A case of obstructive sleep apnea syndrome (OSAS) with narcoleptic features is described; polysomnographic studies were carried out and revealed a severe nocturnal respiratory impairment due to apneic episodes. A multiple sleep latency test (MSLT) showed early REM sleep onset in two out of five series. Nasal CPAP utilization improved the quality of nocturnal sleep and reverted all narcoleptic features in the next day's MSLT.

Keywords: Obstructive sleep apnea syndrome (OSAS). Narcolepsy. Sleep deprivation. CPAP.

Objective: To determine the characteristics of individuals with asthma who are responsive to aerobic training. Methods: This post hoc analysis of pooled data from previous randomized controlled trials involved 101 individuals with moderate to severe asthma who underwent aerobic training. Participants underwent a maximal cardiopulmonary exercise test and completed the Asthma Control Questionnaire and the Asthma Quality of Life Questionnaire before and after a 24-session aerobic training program. Better and worse responders to aerobic training were identified by cluster analysis. Results: Two clusters were identified according to the improvement in peak VO2 after aerobic training (better and worse responders). Characteristics of the better responder group were being older, being female, having higher BMI, and having higher cardiac reserve at baseline when compared with the worse responder group. Also, better responders had worse clinical control, worse quality of life, and lower physical capacity at baseline. After training, worse responders, in comparison with better responders, showed half the improvement in ?peak VO2 (7.4% vs. 13.6%; 95% CI, -12.1 to -0.92%; p < 0.05) and worse asthma control. A weak, negative, but significant association (r = -0.35; p < 0.05) was observed between clinical control and aerobic fitness only in the better responder group. Both groups showed significant improvement in quality of life. Conclusions: Obese individuals with worse exercise capacity, clinical control, and quality of life showed improvement with aerobic training. Moreover, worse responders also improved with training, but to a lesser extent.

Keywords: Asthma; Exercise therapy; Cluster analysis; Status Asthmaticus; Quality of Life; Rehabilitation.

The authors present a case of a patient with Behçet's disease who complained about sudden dyspnea while performing light physical exercises, about non-productive cough, weakness, and frontal headache; he also presented significant weight loss in the last month while being treated for an alleged tuberculosis. After going through an episode of massive hemophthisis, his clinical history and physical examination were reevaluated and his new diagnosis was concluded to be Behçet's disease. Thus, the authors started treatment by giving immunosuppressive drugs and corticosteroids and, as a consequence, regression of the aneurysm was noted. In this article the authors discuss the clinical, radiological, histopathologic and therapeutic features of this syndrome.

Keywords: Behçet's disease. Pulmonary arterial aneurysms.

A total of 287 bronchoscopies were performed in 267 patients infected with the human immunodeficiency virus (HIV). Bronchoalveolar lavage (BAL) and transbronchial biopsies (TBB) were sequentially performed in the same lung, in all cases. Specimens were examined after routine laboratory procedures for microbiologic and histologic analysis. Age ranged from 16 to 78 (median 37.2); 228 were men (85.4%) and 39 were women. Dyspnea was the main symptom in 198 cases (69.0%) and interstitial infiltrates (diffuse or localized) were the most common findings at chest radiographs (179 patients, 62.4%). Endoscopic view was normal in 246 patients (85.7%). Mucosal lesions suggestive of Kaposi's sarcoma (KS) were visible in 12 cases (4.2%). BAL detected 97 infectious agents, simultaneous co-infection occurred in 3 cases. TBB identified 165 pathogens (9 of them in association), anticipating a better yield than BAL in the diagnosis of P. carinii (84 versus 51, respectively) and cytomegalovirus (35 v. 0). Biopsies were unique in establishing the appropriate diagnosis of extrabronchial cancer and describing inespecific pneumonitis. Altogether, a definite diagnosis was obtained by bronchoscopic examination (including endoscopic view, BAL and TBB) in 271 of 287 cases (94.4%). Infections were caused by P. carinii in 105 patients (36.6%), Mycobacterium sp in 40 (13.9%), cytomegalovirus in 35 (12.2%), C. neoformans in 13 (4.5%) etc. Malignancies (including KS) were found in 16 patients (5.6%). More than one pathologic process was present in 28 (9.8%). Nonspecific pneumonitis was diagnosed in 56 cases (19.5%) and normal lung in 20 (7.0%). Complications related to bronchoscopy were pneumothorax (8 patients, 2.8%), haemorrhage (8), thoracic pain (2) and distal pneumonia (2). Chest tubes were required in 4 patients, including one fatal case (mortality rate of 0.3%). Combining BAL and TBB results increases the diagnostic yield of bronchoscopy in AIDS, with a low complication rate. If both techniques are performed, a higher number of infectious agents and more multiple causes of pulmonary disease may be identified.

Keywords: Bronchoscopy/methods. Acquired Immunodeficiency Syndrome/complications. Opportunistic infections related to AIDS/diagnosis.

The authors present a 62-year-old male patient who had pulmonary nocardiosis with poor evolution. He also presented mental confusion, septic shock and a significant leukocytosis. Poor evolution happened even when sulfamethoxazole + trimethoprim replaced by ceftriaxone + clindamycin as an antibiotic therapy were used. Diagnostic methods, epidemiology and therapy of this infection are discussed and revised. The authors emphasize the importance of an early diagnosis, isolation in culture, and antibiogram examination of Nocardia ssp samples for therapeutic adapting.

Keywords: Pneumonia. Nocardia.

Reexpansion pulmonary edema (RPE) is a rare, but frequently lethal, clinical entity. The precise pathophysiologic abnormalities associated with this disorder are still unknown: decreased surfactant levels and a pro-inflammatory status are putative mechanisms. Early diagnosis is crucial, since prognosis depends on early recognition and prompt treatment. Considering the high mortality rates related to RPE, preventive measures are still the best available strategy for patient handling. This review provides a brief overview of the pathophysiology, diagnosis, treatment, and prevention of RPE, with practical recommendations for adequate intervention.

Herein, we describe the case of a 27-year-old female presenting with paraganglioma of the anterior and middle mediastinum and bilateral pulmonary nodules. Treatment consisted of pulmonary resection by anterior bilateral thoracotomy and transverse sternotomy, in which the paraganglioma was excised with the aid of extracorporeal circulation. As neoadjuvant treatments, radiotherapy and chemotherapy were applied. Postoperative evolution was uneventful, and the patient was classified as asymptomatic after 14 months.

Keywords: Key words: Mediastinal tumor. Paraganglioma. Lung metastasis

Lung volume recruitment involves deep inflation techniques to achieve maximum insufflation capacity in patients with respiratory muscle weakness, in order to increase peak cough flow, thus helping to maintain airway patency and improve ventilation. One of these techniques is air stacking, in which a manual resuscitator is used in order to inflate the lungs. Although intrathoracic pressures can rise considerably, there have been no reports of respiratory complications due to air stacking. However, reaching maximum insufflation capacity is not recommended in patients with known structural abnormalities of the lungs or chronic obstructive airway disease. We report the case of a 72-year-old woman who had poliomyelitis as a child, developed torsion scoliosis and post-polio syndrome, and had periodic but infrequent asthma attacks. After performing air stacking for 3 years, the patient suddenly developed a pneumothorax, indicating that this technique should be used with caution or not at all in patients with a known pulmonary pathology.

Keywords: Barotrauma; Pneumothorax; Insufflation.

Objective: To translate, cross-culturally adapt to Brazilian Portuguese, and evaluate the reliability of the Telemedicine Satisfaction Questionnaire (TSQ). Methods: This cross-sectional study involved patients from the Smoking Prevention and Cessation Center (PrevFumo) who participated in at least four of the eight scheduled remote meetings with the PrevFumo psychologist in 2020, 2021, or 2022. Participants were contacted by telephone and asked to answer the 14 questions of the TSQ three times at intervals of 7 or 10 days. Results: We assessed 53 patients (73.3% women). The mean age was 49.7 ± 10.2 years. The mean smoking history was 35.32 ± 24.8 pack-years. Of the 53 patients evaluated, 30.2% had completed high school or had some higher education, and 32.1% were classified as socioeconomic class B2 (A being the highest and E being the lowest). Forty-nine (92.5%) of the patients attended all eight meetings. The TSQ with only three answer options showed high reliability, with approximately 90% agreement after three applications. Patients were satisfied with telemedicine. Conclusions: The TSQ is rapidly applied, is easy to complete, and showed high reliability in our patient sample. Patients declared that they were satisfied with their telemedicine experience.

Keywords: Telemedicine; Patient satisfaction; Surveys and questionnaires; Cross-cultural comparison; Smoking cessation.

Behçet's disease is a systemic disease with clinical manifestations, whose underlying histopathologic lesion is a non-specific vasculitis. Pulmonary artery aneurysms and, more rarely, pleuropulmonary manifestations may be found. Some reports are available in the literature about the use of immunosuppressive agents in these conditions. The authors describe a case in whom clinical remission and radiologic resolution were observed after corticosteroid and cyclophophamide therapy.

Keywords: Behçet's disease. Pulmonary artery aneurysms.

This article addresses the evolution of pleurodesis since the beginning of the 20th century and defines the characteristics of the ideal sclerosing agent. Emphasis is placed on the current tendency towards minimally invasive procedures where insertion of catheters is usually given priority over certain surgical procedures such as placement of drains or thoracoscopy. Among the sclerosing drugs, talc is the one preferred throughout the world. However, the possible appearance of respiratory distress syndrome, which is sometimes fatal, caused the awakening of interest in other drugs. Anti neoplastic drugs do not induce a very efficient pleurodesis and still have the disadvantage of causing important side effects. Sodium hydroxide and silver nitrate produce effective pleurodesis. Both can be used in humans.

Keywords: Pleurodesis. Sclerosing solutions. Clinical procedures.

Objective: To evaluate the pleurodesis and the lung damage caused by intrapleural silver nitrate or talc in an experimental model in rabbits to consider the use in human beings. Design: 112 rabbits were randomized to receive intrapleural 0.5% silver nitrate or 400 mg/kg talc slurry in 2 ml saline. Eight rabbits in each group were sacrificed 1, 2, 4, 6, 8, 10, or 12 months post injection. The degree of pleurodesis (gross pleural fibrosis and inflammation), lung damage (collapse and edema), and cellular infiltrates were graded on a 0 to 4 scale. Results: The intrapleural injection of silver nitrate produced a better pleurodesis than did the intrapleural injection of talc slurry. The lung damage was moderate 1 month after silver nitrate and greater than after talc. They were similar as from the second month. Conclusions: The better pleurodesis induced by silver nitrate persists for at least one year. The more evident lung damage after silver nitrate was mild with reversible changes which show a clear tendency to normalize with time. For these reasons, the efficacy of silver nitrate as a sclerosing agent in humans should be evaluated.

Keywords: Pleurodesis. Talc. Silver nitrate. Pleural effusion.

Introduction: The teaching hospital, HUCFF, Southeastern Brazil, annually receives three hundred tuberculosis cases. Medical students have their practice at that hospital. Objective: To determine the prevalence of Mycobacterium tuberculosis (Mtb) infection among the students of the UFRJ School of Medicine. Design: Cross-sectional study of medical students at different levels of their training programs. Information about social and demographic characteristics, BCG vaccination history, and potential exposures to tuberculosis were obtained with a standardized questionnaire. Tuberculin skin testing was used to determine the prevalence of tuberculosis infection. Results: The prevalence of tuberculin skin testing positivity among medical students increased as they advanced to higher training levels (4.6%, 7.8%, 16.2%, respectively; P = 0.002). The risks were greatest during the years of clinical training, when medical students had more contact with patients. Conclusions: Medical students in the HUCFF/UFRJ may be at an increased risk of M. tuberculosis infection. A program of routine tuberculin skin testing, combined with interventions to confirm TST conversion and to reduce the risk of nosocomial transmission in the workplace is needed.

Keywords: Nosocomial infection. Medical students. Risk factors. Cross-sectional studies.

Alpha-1 antitrypsin deficiency (AATD) is a rare genetic disorder caused by a mutation in the SERPINA1 gene, which encodes the protease inhibitor alpha-1 antitrypsin (AAT). Severe AATD predisposes individuals to COPD and liver disease. Early diagnosis is essential for implementing preventive measures and limiting the disease burden. Although national and international guidelines for the diagnosis and management of AATD have been available for 20 years, more than 85% of cases go undiagnosed and therefore untreated. In Brazil, reasons for the underdiagnosis of AATD include a lack of awareness of the condition among physicians, a racially diverse population, serum AAT levels being assessed in a limited number of individuals, and lack of convenient diagnostic tools. The diagnosis of AATD is based on laboratory test results. The standard diagnostic approach involves the assessment of serum AAT levels, followed by phenotyping, genotyping, gene sequencing, or combinations of those, to detect the specific mutation. Over the past 10 years, new techniques have been developed, offering a rapid, minimally invasive, reliable alternative to traditional testing methods. One such test available in Brazil is the A1AT Genotyping Test, which simultaneously analyzes the 14 most prevalent AATD mutations, using DNA extracted from a buccal swab or dried blood spot. Such advances may contribute to overcoming the problem of underdiagnosis in Brazil and elsewhere, as well as being likely to increase the rate detection of AATD and therefore mitigate the harmful effects of delayed diagnosis.

Keywords: alpha 1-antitrypsin deficiency/diagnosis; alpha 1-antitrypsin deficiency/genetics; Genotyping techniques.

Objective: To answer questions related to the use of anticoagulants in the treatment of COVID-19 patients. Methods: This was a systematic review and meta-analysis of phase 3 randomized controlled trials comparing the use of anticoagulants in non-hospitalized and hospitalized COVID-19 patients. We searched the following databases: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from their inception to January 22, 2022. The risk of bias was assessed by the Cochrane risk-of-bias tool, and the quality of evidence was assessed by the Grading of Recommendations Assessment, Development and Evaluation system. Results: A total of 401 studies were initially selected. Of those, 9 met the inclusion criteria and were therefore analyzed (a total of 6,004 patients being analyzed). In non-hospitalized COVID-19 patients, no significant difference was found between post-discharge prophylactic anticoagulation and no intervention regarding venous thromboembolism or bleeding at 30 days. In hospitalized COVID-19 patients, full anticoagulation resulted in a slight reduction in thrombotic events at 30 days (risk difference, -0.03; 95% CI, -0.06 to -0.00; p = 0.04; I2 = 78%), the quality of evidence being moderate. However, no significant difference was found between full anticoagulation and no intervention regarding the risk of major bleeding, the quality of evidence being very low. No significant difference was found between intermediate- and standard-dose prophylactic anticoagulation (risk difference, -0.01; 95% CI, -0.07 to 0.06; p = 0.81; I2 = 0%), the quality of evidence being very low. Conclusions: Therapeutic anticoagulation appears to have no effect on mortality in COVID-19 patients, resulting in a slight reduction in venous thromboembolism in hospitalized patients.

Keywords: Anticoagulants; COVID-19; SARS-CoV-2.

Background: Tuberculosis is a disease linked to poverty, unequal distribution of wealth, and urbanization, as well as the epidemics of acquired immunodeficiency syndrome epidemic and multidrug resistance. Objective: To analyze indicators of tuberculosis morbidity and mortality in the city of São José do Rio Preto, Brazil from 1985 to 2003, compared with those in the state of São Paulo and in Brazil at large, and to determine the relationship between the risk of occurrence and socioeconomic level. Method: The following official information systems were utilized: the Sistema de Informação de Mortalidade (SIM, Mortality database), the Notificação de Tuberculose (Epi-Tb, Tuberculosis Notification database), the Sistema de Informação de Agravos de Notificação (SINAN, Case-registry database), the Departamento de Informação e Informática do Sistema Único de Saúde (DATASUS, Information Department of the Brazilian Health Ministry) and the Instituto Brasileiro de Geografia e Estatística (IBGE, Brazilian Institute of Geography and Statistics database). New cases reported in 2003 in the urban area were georeferenced and analyzed. A map of the sectors, each classified as representing one of three socioeconomic classes, was drawn up, showing the respective tuberculosis incidence coefficients. Results: Comparing Brazil as a whole to the state of São Paulo, total incidence coefficients and mortality rates were similar, as were gender-related values. In the city of São José do Rio Preto the rates were consistently lower. The proportion of cases presenting tuberculosis/human immunodeficiency virus coinfection varied from 29% to 37%. In 2002, 59% and 65% of tuberculosis-only and coinfected tuberculosis patients, respectively, were under supervised treatment, with a cure rate of 81% and a treatment-abandonment rate of 1%. The risk of developing active tuberculosis was three times higher in the area presenting the lowest socioeconomic levels. Conclusion: Identification of the areas with different levels of risks for tuberculosis enables the Municipal Health Department to deal with the peculiarities of each region and to prioritize those presenting higher incidences of the disease.

Keywords: Tuberculosis. Epidemiology. Socioeconomic class. Supervised Treatment. Infection. HIV.

Background: Pectus excavatum is characterized by concave growth of costal cartilage and depression of the lower sternum. Clinical means of classifying these malformations are few and difficult to apply. Objective: To devise clinical tools for quantifying the deformity and comparing preoperative and postoperative findings. Method: A total of 10 pectus excavatum patients who underwent surgery in which the modified Robicsek technique was used by the Thoracic Surgery Group of the Hospital das Clínicas of the University of São Paulo School of Medicine, were clinically and radiologically evaluated in the preoperative and postoperative periods. Ten control individuals, presenting no thoracic or radiological abnormalities, were submitted to identical evaluations. Deformities at the sternum notch level and at the point of maximum deformity were assessed using the anthropometric index and the Haller index. Results: Multivariate analysis of anthropometric index means revealed significant differences between preoperative and control values and between preoperative and postoperative values, as well as a non-significant difference between postoperative and control values. The same results were obtained when Haller index means were analyzed. A paired comparison of preoperative and postoperative means showed two distinct groups. An 86% canonical correlation was found between the anthropometric index and the Haller index. Conclusion: Patients with pectus excavatum can be quantitatively assessed in the preoperative and postoperative periods through the use of the anthropometric index, which allows objective, comparative evaluation of the results and is easily performed.

Keywords: Funnel Chest. Anthropometry/methods.

Background: Structural alterations to the pulmonary circulation characterize the vascular remodeling process and are likely correlated with local variations in flow and ischemia. Objective: To define the histological alterations to the pulmonary circulation seen after experimentally-induced ischemia of the pulmonary artery and to correlate those alterations with known patterns of blood redistribution and vascular remodeling. Method: Wistar rats (n = 48) were randomized into two groups with ligation of the pulmonary artery and without (controls) and were sacrificed on post-ischemia days 1, 7, 30 and 60. Lungs were removed and inspected for signs of parenchymal injury. External diameters, as well as wall thicknesses in the pulmonary, alveolar and bronchial end arterioles, were measured. Internal diameter and wall thickness percentage were calculated. Results: Infarction, necrosis and hemorrhage occurred only in ischemic lungs. In nonischemic lungs, there was a sustained increase in the internal and external arteriolar diameters, with an initial reduction in wall thickness on day 1, and day-60 values were similar to those seen in controls. In ischemic lungs, there was a transitory reduction in the internal and external diameters of the pulmonary and bronchial end arterioles, together with an initial, equally transitory, increase in their wall thickness. The alveolar arterioles presented sustained and progressive increases in external diameter and wall thickness, with concomitant reductions in internal diameter. Conclusion: This model mimics distal arterial disease in patients with chronic pulmonary thromboembolism. The vascular response in nonischemic lungs was consistent with a pattern of flow remodeling, whereas that seen in ischemic lungs was more consistent with flow and ischemia. In the pulmonary and bronchial end arterioles, the response was transitory, in contrast to the sustained and progressive response seen in the alveolar arterioles, which was probably caused by delayed local flow.

Keywords: Key-words: Pulmonary embolism. Pulmonary circulation. Vascular remodelling. Pulmonary artery.