Asthma-like symptoms, diagnostic tests, and asthma medication use in children and adolescents: a population-based nationwide survey.

OBJECTIVE: This study aimed to estimate the prevalence of asthma-like symptoms, current asthma (CA), asthma diagnostic tests, and inhaled medication use in a nationwide pediatric population (<18 years). METHODS: Pediatric-specific data from a cross-sectional, population-based telephone survey (INAsma study) in Portugal were analyzed. CA was defined as lifetime asthma and (1) wheezing, (2) waking with breathlessness, or (3) asthma attack in the previous 12 months, and/or (4) taking asthma medication at the time of the interview. RESULTS: In total, 716 children were included. The prevalence of asthma-like symptoms was 39.4% [95% confidence interval (95% CI): 35.7-43.3]. The most common symptoms were waking with cough (30.9%) and wheezing (19.1%). The prevalence of CA was 8.4% (95% CI: 6.6-10.7). Among children with CA, 79.9% and 52.9% reported prior allergy testing and pulmonary function testing (PFT), respectively. Inhaled medication use in the previous 12 months was reported by 67.6% (reliever inhalers, 40.1%; controller inhalers, 41.5%). Those who only used inhaled reliever medications experienced more asthma attacks [odds ratio (OR): 2.69]. Significantly fewer children with CA living in rural areas than those living in urban areas had undergone PFT or used inhaled medication (OR: 0.06 for PFT, 0.20 for medication]. CONCLUSIONS: The prevalence of CA in the Portuguese pediatric population was 8.4%. Only half of children with CA had ever undergone PFT; more than half did not use controller inhalers, and those who only used reliever inhalers reported more asthma attacks. These findings suggest that asthma management has been substandard, mainly in rural areas.

Operational definitions of asthma in recent epidemiological studies are inconsistent.

OBJECTIVE: The best combination of questions to define asthma in epidemiological asthma studies is not known. We summarized the operational definitions of asthma used in prevalence studies and empirically assess how asthma prevalence estimates vary depending on the definition used. METHODS: We searched the Thomson Reuters ISI Web of knowledge and included (1) cross-sectional studies (2) on asthma prevalence (3) conducted in the general population and (4) containing an explicit definition of asthma. The search was limited to the 100 most-cited papers or published since January 2010. For each paper, we recorded the asthma definition used and other variables. Then we applied the definitions to the data of the Portuguese National Asthma survey (INAsma) and of the 2005-2006 National Health and Nutrition Examination Survey (NHANES) computing asthma prevalence estimates for the different definitions. RESULTS: Of 1738 papers retrieved, 117 were included for analysis. Lifetime asthma, diagnosed asthma and current asthma were defined in 8, 12 and 29 different ways, respectively. By applying definitions of current asthma on INAsma and NHANES data, the prevalence ranged between 5.3%-24.4% and 1.1%-17.2%, respectively. CONCLUSIONS: There is considerable heterogeneity in the definitions of asthma used in epidemiological studies leading to highly variable estimates of asthma prevalence. Studies to inform a standardized operational definition are needed. Meanwhile, we propose a set of questions to be reported when defining asthma in epidemiological studies.

Effects of occupational exposure to tobacco smoke: is there a link between environmental exposure and disease?

In a previous study, evidence was provided that indoor secondhand tobacco smoke (SHS) air pollution remains high in Lisbon restaurants where smoking is allowed, regardless of the protective measures used. The aim of this study was to determine in these locations the levels of polycyclic aromatic hydrocarbons (PAH) associated with the particulate phase of SHS (PPAH), a fraction that contains recognized carginogens, such as benzo[a]pyrene (BaP). Data showed that restaurant smoking areas might contain PPAH levels as high as 110 ng/m(3), a value significantly higher than that estimated for nonsmoking areas (30 ng/m(3)) or smoke-free restaurants (22 ng/m(3)). The effective exposure to SHS components in restaurant smoking rooms was confirmed as cotinine levels found in workers' urine. Considering that all workers exhibited normal lung function, eventual molecular changes in blood that might be associated with occupational exposure to SHS and SHS-associated PPAH were investigated by measurement of two oxidative markers, total antioxidant status (TAS) and 8-hydroxyguanosine (8-OHdG) in plasma and serum, respectively. SHS-exposed workers exhibited higher mean levels of serum 8-OHdG than nonexposed workers, regardless of smoking status. By using a proteomics approach based on 2D-DIGE-MS, it was possible to identify nine differentially expressed proteins in the plasma of SHS-exposed nonsmoker workers. Two acute-phase inflammation proteins, ceruloplasmin and inter-alpha-trypsin inhibitor heavy chain 4 (ITIH4), were predominant. These two proteins presented a high number of isoforms modulated by SHS exposure with the high-molecular-weight (high-MW) isoforms decreased in abundance while low-MW isoforms were increased in abundance. Whether these expression profiles are due to (1) a specific proteolytic cleavage, (2) a change on protein stability, or (3) alterations on post-translational modification pattern of these proteins remains to be investigated. Considering that these events seem to precede the first symptoms of tobacco-related diseases, our findings might contribute to elucidation of early SHS-induced pathogenic mechanisms and constitute a useful tool for monitoring the effects of SHS on occupationally exposed individuals such as those working in the hospitality industry.

Control of Allergic Rhinitis and Asthma Test (CARAT): dissemination and applications in primary care.

Asthma frequently occurs in association with allergic rhinitis and a combined management approach has been suggested. The Control of Allergic Rhinitis and Asthma Test (CARAT) is the first questionnaire to assess control of both diseases concurrently. However, to have an impact on healthcare it needs to be disseminated and adopted. In this paper we discuss the dissemination of CARAT in different countries and its possible applications in primary care. At present, the adaptation of CARAT for use in different languages and cultures is being led by volunteer researchers and clinicians in 15 countries. Website and smartphone applications have been developed, and a free open model of distribution was adopted to contribute to the dissemination of CARAT. Examples of dissemination activities include distribution of leaflets and posters, educational sessions on the use of the questionnaire in the follow-up of patients, development of clinical studies, collaborations with professional organisations and health authorities, and the inclusion of CARAT in clinical guidelines. The adoption of innovations is an important challenge in healthcare today, and research on the degree of success of dissemination strategies using suitable methods and metrics is much needed. We propose that CARAT can be used in a range of settings and circumstances in primary care for clinical, research and audit purposes, within the overall aim of increasing awareness of the level of disease control and strengthening the partnership between patients and doctors in the management of asthma and rhinitis.

Control of Allergic Rhinitis and Asthma Test (CARAT) can be used to assess individual patients over time.

BACKGROUND: The Control of Allergic Rhinitis and Asthma Test (CARAT10) has been proposed as the first tool to implement the Allergic Rhinitis and its Impact on Asthma initiative guidelines in clinical practice. To serve this purpose, it must have adequate properties to assess the control of an individual over time. This study aimed to prospectively assess the test-retest reliability, responsiveness and longitudinal validity of CARAT10. METHODS: Adults with asthma and allergic rhinitis were enrolled at 4 outpatient clinics of Portuguese central hospitals. At each of the two visits, 4 to 6 weeks apart, patients filled out CARAT10 and additional questionnaires, followed by a medical evaluation blinded to the questionnaires' answers. RESULTS: From the 62 patients included, 51 patients completely filled out CARAT10 at both visits. The test-retest reliability, computed as an intra-class correlation coefficient, was 0.82. Regarding responsiveness, a significant change (p = 0.002) of CARAT10 score in clinically unstable patients was observed (95%CI -5.08; -1.31) and the Guyatt's responsiveness index was 1.54. As for the longitudinal validity assessment, the correlation coefficients of the changes of CARAT10 scores with those of ACQ5 and symptoms VAS ranged from 0.49 to 0.65, while with the physician assessment of control they ranged from 0.31 to 0.41. CONCLUSION: CARAT10 has good test-retest reliability, responsiveness and longitudinal validity. It can be used to assess control of allergic rhinitis and asthma, both to compare groups in clinical studies and to evaluate individual patients in clinical practice.

Prevalence of asthma in Portugal - The Portuguese National Asthma Survey.

BACKGROUND: Asthma is a frequent chronic respiratory disease in both children and adults. However, few data on asthma prevalence are available in Portugal. The Portuguese National Asthma Survey is the first nationwide study that uses standardized methods. We aimed to estimate the prevalence of current asthma in the Portuguese population and to assess the association between 'Current asthma' and comorbidities such as upper airways disease. METHODS: A cross-sectional, population-based, telephone interview survey including all municipalities of Portugal was undertaken. Participants were randomly selected to answer a questionnaire based on the Portuguese version of the GA2LEN survey. 'Current asthma' was defined as self-reported lifetime asthma and at least one of 3 symptoms in the last 12 months: wheezing, waking with breathlessness or having an asthma attack. RESULTS: Data were obtained for 6 003 respondents, with mean age of 38.9 (95%CI 38.2-39.6) years and 57.3% females. In the Portuguese population, the prevalence of 'Current asthma' was 6.8% (95%CI 6.0-7.7) and of 'Lifetime asthma' was 10.5% (95%CI 9.5-11.6) Using GA2LEN definition for asthma, our prevalence estimate was 7.8% (95%CI 7.0-8.8). Rhinitis had a strong association with asthma (Adjusted OR 3.87, 95%CI 2.90-5.18) and the association between upper airway diseases and asthma was stronger in patients with both rhinitis and sinusitis (Adjusted OR 13.93, 95%CI 6.60-29.44). CONCLUSIONS: Current asthma affects 695 000 Portuguese, with a prevalence of 6.8%. People who reported both rhinitis and sinusitis had the highest risk of having asthma.

Control of allergic rhinitis and asthma test--a formal approach to the development of a measuring tool.

BACKGROUND: The concurrent management of allergic rhinitis and asthma (ARA) has been recommended by Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines. However, a tool capable of assessing simultaneously the control of upper and lower airways diseases is lacking. AIM: To describe the studies conducted to design the control of ARA test (CARAT) questionnaire. METHODS: We performed a literature review to generate a list of potentially important items for the assessment of control of ARA. A formal consensus development process, that used an innovative web-based application, was designed - 111 experts in ARA and 60 patients participated. At the final consensus meeting, 25 primary and secondary care physicians formulated the questions and response options. A qualitative feasibility study (n = 31 patients) was conducted to evaluate the comprehensibility of the questionnaire while testing two different designs. RESULTS: Thirty-four potentially important items were identified. All the steps of the consensus process were completed in 2.5 months. The opinions of experts and patients lead to the formulation of 17 questions. At the feasibility study the instructions and wording problems were corrected and a semi-tabular format was chosen. CONCLUSION: A tool to measure the control of allergic rhinitis and asthma was developed using a comprehensive set of methodological steps ensuring the design quality and the face and content validity. Additional validation studies to assess the psychometric properties of the questionnaire have started.