Patient discharge from the ICU is indicated on the basis of clinical evidence and the result of strategies aimed at improving health care. Nevertheless, some patients might be discharged too early. We attempted to identify risk factors for unplanned ICU readmission, using a score for risk assessment, designated the Stability and Workload Index for Transfer (SWIFT) score. We evaluated 100 patients discharged from an ICU and found that the SWIFT score can be used as a tool for improving the assessment of ICU patients and the appropriateness of ICU discharge, thus preventing readmission.

Keywords: Intensive care units; Risk factors; Patient readmission.

The objective of this study was to review the literature, focusing on difficulties encountered in asthma diagnosis and in the establishment of initial inhaled corticosteroid treatment in children under five years of age. The search was limited to studies published between 1991 and 2002 in Portuguese, Spanish, or English and included in the LILACS and MEDLINE databases. Symptoms of asthma, the most common chronic childhood disease, typically appear in the first years of life. There are currently no diagnosis means of making a certain diagnosis of asthma in children under the age of five. Clinical manifestations, when present in toddlers and preschoolers, may require treatment such as that given for asthma, assuming that it is preceded by a critical evaluation. We can conclude that diagnosis of asthma in the first years of life is complex and predominantly clinical. Inhaled corticosteroid treatment is an effective tool, although its risks and benefits must be carefully evaluated.

Keywords: Asthma. Adrenal cortex hormones. Infant. Preschool.

Objective: To study variations in climate (dry or rainy periods) and health services use for the treatment of asthma in children under five years of age. Methods: An ecological study was conducted and involved analysis of the medical charts of all children under the age of five that were diagnosed with asthma and treated in the Municipal Emergency Room of the city of Cuiabá, located in the state of Mato Grosso, Brazil. In accordance with the geographic location of Cuiabá, two climatic periods were identified: a dry season (from May to October) and a rainy season (from November to April). Results: The percentage of children treated that were diagnosed with asthma was 12.2% (3140/25,802), with no gender-based difference. Children from 3 to 5 years of age were most often affected. The overall asthma hospitalization rate was 1.3% (336/25,802), rising to 10.7% (336/3140) among the asthmatic children treated in the emergency room. In the rainy season, the percentage of outpatients seeking treatment for asthma was higher than in the dry season: 39.1% (1228/3140) versus 60.9% (1912/3140). However, during the dry season, a greater proportion of such patients were hospitalized: 52.3% (176/336) versus 47.7% (160/336). These differences were statistically significant (p < 0.05). Conclusions: The dry season, which was correlated with higher asthma hospitalization rates, seems to be related to more severe cases of asthma in children under five years of age.

Keywords: Asthma/prevention & control; Allergens/adverse effects; Respiratory hypersensitivity; Environmental monitoring;

Objetivo: Avaliar o processo diagnóstico da tuberculose pulmonar em indígenas menores de 15 anos, por meio do Sistema de Pontuação do Ministério da Saúde Modificado (SP-MSm), em crianças e adolescentes com resultados negativos na baciloscopia. Métodos: Estudo descritivo retrospectivo de 49 casos de tuberculose em indígenas menores de 15 anos no estado do Mato Grosso do Sul entre 2007 e 2010. Resultados: Dos 49 pacientes, 27 (56%) eram menores de 5 anos, 33 (67%) apresentavam sintomas sugestivos de tuberculose, 24 (49%) tinham baixo peso, e 36 (73,5%) haviam sido vacinados com BCG. O teste tuberculínico foi reator em 28 pacientes (57%). Dentre esses, 18 (64%) apresentaram enduração ≥ 10 mm. Foram realizadas radiografias de tórax em 37 pacientes (76%), sendo que 31 (84%) fizeram apenas um exame. Desses 37 pacientes, os achados radiológicos eram sugestivos de tuberculose em 16 (43%), de infiltrado/condensação em 10 (27%) e normais em 4 (11%). As Equipes de Saúde Indígena foram responsáveis pelo diagnóstico em 31 (63%) dos casos, mas o SP-MS original só foi utilizado em 14 (45%). Os escores do SP-MSm foram determinados em 30 pacientes (61%). Dos 30 casos pontuados, os resultados dos escores indicaram diagnóstico de tuberculose muito provável, possível e pouco provável em 16 (53%), 11 (37%) e 3 (10%), respectivamente. Conclusões: A proporção de diagnóstico muito provável e possível foi concordante com o diagnóstico padrão do serviço (90%), evidenciando a aplicabilidade epidemiológica do SP-MSm para o diagnóstico da tuberculose pulmonar em indígenas, de forma compatível com a realidade do serviço de saúde prestado.

Keywords: Tuberculose pulmonar/diagnóstico; Serviços de saúde do indígena/normas; Serviços de saúde do indígena/organização & administração.

Objective: To evaluate the management of asthma attacks in children up to five years of age treated in the pediatric emergency room of a hospital in the metropolitan area of the city of Recife, Brazil, as well as to determine whether the way in which asthma attacks are managed can influence the duration of emergency room visits for such children. Methods: A descriptive, exploratory study employing a quantitative, cross-sectional approach. The study sample comprised 246 children treated for asthma attacks in an emergency room. The approach used was evaluated in comparison with the approach recommended in the III Brazilian Consensus on Asthma Management, as was the length of time each child spent in the emergency room. Results: In 69 (28.1%) of the cases, the medications were used in accordance with the Consensus guidelines. In 34 (13.8%) of the cases, the doses used were those recommended in the Consensus guidelines, and the guidelines regarding nebulization procedures were followed in 33 cases (13.4%). No correlation was found between the approach taken and the length of the emergency room visit. In the logistic regression analysis, we observed that the adjusted risk of being released from the emergency room sooner than recommended in the Consensus guidelines (a length of time sufficient to allow the response to the treatment to be analyzed) was four times and fifteen times greater, respectively, for children with mild persistent asthma and for those with intermittent asthma. Conclusion: Although there are obstacles to using the asthma management approach recommended in the Consensus guidelines (such obstacles including the lack of familiarity with the guidelines on the part of the multidisciplinary team, as well as the lack of recommended material and therapeutic resources), the duration of emergency room visits was found to be related to the degree of asthma severity.

Keywords: Emergency medicine; Pediatrics; Asthma; Status asthmaticus

Background: In recent decades, the prevalence of asthma has increased. Objectives: To determine the prevalence of asthma symptoms in children and adolescents from 2 to 14 years of age living in Porto Alegre (in the state of Rio Grande do Sul, Brazil) and to determine any potential correlations with socioeconomic profile, treatment and smoking in the home. Methods: A transversal study based on interviews of all families seeking medical attention in June of 2000. Results: The prevalence of asthma symptoms was 49.5%. In 66.8% of families, total income was less than four times the minimum wage, and in more than 50% of homes, the parents had had less than five years of schooling. In 98.5%, prophylactic asthma treatment was not used. In the 174 families studied, 38.7% of mothers and 43.7% of fathers were smokers (32.7% overall). Correlations were found between the following variables: exposure to smoking in the home and number of asthma attacks in the last year (p = 0.02; RR = 2.9; CI: 1.1 - 4.5); maternal level of education and number of attacks in the last year (p = 0.03; RR = 2.03; CI: 1.01 - 4.19); close living quarters and number of attacks in the last year among children exposed to second-hand smoke (p = 0.04; RR = 2.7; CI: 1.4 - 5.1); hospitalization and number of attacks in the last year (p = 0.004; RR = 1.46; CI: 1.15 -1.86); hospitalization and close living quarters (p = 0.03; RR = 1.47; CI: 1.15 -1.86). In children below the age of five, there was correlation between maternal smoking and number of attacks in the last year (p = 0.03; RR = 1.79; CI: 1.04 - 3.08). Conclusion: The prevalence of asthma symptoms was high. The community studied has limited socioeconomic resources, and there is therefore a lack of adequate treatment for asthma. Our results demonstrate the need for prioritized, standardized treatment programs that would give healthcare workers access to the appropriate materials and means of evaluation necessary for asthma control.

Keywords: Key words: Asthma. Prevalence. Smoking in the home. Treatment between episodes of asthma.

Objective: To assess the incidence of necrotizing pneumonia (NP) in children submitted to thoracoscopy, comparing patients with and without NP in terms of the presentation and clinical evolution. Methods: A retrospective study of children with pleural empyema submitted to thoracoscopy. Thoracoscopy was performed in patients not previously submitted to thoracic drainage and in whom there was evidence of loculated effusion or pneumothorax, as well as in those previously submitted to thoracic drainage and in whom there was persistent pneumothorax or fever with purulent discharge. On the basis of the thoracoscopy findings, patients were distributed into two groups: those with NP (NP group) and those without (no-NP group). Results: The study sample comprised 52 patients. Of the 24 patients with NP, 19 (79%) had undergone thoracic drainage prior to thoracoscopy, 11 (46%) presented with pneumothorax, and 16 (67%) developed bronchopleural fistula. In the NP group, the median drainage time and the median length of hospital stay were 18 and 19 days, respectively. Of the 28 patients without NP, 10 (36%) had undergone thoracic drainage prior to thoracoscopy, 9 (32%) presented pneumothorax, and 5 (18%) developed bronchopleural fistula. In the no-NP group, the median drainage time and the median length of hospital stay were 6 and 10 days, respectively. Conclusions: Pneumothorax should raise the suspicion of NP. Early thoracoscopy can be a valuable treatment option for NP in children because it hastens recovery in comparison with the medical treatment alone and avoids extensive late thoracotomy lung resections.

Keywords: Keywords: Empyema, pleural; Thoracoscopy; Pneumonia; Child.

Objective: Asthma and respiratory symptoms are common in children, and many studies have shown associations between childhood symptoms and impaired lung function in adult life. The aim of the present study was to investigate the association of various respiratory symptoms with wheezing patterns (persistent, early, and late-onset) and lung function, as well as to determine whether lung function was associated with atopy or with demographic, socioeconomic, environmental, and gestational factors, in a birth cohort at 6-7 years of age. Methods: The target population consisted of children aged 6-7 years from a birth cohort of 5,304 children born in southern Brazil in 1993. For this follow-up evaluation, 532 of those children were randomly selected, and a sub-sample was submitted to spirometry and skin prick tests. A questionnaire was administered to the parent(s) or legal guardian(s) of each child. Results: Spirometric values were lower in the children with respiratory symptoms or asthma. Mean forced expiratory volume in one second/forced vital capacity ratio (FEV1/FVC ratio) was lower in children with any of the following: current wheezing and asthma; asthma ever; four or more episodes of wheezing within the preceding 12 months; sleep disturbance due to wheezing; and exercise-induced wheezing. Persistent wheezing was associated with lower FEV1/FVC ratio. After multiple linear regression, exercise-induced wheezing was also associated with reduced FEV1/FVC ratio. Nonwhite skin color and wheezing severe enough to limit speech were associated with lower FEV1. Conclusions: Children with persistent wheezing and symptoms of severe asthma have impaired lung function at 6-7 years of age.

Keywords: Asthma; Respiratory function tests; Respiratory sounds; Signs and symptoms, respiratory.

Objective: Pneumococcal pneumonia is a significant cause of morbidity and mortality among adults. The study's main aim was to evaluate the in-hospital mortality and related costs of community-acquired pneumococcal pneumonia in adults. Methods: This cross‑sectional study used medical records of adult patients with pneumococcal pneumonia hospitalized in a university hospital in Brazil from October 2009 to April 2017. All patients aged ≥ 18 years diagnosed with pneumococcal pneumonia were included. Risk factors, intensive care unit admission, length of hospital stay, in-hospital mortality, and direct and indirect costs were analyzed. Results: In total, 186 patients were selected. The mean in-hospital mortality rate was 18% for adults aged < 65 years and 23% for the elderly (≥ 65 years). Bacteremic pneumococcal pneumonia affected 20% of patients in both groups, mainly through chronic respiratory disease (adjusted OR: 3.07, 95% CI: 1.23-7.65, p < 0.01). Over 7 years, annual total direct and indirect costs were USD 28,188 for adults < 65 years (USD 1,746 per capita) and USD 16,350 for the elderly (USD 2,119 per capita). Conclusion: Pneumococcal pneumonia remains an important cause of morbidity and mortality among adults, significantly affecting direct and indirect costs. These results suggest the need for prevention strategies for all adults, especially for patients with chronic respiratory diseases.

Keywords: Pneumococcus; Pneumococcal disease; Pneumonia; Hospital costs; Mortality.

Objective: To determine the prevalence of asthma symptoms and of airflow obstruction in amateur swimmers between 8 and 17 years of age, as well as to assess the awareness of asthma and asthma management among these swimmers, their parents, and their coaches. Methods: Our sample comprised 1,116 amateur swimmers who completed a modified version of the International Study of Asthma and Allergies in Childhood written questionnaire, to which questions regarding the reasons to initiate swimming and regarding asthma management had been added. In addition, the participants underwent spirometry prior to a swimming competition. Results:   The prevalence of asthma symptoms in the last 12 months was 11.5%, and 327 (29.4%) of the participants reported "wheezing or whistling" in the past. Of the 223 swimmers who reported "asthma ever" or "bronchitis ever", only 102 (45.7%) reported having ever been treated: the most common "treatment" was swimming (in 37.3%), and only 12.7% used inhaled corticosteroids. Of the 254 participants (22.7%) with airflow obstruction, only 52  (20.5%) reported having asthma symptoms. Conclusions: Asthma symptoms are present in amateur swimmers, and a considerable number of such swimmers have airflow obstruction without symptoms. It is therefore likely that the prevalence of asthma is underestimated in this population. It is worrisome that, in our study sample, the swimmers previously diagnosed with asthma were not using the recommended treatments for asthma. The clinical implications of these findings underscore the importance of implementing educational measures for amateur swimmers, as well as for their parents and coaches, to help them recognize asthma symptoms and the consequent risks in the sports environment, in order to allow prompt diagnosis and early clinical intervention.

Keywords: Asthma/diagnosis; Asthma/prevention & control; Sports.

Objective: To evaluate the combined impact of videofluoroscopic swallow study (VFSS) and therapeutic feeding and swallowing interventions on clinical outcomes in children with oropharyngeal dysphagia (OPD). Methods: This was an uncontrolled longitudinal analytical study in which OPD patients were evaluated before and after VFSS. Children = 24 months of age diagnosed with OPD in a clinical setting and undergoing VFSS for investigation and management of OPD were included in the study. The study participants received therapeutic feeding and swallowing interventions after having undergone VFSS, being followed at an outpatient clinic for pediatric dysphagia in order to monitor feeding and swallowing difficulties. Respiratory and feeding outcomes were compared before and after VFSS. Results: Penetration/aspiration events were observed in 61% of the VFSSs (n = 72), and therapeutic feeding and swallowing interventions were recommended for 97% of the study participants. After the VFSS, there was a reduction in the odds of receiving antibiotic therapy (OR = 0.007) and in the duration of antibiotic therapy (p = 0.014), as well as in the odds of being admitted to hospital (p = 0.024) and in the length of hospital stay (p = 0.025). A combination of oral and enteral feeding became more common than oral or enteral feeding alone (p = 0.002). Conclusions: A high proportion of participants exhibited penetration/aspiration on VFSS. Therapeutic feeding and swallowing interventions following a VFSS appear to be associated with reduced respiratory morbidity in this population.

Keywords: Fluoroscopy; Deglutition disorders; Respiratory tract diseases; Pneumonia, aspiration; Nutritional support.

Objective: To determine the prevalence of symptoms of asthma, rhinitis and atopic eczema among students between 6 and 7 years of age in the city of Londrina, Brazil. Methods: A population-based study using the International Study of Asthma and Allergies in Childhood (ISAAC) standardized questionnaire (asthma, rhinitis and atopic eczema modules), validated for use in Brazil, in public school students between 6 and 7 years of age. Results: Of the 3,963 questionnaires retrieved, 3,600 (90.8%) were appropriately completed and were used in the analysis. The prevalence of symptoms of asthma, rhinitis and atopic eczema in the last 12 months was 22.0%, 27.3% and 9.6%, respectively. The prevalence of physician-diagnosed asthma, rhinitis and atopic eczema was 10.4%, 23.4% and 11.4%, respectively. The prevalence of rhinoconjunctivitis and flexural eczema was 13.6% and 6.6%, respectively. Although symptoms of asthma and rhinitis were more common in males than in females, no gender difference was found regarding atopic eczema symptoms. Conclusions: The prevalence of symptoms of asthma, rhinitis and atopic eczema in our sample was within the range found at the facilities that participated in phases I and III of the ISAAC in Brazil. The low prevalence of physician-diagnosed asthma suggests that asthma continues to be underdiagnosed.

Keywords: Public health; Epidemiology; Asthma.

Objective: To describe the trends in tumor histology, gender and age among patients with non-small cell lung cancer (NSCLC) treated with lung resection. The histology of lung cancer has changed in developed countries, and there is still little information available on the topic for developing countries. Methods: This was a retrospective study of 1,030 patients with NSCLC treated with lung resection between 1986 and 2015 at a university hospital in southern Brazil. Differences in histology, stage, and type of surgery were analyzed by gender and for three periods (1986-1995, 1996-2005, and 2006-2015). Results: Most (64.5%) of the patients were males, and the main histological types were squamous cell carcinoma (in 40.6%) and adenocarcinoma (in 44.5%). The mean age at surgery during the first period was 56.4 years for women and 58.9 years for men, compared with 62.2 for women and 64.6 for men in the third period (p < 0.001). The proportion of females increased from 26.6% in the first period to 44.1% in the third. From the first to the third period, the proportion of patients with squamous cell carcinoma decreased from 49.6% to 34.8% overall (p < 0.001), decreasing to an even greater degree (from 38.9% to 23.2%) among men. Among the NSCLC patients in our sample, females with adenocarcinoma accounted for 11.9% in the first period and 24.0% in the third period (p < 0.001). Conclusions: As has been seen in developed countries, the rates of lung cancer in females in southern Brazil have been rising over the last three decades, although they have yet to surpass those observed for males in the region. The incidence of squamous cell carcinoma has decreased in males, approaching adenocarcinoma rates, whereas adenocarcinoma has significantly increased among women.

Keywords: Lung neoplasms; Epidemiology; Histology; Adenocarcinoma; Carcinoma, non-small-cell lung; Carcinoma, squamous cell.

Objective: Bacteremia is the most common presentation of invasive disease in community-acquired pneumonia (CAP) due to Streptococcus pneumoniae. We investigated whether bacteremia in pneumococcal CAP worsens outcomes and whether it is related to pneumococcal vaccination (PV). Methods: Secondary analysis of a cohort of patients with pneumococcal CAP confirmed by blood culture, sputum culture, or urinary antigen testing. Demographic, clinical, radiographic, and biochemical data were collected, as were Acute Physiology and Chronic Health Evaluation II (APACHE II) and pneumonia severity index (PSI) scores, comorbidities, and PV history. We drew comparisons between patients with bacteremic pneumococcal CAP (BPP) and those with non-bacteremic pneumococcal CAP (NBPP). Results: Forty-seven patients had BPP, and 71 had NBPP (confirmed by sputum culture in 45 and by urinary antigen testing in 26); 107 had some indication for PV. None of the BPP patients had received PV, compared with 9 of the NBPP patients (p = 0.043). Among the BPP patients, the mean age was higher (76.4 ± 11.5 vs. 67.5 ± 20.9 years), as were APACHE II and PSI scores (16.4 ± 4.6 vs. 14.1 ± 6.5 and 129.5 ± 36 vs. 105.2 ± 45, respectively), as well as the rate of ICU admission for cardiopathy or chronic renal failure (42.5% vs. 22.5%), whereas hematocrit and plasma sodium levels were lower (35.7 ± 5.8 vs. 38.6 ± 6.7% and 133.9 ± 6.0 vs. 137.1 ± 5.5 mEq/L, respectively), although mortality was similar (29.8% vs 28.2%). Conclusions: In this population at high risk for CAP due to S. pneumoniae, the PV rate was extremely low (8.4%). Although BPP patients were more severely ill, mortality was similar between the two groups. Because PV reduces the incidence of BPP, the vaccination rate in at-risk populations should be increased.

Keywords: Pneumococcal vaccines; Pneumonia, bacterial; Streptococcus pneumoniae; Pneumococcal infections; Mortality; Epidemiology.

Objectives: To estimate the prevalence of allergic rhinitis (AR), atopic dermatitis (AD), and wheezing, and to describe their patterns of co-occurrence according to different characteristics in adolescence and early adulthood. Methods: Cross-sectional analyses from the 15-year and 22-year follow-ups of the 1993 Pelotas (Brazil) Birth Cohort. The outcomes were assessed based on self-reported data, and the patterns of co-occurrence were determined using cluster analysis. The sample was described using absolute and relative frequencies according to the independent variables. Venn diagrams were generated to visualize the co-occurrence of AR, AD, and wheezing. Results: Data on AR, AD, and wheezing were available for 4,286 participants at 15 years and 3,789 at 22 years. At 15 years, AR was reported by 20.9% of participants, AD by 25.2%, and wheezing by 33.4%. Meanwhile, at 22 years, AR was reported by 24.6%, AD by 14.2%, and wheezing by 30.7%. Notably, the overlap between AR and wheezing was greater than that of the other conditions (6.9% at 15 years and 8.3% at 22 years). Participants with lower maternal education and lower income were more likely to report having "no health condition". At 15 years, White individuals most frequently reported "three conditions" (4.1%; p<0.001), whereas at 22 years, they primarily reported "two conditions" (15.6%; p<0.001). The co-occurrence of all three health conditions was found to be greater than expected, with an observed rate 2.1 times higher (95% CI 1.4 - 3.0) at 22 years. Conclusions: This study highlights the social gradient in the diagnosis and reporting of co-occurrence of AR, AD, and wheezing

Keywords: asthma, wheezing, allergic rhinitis, atopic dermatitis, epidemiology