Objective: To investigate the correlation between respiratory syncytial viral load and length of hospitalization in infants with acute wheezing episodes. Methods: This was a two-year, cross-sectional study of infants ≤ 12 months of age with bronchiolitis at the time of admission to a tertiary hospital. For the identification of respiratory viruses, nasopharyngeal secretions were collected. Samples were analyzed (throughout the study period) by direct immunofluorescence and (in the second year of the study) by quantitative real-time PCR. We screened for three human viruses: rhinovirus, respiratory syncytial virus, and metapneumovirus. Results: Of 110 samples evaluated by direct immunofluorescence, 56 (50.9%) were positive for a single virus, and 16 (14.5%) were positive for two or more viruses. Among those 72 samples, the most prevalent virus was respiratory syncytial virus, followed by influenza. Of 56 samples evaluated by quantitative real-time PCR, 24 (42.8%) were positive for a single virus, and 1 (1.7%) was positive for two viruses. Among those 25 samples, the most prevalent virus was again respiratory syncytial virus, followed by human rhinovirus. Coinfection did not influence the length of the hospital stay or other outcome s. In addition, there was no association between respiratory syncytial virus load and the length of hospitalization. Conclusions: Neither coinfection nor respiratory syncytial viral load appears to influence the outcomes of acute bronchiolitis in infants.

Keywords: Bronchiolitis; Coinfection; Viral load; Hospitalization; Respiratory syncytial virus, human.

Objective: To compare the expiratory flow increase technique (EFIT) and vibration accompanied by postural drainage (PD) in terms of their effects on the heart rate (HR), respiratory rate (RR) and SpO2 of infants with acute viral bronchiolitis (AVB). Methods: Infants with clinical and radiological diagnosis of AVB were analyzed. The HR, RR and SpO2 were registered at four time points: prior to the procedure; and at 10, 30 and 60 min after the procedure. The patients were divided into three groups: submitted to the EFIT; submitted to vibration/PD; and control. Results: We included 81 infants, 27 per group, with a mean age of 4.52 years and a mean weight of 6.56 kg. Using ANOVA, we found that the EFIT and vibration/PD groups presented no significant differences in relation to the control group in terms of the mean values for HR, RR or SpO2 (p > 0.05). Considering only the four time points evaluated, the mean RR was significantly lower in the EFIT and vibration/PD groups than in the control group (p < 0.05). Conclusions: In terms of overall improvement of cardiorespiratory parameters, neither the EFIT nor vibration/PD provided any benefit to infants with BVA. However, over time, respiratory physical therapy seems to contribute to decreasing the RR in these patients.

Keywords: Bronchiolitis, viral; Physical therapy modalities; Infant.

Objective: To identify associations between genetic polymorphisms (in the MBL2, TGF-β1 and CD14 genes) and the severity of the lung disease in patients with cystic fibrosis (CF), as well as between the presence of ΔF508 alleles and lung disease severity in such patients. Methods: This was a cross-sectional cohort study, based on clinical and laboratory data, involving 105 patients with CF treated at a university hospital in the 2005-2006 period. We included 202 healthy blood donors as controls for the determination of TGF-β1 and CD14 gene polymorphisms. Polymorphisms in the MBL2 and TGF-β1 genes at codon 10, position +869, were genotyped using the allele-specific PCR technique. The C-159T polymorphism in the CD14 gene was genotyped using PCR and enzymatic digestion. Results: Of the 105 CF patients evaluated, 67 presented with severe lung disease according to the Shwachman score. The MBL2 gene polymorphisms were not associated with disease severity in the CF patients. Analysis of the T869C polymorphism in the TGF-β1 gene showed an association only between TC heterozygotes and mild pulmonary disease. Although patients presenting the TT genotype of the C159T polymorphism in the CD14 gene predominated, there was no significant difference regarding lung disease severity. Conclusions: There was an association between the TC genotype of the T869C polymorphism (TGF-β1) and mild pulmonary disease in CF patients. In the CD14 gene, the TT genotype seems to be a risk factor for pulmonary disease but is not a modulator of severity. We found no association between being a ΔF508 homozygote and presenting severe lung disease.

Keywords: Cystic fibrosis; Polymorphism, genetic; Severity of illness index; Mannose-binding lectin; Transforming growth factor beta.

In order to assess the relationship between the physical fitness of asthmatics and the clinical expression of the underlying disease, the authors studied 39 physically active children with moderate to severe but stable asthma. The patients (25 boys and 14 girls, aged between 9 and 16 years) were submitted to clinical evaluation; spirometry before and after bronchodilator (BD); maximal cardiopulmonary exercise test in cycle ergometer with breath-by-breath analysis of ventilatory and gas exchange variables; and, on a separate day, an exercise challenge test. As expected by the clinical stability, FEV1 post-BD was in the normal range in most of the children (mean ± SD = 93.8 ± 13.7% predicted). Maximal oxygen uptake (VO2max) was higher than the lower 95% confidence interval in 31/39 children; and in 29/39, the oxygen uptake at the anaerobic threshold (VO2AT) showed values above the lower limit of normality. Seven patients with low tolerance to exercise (reduced VO2max) presented suggestions of circulatory limitation (cardiovascular and/or peripheral) and only 1 had ventilatory limitation. There was no association or correlation between the lower ventilatory reserve (VEmax/MVV% ratio > 80%) and the decreased VO2max. Reduction in VO2AT, but not VO2max, was associated with some clinical indicators of asthma severity, e.g. (i) higher daily inhaled beclomethasone and frequent courses of oral steroids (p < 0.05) and (ii) higher exercise-induced bronchospasm occurrence (p < 0.01). The results show that (i) most patients with moderate to severe asthma, when clinically stable and physically active, present an adequate level of exercise tolerance; (ii) in estimation of the clinical severity of bronchial asthma in children, VO2AT is a better aerobic index than VO2max.

Keywords: Asthma in children. Exercise tolerance. Maximal oxygen uptake. Anaerobic threshold. Physical fitness. Exercise-induced

Objective: To evaluate the incidence of viral infection in patients with acute asthma treated in the emergency room. Methods: We conducted a cohort study of patients aged 12 and older presenting to the emergency room of the Hospital de Clínicas de Porto Alegre with acute asthma. Nasopharyngeal aspirate was collected, and antigens were detected through indirect immunofluorescence staining for respiratory syncytial virus, adenovirus and influenza, as well as for parainfluenza types 1, 2, 3 and 4. Data were collected regarding demographic characteristics, medical history, the attack that led to the current emergency room visit, and clinical outcomes. Results: From March to July of 2004, 49 patients were examined for viral infection of the respiratory tract. Respiratory viruses were identified in 6 patients (3 with adenovirus, 2 with influenza A, 1 with parainfluenza type 1). The mean age of the patients with viral infection of the respiratory tract was 61.7 ± 11.5 years, compared with 41.7 ± 20.9 years for the patients without such infection (p = 0.027). There were no other significant differences in clinical characteristics or outcomes. Conclusion: The incidence of viral infection of the respiratory tract in acute asthma patients 12 years and older treated in an emergency room was 12.2%, which confirms that viral infection is a significant precipitant of acute asthma for patients in this age bracket.

Keywords: Emergency Service, Hospital; Vírus diseases/prevention & control; Asthma; Respiratory tract infections; Influenza A virus, human

Objective: To determine whether the children and adolescents with acute asthma attacks admitted to two public hospitals in the city of Recife, Brazil underwent outpatient follow-up treatment for the prevention and control of asthma. Methods: A prospective case series study of hospitalized patients with asthma. The patients were asked to complete a questionnaire at admission in order to determine the frequency of prophylactic outpatient follow-up treatment. Patients presenting two or more attacks of asthma that were responsive to bronchodilators were classified as having asthma. Results: In the intervals between asthma attacks, 67% (112/167 - data regarding 2 patients were not available) of the patients had been treated only in the emergency room. Although 53.3%(89/167 - data regarding 2 patients were not provided) of the patients had been referred to outpatient treatment, only 16% (27/169) had visited an outpatient asthma clinic regularly for preventive treatment, and only 13% (22/169) had used prophylactic medication. Conclusion: Most of the children and adolescents hospitalized with asthma had not undergone preventive outpatient follow-up treatment. Various problems related to the health care system, such as non-referral for outpatient follow-up treatment at hospital discharge, limited access to outpatient clinics, and the cost of prophylactic medication, might have contributed to the low rate of outpatient follow-up treatment in the population studied. Public health care policies that allow asthma control programs to work effectively should be implemented.

Keywords: Asthma; Hospitalization; Ambulatory care.

Objective: To determine the presence of staphylococcal superantigen-specific IgE antibodies and degree of IgE-mediated sensitization, as well as whether or not those are associated with the severity of asthma in adult patients. Methods: This was a cross-sectional study involving outpatients with asthma under treatment at a tertiary care university hospital in the city of Rio de Janeiro, Brazil. Consecutive patients were divided into two groups according to the severity of asthma based on the Global Initiative for Asthma criteria: mild asthma (MA), comprising patients with mild intermittent or persistent asthma; and moderate or severe asthma (MSA). We determined the serum levels of staphylococcal toxin-specific IgE antibodies, comparing the results and performing a statistical analysis. Results: The study included 142 patients: 72 in the MA group (median age = 46 years; 59 females) and 70 in the MSA group (median age = 56 years; 60 females). In the sample as a whole, 62 patients (43.7%) presented positive results for staphylococcal toxin-specific IgE antibodies: staphylococcal enterotoxin A (SEA), in 29 (20.4%); SEB, in 35 (24.6%); SEC, in 33 (23.2%); and toxic shock syndrome toxin (TSST), in 45 (31.7%). The mean serum levels of IgE antibodies to SEA, SEB, SEC, and TSST were 0.96 U/L, 1.09 U/L, 1.21 U/L, and 1.18 U/L, respectively. There were no statistically significant differences between the two groups in terms of the qualitative or quantitative results. Conclusions: Serum IgE antibodies to SEA, SEB, SEC, and TSST were detected in 43.7% of the patients in our sample. However, neither the qualitative nor quantitative results showed a statistically significant association with the clinical severity of asthma.

Keywords: Asthma; Immunoglobulin E; Superantigens; Bacterial toxins; Staphylococcus aureus.

Objective: To determine whether the severity of non-neurological critically ill patients correlates with clinical predictors of bronchial aspiration. Methods: We evaluated adults undergoing prolonged orotracheal intubation (> 48 h) and bedside swallowing assessment within the first 48 h after extubation. We collected data regarding the risk of bronchial aspiration performed by a speech-language pathologist, whereas data regarding the functional level of swallowing were collected with the American Speech-Language-Hearing Association National Outcome Measurement System (ASHA NOMS) scale and those regarding health status were collected with the Sequential Organ Failure Assessment (SOFA). Results: The study sample comprised 150 patients. For statistical analyses, the patients were grouped by ASHA NOMS score: ASHA1 (levels 1 and 2), ASHA2 (levels 3 to 5); and ASHA3 (levels 6 and 7). In comparison with the other patients, those in the ASHA3 group were significantly younger, remained intubated for fewer days, and less severe overall clinical health status (SOFA score). The clinical predictors of bronchial aspiration that best characterized the groups were abnormal cervical auscultation findings and cough after swallowing. None of the patients in the ASHA 3 group presented with either of those signs. Conclusions: Critically ill patients 55 years of age or older who undergo prolonged orotracheal intubation (≥ 6 days), have a SOFA score ≥ 5, have a Glasgow Coma Scale score ≤ 14, and present with abnormal cervical auscultation findings or cough after swallowing should be prioritized for a full speech pathology assessment.

Keywords: Deglutition; Deglutition disorders; Intubation, intratracheal; Pneumonia, aspiration; Intensive care units.

This was a cross-sectional study aimed at determining the association between exposure to tobacco displays at the point of sale and susceptibility to smoking in schoolchildren in the 14- to 17-year age bracket. Of the participating students, 69.0%, 21.3%, and 9.7% were classified as never smokers, experimenters, and smokers, respectively. Of the participants who were classified as being exposed to smoking, 18.9% were susceptible to smoking. Of the participants who were classified as being unexposed to smoking, 12.9% were susceptible to smoking (OR = 1.56; 95% CI: 1.04 -2.35; p = 0.029). Exposure to point-of-sale tobacco displays is associated with smoking susceptibility in Brazilian adolescents.

Objective: Obstructive sleep apnea (OSA) is associated with an increased risk of mortality and cardiometabolic diseases. The STOP-Bang questionnaire is a tool to screen populations at risk of OSA and prioritize complementary studies. Our objective was to evaluate the clinical utility of this questionnaire in identifying patients at an increased risk of mortality after discharge in a cohort of hospitalized patients. Methods: This was a prospective cohort study involving consecutive patients admitted to an internal medicine unit between May and June of 2017 who were reevaluated three years after discharge. At baseline, we collected data on comorbidities (hypertension, obesity, diabetes, and fasting lipid profile) and calculated STOP-Bang scores, defining the risk of OSA (0-2 score, no risk; = 3 score, risk of OSA; and = 5 score, risk of moderate-to-severe OSA), which determined the study groups. We also recorded data regarding all-cause and cardiovascular mortality at the end of the follow-up period. Results: The sample comprised 435 patients. Of those, 352 (80.9%) and 182 (41.8%) had STOP-Bang scores = 3 and = 5, respectively. When compared with the group with STOP-Bang scores of 0-2, the two groups showed higher prevalences of obesity, hypertension, diabetes, and dyslipidemia. Multivariate analysis showed an independent association between cardiovascular mortality and STOP-Bang score = 5 (adjusted hazard ratio = 3.12 [95% CI, 1.39-7.03]; p = 0.01). Additionally, previous coronary heart disease was also associated with cardiovascular mortality. Conclusions: In this cohort of hospitalized patients, STOP-Bang scores = 5 were able to identify patients at an increased risk of cardiovascular mortality three years after discharge.

Keywords: Sleep Apnea, Obstructive; Risk assessment; Surveys and questionnaires; Cardiovascular diseases/mortality.

Objective: To determine whether the concentrations of inflammatory mediators (CCL5, soluble intercellular adhesion molecule type 1 [sICAM-1], TNF-α, IL-6 and IL-10) in the nasopharyngeal secretion and in the serum of children with lower respiratory tract infection (LRTI) caused by respiratory syncytial virus (RSV) correlate with the clinical markers of disease severity. Methods: Between July of 2004 and December of 2005, 30 children less than three months of age, diagnosed with LRTI caused by RSV and admitted to a neonatal ICU, were included in this study. Results: The severity of disease at hospital admission, as determined with a modified clinical scoring system, presented a significant positive correlation with sICAM-1 and IL-10 concentrations in the nasopharyngeal secretion, as well as with IL-6 concentrations in the serum, of the patients. In addition, serum IL-6 concentrations presented a significant positive correlation with the duration of oxygen therapy and with the length of hospital stay. Conclusions: At hospital admission, the concentrations of sICAM-1 and IL-10 in the nasopharyngeal secretion, as well as the concentration of IL-6 in the serum, could be used as markers of severity in patients with LRTI caused by RSV. The serum levels of IL-6 determined at admission could also be used to predict prolonged oxygen supplementation and hospital stay.

Keywords: Respiratory syncytial virus, human; Chemokine CCL5; Intercellular adhesion molecule-1; Interleukin-6; Interleukin-10; Tumor necrosis factor-alpha.

Objective: To determine whether climate variability influences the number of hospitalizations for respiratory diseases in infants, children, and adults in the city of Campo Grande, Brazil. Methods: We used daily data on admissions for respiratory diseases, precipitation, air temperature, humidity, and wind speed for the 2004-2008 period. We calculated the thermal comfort index, effective temperature, and effective temperature with wind speed (wind-chill or heat index) using the meteorological data obtained. Generalized linear models, with Poisson multiple regression, were used in order to predict hospitalizations for respiratory disease. Results: The variables studied were (collectively) found to show relatively high correlation coefficients in relation to hospital admission for pneumonia in children (R2 = 68.4%), infants (R2 = 71.8%), and adults (R2 = 81.8%). Conclusions: Our results indicate a quantitative risk for an increase in the number of hospitalizations of children, infants, and adults, according to the increase or decrease in temperature, humidity, precipitation, wind speed, and thermal comfort index in the city under study.

Keywords: Meteorology; Pneumonia/epidemiology; Risk factors.

Objective: Elevated values of body mass index (BMI) have been associated with higher prevalence of asthma in adults. The aim of the present study is to evaluate the association between obesity and asthma severity. Methods: Medical records of two hundred patients older than 20 years of age were evaluated retrospectively. Asthma severity was established after the evaluation of the medical history and diagnosis recorded, spirometry results and the medicines prescribed. BMI was calculated and patients were classified as obese when the BMI was ≥ 30 kg/m2. Results: 23% of the patients presented intermittent asthma, 25.5% presented mild persistent asthma, 24% presented moderate persistent asthma, and 27.5% presented severe persistent asthma. Values of BMI ≤ 29.9 kg/m2 were observed in 68% of the patients and in 32% the BMI was ≥ 30 kg/m2. The odds ratio of the correlation between obesity and asthma severity was 1.17 (95% CI: 0.90-1.53; p > 0.05). Conclusions: In the sample evaluated in this study no correlation between obesity and asthma severity was found for either gender.

Keywords: Asthma; Body mass index, Sex distribution; Obesity.

Objective: To determine whether serum selenium levels are associated with the conversion of bacteriological tests in patients diagnosed with active pulmonary tuberculosis after eight weeks of standard treatment. Methods: We evaluated 35 healthy male controls and 35 male patients with pulmonary tuberculosis, the latter being evaluated at baseline, as well as at 30 and 60 days of antituberculosis treatment. For all participants, we measured anthropometric indices, as well as determining serum levels of albumin, C-reactive protein (CRP) and selenium. Because there are no reference values for the Brazilian population, we used the median of the serum selenium level of the controls as the cut-off point. At 30 and 60 days of antituberculosis treatment, we repeated the biochemical tests, as well as collecting sputum for smear microscopy and culture from the patients. Results: The mean age of the patients was 38.4  11.4 years. Of the 35 patients, 25 (71%) described themselves as alcoholic; 20 (57.0%) were smokers; and 21 (60.0%) and 32 (91.4%) presented with muscle mass depletion as determined by measuring the triceps skinfold thickness and arm muscle area, respectively. Of 24 patients, 12 (39.2%) were classified as moderately or severely emaciated, and 15 (62.5%) had lost > 10% of their body weight by six months before diagnosis. At baseline, the tuberculosis group had lower serum selenium levels than did the control group. The conversion of bacteriological tests was associated with the CRP/albumin ratio and serum selenium levels 60 days after treatment initiation. Conclusions: Higher serum selenium levels after 60 days of treatment were associated with the conversion of bacteriological tests in pulmonary tuberculosis patients.

Keywords: Selenium; Nutritional status; Tuberculosis; Immunity.

Objective: To evaluate the radiological presentation of patients with pulmonary tuberculosis diagnosed in the emergency department and to investigate its association with the time to diagnosis. Methods: This was a prospective observational study involving patients diagnosed with pulmonary tuberculosis in the emergency department of a tertiary university hospital in southern Brazil. Chest X-rays taken on admission were evaluated by a radiologist. The various patterns of radiological findings and locations of the lesions were described. The main study outcome was the total time elapsed between the initial radiological examination and the diagnosis of tuberculosis. Results: A total of 78 patients were included in the study. The median time from chest X-ray to diagnosis was 2 days, early and delayed diagnosis being defined as a time to diagnosis < 2 days and ≥ 2 days, respectively. Sputum smear positivity was associated with early diagnosis (p = 0.005), and positive culture was associated with delayed diagnosis (p = 0.005). Early diagnosis was associated with the presence of sputum (p = 0.03), weight loss (p = 0.047), cavitation (p = 0.001), and consolidation (p = 0.003). Pulmonary cavitation was found to be an independent predictor of early diagnosis (OR = 3.50; p = 0.028). Conclusions: There is a need for tuberculosis-specific protocols in emergency departments, not only to avoid delays in diagnosis and treatment but also to modify the transmission dynamics of the disease.

Keywords: Tuberculosis/diagnosis; Emergency medical services; Radiography, thoracic.

Objective: To analyze the bidirectional association between wheezing and obesity during adolescence and the beginning of adulthood in a cohort in southern Brazil. Methods: This prospective longitudinal study used data from the 1993 birth cohort in Pelotas, Brazil. The following outcome variables were measured at 22 years of age: self-reported wheezing during the last 12 months and obesity (BMI = 30 kg/m2). The following exposure variables were measured at ages 11, 15, and 18: self-reported wheezing (no wheezing or symptom presentation in 1, 2, or 3 follow-ups) and obesity (non-obese or obese in 1, 2, or 3 follow-ups). Crude and adjusted logistical regression stratified by sex were used in the analyses. The reference category was defined as participants who presented no wheezing or obesity. Results: A total of 3,461 participants had data on wheezing and 3,383 on BMI. At 22 years of age, the prevalence of wheezing was 10.1% (95%CI: 9.1; 11.2), and obesity, 16.2% (95%CI: 15.0; 17.6). In females, the presence of wheezing in two follow-ups revealed a 2.22-fold (95%CI: 1.36; 3.61) greater chance of developing obesity at 22 years of age. Meanwhile, the presence of obesity in two follow-ups resulted in a 2.03-fold (95%IC: 1.05; 3.92) greater chance of wheezing at 22 years of age. No associations were found between wheezing and obesity in males. Conclusions: The obtained data suggest a possible positive bidirectional association between wheezing and obesity, with greater odds ratios in the wheezing to obesity direction in females and in the category of occurrence of exposure in two follow-ups.

Keywords: Asthma, BMI, Respiratory Sounds, Wheezing, Body Weight.

Objective: To describe orofacial muscle function in patients with severe asthma. Methods: This was a descriptive study comparing patients with severe controlled asthma (SCA) and severe uncontrolled asthma (SUA). We selected 160 patients, who completed a sociodemographic questionnaire and the 6-item Asthma Control Questionnaire (ACQ-6), as well as undergoing evaluation of orofacial muscle function. Results: Of the 160 patients evaluated, 126 (78.8%) and 34 (21.2%) presented with SCA and SUA, respectively, as defined by the Global Initiative for Asthma criteria. Regardless of the level of asthma control, the most frequent changes found after evaluation of muscle function were difficulty in chewing, oronasal breathing pattern, below-average or poor dental arch condition, and difficulty in swallowing. When the sample was stratified by FEV1 (% of predicted), was significantly higher proportions of SUA group patients, compared with SCA group patients, showed habitual open-mouth chewing (24.8% vs. 7.7%; p < 0.02), difficulty in swallowing water (33.7% vs. 17.3%; p < 0.04), and voice problems (81.2% vs. 51.9%; p < 0.01). When the sample was stratified by ACQ-6 score, the proportion of patients showing difficulty in swallowing bread was significantly higher in the SUA group than in the SCA group (66.6% vs. 26.6%; p < 0.01). Conclusions: The prevalence of changes in the stomatognathic system appears to be high among adults with severe asthma, regardless of the level of asthma control. We found that some such changes were significantly more common in patients with SUA than in those with SCA.

Keywords: Speech/physiology; Stomatognathic system/physiopathology; Asthma/complications; Deglutition disorders; Mastication/physiology.

Objective: To analyze the association between paracoccidioidomycosis (Pcm) and cancer in a series of 25 cases and to review the literature on this topic. Methods: A retrospective review of 25 cases diagnosed with Pcm and cancer, retrieved from a series of 808 consecutive adult patients diagnosed with Pcm based on tests conducted in the Mycology Laboratory of the Santa Casa Complexo Hospitalar, in the city of Porto Alegre, Brazil, between 1972 and 2007. The diagnosis of Pcm was confirmed by means of direct microscopic examination, histopathological examination or immunodiffusion test. All cancer cases were confirmed by histopathological or cytopathological examination. Results: Respiratory symptoms were the principal complaints of the patients evaluated. Pulmonary involvement predominated, followed by skin and lymph node involvement. The most prevalent tumor was bronchial carcinoma, in 15 patients, followed by other types of carcinoma, and 1 patient had Hodgkin's lymphoma. In 16 patients (64%), the site of the Pcm was the same as that of the tumor. In most cases, Pcm treatment consisted of the isolated administration of sulfanilamide, sulfamethoxazole-trimethoprim, ketoconazole, itraconazole or amphotericin B. The most common treatment for cancer was surgery, followed by radiotherapy and chemotherapy. Of the 25 patients, 12 were cured of Pcm, and 4 died. In 9 patients, the final outcome was unknown. In the general population of the area under study, the prevalence of lung cancer was significantly higher in smokers with Pcm than in smokers without Pcm (p < 0.001). Conclusions: A diagnosis of Pcm appears to increase the risk of lung cancer.

Keywords: Paracoccidioides; Paracoccidioidomycosis; Neoplasms.