS: Overall, 85 patients with operable NSCLC underwent PET-CT scan followed by invasive mediastinal staging. Mean age was 65 years, 49 patients were male and 68 were white. One patient presented with active tuberculosis and none had HIV infection. Using any SUV_max > 0 as qualitative criteria for positivity, sensitivity and specificity were 0.87 and 0.45, respectively. Nevertheless, even when the highest SUV cut-off was used (SUV_max ≥5), specificity remained low (0.79), with an estimated positive predictive value of 54%. CONCLUSIONS: Our findings are in line with the most recent publications and guidelines, which recommend that PET-CT must not be solely used as a tool to mediastinal staging, even in a region with high burden of tuberculosis. TRIAL REGISTRATION: The LACOG 0114 study was registered at ClinicalTrials.gov , before study initiation, under identifier NCT02664792.

Hypersensitivity pneumonia associated with metallic straw of mate (chimarrão): A case report.

This case report describes a 61-year-old male who sought treatment for sudden symptoms of dry cough, chest pain and severe dyspnea. On admission, the patient had hypoxemia and predominantly medullary infiltrate that we could observe on his imaging exams. After hospital discharge, he presented two similar episodes, with clinical and radiological improvement with oxygen therapy alone. He denied exposure to birds, mold or chemical agents. However, the patient noticed the onset of symptoms soon after drinking chimarrão. Given the compatible clinical, radiological and laboratory history, the diagnosis of hypersensitivity pneumonitis was performed. The patient was instructed by the medical team not to consume the drink anymore, remaining asymptomatic for more than two years.

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.

2020 Brazilian Thoracic Association recommendations for the management of asthma.

The pharmacological management of asthma has changed considerably in recent decades, as it has come to be understood that it is a complex, heterogeneous disease with different phenotypes and endotypes. It is now clear that the goal of asthma treatment should be to achieve and maintain control of the disease, as well as to minimize the risks (of exacerbations, disease instability, accelerated loss of lung function, and adverse treatment effects). That requires an approach that is personalized in terms of the pharmacological treatment, patient education, written action plan, training in correct inhaler use, and review of the inhaler technique at each office visit. A panel of 22 pulmonologists was invited to perform a critical review of recent evidence of pharmacological treatment of asthma and to prepare this set of recommendations, a treatment guide tailored to use in Brazil. The topics or questions related to the most significant changes in concepts, and consequently in the management of asthma in clinical practice, were chosen by a panel of experts. To formulate these recommendations, we asked each expert to perform a critical review of a topic or to respond to a question, on the basis of evidence in the literature. In a second phase, three experts discussed and structured all texts submitted by the others. That was followed by a third phase, in which all of the experts reviewed and discussed each recommendation. These recommendations, which are intended for physicians involved in the treatment of asthma, apply to asthma patients of all ages.

Guidelines for the pharmacological treatment of COVID-19. The task-force/consensus guideline of the Brazilian Association of Intensive Care Medicine, the Brazilian Society of Infectious Diseases and the Brazilian Society of Pulmonology and Tisiology. / Diretrizes para o tratamento farmacológico da COVID-19. Consenso da Associação de Medicina Intensiva Brasileira, da Sociedade Brasileira de Infectologia e da Sociedade Brasileira de Pneumologia e Tisiologia.

INTRODUCTION: Different therapies are currently used, considered, or proposed for the treatment of COVID-19; for many of those therapies, no appropriate assessment of effectiveness and safety was performed. This document aims to provide scientifically available evidence-based information in a transparent interpretation, to subsidize decisions related to the pharmacological therapy of COVID-19 in Brazil. METHODS: A group of 27 experts and methodologists integrated a task-force formed by professionals from the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB), the Brazilian Society of Infectious Diseases (Sociedad Brasileira de Infectologia - SBI) and the Brazilian Society of Pulmonology and Tisiology (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT). Rapid systematic reviews, updated on April 28, 2020, were conducted. The assessment of the quality of evidence and the development of recommendations followed the GRADE system. The recommendations were written on May 5, 8, and 13, 2020. RESULTS: Eleven recommendations were issued based on low or very-low level evidence. We do not recommend the routine use of hydroxychloroquine, chloroquine, azithromycin, lopinavir/ritonavir, corticosteroids, or tocilizumab for the treatment of COVID-19. Prophylactic heparin should be used in hospitalized patients, however, no anticoagulation should be provided for patients without a specific clinical indication. Antibiotics and oseltamivir should only be considered for patients with suspected bacterial or influenza coinfection, respectively. CONCLUSION: So far no pharmacological intervention was proven effective and safe to warrant its use in the routine treatment of COVID-19 patients; therefore such patients should ideally be treated in the context of clinical trials. The recommendations herein provided will be revised continuously aiming to capture newly generated evidence.

Obesity and obstructive sleep apnea-hypopnea syndrome: the impact of bariatric surgery.

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is characterized by successive episodes of cessation or decrease in respiratory airflow, in which obesity is an important risk factor. The prevalence of the disease in morbidly obese patients is approximately 70%. Treatment is based on the use of continuous positive airway pressure (CPAP) and weight loss in obese patients. Weight loss by dieting often produces unsatisfactory results, and the use of CPAP does not show good adherence because of being long-term and uncomfortable. Bariatric surgery has emerged as the treatment for morbid obesity and various associated co-morbidities. This article reviews the principal studies that evaluate the modifications in obstructive sleep apnea after bariatric surgery, showing that surgery is an effective treatment for the management of OSAHS in morbidly obese patients.

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.

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.

2020 Brazilian Thoracic Association recommendations for the management of asthma / Recomendações para o manejo da asma da Sociedade Brasileira de Pneumologia e Tisiologia - 2020

ABSTRACT The pharmacological management of asthma has changed considerably in recent decades, as it has come to be understood that it is a complex, heterogeneous disease with different phenotypes and endotypes. It is now clear that the goal of asthma treatment should be to achieve and maintain control of the disease, as well as to minimize the risks (of exacerbations, disease instability, accelerated loss of lung function, and adverse treatment effects). That requires an approach that is personalized in terms of the pharmacological treatment, patient education, written action plan, training in correct inhaler use, and review of the inhaler technique at each office visit. A panel of 22 pulmonologists was invited to perform a critical review of recent evidence of pharmacological treatment of asthma and to prepare this set of recommendations, a treatment guide tailored to use in Brazil. The topics or questions related to the most significant changes in concepts, and consequently in the management of asthma in clinical practice, were chosen by a panel of experts. To formulate these recommendations, we asked each expert to perform a critical review of a topic or to respond to a question, on the basis of evidence in the literature. In a second phase, three experts discussed and structured all texts submitted by the others. That was followed by a third phase, in which all of the experts reviewed and discussed each recommendation. These recommendations, which are intended for physicians involved in the treatment of asthma, apply to asthma patients of all ages.

RESUMO O manejo farmacológico da asma mudou consideravelmente nas últimas décadas, com base no entendimento de que a asma é uma doença heterogênea e complexa, com diferentes fenótipos e endótipos. Agora está claro que o objetivo do tratamento da asma deve ser alcançar e manter o controle da doença e evitar riscos futuros (exacerbações, instabilidade da doença, perda acelerada da função pulmonar e efeitos adversos do tratamento). Isso implica em uma abordagem personalizada, incluindo tratamento farmacológico, educação do paciente, plano de ação por escrito, treinamento para uso do dispositivo inalatório e revisão da técnica inalatória a cada visita ao consultório. Um painel de 22 pneumologistas brasileiros foi convidado a revisar criticamente evidências recentes de tratamento farmacológico da asma e a preparar esta recomendação, um guia de tratamento adaptado à nossa realidade. A escolha dos tópicos ou questões relacionadas às mudanças mais significativas nos conceitos e, consequentemente, no manejo da asma na prática clínica foi realizada por um painel de especialistas. Foi solicitado a cada especialista que revisasse criticamente um tópico ou respondesse a uma pergunta, com base em evidências, para estas recomendações. Numa segunda fase, três especialistas discutiram e estruturaram todos os textos submetidos pelos demais e, na última fase, todos revisaram e discutiram cada recomendação. As presentes recomendações se aplicam a adultos e crianças com asma e destinam-se a médicos envolvidos no tratamento da doença.

Diretrizes para o tratamento farmacológico da COVID-19. Consenso da Associação de Medicina Intensiva Brasileira, da Sociedade Brasileira de Infectologia e da Sociedade Brasileira de Pneumologia e Tisiologia / Guidelines for the pharmacological treatment of COVID-19. The task-force/consensus guideline of the Brazilian Association of Intensive Care Medicine, the Brazilian Society of Infectious Diseases and the Brazilian Society of Pulmonology and Tisiology

RESUMO Introdução: Há diversas terapias sendo utilizadas, consideradas ou propostas para o tratamento da COVID-19, muitas carecendo de apropriada avaliação de efetividade e segurança. O propósito deste documento é fornecer recomendações baseadas nas evidências científicas disponíveis e em sua interpretação transparente, para subsidiar decisões sobre o tratamento farmacológico da COVID-19 no Brasil. Métodos: Um grupo de 27 especialistas e metodologistas integraram a força-tarefa formada pela Associação de Medicina Intensiva Brasileira (AMIB), pela Sociedade Brasileira de Infectologia (SBI) e pela Sociedade Brasileira de Pneumologia e Tisiologia (SBPT). Foram realizadas revisões sistemáticas rápidas, atualizadas até 28 de abril de 2020. A qualidade das evidências e a elaboração das recomendações seguiram o sistema GRADE. As recomendações foram elaboradas nos dias 5, 8 e 13 de maio de 2020. Resultados: Foram geradas 11 recomendações, embasadas em evidência de nível baixo ou muito baixo. Não há indicação para uso de rotina de hidroxicloroquina, cloroquina, azitromicina, lopinavir/ritonavir, corticosteroides ou tocilizumabe no tratamento da COVID-19. Heparina deve ser utilizada em doses profiláticas no paciente hospitalizado, mas não deve ser realizada anticoagulação na ausência de indicação clínica específica. Antibacterianos e oseltamivir devem ser considerados somente nos pacientes em suspeita de coinfecção bacteriana ou por influenza, respectivamente. Conclusão: Até o momento, não há intervenções farmacológicas com efetividade e segurança comprovada que justifiquem seu uso de rotina no tratamento da COVID-19, devendo os pacientes serem tratados preferencialmente no contexto de pesquisa clínica. As recomendações serão revisadas continuamente, de forma a capturar a geração de novas evidências.

ABSTRACT Introduction: Different therapies are currently used, considered, or proposed for the treatment of COVID-19; for many of those therapies, no appropriate assessment of effectiveness and safety was performed. This document aims to provide scientifically available evidence-based information in a transparent interpretation, to subsidize decisions related to the pharmacological therapy of COVID-19 in Brazil. Methods: A group of 27 experts and methodologists integrated a task-force formed by professionals from the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB), the Brazilian Society of Infectious Diseases (Sociedad Brasileira de Infectologia - SBI) and the Brazilian Society of Pulmonology and Tisiology (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT). Rapid systematic reviews, updated on April 28, 2020, were conducted. The assessment of the quality of evidence and the development of recommendations followed the GRADE system. The recommendations were written on May 5, 8, and 13, 2020. Results: Eleven recommendations were issued based on low or very-low level evidence. We do not recommend the routine use of hydroxychloroquine, chloroquine, azithromycin, lopinavir/ritonavir, corticosteroids, or tocilizumab for the treatment of COVID-19. Prophylactic heparin should be used in hospitalized patients, however, no anticoagulation should be provided for patients without a specific clinical indication. Antibiotics and oseltamivir should only be considered for patients with suspected bacterial or influenza coinfection, respectively. Conclusion: So far no pharmacological intervention was proven effective and safe to warrant its use in the routine treatment of COVID-19 patients; therefore such patients should ideally be treated in the context of clinical trials. The recommendations herein provided will be revised continuously aiming to capture newly generated evidence.

Profile of eicosanoids in breath condensate in asthma and COPD.

The collection of exhaled breath condensates (EBC) is a noninvasive method for obtaining samples from the lungs. Eicosanoids are lipid mediators implicated in the asthmatic inflammatory response. The objective of our study was to investigate whether the profile of eicosanoid lipid mediators in EBC can characterize the inflammation in asthma and chronic obstructive pulmonary disease (COPD). EBC samples were collected from 22 healthy controls (C), 25 mild intermittent asthmatics (MIA), 20 with moderate to severe asthma (MSA) and 20 with moderate to severe COPD. EBC samples were analyzed by unique tandem mass spectrometry that allows the quantification of up to 25 eicosanoid mediators simultaneously. No differences were found between MIA and C. Subjects with MSA and COPD had higher levels of 6-keto, PGE2, LTB4, 11-12 EET and AA, while lower levels of LXA4, 11DHyTxB2, 11HETE and 8,9EET, when compared to MSA and C (p < 0.05). Our study shows that the analysis of EBC through mass spectrometry is mixed and has a similar response in MSA and COPD when compared to MIA and controls.

Tromboembolismo pulmonar / Pulmonary thromboembolism

Tromboembolismo pulmonar é uma doença comum, subdiagnosticada e potencialmente letal. Seu ágil diagnóstico e tratamento determinam desfechos favoráveis. A angiotomografia computadorizada é seu principal método diagnóstico, e seu tratamento agudo consiste em anticoagulação.

Pulmonary thromboembolism is a common, potentially lethal, and underdiagnosed disease. Its prompt diagnosis and treatment are key determinants for favorable outcomes. Computed angiotomography is the main diagnostic tool, and its acute treatment consists in anticoagulation.

Dispneia aguda no paciente hospitalizado: diagnóstico diferencial e manejo / Acute dyspnea in inpatient: diagnosis and management

A dispneia aguda é uma intercorrência comum nos pacientes hospitalizados. Diversas são as condições clínicas que podem se manifestar com esse sintoma, e determinar a etiologia subjacente em cada caso é fundamental para garantir manejo adequado e o melhor desfecho. O objetivo deste artigo é revisar os diagnósticos diferenciais e orientar o manejo de episódios de dispneia aguda.

Acute dyspnea is a common symptom in in-patients. Several clinical conditions can present themselves with this symptom, and determining the subjacent etiology in each case is essential in order to provide the best approach and ensure the best result. The purpose of this paper is to review the differential diagnosis and treatment of acute dyspnea.

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.

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.

Anéis de Kayser-Fleisher / Kayser-Fleisher rings

Os anéis de Kayser-Fleischer (K-F) säo alteraçöes pigmentadas localizadas na membrana de Descemet, principalmente na regiäo perilímbica na córnea. Estäo associadas à doença de Wilson, sendo a manifestaçäo oftalmológica mais comum da mesma e se correlacionam diretamente ao tempo de evoluçäo desta doença. Os anéis de K-F caracterizam-se pela deposiçäo de granulaçöes de cobre de tamanhos e formas variadas na córnea e predominam na periferia corneana. A doença diretamente ligada ao aparecimento dos anéis de K-F, a doença de Wilson, caracteriza-se por distúrbio metabólico com acúmulo de cobre nos tecidos humanos, principalmente no fígado. A presença de anéis pigmentados na córnea nem sempre é diagnóstico de anéis de K-F, devendo ser diferenciados de outras alteraçöes pigmentadas da córnea näo ligadas à doença de Wilson. Estas englobam a vasta maioria de doenças hepato-biliares que podem ocasionar acúmulo de cobre, além de corpos estranhos intraoculares contendo cobre, mieloma múltiplo, entre outras. O objetivo do presente artigo é revisar alguns aspectos desta alteraçäo pigmentada corneana, os anéis de K-F, além de descrever algumas características da principal doença ligada ao seu aparecimento.