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    "textoCompleto" => "<p class="elsevierStylePara">Dear Editor&#44;</p> <p class="elsevierStylePara">Smoking is a major cause of morbidity and mortality&#46; This fact is well known by the whole medical community and the population in general&#46; Respiratory diseases&#44; which can be diagnosed by changes in lung function tests&#44; are among the various consequences&#46; The sooner disease is identified&#44; the sooner the monitoring of symptoms and intervention can start&#44; smoking cessation in particular&#46;<a href="&#35;bib11" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib12" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib13" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib14" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib15" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib16" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib17" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">7</span></a> In fact&#44; smoking cessation is of the upmost importance even before the existence of any symptoms or presence of any disease&#46;</p> <p class="elsevierStylePara">With this in mind&#44; we investigated a population of smokers and characterized it based on smoking history&#44; symptoms &#40;dyspnea &#8211; characterized by the <span class="elsevierStyleItalic">modified Medical Research Council</span>&#41; and spirometry changes&#46;</p> <p class="elsevierStylePara">The study&#44; approved by the scientific ethical committee &#40;reference number 203&#47;03-2014&#44; Supplementary material I&#41;&#44; took place at a healthcare facility in the district of Coimbra&#44; USF BRIOSA&#44; which belongs to the ACES Baixo Mondego&#46;</p> <p class="elsevierStylePara">The population consisted of patients who were diagnosed with &#8220;Tobacco Abuse&#8221; &#40;ICPC-2 P17&#41;&#46; From them&#44; a convenient sample of 76 patients aged between 40 and 75 years old were selected to be part of the study&#46; Another criterion was that no participant was diagnosed with acute respiratory illness&#44; dementia or was bedridden&#46;</p> <p class="elsevierStylePara">The patients were invited to participate by their family physician&#46; An interview was scheduled when they accepted in order to provide them with the explanation of the study and its goal&#46; After this description&#44; patients were invited to give their formal written consent &#40;Supplementary material II&#41; and asked to answer a questionnaire &#40;mMRC questionnaire&#44; Supplementary material III&#41;&#46; This was followed by a pre-bronchodilator and a post-bronchodilator spirometry performed by a cardiopneumology technician&#46; The spirometry results<a href="&#35;bib18" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">8</span></a> were described using the criteria implemented by the American Thoracic Society&#47;European Respiratory Society&#46; These were then analyzed by OpenEpi<span class="elsevierStyleSup">&#174;</span> with descriptive and inferential statistics &#40;<span class="elsevierStyleItalic">U</span> Mann&#8211;Whitney and Kruskal&#8211;Wallis tests&#41; and&#44; in this study&#44; differences were considered as being statistically significant whenever the correspondent <span class="elsevierStyleItalic">p</span>-value was lower than 0&#46;05&#46;</p> <p class="elsevierStylePara">We invited 76 patients&#58; 67 people attended and 7 users were excluded and so the sample was composed of 60 patients&#44; more than half of which were women &#40;53&#46;3&#37; females&#41;&#46; The average age of participants was 55&#46;9 years and 38&#46;3&#37; of them were asymptomatic&#46;</p> <p class="elsevierStylePara">Looking at the spirometry results &#40;<span class="elsevierStyleItalic">n</span>&#160;&#61;&#160;60&#41; we observed that 58&#46;3&#37; of the population was normal &#91;95&#37; CI 45&#46;7&#8211;69&#46;9&#37;&#93;&#44; and 18&#46;3&#37; had non-reversible obstruction &#91;95&#37; CI 10&#46;6&#8211;29&#46;9&#93;&#46; On the other hand&#44; 15&#46;1&#37; of the individuals had obstruction of the small airways &#91;95&#37; CI 8&#46;1&#8211;26&#46;1&#93; and 8&#46;3&#37; had reversible obstruction &#91;95&#37; CI 3&#46;6&#8211;18&#46;1&#93;&#46; These changes were not influenced either by the pack-year units &#40;<span class="elsevierStyleItalic">p</span>-value&#160;&#61;&#160;0&#46;478&#41; or dyspnea &#40;<span class="elsevierStyleItalic">p</span>-value&#160;&#61;&#160;0&#46;384&#41;&#46;</p> <p class="elsevierStylePara">One-quarter of the participants mentioned were aware of their pulmonary disease&#44; prior to the study&#46; In particular&#44; four patients&#44; in whom a non-reversible obstruction was observed&#44; stated that they had been diagnosed with bronchopneumonia&#44; asthma&#44; tuberculosis and emphysema&#46; Tuberculosis was also reported by a patient with small airway obstruction and by one individual with a reversible obstruction&#46; Also in the group of patients with small airway obstruction&#44; two mentioned that they suffered from bronchitis&#46; Lastly&#44; patients without spirometry alterations reported six diseases&#58; bronchopneumonia&#44; bronchitis&#44; chronic obstructive pulmonary disease&#44; pulmonary infection&#44; pulmonary lesion and tuberculosis&#46; This segmentation of patients was based on the information provided by them&#44; given in their own words and without any codification&#46; We are aware that this kind of information can lead to mistakes in diagnosis&#44; although these descriptions reflect the knowledge that patients had about their illness&#46; For that reason&#44; we believe that it is important to keep to the patient&#39;s words which is why we cannot provide more specific descriptions&#46;</p> <p class="elsevierStylePara">In relation to the distribution of patients with non-reversible obstruction in spirometry&#44; three groups were defined in accordance with GOLD criteria&#46; Group A represents 72&#46;7&#37; of the sample&#44; group B is associated with 9&#46;1&#37; and lastly&#44; 18&#46;2&#37; belongs to group C&#46; Note that the diagnosed patient&#44; previously to the study&#44; was part of group A&#46; Group C was surprisingly large&#44; which could be related to inaccurate answers to the mMRC questionnaire&#59; individuals might have reported themselves as asymptomatic because&#44; in real life&#44; they do not perceive the symptoms and limitations of their disease&#46;</p> <p class="elsevierStylePara">To sum up&#44; let us consider a sample of 100 individuals older than 40 years with a history of smoking&#46; In accordance with the above described results&#44; 41 of them will report some alteration in the spirometry&#58; 18 patients will be diagnosed with a non-reversible obstruction&#44; 8 people with reversible obstruction and 15 participants will have alterations in the small airway&#46;</p> <p class="elsevierStylePara">We also compared these results with the records available in our healthcare facility&#46; We observed a difference of 14&#46;6&#37; between both values&#58; the above study reported 18&#46;0&#37; chronic obstructive pulmonary disease while our records only show 3&#46;4&#37;&#46; This significant difference can be partly explained by &#40;a&#41; the absence of relationship between the pack-year units and dyspnea with the presence of alterations in spirometry&#44; as found in this study&#59; &#40;b&#41; as mentioned by some physicians&#44; the lack of accessibility to a spirometry&#59; &#40;c&#41; the lack of evidence of cost-effective benefit in this screening and &#40;d&#41; the probability of a false positive result in healthy individuals&#46;</p> <p class="elsevierStylePara">This study has some limitations&#44; namely&#44; the use of a non-randomized sample &#40;the patients were invited to participate by their family physician&#41;&#44; the small size of the sample and the fact that other causes for non-reversible obstruction were not excluded&#46;</p> <p class="elsevierStylePara">However&#44; the prevalence of chronic obstructive pulmonary disease follows the results reported by other studies &#40;21&#8211;34&#46;8&#37;&#41; with a similar design&#46;<a href="&#35;bib12" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib14" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib16" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib17" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">7</span></a></p> <p class="elsevierStylePara">Similar studies&#44;<a href="&#35;bib19" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib20" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">10</span></a> reporting results for other countries&#44; have found a significant relationship between the PYU and dyspnea in the presence of alterations in the spirometry&#46; Therefore&#44; based only on our study&#44; we cannot state the significance of these particular findings&#46; In a scenario that these represent the truth&#44; could be this the reason for the under-diagnosis of this disease&#63; If patients do not feel ill or if the doctor does not understand the importance of the low and mild smoker&#39;s risk factor&#44; there is no further investigation and consequently&#44; no disease&#46; On the other hand&#44; the low <span class="elsevierStyleItalic">p</span>-value observed may be due to the small sample size&#46; Might other studies&#44; for which a significant difference was observed&#44; have compelled their <span class="elsevierStyleItalic">p</span>-value by the large sample used and then differences were found where there were none&#63;</p> <p class="elsevierStylePara">What are the consequences of these results&#63; Is this evidence enough to recommend an early screening in asymptomatic smokers&#63; Or should we perform a &#8220;case-finding&#8221; approach&#44; with questionnaires&#63; Are the available resources in the national healthcare system enough to carry out this early detection&#63; What are the reasons of this apparent under-diagnosis&#63;</p> <p class="elsevierStylePara">This study was the first of its kind in our healthcare facility&#46; The results obtained raise issues regarding the screening of this pathology and reinforce the need for investment in this area&#46; As a matter of fact&#44; in 2014&#44; the results here described led to the extension of this project to other geographical areas served by the ACES Baixo Mongedo&#44; involving a significant number of healthcare units&#46; In addition&#44; the study also highlighted the need to improve coordination between primary and secondary healthcare in the management of this disease&#46;</p> <a name="sec0005" class="elsevierStyleCrossRefs"></a> <span class="elsevierStyleSectionTitle">Funding</span> <p class="elsevierStylePara">This study was sponsored &#40;spirometry and a cardiopneumology technician&#41; by Novartis<span class="elsevierStyleSup">&#174;</span>&#44; Portugal&#46;</p> <a name="sec0010" class="elsevierStyleCrossRefs"></a> <span class="elsevierStyleSectionTitle">Conflicts of interest</span> <p class="elsevierStylePara">This study was sponsored &#40;spirometry and a cardiopneumology technician&#41; by Novartis<span class="elsevierStyleSup">&#174;</span>&#44; Portugal&#46;</p> <p class="elsevierStylePara">Acknowledgments</p> <p class="elsevierStylePara">We thank USF BRIOSA&#44; and all their healthcare professionals&#44; for receiving us and for the commitment during this study&#46;</p> <p class="elsevierStylePara">We thank Marisa Figueiredo for reviewing this manuscript&#46;</p> <a name="sec0015" class="elsevierStyleCrossRefs"></a> <span class="elsevierStyleSectionTitle">Appendix A&#46; Supplementary data</span> <p class="elsevierStylePara">Supplementary data associated with this article can be found&#44; in the online version&#44; at doi&#58;10&#46;1016&#47;j&#46;rppnen&#46;2015&#46;02&#46;004&#46;</p> <a name="sec0020" class="elsevierStyleCrossRefs"></a> <span class="elsevierStyleSectionTitle">Appendix A&#46; Supplementary data</span> <p class="elsevierStylePara">The following are the supplementary data to this article&#58;</p> <p class="elsevierStylePara"><elsevierMultimedia href</elsevierMultimedia></p> <p class="elsevierStylePara"><elsevierMultimedia href</elsevierMultimedia></p> <p class="elsevierStylePara"><elsevierMultimedia href</elsevierMultimedia></p> <p class="elsevierStylePara">Corresponding author&#46; Ivoreismgf&#64;gmail&#46;com</p>"
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Characterizing a population of smokers: An observational, transversal, non-randomized pilot study based on smoking history and spirometry changes
I.. Reisa,
Corresponding author
ivoreismgf@gmail.com

Corresponding author. Ivoreismgf@gmail.com
, J.. Alvesa, I.. Silvab, T.. Ormondea, C.. Ferreirac, J.. Moitac
a USF BRIOSA, ACES Baixo Mondego, Portugal
b USF Santa Joana, ACES Baixo Vouga, Portugal
c Centro Hospitalar Universitário de Coimbra (CHUC) – Hospital Geral, Portugal
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    "textoCompleto" => "<p class="elsevierStylePara">Dear Editor&#44;</p> <p class="elsevierStylePara">Smoking is a major cause of morbidity and mortality&#46; This fact is well known by the whole medical community and the population in general&#46; Respiratory diseases&#44; which can be diagnosed by changes in lung function tests&#44; are among the various consequences&#46; The sooner disease is identified&#44; the sooner the monitoring of symptoms and intervention can start&#44; smoking cessation in particular&#46;<a href="&#35;bib11" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib12" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib13" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib14" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib15" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib16" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib17" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">7</span></a> In fact&#44; smoking cessation is of the upmost importance even before the existence of any symptoms or presence of any disease&#46;</p> <p class="elsevierStylePara">With this in mind&#44; we investigated a population of smokers and characterized it based on smoking history&#44; symptoms &#40;dyspnea &#8211; characterized by the <span class="elsevierStyleItalic">modified Medical Research Council</span>&#41; and spirometry changes&#46;</p> <p class="elsevierStylePara">The study&#44; approved by the scientific ethical committee &#40;reference number 203&#47;03-2014&#44; Supplementary material I&#41;&#44; took place at a healthcare facility in the district of Coimbra&#44; USF BRIOSA&#44; which belongs to the ACES Baixo Mondego&#46;</p> <p class="elsevierStylePara">The population consisted of patients who were diagnosed with &#8220;Tobacco Abuse&#8221; &#40;ICPC-2 P17&#41;&#46; From them&#44; a convenient sample of 76 patients aged between 40 and 75 years old were selected to be part of the study&#46; Another criterion was that no participant was diagnosed with acute respiratory illness&#44; dementia or was bedridden&#46;</p> <p class="elsevierStylePara">The patients were invited to participate by their family physician&#46; An interview was scheduled when they accepted in order to provide them with the explanation of the study and its goal&#46; After this description&#44; patients were invited to give their formal written consent &#40;Supplementary material II&#41; and asked to answer a questionnaire &#40;mMRC questionnaire&#44; Supplementary material III&#41;&#46; This was followed by a pre-bronchodilator and a post-bronchodilator spirometry performed by a cardiopneumology technician&#46; The spirometry results<a href="&#35;bib18" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">8</span></a> were described using the criteria implemented by the American Thoracic Society&#47;European Respiratory Society&#46; These were then analyzed by OpenEpi<span class="elsevierStyleSup">&#174;</span> with descriptive and inferential statistics &#40;<span class="elsevierStyleItalic">U</span> Mann&#8211;Whitney and Kruskal&#8211;Wallis tests&#41; and&#44; in this study&#44; differences were considered as being statistically significant whenever the correspondent <span class="elsevierStyleItalic">p</span>-value was lower than 0&#46;05&#46;</p> <p class="elsevierStylePara">We invited 76 patients&#58; 67 people attended and 7 users were excluded and so the sample was composed of 60 patients&#44; more than half of which were women &#40;53&#46;3&#37; females&#41;&#46; The average age of participants was 55&#46;9 years and 38&#46;3&#37; of them were asymptomatic&#46;</p> <p class="elsevierStylePara">Looking at the spirometry results &#40;<span class="elsevierStyleItalic">n</span>&#160;&#61;&#160;60&#41; we observed that 58&#46;3&#37; of the population was normal &#91;95&#37; CI 45&#46;7&#8211;69&#46;9&#37;&#93;&#44; and 18&#46;3&#37; had non-reversible obstruction &#91;95&#37; CI 10&#46;6&#8211;29&#46;9&#93;&#46; On the other hand&#44; 15&#46;1&#37; of the individuals had obstruction of the small airways &#91;95&#37; CI 8&#46;1&#8211;26&#46;1&#93; and 8&#46;3&#37; had reversible obstruction &#91;95&#37; CI 3&#46;6&#8211;18&#46;1&#93;&#46; These changes were not influenced either by the pack-year units &#40;<span class="elsevierStyleItalic">p</span>-value&#160;&#61;&#160;0&#46;478&#41; or dyspnea &#40;<span class="elsevierStyleItalic">p</span>-value&#160;&#61;&#160;0&#46;384&#41;&#46;</p> <p class="elsevierStylePara">One-quarter of the participants mentioned were aware of their pulmonary disease&#44; prior to the study&#46; In particular&#44; four patients&#44; in whom a non-reversible obstruction was observed&#44; stated that they had been diagnosed with bronchopneumonia&#44; asthma&#44; tuberculosis and emphysema&#46; Tuberculosis was also reported by a patient with small airway obstruction and by one individual with a reversible obstruction&#46; Also in the group of patients with small airway obstruction&#44; two mentioned that they suffered from bronchitis&#46; Lastly&#44; patients without spirometry alterations reported six diseases&#58; bronchopneumonia&#44; bronchitis&#44; chronic obstructive pulmonary disease&#44; pulmonary infection&#44; pulmonary lesion and tuberculosis&#46; This segmentation of patients was based on the information provided by them&#44; given in their own words and without any codification&#46; We are aware that this kind of information can lead to mistakes in diagnosis&#44; although these descriptions reflect the knowledge that patients had about their illness&#46; For that reason&#44; we believe that it is important to keep to the patient&#39;s words which is why we cannot provide more specific descriptions&#46;</p> <p class="elsevierStylePara">In relation to the distribution of patients with non-reversible obstruction in spirometry&#44; three groups were defined in accordance with GOLD criteria&#46; Group A represents 72&#46;7&#37; of the sample&#44; group B is associated with 9&#46;1&#37; and lastly&#44; 18&#46;2&#37; belongs to group C&#46; Note that the diagnosed patient&#44; previously to the study&#44; was part of group A&#46; Group C was surprisingly large&#44; which could be related to inaccurate answers to the mMRC questionnaire&#59; individuals might have reported themselves as asymptomatic because&#44; in real life&#44; they do not perceive the symptoms and limitations of their disease&#46;</p> <p class="elsevierStylePara">To sum up&#44; let us consider a sample of 100 individuals older than 40 years with a history of smoking&#46; In accordance with the above described results&#44; 41 of them will report some alteration in the spirometry&#58; 18 patients will be diagnosed with a non-reversible obstruction&#44; 8 people with reversible obstruction and 15 participants will have alterations in the small airway&#46;</p> <p class="elsevierStylePara">We also compared these results with the records available in our healthcare facility&#46; We observed a difference of 14&#46;6&#37; between both values&#58; the above study reported 18&#46;0&#37; chronic obstructive pulmonary disease while our records only show 3&#46;4&#37;&#46; This significant difference can be partly explained by &#40;a&#41; the absence of relationship between the pack-year units and dyspnea with the presence of alterations in spirometry&#44; as found in this study&#59; &#40;b&#41; as mentioned by some physicians&#44; the lack of accessibility to a spirometry&#59; &#40;c&#41; the lack of evidence of cost-effective benefit in this screening and &#40;d&#41; the probability of a false positive result in healthy individuals&#46;</p> <p class="elsevierStylePara">This study has some limitations&#44; namely&#44; the use of a non-randomized sample &#40;the patients were invited to participate by their family physician&#41;&#44; the small size of the sample and the fact that other causes for non-reversible obstruction were not excluded&#46;</p> <p class="elsevierStylePara">However&#44; the prevalence of chronic obstructive pulmonary disease follows the results reported by other studies &#40;21&#8211;34&#46;8&#37;&#41; with a similar design&#46;<a href="&#35;bib12" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib14" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib16" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib17" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">7</span></a></p> <p class="elsevierStylePara">Similar studies&#44;<a href="&#35;bib19" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib20" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">10</span></a> reporting results for other countries&#44; have found a significant relationship between the PYU and dyspnea in the presence of alterations in the spirometry&#46; Therefore&#44; based only on our study&#44; we cannot state the significance of these particular findings&#46; In a scenario that these represent the truth&#44; could be this the reason for the under-diagnosis of this disease&#63; If patients do not feel ill or if the doctor does not understand the importance of the low and mild smoker&#39;s risk factor&#44; there is no further investigation and consequently&#44; no disease&#46; On the other hand&#44; the low <span class="elsevierStyleItalic">p</span>-value observed may be due to the small sample size&#46; Might other studies&#44; for which a significant difference was observed&#44; have compelled their <span class="elsevierStyleItalic">p</span>-value by the large sample used and then differences were found where there were none&#63;</p> <p class="elsevierStylePara">What are the consequences of these results&#63; Is this evidence enough to recommend an early screening in asymptomatic smokers&#63; Or should we perform a &#8220;case-finding&#8221; approach&#44; with questionnaires&#63; Are the available resources in the national healthcare system enough to carry out this early detection&#63; What are the reasons of this apparent under-diagnosis&#63;</p> <p class="elsevierStylePara">This study was the first of its kind in our healthcare facility&#46; The results obtained raise issues regarding the screening of this pathology and reinforce the need for investment in this area&#46; As a matter of fact&#44; in 2014&#44; the results here described led to the extension of this project to other geographical areas served by the ACES Baixo Mongedo&#44; involving a significant number of healthcare units&#46; In addition&#44; the study also highlighted the need to improve coordination between primary and secondary healthcare in the management of this disease&#46;</p> <a name="sec0005" class="elsevierStyleCrossRefs"></a> <span class="elsevierStyleSectionTitle">Funding</span> <p class="elsevierStylePara">This study was sponsored &#40;spirometry and a cardiopneumology technician&#41; by Novartis<span class="elsevierStyleSup">&#174;</span>&#44; Portugal&#46;</p> <a name="sec0010" class="elsevierStyleCrossRefs"></a> <span class="elsevierStyleSectionTitle">Conflicts of interest</span> <p class="elsevierStylePara">This study was sponsored &#40;spirometry and a cardiopneumology technician&#41; by Novartis<span class="elsevierStyleSup">&#174;</span>&#44; Portugal&#46;</p> <p class="elsevierStylePara">Acknowledgments</p> <p class="elsevierStylePara">We thank USF BRIOSA&#44; and all their healthcare professionals&#44; for receiving us and for the commitment during this study&#46;</p> <p class="elsevierStylePara">We thank Marisa Figueiredo for reviewing this manuscript&#46;</p> <a name="sec0015" class="elsevierStyleCrossRefs"></a> <span class="elsevierStyleSectionTitle">Appendix A&#46; Supplementary data</span> <p class="elsevierStylePara">Supplementary data associated with this article can be found&#44; in the online version&#44; at doi&#58;10&#46;1016&#47;j&#46;rppnen&#46;2015&#46;02&#46;004&#46;</p> <a name="sec0020" class="elsevierStyleCrossRefs"></a> <span class="elsevierStyleSectionTitle">Appendix A&#46; Supplementary data</span> <p class="elsevierStylePara">The following are the supplementary data to this article&#58;</p> <p class="elsevierStylePara"><elsevierMultimedia href</elsevierMultimedia></p> <p class="elsevierStylePara"><elsevierMultimedia href</elsevierMultimedia></p> <p class="elsevierStylePara"><elsevierMultimedia href</elsevierMultimedia></p> <p class="elsevierStylePara">Corresponding author&#46; Ivoreismgf&#64;gmail&#46;com</p>"
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Article information
ISSN: 08732159
Original language: English
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