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 quantify the use of health care resources among patients enrolled in the Bahia State Asthma and Allergic Rhinitis Control Program. Methods: As of January of 2006, 1405 patients had enrolled in the program, which is carried out in four referral centers in the city of Salvador. These patients formed the basis of this retrospective/prospective, observational cohort study. The preliminary analysis involved 269 consecutive patients, all above the age of 12 and diagnosed with severe asthma. After being seen by pulmonologists, nurses, pharmacologists and psychologists, the patients received inhaled asthma medications. Based on patient interviews and charts, the year preceding enrollment in the program was compared with the first year enrolled in the program in terms of the following quantifiable parameters: hospital admissions; emergency room visits; courses of oral corticosteroids; and days of school/work missed due to asthma attacks. Results: In this sample of patients with severe asthma, enrollment in the program resulted in significant reductions in the number of emergency room visits and hospital admissions (of 85% and 90%, respectively). There were also reductions in the number of school/work days missed due to asthma attacks and in the number of courses of oral corticosteroids (of 86% and 67%, respectively). Conclusion: A program designed to control severe asthma in referral outpatient clinics and including pharmacological services at no charge can lead to a pronounced reduction in the demand for Unified Health Care System resources.

Keywords: Asthma/therapy; Asthma/prevention  control; Hospitalization; National Health System (BR)

Objective: To describe the prevalences of asthma and rhinitis in adolescents (13-14 years of age) in the city of Fortaleza, Brazil, in 2010, comparing the results with those obtained in a prevalence survey conducted in 2006-2007. Methods: This was a cross-sectional study involving probabilistic samples of 3,015 and 3,020 adolescents in surveys conducted in 2006-2007 and 2010, respectively. The International Study of Asthma and Allergies in Childhood protocol was used on both occasions. Results: Comparing the two periods, there were no significant differences regarding cumulative wheezing, active asthma, four or more wheezing attacks within the last year, sleep disturbed by wheezing more than one night per week, and speech-limiting wheezing. The prevalences of exercise-induced wheezing, dry cough at night, and physician-diagnosed asthma were significantly higher in 2010 than in the 2006-2007 period (p < 0.01 for all). The prevalence of physician-diagnosed rhinitis was significantly lower in 2010 (p = 0.01), whereas there were no significant differences between the two periods regarding cumulative rhinitis, current rhinitis, and rhinoconjunctivitis. In both periods, dry cough at night, current rhinitis, and rhinoconjunctivitis were significantly more prevalent in females than in males (p < 0.01 for all). Also in both periods, active asthma, current rhinitis, and rhinoconjunctivitis were more prevalent in private school students than in public school students (p < 0.01 for all). Conclusions: Our data show that the prevalences of asthma and rhinitis symptoms remain high among 13- and 14-year-olds in Fortaleza, predominantly among females and private school students.

Keywords: Asthma/epidemiology; Rhinitis/epidemiology; Adolescent.

Objective: Studies assessing the characteristics and management of patients hospitalized with asthma have been limited to a small number of facilities and have evaluated short time periods. The present study evaluated long-term changes among hospitalized asthma patients at a large number of facilities. Methods: This was a retrospective, hospital-based observational case series, designated the Study of Severe Asthma in Latin America and Spain, which was conducted in Spain and in eight Latin-American countries. We reviewed the hospital records of 3,038 patients (age range, 15-69 years) hospitalized with acute severe asthma at one of nineteen tertiary-care hospitals in 1994, 1999 and 2004. Results: Over time, the use of inhaled corticosteroids and long-acting β2 agonists increased significantly, whereas the use of theophylline as a controller medication decreased. The utilization of pulmonary function tests also increased. There was a significant reduction in the mean hospital stay (8.5 days, 7.4 days and 7.1 days in 1994, 1999 and 2004, respectively, p = 0.0001) and a significant increase in the mean of the lowest arterial pH at hospital admission. In contrast, there was a significant decrease in the proportion of cases in which PEF was determined in the emergency room (48.6% in 1994 vs. 43.5% in 2004, p = 0.0001). We found the quality of asthma management and care to be generally better in Spain than in Latin America. Conclusions: Although there have been certain improvements in the management of asthma between severe exacerbations and during hospitalization, asthma management remains suboptimal in Spain and, especially, in Latin America.

Keywords: Status asthmaticus; Asthma/therapy; Hospitalization.

Objective: Wood smoke exposure is a risk factor for COPD. For a given degree of airway obstruction, the reduction in DLCO is smaller in individuals with wood smoke-related COPD than in those with smoking-related COPD, suggesting that there is less emphysema in the former. The objective of this study was to compare HRCT findings between women with wood smoke-related COPD and women with smoking-related COPD. Methods:áTwenty-two women with severe COPD (FEV1/FVC ratio < 70% and FEV1 < 50%) were divided into two groups: those with wood smoke-related COPD (n = 12) and those with smoking-related COPD (n = 10). The two groups were compared regarding emphysema scores and airway involvement (as determined by HRCT); and functional abnormalities-spirometry results, DLCO, alveolar volume (VA), the DLCO/VA ratio, lung volumes, and specific airway resistance (sRaw). Results: There were no significant differences between the two groups in terms of FEV1, sRaw, or lung hyperinflation. Decreases in DLCO and in the DLCO/VA ratio were greater in the smoking-related COPD group subjects, who also had higher emphysema scores, in comparison with the wood smoke-related COPD group subjects. In the wood smoke-related COPD group, HRCT scans showed no significant emphysema, the main findings being peribronchial thickening, bronchial dilation, and subsegmental atelectasis. Conclusions: Female patients with severe wood smoke-related COPD do not appear to develop emphysema, although they do show severe airway involvement. The reduction in DLCO and VA, with a normal DLCO/VA ratio, is probably due to severe bronchial obstruction and incomplete mixing of inspired gas during the determination of single-breath DLCO.

The tumor-node-metastasis (TNM) staging system for lung cancer has been modified since its first edition in the late 1960s. Its seventh edition has been recently published and, for the first time, a truly worldwide database was analyzed in order to propose modifications in the staging. Significant changes have been made in the tumor and metastasis descriptors. Although the recommendations for the node descriptor have remained unchanged, the analysis of the factors related to this descriptor suggests that modifications will be made in the future. The forthcoming revisions of the TNM staging system might take the molecular aspects of lung cancer into consideration, aiming at a more refined staging system.

Keywords: Lung neoplasms; Neoplasm staging; Epidemiologic methods.

Tobacco use is the leading preventable cause of death in most countries, including Brazil. Smoking cessation is an important strategy for reducing the morbidity and mortality associated with tobacco-related diseases. An inverse relationship between nicotine use and body weight has been reported, in which body weight tends to be lower among smokers than among nonsmokers. Smoking abstinence results in an increase in body weight for both males and females. On average, sustained quitters gain from 5 to 6 kg, although approximately 10% gain more than 10 kg. Pharmacological treatment for smoking cessation attenuates weight gain. The importance of smoking cessation as a contributing cause of the current obesity epidemic has been little studied. In the USA, the rate of obesity attributable to smoking cessation has been estimated at approximately 6.0% and 3.2% for males and females, respectively. Although the mechanisms are unclear, there is evidence that dopamine and serotonin are appetite suppressants. The administration of nicotine, regardless of the delivery system, acutely raises the levels of these neurotransmitters in the brain, reducing the need for energy intake and consequently suppressing appetite. In addition, nicotine has a direct effect on adipose tissue metabolism, influencing the rate of weight gain following smoking cessation. Leptin, ghrelin and neuropeptide Y are substances that might constitute factors involved in the inverse relationship between nicotine and body mass index, although their roles as determinants or consequences of this relationship have yet to be determined.

Keywords: Smoking; Body weight changes; Nicotine; Body mass index; Leptin; Peptide hormones/ghrelin.

Advances in the understanding that severe asthma is a complex and heterogeneous disease and in the knowledge of the pathophysiology of asthma, with the identification of different phenotypes and endotypes, have allowed new approaches for the diagnosis and characterization of the disease and have resulted in relevant changes in pharmacological management. In this context, the definition of severe asthma has been established, being differentiated from difficult-to-control asthma. These recommendations address this topic and review advances in phenotyping, use of biomarkers, and new treatments for severe asthma. Emphasis is given to topics regarding personalized management of the patient and selection of biologicals, as well as the importance of evaluating the response to treatment. These recommendations apply to adults and children with severe asthma and are targeted at physicians involved in asthma treatment. A panel of 17 Brazilian pulmonologists was invited to review recent evidence on the diagnosis and management of severe asthma, adapting it to the Brazilian reality. Each of the experts was responsible for reviewing a topic or question relevant to the topic. In a second phase, four experts discussed and structured the texts produced, and, in the last phase, all experts reviewed and approved the present manuscript and its recommendations.

Keywords: Asthma/therapy; Asthma/drug therapy; Asthma/prevention & control; Antibodies, monoclonal, humanized.

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.

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: The translation and cross-cultural adaptation of a specific scoring instrument for the comprehensive control of asthma, the Asthma Control Scoring System (ACSS), for use in Brazil. Methods: The protocol included ten steps: acquisition of written permission from the author of the ACSS; translation of the instrument to Brazilian Portuguese, carried out by three separate translators; analysis and comparison of the three versions by a review committee; literal back-translation to English; review and harmonization of the back-translation; acquisition of the approval of the original author; review of the translation by specialists; cognitive debriefing: test of clarity to, understanding by, and acceptance of the target population (evaluation of the translation by 10 health care workers); second cognitive debriefing: review of the revised version by a second group of health care workers; and reconciliation and preparation of the final version by the review committee. Results: The Brazilian Portuguese-language version of the ACSS showed clarity, understandability, and acceptability. The instrument was considered to be comprehensive because it includes the clinical manifestations of asthma, as well as the functional and inflammatory aspects of the disease. Conclusions: With the use of this careful methodology in the translation and cross-cultural adaptation of the ACSS, we have ensured its cultural adequacy for Brazil. The use of this instrument could facilitate future studies on asthma control.

Keywords: Asthma/classification; Asthma/prevention & control; Questionnaires.

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 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 present a locally developed system of computer vision for use with HRCT images, designated SIStema para a Detecção e a quantificação de Enfisema Pulmonar (SISDEP, System to Detect and Quantify Pulmonary Emphysema), and to compare this system with a freeware system tool. Methods: Thirty-three HRCT images scanned at the apex, hilum and base of the lungs of 11 patients with COPD were analyzed. The SISDEP was compared with the Osiris Medical Imaging Software Program regarding lung parenchyma segmentation, precision of the measurement of the cross-sectional area of the lungs in mm2, mean lung density (MLD), relative area (RA) of the lung occupied by voxels with attenuation values < −950 Hounsfield units (RA −950), 15th percentile point (Perc15) and visualization of hyperinflated areas using a color mask. Results: Although both computational systems were efficient in segmenting the lungs, the SISDEP performed this task automatically and more rapidly. There were significant correlations between the two systems in terms of the results obtained for lung cross-sectional area, MLD, RA −950 and Perc15 (r2 = 0.99, 0.99, 0.99 and 1.00, respectively). The color mask tool of the SISDEP allowed excellent visualization of hyperinflated areas, discriminating them from normal areas. Conclusions: The SISDEP was efficient in segmenting the lungs and quantifying lung hyperinflation, presenting an excellent correlation with the Osiris system. The SISDEP constitutes a promising computational tool for diagnosing and assessing the progression of emphysema in HRCT images of COPD patients.

Keywords: Pulmonary disease, chronic obstructive; Emphysema; Tomography, X-ray computed; Decision making, computer-assisted.

Objective: To determine whether polymorphisms of the IL10 and IL17 genes are associated with severe asthma control and bronchodilator reversibility in children and adolescents with severe asthma. Methods: This was a cross-sectional study, nested within a prospective cohort study of patients with severe asthma. Two outcomes were evaluated: asthma control and bronchodilator reversibility. We extracted DNA from peripheral blood and genotyped three single nucleotide polymorphisms: rs3819024 and rs2275913 in the IL17A gene; and rs3024498 in the IL10 gene. For the association analyses, we performed logistic regression in three genetic models (allelic, additive, and dominant). Results: The rs3024498 C allele in the IL10 gene was associated with failure to achieve asthma control despite regular treatment (p = 0.02). However, the G allele of the IL17A rs3819024 polymorphism was associated with failure to respond to stimulation with a ß2 agonist. The rs2275913 polymorphism of the IL17A gene showed no relationship with asthma control or bronchodilator reversibility. Conclusions: In pediatric patients with severe asthma, the IL10 polymorphism appears to be associated with failure to achieve clinical control, whereas the IL17A polymorphism appears to be associated with a worse bronchodilator response. Knowledge of the involvement of these polymorphisms opens future directions for pharmacogenetic studies and for the implementation of individualized therapeutic management of severe asthma in pediatric patients.

Keywords: Polymorphism, genetic; Interleukin-10; Interleukin-17; Asthma.

Objective: To analyze the role that low income plays in the development of asthma in children and adolescents. Methods: A case-control study using a questionnaire. Results: A total of 687 participants were studied at a tertiary hospital via the Brazilian Unified Health System. Ages ranged from 5 to 15 years, and 54.7% of the participants were male. Nearly half of the individuals (49.1%) lived in the metropolitan area of the city of Recife, and the remainder lived in the countryside. Most (98.1%) lived in concrete houses or apartments, with a mean of 5.7 rooms and 4.8 occupants per residence. Mean maternal level of education was 6.8 years of schooling. The median monthly per capita income was R$ 103.75 (Brazilian reals). The sample was stratified according to cut-off points related to the national minimum wage (R$ 350.00): <25% of minimum wage = very low income (39% of the sample); <50% of minimum wage = low income (37.3% of the sample); and ≥50% of minimum wage = satisfactory income (23.7% of the sample). There was no association between poverty and development of asthma. Conclusions: Poverty is not protective against asthma in children and adolescents treated via the Brazilian Unified Health System, as we might suppose based on the hygiene hypothesis. However, cohort studies are needed in order to confirm these findings.

Keywords: Asthma; Poverty; National health programs/Brazil; Child; Adolescent; Case-control studies.

Objective: To evaluate the association between nutritional status measurements and pulmonary function in children and adolescents with cystic fibrosis. Methods: We evaluated the nutritional status of 48 children and adolescents (aged 6-18 years) with cystic fibrosis based on body mass index (BMI) and body composition measurements-mid-arm muscle circumference (MAMC) and triceps skinfold thickness (TST)-at a referral center in the city of Rio de Janeiro, Brazil. Pulmonary function was assessed by means of spirometry, using FEV1 to classify the severity of airway obstruction. We used Student's t-tests for comparisons between proportions and linear regression analysis for associations between continuous variables. The level of significance was set at p < 0.05. Results: The evaluation of nutritional status based on BMI identified a smaller number of malnourished patients than did that based on MAMC (14 vs. 25 patients, respectively). Most of the patients presented mild pulmonary disease. Mean FEV1 was 82.5% of predicted. Pulmonary function was found to correlate significantly with BMI, MAMC and TST (p = 0.001, p = 0.001 and p = 0.03, respectively). All subjects with moderate or severe pulmonary involvement were considered malnourished based on BMI and body composition parameters. Of the 25 patients considered malnourished based on body composition (MAMC), 19 were considered well-nourished based on their BMI. Conclusions: In the present study, all nutritional status measurements correlated directly with the pulmonary function of children and adolescents with cystic fibrosis. However, body composition measurements allowed earlier detection of nutritional deficiencies.

Keywords: Cystic fibrosis; Body composition; Spirometry; Nutrition assessment.

Objective: To determine whether the level of physical activity in daily life (PADL) is associated with pulmonary function in adult smokers. Methods: We selected 62 adult smokers from among the participants of an epidemiological study conducted in the city of Santos, Brazil. The subjects underwent forced spirometry for pulmonary function assessment. The level of PADL was assessed by the International Physical Activity Questionnaire and triaxial accelerometry, the device being used for seven days. The minimum level of PADL, in terms of quantity and intensity, was defined as 150 min/week of moderate to vigorous physical activity. Correlations between the studied variables were tested with Pearson's or Spearman's correlation coefficient, depending on the distribution of the variables. We used linear multiple regression in order to analyze the influence of PADL on the spirometric variables. The level of significance was set at 5%. Results: Evaluating all predictors, corrected for confounding factors, and using pulmonary function data as outcome variables, we found no significant associations between physical inactivity, as determined by accelerometry, and spirometric indices. The values for FVC were lower among the participants with arterial hypertension, and FEV1/FVC ratios were lower among those with diabetes mellitus. Obese participants and those with dyslipidemia presented with lower values for FVC and FEV1. Conclusions: Our results suggest that there is no consistent association between physical inactivity and pulmonary function in adult smokers. Smoking history should be given special attention in COPD prevention strategies, as should cardiovascular and metabolic comorbidities.

Keywords: Smoking; Respiratory function tests; Motor activity; Accelerometry.

Objective: To evaluate the association between adherence to treatment and mortality among Chronic Obstructive Pulmonary Disease (COPD) patients treated in the Brazilian public health system. Methods: This is cohort study of moderate-to-severe COPD patients monitored in a public pharmaceutical care-based Disease Management Program (DMP). All subjects who died one year after the beginning of the cohort were age-matched with those who remained alive at the end of the cohort period. Treatment adherence was measured through pharmacy records. Patients who received at least 90% of the prescribed doses were considered adherent to treatment. Results: Of the 333 patients (52.8% age = 65 years, 67.9% male), 67.3% were adherent to treatment (adherence rate, 87.2%). Mortality was associated with lack of adherence (p = 0.04), presence of symptoms (mMRC = 2) and COPD treatment use. The death was associated with non-adherence, presence of symptoms and previous hospitalization. After adjustment, non-adherent patients to treatment were almost twice times likely to die compared to those adherents (Hazard Ratio (HR) 1.86; CI 1.16-2.98, p = 0.01). Conclusion: Non-adherence to treatment was associated with higher mortality among moderate-to-severe COPD patients treated in the Brazilian public health system. Strategies to monitor and optimize adherence should be strengthened to reduce COPD-related mortality.

Keywords: COPD; Treatment adherence; Mortality; Pharmaceutical care.