Objective: To evaluate the effects of immunization with a DNA-hsp65 vaccine in an experimental model of pulmonary fibrosis. Methods: A total of 120 male C57BL/6 mice were distributed into four groups: SS, injected with saline (placebo) and then receiving intratracheal (IT) instillation of saline; SB, injected with saline (placebo) and then receiving IT instillation of bleomycin; PB, treated with plasmid only, without bacterial genome, and then receiving IT instillation of bleomycin; and BB, treated with the vaccine and then receiving IT instillation of bleomycin. Bleomycin was instilled 15 days after the last immunization, and the animals were killed six weeks thereafter. The left and right lungs were removed, the former for morphological analysis and the latter for hydroxyproline measurements. Results: The proportion of deaths within the first 48 h after the IT instillation (deaths attributed to the surgical procedure) was higher in the SB group than in the SS group (57.7% vs. 11.1%). The mean area of pulmonary interstitial septa was greater in the SB and PB groups (53.1 ± 8.6% and 53.6 ± 9.3%, respectively) than in the SS and BB groups (32.9 ± 2.7% and 34.3 ± 6.1%, respectively). The mean area of interstitial septa stained by picrosirius was greater in the SB, PB and BB groups than in the SS group (8.2 ± 4.9%, 7.2 ± 4.2% and 6.6 ± 4.1%, respectively, vs. 2.0 ± 1.4%). The total hydroxyproline content in the lung was significantly lower in the SS group (104.9 ± 20.9 pg/lung) than in the other groups (SB: 160.4 ± 47.8 pg/lung; PB: 170.0 ± 72.0 pg/lung; and BB: 162.5 ± 39.7 pg/lung). Conclusions: Immunization with the DNA-hsp65 vaccine reduced the deposition of noncollagen matrix in a model of bleomycin-induced lung lesion.

Keywords: Pulmonary fibrosis; Bleomycin; Collagen.

Objective: To determine the prevalence of allergic bronchopulmonary aspergillosis (ABPA) in patients with cystic fibrosis treated at a referral center in the state of Bahia, Brazil. Methods: A cross-sectional study, with prospective data collection, carried out at the Cystic Fibrosis Referral Center of Bahia of the Octávio Mangabeira Specialized Hospital. We evaluated 74 patients diagnosed with cystic fibrosis, older than six years of age, treated between December 9, 2003 and March 7, 2005. We analyzed the following variables: gender, age, forced vital capacity, forced expiratory volume in one second, pharmacodynamic response, chest X-ray findings, facial sinus X-ray findings, wheezing, cultures for Aspergillus spp., total immunoglobulin E (IgE), specific IgE for Aspergillus fumigatus and immediate skin test reactivity to A. fumigatus antigen. Results: Of the 74 patients, 2 were diagnosed with ABPA. We found total IgE levels > 1,000 IU/mL in 17 (23%), positive immediate skin reactivity to A. fumigatus antigen in 19 (25.7%) and wheezing in 60 (81.1%). Conclusions: The prevalence of ABPA was 2.7%. The high levels of total IgE, high incidence of wheezing and high rate of immediate skin test reactivity to A. fumigatus antigen suggest that these patients should be carefully monitored due to their propensity to develop ABPA.

Keywords: Cystic fibrosis; Aspergillosis, allergic bronchopulmonary; Immunoglobulin E/diagnostic use; Hypersensitivity, immediate/diagnosis; Gliotoxin.

Objective: To evaluate pulmonary function and respiratory muscle strength in chronic renal failure patients, correlating these variables with hemodialysis-related weight fluctuation; to study the correlation between the duration of hemodialysis and potential respiratory alterations. Methods: Seventeen patients (median age, 47 years; interquartile range, 41-52 years), submitted to three weekly hemodialysis sessions for a median of 27 months (interquartile range, 14-55) were evaluated. Twelve of the patients were male. The patients underwent spirometry. Maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) were measured prior to and after the first hemodialysis session of the week. Body weight was quantified prior to and after each of the three weekly sessions. Results: Before the first hemodialysis session of the week, 8 patients presented mild restrictive defect, which normalized after the session in 2 of those patients. After dialysis, there was a significant increase in forced vital capacity (p = 0.02) and a significant decrease in body weight (p = 0.0001). Weight fluctuation over 3 days without hemodialysis tended to correlate with the variation in forced vital capacity in the first weekly session (r = 0.47; p = 0.055). Duration of hemodialysis correlated with predialysis MIP (r = −0.3; p = 0.03) and MEP (r = −0.63; p = 0.006). Conclusions: More pronounced weight gain in the interdialytic period is associated with worsening of lung function, which is almost fully reversible by hemodialysis. In addition, longer duration of hemodialysis is associated with decreased respiratory muscle strength.

Keywords: Spirometry; Respiratory muscles/physiopathology; Kidney failure, chronic; Renal dialysis.

Objective: To evaluate the usefulness of determining the inflammatory component of airway diseases (inflammometry) by induced sputum cell counts, as well as its influence on treatment decisions in a tertiary facility for the treatment of respiratory diseases. Methods: We analyzed 151 sputum samples from 132 consecutive patients referred for clinical sputum induction by five pulmonologists between July of 2006 and February of 2007. A structured questionnaire related to the reasons for requesting the test and to the therapeutic decision making based on test results was completed by each attending physician upon receiving the test results. Induced sputum was obtained and processed according to a technique previously described. Results: The principal motives for ordering the test were inhaled corticosteroid dose titration in patients with moderate-to-severe asthma (in 54.3%), investigation of chronic cough (in 30.5%), and monitoring airway inflammation in patients with bronchiectasis (in 7.3%) or chronic obstructive pulmonary disease (in 6%). Of the 82 patients with asthma, 47 (57%) presented eosinophilic bronchitis (>3% eosinophils). Nonasthmatic eosinophilic bronchitis was diagnosed in 9 (19%) of the 46 patients with chronic cough. Neutrophilic bronchitis (>65% neutrophils) was found in 13 patients, of which 5 had asthma, 2 had chronic cough, and 6 had chronic obstructive pulmonary disease/bronchiectasis. Based on the induced sputum results, the corticosteroid dose was modified in 48 asthma patients (64.7%). Conclusions: The systematic application of inflammometry using induced sputum cell counts can be beneficial for patients with airway diseases, particularly those with asthma or chronic cough.

Keywords: Sputum; Asthma; Bronchitis.

Objective: The emergence of tuberculosis/HIV co-infection and the increase in the number of cases of infection with nontuberculous mycobacteria (NTM) require rapid laboratory test results in the isolation and identification of mycobacteria. The objective of this study was to evaluate the identification of mycobacteria by means of gene probes in comparison with that obtained using classical biochemical methods. Methods: Between 2002 and 2004, 178 mycobacterial cultures, all testing positive for acid-fast bacilli, were analyzed. Samples were obtained from clinical specimens of patients with respiratory symptoms or with clinical suspicion of pulmonary tuberculosis/mycobacteriosis who were treated in the greater metropolitan area of Santos. Results: The gene probe identified 137 samples (77%) as Mycobacterium tuberculosis complex and 41 (23%) as NTM. Discordant results between the methods (3%) were obtained only in the year of implementation (2002). When comparing the methods, the sensitivity, specificity, positive predictive value and negative predictive value of the gene probe method were 98%, 93%, 98% and 93%, respectively. Conclusions: Despite the cost, the identification of mycobacteria using the molecular technique is faster: maximum 3 h vs. 28-30 days for classical methods. The use of gene probes is a validated molecular technique. It is fast, easy to use and readily available on the market. It has high specificity and sensitivity, which justifies its implementation and routine use in referral laboratories, since it facilitates the diagnosis providing agile clinical interventions.

Keywords: Mycobacterium tuberculosis; Tuberculosis/diagnosis; Mycobacterium/classification; DNA probes.

Objective: To assess the prevalence of and factors associated with smoking experimentation among adolescents. Methods: Cross-sectional study, using a specific questionnaire to interview 2,883 students from 7th to 10th grade in schools located in the urban area of the city of Cuiabá, in the state of Mato Grosso, Brazil. Prevalence was estimated, and the principal factors related to cigarette experimentation were analyzed. Subsequently, a hierarchical logistic model was used to describe the chances of cigarette experimentation related to the variables being investigated. Results: The prevalence of cigarette experimentation was 30.2%. In the final model of the analysis, the main variables related to cigarette experimentation were low maternal level of education (OR = 2.44; 95% CI: 1.72-3.47); low socioeconomic level (OR = 1.39; 95% CI: 1.01-1.93); studying in a public school (OR = 1.56; 95% CI: 1.22-2.00); being in 10th grade (OR = 3.45; 95% CI: 2.63-4.54); attending school in the evening (OR = 2.44; 95% CI: 1.85-3.22); having divorced parents (OR = 1.23; 95% CI: 1.02-1.49); having been held back for one school year (OR = 2.17; 95% CI: 1.78-2.70); having friends who smoke (OR = 3.75; 95% CI: 2.99-4.70) having a sibling who smokes (OR = 2.44; 95% CI: 1.82-3.27); and being older (age 17-19 years) (OR = 2.44; 95% CI: 1.39-4.17). Conclusions: A high proportion of adolescents have experimented with smoking. After adjusting for confounding variables, the factors most strongly associated with cigarette experimentation were maternal level of education, age of the adolescent, attending school in the evening, having been held back for one school year and having a sibling who smokes. Preventive measures must be directed at adolescents in schools in order to control smoking.

Keywords: Smoking; Adolescent; Students; Risk factors.

Objective: To determine the frequency of smoking among hospitalized patients in a general hospital, and to evaluate their profile. Methods: A random representative sample of 111 patients, classified as nonsmokers, former smokers or smokers, was evaluated. The smokers were submitted to the Fagerström test and measurement of expired carbon monoxide. Expired carbon monoxide higher than 6 ppm was considered a significant indicator of recent smoking. Results: Of the 111 patients in the sample, 60 (54%) were female. The mean age was 70 years. Of the 111 patients, 56 (51%) had never smoked, 36 (32%) were former smokers, and 19 (17%) were smokers. All of the smokers were male. The smokers were younger (58 ± 17 years) than the nonsmokers (68 ± 12 years) and the former smokers (73 ± 14 years)-ANOVA: F = 6.57 (p = 0.002). Among the smokers, the mean tobacco intake was 43 pack-years and the mean Fagerström score was 5.0. Of the 19 smokers, 11 (58%) had respiratory symptoms and 3 had withdrawal symptoms. The mean expired carbon monoxide in the smokers was 5.0 ppm. Expired carbon monoxide levels were higher than 6 ppm in 8 (42%) of the smokers. There was a higher prevalence of smokers in some wards: 70% of all smokers were hospitalized on only five wards. Conclusions: In a large tertiary hospital, 17% of the hospitalized patients were smokers, and 7% had smoked within the last 8 h. The smokers were younger men, hospitalized on specific wards.

Keywords: Smoking; Hospitalization; Carbon monoxide/diagnostic use.

Objective: To evaluate the pattern of pro-inflammatory cytokines, anti-inflammatory cytokines and the acute phase response (APR) as markers of the response to treatment of pulmonary tuberculosis. Methods: Twenty-eight patients with pulmonary tuberculosis were evaluated at three time points: pretreatment (T0), treatment month 3 (T3) and treatment month 6 (T6). Levels of interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α), interleukine-10 (IL-10) and transforming growth factor-beta (TGF-β) were determined using ELISA in the supernatant of peripheral blood mononuclear cell and monocyte culture. Levels of total protein, albumin, globulins, C-reactive protein (CRP), alpha-1-acid glycoprotein (AAG) and erythrocyte sedimentation rate (ESR) were also determined. All of these parameters were also evaluated, only once, in a group of healthy controls. Results: In relation to controls, patients presented cytokine levels and APR that were higher at T0, lower at T3 and either lower (TNF-α, IL-10, TGF-β, AAG and ESR) or normal (IFN-γ and CRP) at T6. Conclusions: For individuals with negative smear sputum microscopy, CRP, AAG and ESR are potential markers of pulmonary tuberculosis and of the need for treatment; CRP (T0 > T3 > T6 = reference) can also be a marker of treatment response. In the patients, the Th0 profile (IFN-γ, IL-10, TNF-α and TGF-β), inducer of and protector against inflammation, predominated at T0, whereas the Th2 profile (IL-10, TNF-α and TGF-β), protecting against the harmful pro-inflammatory effect of the remaining TNF-α, predominated at T6. The behavior of IFN-γ (T0 > T3 > T6 = controls) suggests its use as a marker of treatment response.

Keywords: Acute-phase proteins; Cytokines; Mycobacterium tuberculosis; Tuberculosis/therapy.

Objective: To study the incidence of nontuberculous mycobacteria and the range of species isolated between 1996 and 2005 at a regional branch of the Adolfo Lutz Institute-located in the city of São José do Rio Preto, Brazil-and to show the importance of laboratory testing. Methods: Mycobacteria were isolated from pulmonary and extrapulmonary specimens and identified through phenotyping and molecular methods (polymerase chain reaction-restriction enzyme analysis). Results: We isolated 317 nontuberculous mycobacterium strains: ­Mycobacterium avium complex, 182 (57.4%); M. gordonae, 33 (10.4%); M. fortuitum, 25 (7.9%); M. chelonae, 8 (2.5%); M. terrae complex, 8 (2.5%); M. kansasii, 7 (2.2%); and less frequent species, 54 (17%). During this period, 72 cases (33.3%) were characterized as mycobacteriosis, according to bacteriological criteria established by the American Thoracic Society in 2007. Of those 72 cases, 56 were attributed to M. avium complex. Of those 56, 29 (51.8%) were characterized as disseminated disease. Six cases were attributed to M. fortuitum, 3 to M. gordonae, 2 to M. chelonae, 1 to M. abscessus, 1 to M. kansasii, 1 to M. intracellulare, 1 to M. malmoense and 1 to ­Mycobacterium ssp. Conclusions: These results show the importance of the bacteriological diagnosis, since identification of the species enables early and appropriate treatment.

Keywords: Mycobacteria, atypical/isolation & purification; Mycobacteria, atypical/classification; Diagnostic techniques and procedures.

This was a retrospective analysis of the medical charts of 145 patients treated at the Bronchoscopy and Thoracic Surgery Clinic of the Hospital das Clínicas da Universidade Estadual de Campinas (HC-Unicamp, State University of Campinas Hospital das Clínicas) over a period of 10 years. There was a significant difference related to the site of first medical visit (HC-Unicamp versus other institutions) in terms of the time elapsed between the suspicion of bronchial aspiration and the actual respiratory endoscopic examination. However, no significant difference was found in the rate of positive results. The low number of referral centers that provide emergency respiratory endoscopy can negatively influence the treatment of patients under suspicion of bronchial aspiration, jeopardizing the overall recovery in the mid- and long-term.

Keywords: Airway obstruction; Respiratory aspiration; Bronchoscopy.

Silicosis, the most prevalent of the pneumoconioses, is caused by inhalation of crystalline silica particles. Silica-exposed workers, with or without silicosis, are at increased risk for tuberculosis and nontuberculous mycobacteria-related diseases. The risk of a patient with silicosis developing tuberculosis is higher (2.8 to 39 times higher, depending on the severity of the silicosis) than that found for healthy controls. Various regimens for tuberculosis chemoprophylaxis in patients with silicosis have been studied, all of which present similar efficacy and overall risk reduction to about one half of that obtained with placebo. Long-term regimens have potential side effects (particularly hepatotoxicity). In addition, the use of such regimens can jeopardize adherence to treatment. The current guidelines recommend that tuberculin skin tests be performed, and, if positive, that chemoprophylaxis be instituted. There are several possible regimens, varying in terms of the drugs prescribed, as well as in terms of treatment duration. We recommend the use of isoniazid at 300 mg/day (or 10 mg/kg/day) for six months for patients with silicosis, as well as for healthy patients with periods of exposure to silica longer than 10 years and strongly positive tuberculin skin test results (induration ≥ 10 mm). Nevertheless, further studies are necessary so that indications, drugs, doses and duration of chemoprophylaxis regimens can be more properly defined.

Keywords: Silicosis; Tuberculosis; Diagnostic techniques and procedures; Chemoprevention.

With the objective of establishing guidelines for the prevention, diagnosis and treatment of compensatory hyperhidrosis, consensus meetings were held. Attendees included a general surgeon and thoracic surgeons affiliated with the Brazilian Society of Thoracic Surgery. The topics addressed were those that would ostensibly broaden multidisciplinary knowledge. Based on recent guidelines for the prevention, diagnosis and (clinical and surgical) treatment of compensatory hyperhidrosis, as well as on a review of the medical literature, the participants prepared a preliminary text, whose recommendations were revised and subsequently approved by all of the participants. The consensus text was posted on the Internet, becoming the object of further corrections and revisions prior to taking on its present form.

Keywords: Hyperhidrosis/therapy; Hyperhidrosis/surgery; Sympathectomy/methods; Postoperative complications; Thoracic surgery, video‑assisted.

We report the case of a patient who twice developed gynecomastia following tuberculosis treatment. An 18-year-old male developed painful bilateral gynecomastia after three months of treatment with the isoniazid-rifampin-pyrazinamide regimen. Partial resolution of gynecomastia was achieved at the end of treatment. The patient was retreated with the same regimen eight years later, and gynecomastia recurred after six months of treatment. Hormone levels were normal, and a mammogram revealed bilateral gynecomastia. The isoniazid was discontinued, and the gynecomastia was partially resolved by the end of treatment. Four years later, gynecomastia was not detected. We conclude that isoniazid-related gynecomastia completely resolves when the medication is discontinued. Therefore, pharmacological and surgical treatment should be avoided.

Keywords: Isoniazid/adverse effects; Gynecomastia/chemically induced; Tuberculosis.

Cystic lymphangioma is a rare congenital benign tumor. It results from focal proliferation of well-differentiated lymphatic tissue originating from abnormal development of the lymphatic system. Most cystic lymphangiomas occur in the primitive lymph sacs of children or young adults. They generally appear in the neck (75%) and axillary region (20%). Only 1% are located in the mediastinum. Acquired lymphangiomas, which are principally seen in middle-aged adults, are caused by a process of chronic lymphatic obstruction secondary to surgery, chronic infection, or radiation. Here, we present the case of a 50-year-old male with cystic lymphangioma of the mediastinum, detected on a routine chest X-ray.

Keywords: Lymphangioma, cystic; Mediastinum; Incidental findings.

We report the case of a patient with chronic obstructive pulmonary disease and bronchiectasis, chronically using corticosteroids, who acquired pulmonary nocardiosis, which presented as multiple cavitated nodules. The principal symptoms were fever, dyspnea and productive cough with purulent sputum. Chest X-ray and computed tomography of the chest revealed nodules, some of which were cavitated, in both lungs. Sputum smear microscopy and culture revealed the presence of Nocardia spp. The patient was treated with imipenem and cilastatin, which produced an excellent clinical response.

Keywords: Pulmonary disease, chronic obstructive; Nocardia infections; Bronchiectasis.