Background: Asthma is the most common chronic disease among adolescents. Objective: To determine the prevalence of asthma and asthma-related symptoms using the International Study of Asthma and Allergies in Childhood (ISAAC) protocol to evaluate adolescents in the city of Santa Maria, located in the state of Rio Grande do Sul, Brazil. Method: A cross-sectional study evaluating 3066 schoolchildren from 13 to 14 years of age, selected by random sampling, as indicated in the ISAAC protocol. Data were collected from March to June of 2003 using the standardized ISAAC questionnaire, which was completed by the adolescents in the classroom and under the supervision of the researchers. Results: A total of 3066 valid questionnaires (95.5%) were collected. Among the asthma-related symptoms evaluated, the following prevalences were determined: history of wheezing: 42.1%; wheezing within the last 12 months: 16.7%; four or more wheezing attacks within the last 12 months: 1.9%; sleep disturbance on one or more nights a week within the last 12 months: 3.8%; impaired speech within the last 12 months: 3.8%; history of asthma: 14.9%; wheezing after exercise within the last 12 months: 19%; dry cough at night within the last 12 months: 32.4%. Values were significantly higher among females. Conclusion: The prevalence of asthma-related symptoms among adolescents living in the city of Santa Maria was high, predominantly among the females. However, the rate was comparable to the international average and was lower than those observed in larger metropolitan areas in Brazil. These findings underscore the need for regional studies in order to better understand the prevalence of asthma in Brazil.

Keywords: Asthma. Adolescent. Epidemiology.

Background: Lung volume reduction surgery is an alternative treatment for advanced pulmonary emphysema. Radiological evaluation of the type and distribution of emphysema, together with the results of pulmonary function testing, seem to be the main criteria used in deciding whether or not the procedure is indicated. Objective: To determine the extent of scientific evidence available regarding the radiological profile of the ideal candidate for lung volume reduction surgery. Method: A systematic review of the literature from January 1994 to January 2004 using the following databases: MEDLINE, EMbase, LILACS, The Cochrane Library and EBM Reviews. Results: Of 208 articles identified, 16 met the study criteria. Two were randomized (one multicentric, named the 'National Emphysema Treatment Trial' and including 1218 patients, and the other including only 30 patients). The other 14 articles were observational studies. The National Emphysema Treatment Trial identified a subgroup of patients with favorable prognoses when submitted to lung volume reduction surgery. This group consisted of patients with advanced heterogeneous pulmonary emphysema with upper lobe predominance, diffuse pulmonary distention and low exercise capacity. The pattern of the results obtained in the remainder of the studies was consistent with the individual analyses, despite their heterogeneity. In the observational studies, surgical benefit, mortality rates and quality of life were assessed. Conclusion: The radiological pattern, characterized by the type, heterogeneity, distribution and diffuse distention, together with the degree of emphysema severity, represents the main predictor of a positive surgical outcome. Due to the paucity of studies in the literature, this is a grade B recommendation.

Keywords: Pulmonary emphysema. Lung surgery. Tomography X-ray computed. Review.

Background: The decision to drain parapneumonic pleural effusion in children is still controversial. An indicative scoring system to assess the need for chest-tube drainage arose from a partnership between pediatricians and surgeons. Objective: To evaluate the utility of the score in indicating whether drainage should be performed in pediatric patients with parapneumonic effusion. Method: A cross-sectional study involving 250 inpatients with parapneumonic effusion, treated in a tertiary-care hospital between 1994 and 1999. The following variables were analyzed: clinical presentation, chest X-rays, pleural fluid culture and biochemical analysis of the pleural fluid, as well as the score and treatment. The score was based on four categories: general appearance of the pleural fluid, chest X-rays, laboratory findings, and the second thoracentesis. Drainage was recommended for patients scoring higher than 5.5. Results: Of 941 children with pneumonia, parapneumonic effusion occurred in 304 (32.2%), 250 of which were included in the study. Of those, 146 (58.4%) were male, with mean of age of 3 years (median, 2 years). The cutoff points (determined through receiver operating characteristic curve analysis) for suggesting pleural drainage were pH < 7.29 (89.2% sensitivity and 76.5% specificity), score > 5.0 (68.7% sensitivity and 81.7% specificity). These values were more strongly correlated with the need for drainage (p = 0.001), as were those reported in the literature (pH = 7.0 and glucose < 40). The lactate dehydrogenase did not prove to be a good parameter for indicating a need for drainage. Conclusion: In addition to the purulent aspect, pH = 7.29 and score were the best indicators of the need for chest-tube drainage in pediatric patients with parapneumonic effusion. However, we suggest that some score variables be readjusted to improve the usefulness of this particular scoring system.

Keywords: Empyema. Pleural effusion. Pneumonia.

Background: Open lung biopsy is regarded as the gold standard for the diagnosis of diffuse pulmonary infiltrates. Objective: To determine the diagnostic yield, therapeutic changes, complications and mortality attributed to open lung biopsy in patients with diffuse pulmonary infiltrates and on mechanical ventilation. Method: We reviewed, retrospectively, the charts of 24 patients, ranging from 26 to 89 years of age, admitted to the intensive care units of two private hospitals and submitted to open lung biopsy. Results: Diagnostic positivity was found in 100% of patients, resulting in an alteration in the treatment regimen in 75%. Postoperative complications occurred in five patients (20.8%). There were no biopsy-related deaths, although global mortality was 45.8%. Conclusion: Open lung biopsy is a safe and high yield procedure for diagnosing diffuse pulmonary infiltrate in patients on mechanical ventilation. Despite the fact that no mortality impact factor has been assigned to such patients, data in the literature regarding prognosis must be taken into consideration.

Keywords: Biopsy. Respiratory insufficiency. Respiration artificial.

Background: The appearance of tuberculosis/human immunodeficiency virus co-infection and the growing number of diseases caused by nontuberculous mycobacteria, as well as the confusion that these can cause in relation to emerging multidrug-resistant strains, require more accurate and rapid laboratory results, not only in the isolation of strains but also in their identification. Objective: A comparative study evaluating a new tool of molecular identification, which uses a genetic probe based on the 16S rDNA sequence of the Mycobacterium tuberculosis gene (Gen-Probe Accuprobe® Gen Probe, Inc.), and the classic methodology. Method: Fifty-five Mycobacterium strains, isolated from the sputum of patients treated at a tuberculosis reference clinic, were selected for study. Subcultures were performed in three tubes: one submitted to genetic identification, one analyzed through classical tests (production and accumulation of niacin; growth in the Lowenstein-Jensen medium with the inhibitor agents p-nitrobenzoic acid and thiophene-2-carboxylic acid hydrazide added), and one held in reserve. Results: The probe identified 51 cases as belonging to the M. tuberculosis complex (one associated with M. kansasii) and the other 4 as nontuberculous mycobacteria, later identified as M. kansasii (3) and M. avium (1). Using traditional methods, 47 samples were identified as belonging to the M. tuberculosis complex, 4 were classified as fitting the profile of nontuberculous mycobacteria (in agreement with the genetic probe results), and 4 were unidentified, 1 of which presented the exact characteristics that 2 mycobacterium species have in common. Conclusion: The benefits of the molecular biology technique justify its implementation and routine use, in combination with classical methods, in a high-traffic clinic where complex cases of tuberculosis are treated.

Keywords: Mycobacterium tuberculosis. Molecular probe techniques.

Background: The risk for nosocomial transmission of tuberculosis exists in health care institutions. Objective: To evaluate indicators of transmission risk among patients with pulmonary tuberculosis treated at a university hospital. Method: A retrospective study covering the January 1997 to September of 1999 period and evaluating patients admitted to the Hospital de Clínicas of the Universidade Estadual de Campinas with pulmonary tuberculosis. Three intervals were determined: from admission to collection of sputum for acid-fast bacilli microscopy; from admission to implementation of airborne infection control measures; from sputum collection to the initiation of treatment. Results: The final sample included 63 cases. Concomitant human immunodeficiency virus-positivity was found in 31.7%. Forty patients (63.5%) were admitted through the emergency room. In 42 (66.7%) patients, TB was suspected at admission. The interval between admission and sputum collection exceeded 12 hours in 27.5% of cases admitted through the emergency room and in 30.4% of those admitted directly to wards (p = 0.803). Delayed respiratory isolation occurred in 31 cases (49.2%). The delay in isolation was correlated to no diagnosis of tuberculosis at admission (p < 0.000) and lower bacillary load in the sputum (p = 0.032). Co-infection with human immunodeficiency virus (p = 0.530), hospitalization ward (p = 0.284) and underlying diseases (p = 0.541) were not correlated with delayed isolation. The interval between sputum collection and initiation of treatment was greater than 24 hours in 15.9% of the cases. Conclusion: Delayed isolation was observed in many cases. Policies of continuing education are called for, especially in high-risk areas.

Keywords: Tuberculosis. Infection Control. Brazil. Delay. Diagnosis.

Background: Tuberculosis continues to be a global health problem. Objective: To evaluate an automated system designed to diagnose tuberculosis, comparing it to sputum microscopy and culture in Löwenstein-Jensen medium. Method: A comparative study using 844 sputum samples, collected between September and December of 1999 at a reference center for tuberculosis in São Paulo, Brazil, to draw distinctions between the results obtained through the use of the automated system and those obtained through sputum microscopy and culture in Löwenstein-Jensen medium. Results: Of the 844 samples evaluated, 27.1% tested positive for acid-fast bacilli, and 72.9% tested negative. In Löwenstein-Jensen culture, 34.7% were positive and 63% were negative, compared with 37.1% positivity and 56.9% negativity using the automated system. Sensitivity was 98.1% for the automated system and 91.9% for Löwenstein-Jensen culture. Specificity and positive predictive value were 100% for both methods. Negative predictive value was 98.9% for the automated system and 95.5% for Löwenstein-Jensen culture. The degree of accuracy was 99.3% for the automated system and 97% for Löwenstein-Jensen culture, and the Kappa was 0.99 for the automated system and 0.94 for Löwenstein-Jensen culture. The difference between the mean time to detection of mycobacteria using the automated system (10.5 days) and that found using Löwenstein-Jensen culture (34.7 days) was statistically significant. Conclusion: The difference between the culture yield obtained using the automated system and that achieved with Löwenstein-Jensen culture was statistically significant. Mean time to detection of mycobacteria was significantly shorter with the automated system. The higher yield provided by this new system justifies its use in a reference center for tuberculosis in São Paulo

Keywords: Mycobacterium tuberculosis. Diagnostic. Automated systems.

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.

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

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

Sarcoidosis is a systemic disease of unknown etiology, characterized by noncaseating granulomas. Although it may affect any organ, morbidity and mortality are most commonly related to pulmonary involvement, which is found in 80-90% of patients. This study illustrates the principal manifestations of sarcoidosis seen in high-resolution computed tomography scans, including typical as well as atypical forms.

Keywords: Sarcoidosis. Lung. High-resolution computed tomography.

This article presents a case report of osteoarticular tuberculosis affecting lumbar sacral column non-typical attack. The diagnosis remains a medical challenge because the symptoms and bone lesions are not specific and can be mislead with other morbidity such as inflammatory, circulatory, metabolic, traumatic, congenital and tumoral diseases. The disease is degenerative and the prognosis not satisfactory. Besides the clinical aspects and laboratory, imaging results, including computed tomography and magnetic ressonance, are discussed. A PCR system targeting the IS 6110 of M. tuberculosis was positive, strongly suggesting the presence of this pathogen. This assay would be particularly indicated when quick and sensitive diagnosis of tuberculosis is required.

Keywords: Tuberculosis. Spondylitis. PCR. Diagnostic.

Munchhausen syndrome results from a psychiatric disorder in which patients attempt to demonstrate signs and symptoms of serious organic diseases. In a review of the literature, we found 23 cases of Munchhausen syndrome accompanied by factitious hemoptysis, 2 presenting the same mechanism described herein. We report the case of a 23-year-old male with a recent history of multiple hospital admissions for investigation of bloody sputum, although no conclusive diagnosis had been made. Upon insistent questioning the patient admitted to aspirating his own blood with a syringe, holding it in his mouth and eliminating it in order to simulate hemoptysis. Munchhausen syndrome should be considered in patients presenting hemoptysis of obscure etiology.

Keywords: Munchhausen syndrome. Factitious hemoptysis. Diagnosis

Although the incidence of bronchial anastomosis as a complication of lung transplantation has decreased in recent years, it remains a significant cause of morbidity and mortality in these patients. Treatment options include balloon dilatation, laser photocoagulation, placement of a stent (silicone or metal), and performing a second operation. We report the case of a patient who presented bronchial stenosis after left lung transplantation and was treated with a self-expanding metal alloy (nitinol) stent (UltraflexÒ). Despite the fact that this was the first case of stenosis treated in this fashion in Brazil, the positive clinical response, in agreement with results reported in the literature, indicates that this treatment is a viable alternative in such cases.

Keywords: Lung transplantation. Tracheal stenosis. Prosthesis and implants. Stents. Postoperative complications.