Objective: To evaluate the experience in diagnosing and treating malignant pleural mesothelioma (MPM) accumulated over 5 years in a tertiary public hospital. Methods: The medical charts of the patients diagnosed with MPM between January of 2000 and February of 2005 were evaluated retrospectively. Results: Of the 17 patients analyzed, 14 were male and 3 were female. The mean age was 54.1 years (range, 13-75 years). The biopsy specimens for histopathological examination were obtained through thoracoscopy in 9 patients (53%), Cope needle in 5 (29.5%), and open pleural biopsy in 3 (17.5%). The following histological types were identified: epithelial, in 14 patients (82%); sarcomatoid, in 1 (6%); and biphasic, in 2 (12%). The therapeutic approaches used were as follows: multimodal (pleuropneumonectomy and adjuvant radiotherapy and chemotherapy) in 6 patients (35%); chemotherapy and radiotherapy in 6 (35%); radiotherapy alone in 3 (17.5%); and chemotherapy alone in 2 (12%). The mean survival was 11 months (range, 1-26 months). Conclusions: In the cases studied, an integrated multidisciplinary approach was used, and a highly complex hospital infrastructure was available for the diagnosis and treatment of MPM, as recommended in the literature. However, the mean survival was only 11 months, reflecting the aggressiveness of the disease.

Keywords: Mesothelioma; Pleura; Surgery; Diagnosis.

Malignant mesotheliomas are rare types of cancers that affect the mesothelial surfaces, usually the pleura and peritoneum. They are associated with asbestos exposure, but due to a latency period of more than 30 years and difficult diagnosis, most cases are not detected until they reach advanced stages. Treatment options for this tumor type are very limited and survival ranges from 12 to 36 months. This review discusses the molecular physiopathology, current diagnosis, and latest therapeutic options for this disease.

Keywords: Pleural Mesothelioma; Treatment; Molecular Alterations.

Malignant mesothelioma (MM) is a highly aggressive form of cancer, has a long latency period, and is resistant to chemotherapy. It is extremely fatal, with a mean survival of less than one year. The development of MM is strongly correlated with exposure to asbestos and erionite, as well as to simian virus 40. Although various countries have banned the use of asbestos, MM has proven to be difficult to control and there appears to be a trend toward an increase in its incidence in the years to come. In Brazil, MM has not been widely studied from a genetic or biochemical standpoint. In addition, there have been few epidemiological studies of the disease, and the profile of its incidence has yet to be well established in the Brazilian population. The objective of this study was to review the literature regarding the processes of malignant transformation, as well as the respective mechanisms of tumorigenesis, in MM.

Keywords: Occupational diseases; Mesothelioma; Genes, tumor suppressor; Oncogenes; Signal transduction.

Objective: To review the pathological diagnosis of possible cases and/or hidden cases of malignant mesothelioma (MM) between 2000 and 2012 using the Hospital-Based Cancer Registry database in the state of São Paulo, Brazil. Methods: Possible cases were retrieved by assessing the database. Inclusion criteria were being older than 30 years of age and having ICD-O-3 topography and morphology codes related to MM. A board of expert pathologists reviewed the pathology reports and requested paraffin blocks in cases that demanded revision. After staining with calretinin, D2-40, WT-1 (as positive MM markers) and Ber-EP4 and MOC31 (as negative MM markers), cases were divided and studied independently by a pair of pathologists to confirm or discard the diagnosis of MM. Results: Our sample comprised 482 cases from 25 hospitals, and 130 needed further histological revision. We received 73 paraffin blocks with adequate material. After board analysis, there were 9 cases with a definitive diagnosis of MM, improving the diagnostic rate in 12%. Two cases of previously diagnosed MM were discarded by review. Conclusions: Our results confirm that part of MM underdiagnosis and underreporting in Brazil is due to incomplete or mistaken pathological diagnosis.

Keywords: Mesothelioma, malignant/pathology; Mesothelioma, malignant/diagnosis; Immunohistochemistry; Registries.

Objective: To evaluate the process of diagnosing patients with malignant pleural mesothelioma (MPM) at a tertiary care hospital. Methods: This was a retrospective study involving patients referred to a tertiary-care cancer center in Brazil between 2009 and 2020. The diagnostic process was divided into four steps: onset of symptoms, referral to a specialist visit, histopathological diagnosis, and beginning of treatment. The intervals between each phase and the factors for delays were evaluated. Data including clinical status, radiological examinations, staging, treatment modalities, and survival outcomes were collected. Results: During the study period, 66 patients (mean age = 64 years) were diagnosed with MPM and underwent treatment. Only 27 (41%) of the patients had knowledge of prior exposure to asbestos. The median number of months (IQR) between the onset of symptoms and the first specialist visit, between the specialist visit and histopathological characterization, and between definite diagnosis and beginning of treatment was, respectively, 6.5 (2.0-11.4), 1.5 (0.6-2.1), and 1.7 (1.2-3.4). The knowledge of prior asbestos exposure was associated with a shorter time to referral to a specialist (median: 214 vs. 120 days; p = 0.04). A substantial number of nondiagnostic procedures and false-negative biopsy results (the majority of which involved the use of Cope needle biopsy) were found to be decisive factors for the length of waiting time. The mean overall survival was 11.9 months. Conclusions: The unfamiliarity of health professionals with MPM and the patient's lack of knowledge of prior asbestos exposure were the major factors to cause a long time interval between the onset of symptoms and beginning of treatment. An overall survival shorter than 1 year is likely to have been due to the aforementioned delays.

Keywords: Mesothelioma; Mesothelioma, malignant; Pleural effusion, malignant; Pleural diseases.

Objective: Various markers have shown promise as diagnostic markers and prognostic predictors in malignant mesothelioma (MM). Methods: Through morphometric and immunological studies of markers in stromal components (calretinin, CEA, Leu-M1 and thrombomodulin) and nuclear components (p53 and Ki-67), we evaluated post-diagnosis survival in 58 patients with MM. Results: The histologic pattern of the MM was typical in 50 cases and atypical in 8. Through immunohistochemistry, we confirmed 40 cases of mesothelioma and 11 cases of adenocarcinoma, although we were unable to classify 7 of the 8 cases presenting atypical histologic patterns. Cox multivariate analysis revealed that the risk factor for death was higher (476.2) among patients of advanced age, presenting the biphasic subtype and testing positive for components expressed at the nuclear level. Conclusion: The most useful immunohistochemical markers were was calretinin (for mesothelioma) and CEA (for adenocarcinoma). Immunohistochemical quantification of thrombomodulin facilitated the diagnosis of mesothelioma in patients testing positive for both calretinin and CEA. The most useful prognostic information was that provided by the routine histopathological analysis of the tumor type. It is of note that the combination of a mean age of 55 years and 30.5% immunohistochemical markers in nuclear components created a natural dividing point between patients in which survival was shorter than expected and those in which it was longer than expected. Therefore, histopathological analysis offers a powerful weapon with great potential to inform decisions regarding the use of adjuvant chemotherapy after surgical excision of a mesothelioma.

Keywords: Pleural neoplasms; Mesothelioma; Tumor markers, Biological; Carcinoembryonic antigen; Prognosis.

Objective: Previous studies have demonstrated that closed pleural biopsy (CPB) has a sensitivity of less than 60% for diagnosing malignancy. Therefore, controversy has recently emerged regarding the value of CPB as a diagnostic test. Our objective was to assess the accuracy of CPB in diagnosing malignancy in patients with pleural effusion. Methods: This was a prospective 8-year study of individuals who underwent CPB to establish the etiology of pleural effusion. Information on each patient was obtained from anatomopathological reports and medical records. When CPB findings showed malignancy or tuberculosis, the biopsy was considered diagnostic, and that was the definitive diagnosis. In cases in which biopsy histopathological findings were nonspecific, a definitive diagnosis was established on the basis of other diagnostic procedures, such as thoracoscopy, thoracotomy, fiberoptic bronchoscopy, biochemical and cellular measurements in pleural fluid, and/or microbiological tests. The accuracy of CPB was determined with 2 × 2 contingency tables. Results: A total of 1034 biopsies from patients with pleural effusion were studied. Of those, 171 (16.54%) were excluded from the accuracy analysis either because of inadequate samples or insufficient information. The results of the accuracy analysis were as follows: sensitivity, 77%; specificity, 98%; positive predictive value, 99%; negative predictive value, 66%; positive likelihood ratio, 38.5; negative likelihood ratio, 0.23; pre-test probability, 2.13; and post-test probability, 82. Conclusions: CPB is useful in clinical practice as a diagnostic test, because there is an important change from pre-test to post-test probability.

Keywords: Biopsy; Pleural effusion, malignant/diagnosis; Pleural effusion, malignant/epidemiology.

Objective: To determine the morbidity and mortality related to respiratory diseases among adults attending a tertiary-care hospital in Nigeria. Methods: We carried out a retrospective study of 183 adult patients (> 15 years of age), diagnosed with respiratory diseases between November of 2006 and October of 2008 at the Federal Medical Centre in Ido-Ekiti, Nigeria. Results: Of the 183 patients enrolled in the study, 78 (42.6%) were male and 105 (57.4%) were female, the male:female ratio being 1:1.4. Respiratory diseases were predominant in the 25-44 year age bracket (37.2%) and lower socioeconomic class (81.4%). Pulmonary TB was the leading cause of morbidity (in 42.1%), followed by asthma (in 17.5%) and pneumonia (in 15.3%). Lung cancer was uncommon (in only 0.6%). Pulmonary TB was the leading cause of hospitalization for respiratory disease (in 32%). Pulmonary TB, asthma, pneumonia and pleural pathologies were more common in women, whereas COPD was more common in men. The most common comorbidity was HIV infection (in 11.5%). The overall mean length of hospital stay was 14 days. Overall mortality was 8.7%; 50% of the deaths were attributed to pulmonary TB, 25% were attributed to pleural disease, 12.5% were attributed to pneumonia, and 6.25% were attributed to acute exacerbation of COPD. Mortality was higher in women and in the 25-44 year age bracket. Conclusions: Pulmonary TB, asthma and pneumonia were the leading causes of respiratory disease-related morbidity. Pulmonary TB was the leading cause of respiratory disease-related mortality among the adult Nigerians evaluated. Therefore, these conditions should be given higher priority in patient care. In addition, antiretroviral therapy should be readily accessible and affordable to HIV-infected individuals.

Keywords: Morbidity; Mortality; Respiratory tract diseases; Africa.

Objective: To evaluate the prevalence of respiratory symptoms as the motive for emergency room visits by adult and pediatric patients, describing the major clinical syndromes diagnosed and the outcomes of the patients. Methods: A cross-sectional study conducted in the emergency room of a tertiary care university hospital. Between November of 2008 and November of 2009, we reviewed the total number of emergency room visits per day. Children and adults who presented with at least one respiratory symptom were included in the study. The electronic medical records were reviewed, and the major characteristics of the patients were recorded. Results: During the study period, there were 37,059 emergency room visits, of which 11,953 (32.3%) were motivated by respiratory symptoms. The prevalence of emergency room visits due to respiratory symptoms was 28.7% and 38.9% among adults and children, respectively. In adults, the rates of hospitalization and mortality were 21.2% and 2.7%, respectively, compared with 11.9% and 0.3%, respectively, in children. Among the adults, the time from symptom onset to emergency room visit correlated positively with the need for hospitalization (p < 0.0001), the length of the hospital stay (p < 0.0001), and the mortality rate (p = 0.028). Conclusions: We found a high prevalence of respiratory symptoms as the motive for emergency room visits by adult and pediatric patients. Our results could inform decisions regarding the planning of prevention measures. Further epidemiological studies are needed in order to clarify the risk factors for severe respiratory symptoms.

Objective: To implement community-acquired pneumonia (CAP) guidelines at a public hospital in Brazil and to evaluate the impact of these guidelines on health care quality. Methods: A quasi-experimental study, with a before-and-after design, involving adult patients diagnosed with CAP and hospitalized between July of 2007 and October of 2008 in the general ward of the Marília School of Medicine Hospital das Clínicas, located in the city of Marília, Brazil. Results: During the study period, 68 patients were diagnosed with CAP: 48 before the implementation of the guidelines and 20 after their implementation. After the implementation of the guidelines, 85% of the cases were treated in accordance with the guidelines, and there was a significant increase in the use of antibiotic therapy for atypical bacteria in patients with severe CAP (6.3% vs. 75.0%; p < 0.001). Comparing the pre-implementation and post-implementation periods, we observed a trend toward a decrease in the mortality (35.4% vs. 15.0%; p = 0.09) and toward an increase in the recording of SpO2 in the medical charts of the patients (18% vs. 30%; p = 0.42). During the study period, the degree of severity was not recorded on the medical charts of most patients. In addition, the initiation of antibiotic therapy followed a pre-established schedule, regardless of the severity of the infection. Conclusions: This study showed that, although the development and implementation of CAP guidelines promoted the optimization of the treatment, there were no significant differences regarding the assessment of severity, SpO2 recording, or the initiation of antibiotic therapy. Therefore, strategies that are more effective are needed in order to modify variables related to the work of physicians and nurses.

Keywords: Guideline adherence; Pneumonia; Health care quality, access, and evaluation; Community-acquired infections.

Objective: Epidemiologic survey of respiratory diseases that cause hospital admissions at the Internal Medicine Service, Hospital Geral de Caxias do Sul (SCM-HG), a tertiary university hospital in the State of Rio Grande do Sul, Southern Brazil. Patients and methods: Retrospective study conducted at SCM-HG between November 1998 and November 1999. Data were obtained from medical records and included: a) major admission cause; b) associated diseases; c) sazonal variability; d) hospitalization length; e) mortality. Results: There were 1,200 admissions at SCM-HG, 228 (19%) caused by a respiratory disease. COPD (41.3%), pneumonias (29.8%) and bronchial asthma (9.6%) were the most prevalent. Fifty subjects (21.9%) presented comorbidity: cardiac failure (7.7%), systemic arterial hypertension (6.4%) and diabetes mellitus (4.4%). Pneumonias predominated between September and November, bronchial asthma frequency raised in October and November, and COPD prevailed from May to November. The admissions had an average duration of 10.4 ± 10 days. Twenty-six (11.4%) patients died. Conclusions: 1) Respiratory diseases were responsible for approximately 1/5 of the admissions. 2) COPD patients represented the biggest quota of admissions. 3) Patients with respiratory diseases stayed for a long time as compared with the others hospitalized patients (10.4 versus 7.7 days). 4) COPD, pneumonias and bronchial asthma behaved as expected regarding sazonal variability.

Keywords: Lung diseases. Asthma. Pneumonia. Epidemiology. University hospitals. Patient admission.

Objective: To determine the diagnostic sensitivity of bacteriological analyses in induced sputum (IS) for the diagnosis of pulmonary tuberculosis (TB) and to identify the clinical characteristics associated with the confirmed diagnosis, as well as to determine the diagnostic yield of bronchoscopy carried out when IS tests negative for AFB in smear microscopy. Methods: A retrospective, cross-sectional study of patients suspected of having active pulmonary TB and referred to our clinic for sputum induction. We consecutively reviewed the laboratory data of all patients submitted to sputum induction between June of 2003 and January of 2006, as well as their electronic medical records. In addition, the results of the bacteriological analysis of bronchoscopic specimens collected from the patients whose AFB tests were negative in IS were reviewed. Results: Of the 417 patients included in the study, 83 (19.9%) presented IS samples that tested positive for TB (smear microscopy or culture). In the logistic regression analysis, radiological findings of cavitation (OR = 3.8; 95% CI: 1.9-7.6) and of miliary infiltrate (OR = 3.7; 95% CI: 1.6-8.6) showed the strongest association with the diagnosis of pulmonary TB. In 134 patients, bronchoscopy was carried out after negative AFB results in IS and added 25 (64.1%) confirmed diagnoses of pulmonary TB. Conclusions: In our clinical practice, the frequency of confirmed diagnosis of pulmonary TB using IS (19.9%) was lower than that previously reported in controlled trials. Cavitation and miliary infiltrate increase the diagnostic probability of pulmonary TB using IS. The use of bronchoscopy when IS tests negative for AFB significantly increases sensitivity in the diagnosis of pulmonary TB.

Keywords: Tuberculosis, pulmonary; Diagnosis; Sputum.

Objective: To evaluate the role of intrapleural positioning of a pleural catheter in early lung expansion and pleurodesis success in patients with recurrent malignant pleural effusion (RMPE). Methods: This was a retrospective study nested into a larger prospective cohort study including patients with RMPE recruited from a tertiary university teaching hospital between June of 2009 and September of 2014. The patients underwent pleural catheter insertion followed by bedside pleurodesis. Chest CT scans were performed twice: immediately before pleurodesis (iCT) and 30 days after pleurodesis (CT30). Catheter positioning was categorized based on iCT scans as posterolateral, anterior, fissural, and subpulmonary. We used the pleural volume on iCT scans to estimate early lung expansion and the difference between the pleural volumes on CT30 and iCT scans to evaluate radiological success of pleurodesis. Clinical pleurodesis success was defined as no need for any other pleural procedure. Results: Of the 131 eligible patients from the original study, 85 were included in this nested study (64 women; mean age: 60.74 years). Catheter tip positioning was subpulmonary in 35 patients (41%), anterior in 23 (27%), posterolateral in 17 (20%), and fissural in 10 (12%). No significant differences were found among the groups regarding early lung expansion (median residual pleural cavity = 377 mL; interquartile range: 171-722 mL; p = 0.645), radiological success of pleurodesis (median volume = 33 mL; interquartile range: −225 to 257 mL; p = 0.923), and clinical success of pleurodesis (85.8%; p = 0.676). Conclusions: Our results suggest that the position of the tip of the pleural catheter influences neither early lung expansion nor bedside pleurodesis success in patients with RMPE.

Keywords: Pleurodesis; Pleural effusion, malignant; Tomography; Catheters.

Objective: To describe the patient profile, mortality rates, the accuracy of prognostic scores, and mortality-associated factors in patients with community-acquired pneumonia (CAP) in a general hospital in Brazil. Methods: This was a cohort study involving patients with a clinical and laboratory diagnosis of CAP and requiring admission to a public hospital in the interior of Brazil between March 2014 and April 2015. We performed multivariate analysis using a Poisson regression model with robust variance to identify factors associated with in-hospital mortality. Results: We included 304 patients. Approximately 70% of the patients were classified as severely ill on the basis of the severity criteria used. The mortality rate was 15.5%, and the ICU admission rate was 29.3%. After multivariate analysis, the factors associated with in-hospital mortality were need for mechanical ventilation (OR: 3.60; 95% CI: 1.85-7.47); a Charlson Comorbidity Index score > 3 (OR: 1.30; 95% CI: 1.18-1.43); and a mental Confusion, Urea, Respiratory rate, Blood pressure, and age > 65 years (CURB-65) score > 2 (OR: 1.46; 95% CI: 1.09-1.98). The mean time from patient arrival at the emergency room to initiation of antibiotic therapy was 10 h. Conclusions: The in-hospital mortality rate of 15.5% and the need for ICU admission in almost one third of the patients reflect the major impact of CAP on patients and the health care system. Individuals with a high burden of comorbidities, a high CURB-65 score, and a need for mechanical ventilation had a worse prognosis. Measures to reduce the time to initiation of antibiotic therapy may result in better outcomes in this group of patients.

Keywords: Community-acquired infections; Pneumonia; Hospital mortality; Risk factors.

Objective: To evaluate the risk factors for the development of tuberculosis and multidrug-resistant tuberculosis (MDR-TB) in patients treated at a tertiary referral hospital. Methods: This was a cross-sectional study based on data obtained from patients treated at the Júlia Kubitschek Hospital, located in the city of Belo Horizonte, Brazil, between October of 2012 and October of 2014. We evaluated sociodemographic, behavioral, clinical, and radiological variables. The outcome considered to identify associations between tuberculosis and the explanatory variables was the treatment prescribed. To evaluate the associations between MDR-TB and the same explanatory variables, the change in MDR-TB treatment was considered. Results: The factors associated with tuberculosis were alcoholism, comorbidities, pulmonary cavitations, and a radiological pattern suggestive of tuberculosis. Cavitation and previous treatment for tuberculosis were associated with MDR-TB. Conclusions: Despite the significant progress made in the fight against tuberculosis, there is a need for coordinated actions that include social protection measures and patient support.

Keywords: Tuberculosis; Risk factors; Tuberculosis, multidrug-resistant.

Objective: To evaluate the safety and feasibility of the use of indwelling pleural catheters (IPCs) in patients with malignant pleural effusion (MPE). Methods: We prospectively collected data from patients with MPE undergoing IPC placement between January of 2014 and July of 2015. All patients submitted to IPC placement had a life expectancy > 30 days, in accordance with the MPE treatment guidelines established by the British Thoracic Society. The data collected included gender, age, body mass index, primary cancer site, duration of IPC drainage, IPC-related complications, length of hospital stay, pleural effusion recurrence, and occurrence of spontaneous pleurodesis. Results: A total of 19 patients underwent IPC placement during the study period. Median overall survival after IPC insertion was 145 days. The median follow-up among the surviving patients was 125 days (range, 53-485 days), and the median time between catheter insertion and removal was 31 days (range, 2-126 days). There were IPC-related complications in 5 patients (26.2%), and spontaneous pleurodesis was achieved in 8 (42.0%). Among those 8 patients, the IPC was removed between days 30 and 126 in 4, and spontaneous pleurodesis occurred within the first 30 days in 4. Conclusions: The use of IPCs seems to be feasible and safe in patients with MPE.

Keywords: Pleural effusion, malignant; Survival; Palliative care.