Palliative care was initially developed for patients with advanced cancer. The concept has evolved and now encompasses any life-threatening chronic disease. Studies carried out to compare end-of-life symptoms have shown that although symptoms such as pain and dyspnea are as prevalent in patients with lung disease as in patients with cancer, the former receive less palliative treatment than do the latter. There is a need to refute the idea that palliative care should be adopted only when curative treatment is no longer possible. Palliative care should be provided in conjunction with curative treatment at the time of diagnosis, by means of a joint decision-making process; that is, the patient and the physician should work together to plan the therapy, seeking to improve quality of life while reducing physical, psychological, and spiritual suffering.

Keywords: Palliative care; Pulmonary medicine; Quality of life.

Background: A residency in Pulmonary Medicine represents the best source of training for those who wish to specialize in the area. In Brazil, the Comissão Nacional de Residência Médica (National Committee of Medical Residency) regulates such programs. Objective: To analyze the number of programs and their levels state of accreditation, the number of residents and the distribution of these programs and residents among the various institutions throughout Brazil. Methods: The list of programs furnished by the National Committee of Medical Residency in April 2003 was analyzed, and the basic criteria for accreditation in the area (according to the legislation currently in effect) were reviewed. Results: Of the 58 accredited programs, 35 are offered in hospitals in the southeastern region of Brazil, and 133 of the residents are also there. In contrast, there is only 1 accredited program, and there are only 3 residents enrolled in that program. Conclusion: Although all 58 programs are accredited, most are clustered in the southeastern region. It is therefore necessary that the Comissão Nacional de Residência Médica and the Sociedade Brasileira de Pneumologia e Tisiologia (Brazilian Society of Pulmonology and Phthisiology) begin a joint project in order to manage the creation of new programs. Thus, the number of programs and residents required for each of the various regions could be determined.

Keywords: Residency/Medical, Pulmonary Disease (Specialty), Internship and Residency

Objectives: Evaluate the results of the Brazilian Society of Tisiology and Pulmonary Medicine Board Examination and verify the factors related to acceptance. Planning: Retrospective analysis comparing scores obtained in practical and written examinations and acceptance to gender, years since graduation, years of pulmonary medicine practice, regional and national meetings attendance, place, and duration, as well as having or not attended residence or training programs. Population: Between 1992 and 1996, 199 candidates - 81 females and 108 males - took the board examination. Results: In this period, 54.3% of the candidates were approved. Mean written score was 6.27 ± 0.95 for the approved candidates and 4.30 ± 0.76 for those who were not approved (p = 0.0001, t test). Mean practical score was 7.18 ± 0.92 versus 5.17 ± 1.38 (p = 0.001). The overall mean of the written score was significantly lower than that of the practical score (53.78 ± 13.16 x 62.62 ± 15.32, p < 0.001). Univariate analysis showed that the approved group had fewer years since graduation (p = 0.001), fewer years of pulmonary medicine practice (p = 0.01); lower training attendance for a shorter period (p = 0.01), and a higher frequency of residence attendance for a longer period (p < 0.001) in the approved group. Logistic regression showed that residence (p = 0.002) and place of residence (p = 0.006) were the only predictive factors for approval. Multiple linear regression showed that only residence (coefficient 2.26, p = 0.016), place of residence (4.43, p = 0.002), and training (-1.97, p = 0.047) predicted the overall board score. Conclusion: The efficacy of the board exmination is hereby proven, since it accepts candidates with better medical background (residence). Some medical education methods, such as years of practice, meeting and training attendance need to be revised, since they do not determine approval.

Keywords: Medical education. Residence. Board certificate.

Background: The Hospital Ferreira Machado, utilized, in part, as a clinical training center for graduate students from the Faculdade de Medicina de Campos, admitted 65 tuberculosis (TB) patients in 2001. Objective: To estimate the prevalence of positive tuberculin skin tests (TST) among medical students during distinct periods of their training and to identify and analyze correlated factors. To compare positivity rates, taking into account the booster effect, and estimate incidence of positive TST by class year. Methods: A cross-sectional study was conducted among 500 students registered in the first semester of 2002. Using a structured and validated questionnaire, data regarding demographics, BCG vaccination and potential exposure to TB patients were obtained. A professional licensed by the Health Department administered the TSTs, and the twostep Mantoux method (PPD Rt23) was used. Results: Of the 500 eligible subjects, 316 (63.2%) were excluded. Analysis showed increasing two-step TST positivity rates corresponding to extent of clinical experience (4%, 6.4% and 13.1%) and a tendency toward correlation with professional level. The highest percentage of positive TSTs was found during the period of clinical training, which corresponded to the time of greatest exposure to patients (1000 hours). Conclusions: a) the TST positivity rate was high (7.9%) among students; b) TST was correlated with in-hospital training stage; c) evaluation of the booster effect lead us to highly recommended boosters in order to reduce the number of false-negative TST results.

Keywords: Tuberculin. Tuberculin test. Tuberculosis. Students/Medical. Cross-sectional studies.

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 describe the performance of a pulmonologist-led lung cancer screening pro-gram using low dose CT (LDCT) in a cohort of outpatients with stable respiratory diseases in the Brazilian public health care system. Methods: This was a retrospective analysis of the first two rounds of lung cancer screening of patients enrolled in the program. Inclusion criteria were being between 55 and 80 years of age, being a current or former smoker (smoking cessation = 15 years), and having a smoking history = 30 pack-years. LDCT results were interpreted in accordance with the Lung CT Screening Reporting and Data System, and those with a score of 3 or 4 were considered posi-tive screening. Incidental pleuropulmonary findings were sought in all reports. Results: LDCTs were requested for 791 patients during the study period, and 712 patients (90%) met the screening criteria. The mean patient age was 63 years, and most participants were current smokers (56%) with emphysema (78.5%) and other pleuropulmonary findings on CT (64%). Screening was positive in 14.0% and 5.6% of the cases in the first and second screening rounds, respectively. Lung cancer was detected in 1.5% of the patients in both first and second rounds (positive predictive value: 11.0% and 26.6%, respectively). The rate of early-stage (TNM I or II) screen-detected non-small cell carcinoma was 64.3%. Of the patients with positive screening, 19% were lost to follow-up before investigation was complete. Conclusions: The results of this screening program suggest its adequate performance in a cohort of patients with significant respiratory morbidity. The loss to follow-up rate highlights the need for constant monitoring and interventions to ensure adherence.

Keywords: Lung neoplasms; Diagnostic screening programs; Early detection of cancer; Brazil; Tuberculosis.

Poor sleep quality is a consistently reported by patients in the ICU. In such a potentially hostile environment, sleep is extremely fragmented and sleep architecture is unconventional, with a predominance of superficial sleep stages and a limited amount of time spent in the restorative stages. Among the causes of sleep disruption in the ICU are factors intrinsic to the patients and the acute nature of their condition, as well as factors related to the ICU environment and the treatments administered, such as mechanical ventilation and drug therapy. Although the consequences of poor sleep quality for the recovery of ICU patients remain unknown, it seems to influence the immune, metabolic, cardiovascular, respiratory, and neurological systems. There is evidence that multifaceted interventions focused on minimizing nocturnal sleep disruptions improve sleep quality in ICU patients. In this article, we review the literature regarding normal sleep and sleep in the ICU. We also analyze sleep assessment methods; the causes of poor sleep quality and its potential implications for the recovery process of critically ill patients; and strategies for sleep promotion.

Keywords: Sleep; Sleep deprivation; Intensive care units.

Objective: To assess the diagnostic performance of the Xpert MTB/RIF assay, a rapid molecular test for tuberculosis, comparing it with that of AFB staining and culture, in BAL fluid (BALF) samples from patients with clinically suspected pulmonary tuberculosis (PTB) who are sputum smear-negative or produce sputum samples of insufficient quantity. Methods: This was a retrospective study of 140 cases of suspected PTB in patients who were smear-negative or produced insufficient sputum samples and were evaluated at a tertiary teaching hospital in the city of Rio de Janeiro, Brazil. All of the patients underwent fiberoptic bronchoscopy with BAL. The BALF specimens were evaluated by AFB staining, mycobacterial culture, and the Xpert MTB/RIF assay. Results: Among the 140 patients, results for all three microbiological examinations were available for 73 (52.1%), of whom 22 tested positive on culture, 17 tested positive on AFB staining, and 20 tested positive on the Xpert MTB/RIF assay. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy for AFB staining were 68.1%, 96.1%, 88.2%, 87.5%, and 87.6%, respectively, compared with 81.8%, 96.1%, 90.0%, 92.4%, and 91.8%, respectively, for the Xpert MTB/RIF assay. The agreement between AFB staining and culture was 82.3% (kappa = 0.46; p < 0.0001), whereas that between the Xpert MTB/RIF assay and culture was 91.8% (kappa = 0.8; p < 0.0001). Conclusions: In BALF samples, the Xpert MTB/RIF assay performs better than do traditional methods, providing a reliable alternative to sputum analysis in suspected cases of PTB. However, the rate of discordant results merits careful consideration.

Keywords: Tuberculosis; Molecular diagnostic techniques; Bronchoscopy; Bronchoalveolar lavage fluid; Mycobacterium tuberculosis.

Objective: To estimate the rates of recurrence, cure, and treatment abandonment in patients with pulmonary tuberculosis treated with a four-drug fixed-dose combination (FDC) regimen, as well as to evaluate possible associated factors. Methods: This was a retrospective observational study involving 208 patients with a confirmed diagnosis of pulmonary tuberculosis enrolled in the Hospital Tuberculosis Control Program at the Institute for Thoracic Diseases, located in the city of Rio de Janeiro, Brazil. Between January of 2007 and October of 2010, the patients were treated with the rifampin-isoniazid-pyrazinamide (RHZ) regimen, whereas, between November of 2010 and June of 2013, the patients were treated with the rifampin-isoniazid-pyrazinamide-ethambutol FDC (RHZE/FDC) regimen. Data regarding tuberculosis recurrence and mortality in the patients studied were retrieved from the Brazilian Case Registry Database and the Brazilian Mortality Database, respectively. The follow-up period comprised two years after treatment completion. Results: The rates of cure, treatment abandonment, and death were 90.4%, 4.8%, and 4.8%, respectively. There were 7 cases of recurrence during the follow-up period. No significant differences in the recurrence rate were found between the RHZ and RHZE/FDC regimen groups (p = 0.13). We identified no factors associated with the occurrence of recurrence; nor were there any statistically significant differences between the treatment groups regarding adverse effects or rates of cure, treatment abandonment, or death. Conclusions: The adoption of the RHZE/FDC regimen produced no statistically significant differences in the rates of recurrence, cure, or treatment abandonment; nor did it have any effect on the occurrence of adverse effects, in comparison with the use of the RHZ regimen.

Keywords: Tuberculosis, pulmonary, Drug combinations; Recurrence.

Objective: To determine the incidence of active tuberculosis (TB) in a cohort of health care workers (HCWs). Methods: Descriptive study of active TB cases identified in an occupational health screening of 6,112 HCWs between 2005 and 2010. Cases of active TB were defined as those in which Mycobacterium tuberculosis was identified by direct microscopy or culture; those in which there were symptoms or clinical signs of TB and necrotizing granuloma, as detected by histology; and those in which the radiological findings were consistent with active TB. Results: Among the 6,112 HCWs evaluated, we identified 62 cases of active TB: pulmonary TB (n = 43); pleural TB (n = 15); lymph node TB (n = 2); pericardial TB (n = 1); and cutaneous TB (n = 1). Seven HCWs were asymptomatic at the time of diagnosis. Of the 62 cases of active TB, 48 developed within the first 10 years of occupational exposure in the workplace, 36 of those occurring within the first 5 years. Physicians and nurses accounted for the highest numbers of cases (22 and 21, respectively). Conclusions: In HCWs employed in Portugal, the TB burden is high. Physicians and nurses are the HCWs who are at the highest risk of developing active TB. We found the risk of developing this disease to be highest in the first years of exposure, as has been reported in previous studies. In high-incidence countries, TB screening of HCWs is important for controlling the transmission of this disease.

Keywords: Tuberculosis/diagnosis; Occupational health; Health personnel.

Objectives: To identify the degree of risk and the practice of prophylaxis to venous thromboembolism (VTE) in an intensive care unit (ICU). Methods: The subjects were patients admitted to the ICU between December 1997 and February 1998. Patients were excluded if they were in anticoagulant therapy or presented contra-indication to heparin. Determination of risk factors and classification of the degree of risk for VTE were done according to international consensus. The ICU medical staff did not know about the study. Results: The authors evaluated one hundred and eighty patients with a mean age of 58 years (±16.5). Risk factors more frequently found were: age ³ 40 years (85.0%), surgery (47.8%), thoracic or abdominal infection (22.8%). Two or more risk factors were present in 146 (81%) cases. In the evaluation of VTE risk, 142 (79%) patients were classified as moderate/high risk. Prophylactic measures were prescribed to 102 patients (57%), and heparin was used in 60% of moderate/high risk cases. There was a significant association between risk level and the number of risk factors with the use of prophylaxis (p < 0.05). Conclusion: VTE risk factors were frequent in the sample analyzed. However, 40% of patients considered moderate/high risk did not receive pharmacological prophylaxis for VTE.

Keywords: thromboembolism, prevention & control

Objective: To determine the prevalence of smoking among elderly patients admitted to long-term care facilities (LTCFs) and to determine whether the degree of nicotine dependence is associated with sociodemographic variables, affective ties, motivation for smoking cessation and depression. Methods: Cross-sectional, population-based study involving 573 individuals over the age of 60, admitted to 13 LTCFs in the Federal District of Brasília, Brazil. We analyzed the following variables: type of LTCF, gender, age, level of education, monthly income, marital status, retirement status, affective ties, probable depression, motivation for smoking cessation and degree of nicotine dependence. In order to collect these data, the following instruments were used: a sociodemographic questionnaire; the Flanagan Quality of Life Scale; the Mini-Mental State Examination; the Geriatric Depression Scale; the Richmond test; and the Fagerström Test for Nicotine Dependence. Results: The prevalence of smokers in the study sample (573 individuals) was 23.0%. Of the 132 smokers, there were 90 males (25.8%) and 42 females (18.7%). Of these, 116 smokers were included in the study, 70 of whom (60.3%) presented with probable depression. The degree of nicotine dependence was found to be significantly associated with level of education, monthly income, affective ties, motivation for smoking cessation and probable depression, although not with the type of LTCF, gender, age, retirement status or marital status. Conclusions: Among elderly patients admitted to LTCFs in the Federal District of Brasília, the prevalence of smoking is high and the motivation for smoking cessation is low.

Keywords: Smoking; Homes for the aged; Health services for the aged.

Objective: COPD is one of the major causes of morbidity and mortality worldwide. Health care providers should counsel their smoking patients with COPD to quit smoking as the first treatment step. However, in countries with high prevalences of smoking, health care workers may also be smokers. The aim of this study was to determine the frequency and severity of COPD in health care workers who smoke. Methods: This was a cross-sectional study. All health care workers who smoke, from nine health care centers in Serbia, were invited to participate in the study and perform spirometry. The diagnosis of COPD was based on a post-bronchodilator FEV1/FVC ratio of < 0.70. All patients completed the COPD Assessment Test and the Fagerström Test for Nicotine Dependence. Results: The study involved 305 subjects, and 47 (15.4%) were male. The mean age of the participants was 49.0 ± 6.5 years. Spirometry revealed obstructive ventilatory defect in 33 subjects (10.8%); restrictive ventilatory defect, in 5 (1.6%); and small airway disease, in 96 (31.5%). A diagnosis of COPD was made in 29 patients (9.5%), 25 (86.2%) of whom were newly diagnosed. On the basis of the Global Initiative for COPD guidelines, most COPD patients belonged to groups A or B (n = 14; 48.2%, for both); 1 belonged to group D (3.6%); and none, to group C. Very high nicotine dependence was more common in those with COPD than in those without it (20.7% vs. 5.4%, p = 0.01). Conclusions: In this sample of health care workers, the frequency of COPD was comparable with that in the general population. The presence of COPD in health care workers who smoke was associated with higher nicotine dependence.

Keywords: Pulmonary disease, chronic obstructive/prevention & control; Smoking; Health personnel.

Objective: To determine whether the use of a set of preoperative variables can predict the need for postoperative ICU admission. Methods: This was a prospective observational cohort study of 120 patients undergoing elective pulmonary resection between July of 2009 and April of 2012. Prediction of ICU admission was based on the presence of one or more of the following preoperative characteristics: predicted pneumonectomy; severe/very severe COPD; severe restrictive lung disease; FEV1 or DLCO predicted to be < 40% postoperatively; SpO2 on room air at rest < 90%; need for cardiac monitoring as a precautionary measure; or American Society of Anesthesiologists physical status ≥ 3. The gold standard for mandatory admission to the ICU was based on the presence of one or more of the following postoperative characteristics: maintenance of mechanical ventilation or reintubation; acute respiratory failure or need for noninvasive ventilation; hemodynamic instability or shock; intraoperative or immediate postoperative complications (clinical or surgical); or a recommendation by the anesthesiologist or surgeon to continue treatment in the ICU. Results: Among the 120 patients evaluated, 24 (20.0%) were predicted to require ICU admission, and ICU admission was considered mandatory in 16 (66.6%) of those 24. In contrast, among the 96 patients for whom ICU admission was not predicted, it was required in 14 (14.5%). The use of the criteria for predicting ICU admission showed good accuracy (81.6%), sensitivity of 53.3%, specificity of 91%, positive predictive value of 66.6%, and negative predictive value of 85.4%. Conclusions: The use of preoperative criteria for predicting the need for ICU admission after elective pulmonary resection is feasible and can reduce the number of patients staying in the ICU only for monitoring.

Keywords: Thoracic surgery; Risk factors; Intensive care units.