Overprescription of short-acting ß2 agonists: reflections from the SABINA study in Brazil.

OBJECTIVE: To assess prescription patterns for short-acting b2 agonists (SABAs) and other asthma medications in asthma patients treated by specialists and participating in the SABA use IN Asthma (SABINA) study in Brazil. METHODS: This was an observational, cross-sectional study conducted at five sites in different regions of Brazil. The primary endpoints were to record SABA prescriptions and obtain data on over-the-counter (OTC) SABA purchases at the pharmacy. RESULTS: Data on 218 asthma patients were analyzed. Of those 218 patients, 80.3% were prescribed SABAs in addition to their maintenance therapy, with a mean of 11.2 SABA canisters in the previous 12 months. Of those patients, 71.4% were prescribed ≥ 3 canisters and 42.2% were prescribed ≥ 10 canisters. None of the patients were prescribed SABA monotherapy. A total of 14.2% of the patients reported purchasing SABAs OTC at a pharmacy without a prescription. Of those, 48.4% purchased ≥ 3 SABA canisters. A fixed-dose combination of an inhaled corticosteroid and a long-acting b2 agonist was prescribed to 95.0% of the patients. In the year before the study visit, 45.0% of the patients received at least one course of oral corticosteroid burst treatment. Asthma was well controlled in 43.1% of the patients, partly controlled in 34.9%, and uncontrolled in 22.0%. Patients reported a mean of 1.1 severe asthma exacerbations, with 49.1% experiencing 1 or more severe exacerbations. CONCLUSIONS: Overprescription and OTC purchases of SABAs are common in Brazil, possibly leading to the need for courses of oral corticosteroids. The health care community should collaborate to implement evidence-based recommendations and promote health education to improve asthma management in Brazil.

Overprescription of short-acting β2 agonists: reflections from the SABINA study in Brazil / Prescrição excessiva de β2-agonistas de curta duração: reflexões a partir do estudo SABINA no Brasil

ABSTRACT Objective: To assess prescription patterns for short-acting b2 agonists (SABAs) and other asthma medications in asthma patients treated by specialists and participating in the SABA use IN Asthma (SABINA) study in Brazil. Methods: This was an observational, cross-sectional study conducted at five sites in different regions of Brazil. The primary endpoints were to record SABA prescriptions and obtain data on over-the-counter (OTC) SABA purchases at the pharmacy. Results: Data on 218 asthma patients were analyzed. Of those 218 patients, 80.3% were prescribed SABAs in addition to their maintenance therapy, with a mean of 11.2 SABA canisters in the previous 12 months. Of those patients, 71.4% were prescribed ≥ 3 canisters and 42.2% were prescribed ≥ 10 canisters. None of the patients were prescribed SABA monotherapy. A total of 14.2% of the patients reported purchasing SABAs OTC at a pharmacy without a prescription. Of those, 48.4% purchased ≥ 3 SABA canisters. A fixed-dose combination of an inhaled corticosteroid and a long-acting b2 agonist was prescribed to 95.0% of the patients. In the year before the study visit, 45.0% of the patients received at least one course of oral corticosteroid burst treatment. Asthma was well controlled in 43.1% of the patients, partly controlled in 34.9%, and uncontrolled in 22.0%. Patients reported a mean of 1.1 severe asthma exacerbations, with 49.1% experiencing 1 or more severe exacerbations. Conclusions: Overprescription and OTC purchases of SABAs are common in Brazil, possibly leading to the need for courses of oral corticosteroids. The health care community should collaborate to implement evidence-based recommendations and promote health education to improve asthma management in Brazil.

RESUMO Objetivo: Avaliar os padrões de prescrição de short-acting b2 agonists (SABAs, b2-agonistas de curta duração) e outros medicamentos para asma em pacientes tratados por especialistas e participantes do estudo SABA use IN Asthma (SABINA) no Brasil. Métodos: Trata-se de um estudo transversal observacional realizado em cinco locais em diferentes regiões do Brasil. Os desfechos primários foram registrar as prescrições de SABAs e obter dados a respeito da compra de SABAs sem receita médica na farmácia. Resultados: Foram analisados dados a respeito de 218 pacientes com asma. Dos 218 pacientes, 80,3% receberam prescrição de SABA além da terapia de manutenção, com uma média de 11,2 frascos de SABA nos 12 meses anteriores. Destes, 71,4% receberam prescrição de ≥ 3 frascos e 42,2% receberam prescrição de ≥ 10 frascos. Nenhum dos pacientes recebeu prescrição de monoterapia com SABA. Do total de pacientes, 14,2% relataram que compraram SABAs sem receita médica na farmácia. Destes, 48,4% compraram ≥ 3 frascos de SABA. Foram prescritas doses fixas combinadas de corticosteroide inalatório e b2-agonista de longa duração para 95,0% dos pacientes. No ano anterior à visita do estudo, 45,0% dos pacientes receberam pelo menos um ciclo de tratamento de curta duração com corticosteroide oral. A asma estava bem controlada em 43,1% dos pacientes, parcialmente controlada em 34,9% e não controlada em 22,0%. Os pacientes relataram uma média de 1,1 exacerbações graves da asma, sendo que 49,1% apresentaram uma ou mais exacerbações graves. Conclusões: A prescrição excessiva e a compra de SABAs sem receita médica são comuns no Brasil e possivelmente levam à necessidade de uso de corticosteroides orais. A comunidade de profissionais de saúde deve colaborar para implantar recomendações baseadas em evidências e promover a educação em saúde para melhorar o manejo da asma no Brasil.

Variants in interferon gamma inducible protein 16 (IFI16) and absent in melanoma 2 (AIM2) genes that modulate inflammatory response are associated with periodontitis.

OBJECTIVE: Evaluate the association of genetic variants of the interferon gamma inducible protein 16 (IFI16) and absent in melanoma 2 (AIM2) genes with periodontitis. METHODS: The study involved 117 individuals with periodontitis and 389 without periodontitis, all Brazilians, miscegenated. Individuals with periodontitis presented at least 4 teeth with ≥ 1 site with probing depth ≥ 4 mm; clinical attachment level ≥ 3 mm on the same site and bleeding upon stimulus. Genotyping was performed using the Infinium Multi-Ethnic AMR/AFR-8 Bead Chip focused on Hispanic and African American populations with approximately 2 million markers of the human genome. Multivariate logistic regression was performed to identify associations in additive, dominant and recessive models adjusted for covariates age, obesity, mouth breathing, flossing, asthma, and ancestry. RESULTS: In IFI16, the rs75985579-A is positively associated with periodontitis in the additive (Odds Ratio adjusted (ORadjusted) 2.65, 95% confidence interval (CI):1.25-5.60, p value: 0.007) and dominant models (ORadjusted 2.56, 95%CI:1.13-5.81, p value: 0.017). In AIM2, the rs76457189-G, is associated negatively with periodontitis in two genetic models evaluated, additive (ORadjusted 0.21, 95%CI:0.05-0.94, p value: 0.022) and dominant (ORadjusted 0.21, 95%CI:0.05-0.94, p value: 0.022). CONCLUSIONS: These results have shown that variants in the IFI16 and AIM2 genes are associated with periodontitis. Individuals with at least one A (adenine) allele of the rs75985579 (IFI16) are more than twice as likely to have periodontitis, while individuals with the G (guanine) allele of rs76457189 (AIM2) are less likely to be diagnosed with periodontitis, providing a negative association with periodontitis.

Prevalence of the eosinophilic phenotype among severe asthma patients in Brazil: the BRAEOS study.

OBJECTIVE: To assess the prevalence of the eosinophilic and allergic phenotypes of severe asthma in Brazil, as well as to investigate the clinical characteristics of severe asthma patients in the country. METHODS: This was a cross-sectional study of adult patients diagnosed with severe asthma and managed at specialized centers in Brazil. The study was conducted in 2019. RESULTS: A total of 385 patients were included in the study. Of those, 154 had a blood eosinophil count > 300 cells/mm3 and 231 had a blood eosinophil count of ≤ 300 cells/mm3. The median age was 54.0 years, and most of the patients were female, with a BMI of 29.0 kg/m2 and a history of allergy (81.6%). The prevalence of patients with a blood eosinophil count > 300 cells/mm3 was 40.0% (95% CI: 35.1-44.9), and that of those with a blood eosinophil count > 300 cells/mm3 and a history of allergy was 31.9% (95% CI: 27.3-36.6). Age and BMI showed positive associations with a blood eosinophil count > 300 cells/mm3 (OR = 0.97, p < 0.0001; and OR = 0.96, p = 0.0233, respectively), whereas the time elapsed since the onset of asthma symptoms showed an increased association with a blood eosinophil count > 300 cells/mm3 (OR = 1.02, p = 0.0011). CONCLUSIONS: This study allowed us to characterize the population of severe asthma patients in Brazil, showing the prevalence of the eosinophilic phenotype (in 40% of the sample). Our results reveal the relevance of the eosinophilic phenotype of severe asthma at a national level, contributing to increased effectiveness in managing the disease and implementing public health strategies.

Preclinical and clinical experience with dupilumab on the correlates of live attenuated vaccines.

Background: The safety and tolerability of live attenuated vaccines in patients administered dupilumab for moderate-to-severe asthma have not been previously evaluated. During the LIBERTY ASTHMA TRAVERSE open-label extension study (ClinicalTrials.gov identifier NCT02134028), a yellow fever outbreak in Brazil required administration of a live attenuated vaccine to at-risk individuals. Objective: Our aim was to evaluate immune response to a live attenuated vaccine in the context of IL-4 receptor blockade (REGN1103, a dupilumab surrogate) in mice and in dupilumab-treated patients with moderate-to-severe asthma who participated in TRAVERSE. Methods: In the preclinical study, mice were coadministered REGN1103/isotype control and live attenuated influenza vaccine/control, followed by influenza virus challenge. During TRAVERSE, 37 patients discontinued dupilumab treatment and were administered 17D live attenuated yellow fever vaccine (YFV). Safety and tolerability data, dupilumab serum concentrations, and plaque reduction neutralization titers before and after vaccination were collected. Results: In the preclinical study, there was no impact of REGN1103 on vaccine efficacy in mice. In TRAVERSE, all 37 patients who received YFV achieved seroprotection despite most having therapeutic levels of dupilumab, with the magnitude of response appearing unrelated to prevaccination dupilumab concentrations. No instances of vaccine-related adverse events or vaccine hypersensitivity were reported in 36 patients; 1 patient reported nonserious body ache, malaise, and dizziness 7 days after vaccination but recovered fully. Conclusion: The preclinical model suggested that dupilumab does not affect the efficacy of live attenuated influenza vaccine. The live attenuated YFV did not raise safety concerns and appeared to be well tolerated in patients with asthma who recently discontinued dupilumab treatment, and dupilumab concentrations had no apparent impact on immunologic response to the vaccine.

Prevalence of the eosinophilic phenotype among severe asthma patients in Brazil: the BRAEOS study / Prevalência do fenótipo eosinofílico em pacientes com asma grave no Brasil: o estudo BRAEOS

ABSTRACT Objective: To assess the prevalence of the eosinophilic and allergic phenotypes of severe asthma in Brazil, as well as to investigate the clinical characteristics of severe asthma patients in the country. Methods: This was a cross-sectional study of adult patients diagnosed with severe asthma and managed at specialized centers in Brazil. The study was conducted in 2019. Results: A total of 385 patients were included in the study. Of those, 154 had a blood eosinophil count > 300 cells/mm3 and 231 had a blood eosinophil count of ≤ 300 cells/mm3. The median age was 54.0 years, and most of the patients were female, with a BMI of 29.0 kg/m2 and a history of allergy (81.6%). The prevalence of patients with a blood eosinophil count > 300 cells/mm3 was 40.0% (95% CI: 35.1-44.9), and that of those with a blood eosinophil count > 300 cells/mm3 and a history of allergy was 31.9% (95% CI: 27.3-36.6). Age and BMI showed positive associations with a blood eosinophil count > 300 cells/mm3 (OR = 0.97, p < 0.0001; and OR = 0.96, p = 0.0233, respectively), whereas the time elapsed since the onset of asthma symptoms showed an increased association with a blood eosinophil count > 300 cells/mm3 (OR = 1.02, p = 0.0011). Conclusions: This study allowed us to characterize the population of severe asthma patients in Brazil, showing the prevalence of the eosinophilic phenotype (in 40% of the sample). Our results reveal the relevance of the eosinophilic phenotype of severe asthma at a national level, contributing to increased effectiveness in managing the disease and implementing public health strategies.

RESUMO Objetivo: Avaliar a prevalência dos fenótipos eosinofílico e alérgico da asma grave no Brasil e investigar as características clínicas dos pacientes com asma grave no país. Métodos: Estudo transversal com pacientes adultos com diagnóstico de asma grave atendidos em centros especializados no Brasil. O estudo foi realizado em 2019. Resultados: Foram incluídos no estudo 385 pacientes. Destes, 154 apresentavam contagem de eosinófilos no sangue > 300 células/mm3 e 231 apresentavam contagem de eosinófilos no sangue ≤ 300 células/mm3. A mediana da idade foi de 54,0 anos, e a maioria dos pacientes era do sexo feminino, com IMC de 29,0 kg/m2 e história de alergia (81,6%). A prevalência de pacientes com contagem de eosinófilos no sangue > 300 células/mm3 foi de 40,0% (IC95%: 35,1-44,9), e a daqueles com contagem de eosinófilos no sangue > 300 células/mm3 e história de alergia foi de 31,9% (IC95%: 27,3-36,6). A idade e o IMC apresentaram associações positivas com contagem de eosinófilos no sangue > 300 células/mm3 (OR = 0,97, p < 0,0001 e OR = 0,96, p = 0,0233, respectivamente), ao passo que o tempo decorrido desde o início dos sintomas de asma apresentou associação aumentada com contagem de eosinófilos no sangue > 300 células/mm3 (OR = 1,02, p = 0,0011). Conclusões: Este estudo possibilitou a caracterização da população de pacientes com asma grave no Brasil, mostrando a prevalência do fenótipo eosinofílico (em 40% da amostra). Nossos resultados revelam a relevância do fenótipo eosinofílico da asma grave em nível nacional, contribuindo para aumentar a eficácia no manejo da doença e na implantação de estratégias de saúde pública.

An expert review on breaking barriers in severe asthma in Brazil: Time to act.

Currently, Brazil lacks a national asthma management program and is burdened with nearly 200,000 hospitalizations due to the disease per year and approximately 5 deaths per day. The purpose of this article was to analyze the current issues surrounding severe asthma in Brazil, as the status of diagnosis and treatment is largely unknown, and to provide feasible recommendations to elicit imminent action. A panel of Brazilian medical experts in the field of severe asthma was provided with a series of relevant questions to address prior to a multi-day conference. Within this conference, each narrative was discussed and edited by the entire group. Through numerous rounds of discussion consensus was achieved. In order to overcome barriers to adequate asthma treatment, this panel recommends specific initiatives that can be implemented in the short-term to decrease the burden of severe asthma in Brazil. With increasing healthcare costs and limited resources globally, there is an opportunity to implement these recommendations in other countries in order to achieve adequate asthma care. Severe asthma is a heterogeneous and complex disease with various phenotypes that requires strict attention for diagnosis and management. Although this disease affects only a small proportion of the population with asthma, it poses a great burden to healthcare systems. Thus, barriers to diagnosis, treatment, and management should be overcome as quickly and efficiently as possible.

Oropharyngeal Swallowing Dynamic Findings in People with Asthma.

Airflow obstruction in people with asthma, similar to COPD, may interfere with swallowing, increasing the risk of food or liquid entrance into the lower airways, and favoring the uncontrolled disease. To describe the complaints and findings of the oropharyngeal swallowing mechanisms in patients with mild and severe asthma, a cross-sectional study was performed. A total of 135 participants with asthma were studied, of whom 97 had severe asthma and 38 had mild asthma. All subjects answered a questionnaire with demographic information, disease exacerbations, Asthma Control Questionnaire 6 (ACQ6-Juniper 1999), GastroEsophageal Reflux Disease Symptoms Questionnaire (GERD-SQ-Fornari et al. 2004), and Eating Assessment Tool 10 (EAT-10-Gonçalves et al., 2013). The oral and pharyngeal swallowing assessment occurred via videofluoroscopic swallowing evaluation. The age range of the participants was from 19 to 80 years, with a predominance of females (78.6%). Uncontrolled asthma was observed in 50 (52%) of the patients with severe asthma and in 11 (29%) of the patients with mild asthma (ACQ6 > 1.5). The GERD-SQ and EAT-10 scores were similar in both groups. In the bivariate analysis, the group with severe asthma presented with more changes when compared to the group with mild asthma in the following events: atypical lingual movement during the swallowing of liquid in the volumes of 5 ml (p = 0.003) and 10 ml (p = 0.001), and solid (p = 0.009); oral transit time increased in swallowing of liquid in the volumes of 5 ml (p = 0.003) and 20 ml (p = 0.026); beginning of the pharyngeal swallowing phase below the mandibular ramus (p = 0.003); pharyngeal residue (p = 0.017) of solid consistency; laryngeal penetration of 5 ml (p = 0.050) and 20 ml (p = 0.032) of liquid; increased transition time between the oral and pharyngeal swallowing phases (p = 0.035) and increased pharyngeal transit time (p = 0.045) of solid consistency. Tracheal aspiration was observed only in the group with severe asthma. After the multivariate analysis, atypical tongue movement maintained a statistically significant difference between the two groups. Oropharyngeal swallowing alternations were frequent in the studied sample and more markedly present in patients with severe asthma. Multivariate regression revealed atypical lingual movement, which was greater in patients with severe asthma. The clinical significance of these findings should be further investigated.

Oral health-related quality of life in individuals with severe asthma.

OBJECTIVE: To evaluate oral health-related quality of life (OHRQoL) among individuals with severe asthma, comparing it with that observed among individuals with mild-to-moderate asthma and individuals without asthma. METHODS: We conducted a cross-sectional study of 125 individuals: 40 with severe asthma; 35 with mild-to-moderate asthma; and 50 without asthma. We calculated the decayed, missing, and filled teeth (DMFT) index, as well as the Periodontal Screening and Recording index, and determined the stimulated salivary flow rate. We applied three structured questionnaires: the 14-item Oral Health Impact Profile (OHIP-14); the Medical Outcomes Study 36-Item Short-Form Health Survey, version 2 (SF-36v2); and the Work Ability Index (WAI). RESULTS: Periodontitis and reduced salivary flow were both more common in the severe asthma group than in the mild-to-moderate asthma and no-asthma groups. In addition, the WAI scores were lower in the severe asthma group than in the mild-to-moderate asthma and no-asthma groups, as were the scores for all SF-36v2 domains. The individuals with severe asthma also scored lower for the OHIP-14 domains than did those without asthma. Although the mean DMFT index did not differ significantly among the groups, the mean number of missing teeth was highest in the severe asthma group. Strong correlations between the SF-36v2 Component Summaries and poorer OHRQoL were only observed in the severe asthma group. CONCLUSIONS: Severe asthma appears to be associated with poorer oral health, poorer OHRQoL, a lower WAI, and lower scores for SF-36v2 domains.

Corticosteroid Use and Periodontal Disease: A Systematic Review.

Periodontitis affects the teeth supporting structures, such as periodontal tissues. We aimed to evaluate the association between periodontal disease and corticosteroid use. We searched in MEDLINE, Web of Sciences, SCOPUS, LILACS, and Cochrane databases, using the descriptors "Periodontal diseases" AND ("adrenal cortex hormones" OR "adrenal cortex hormones" OR ("adrenal" AND "cortex" AND "hormones") OR "adrenal cortex hormones" OR "corticosteroid"). We selected the summaries of observational studies, addressing periodontal disease in patients using corticosteroids. The search resulted in 403 articles. After applying the selection criteria, eight studies remained; being two retrospective cohorts and six cross-sectional studies. There are few studies with appropriate methodology to produce sound evidence about the causal relationship between the use of corticosteroids and periodontitis. However, two retrospective cohorts confirmed that chronic corticosteroid use is associated with the incidence of periodontal disease. Dental staff must be aware of this association for better management of periodontal disease therapy in patients using corticosteroids.

Asthma similarities across ProAR (Brazil) and U-BIOPRED (Europe) adult cohorts of contrasting locations, ethnicity and socioeconomic status.

BACKGROUND: Asthma prevalence is 339 million globally. 'Severe asthma' (SA) comprises subjects with uncontrolled asthma despite proper management. OBJECTIVES: To compare asthma from diverse ethnicities and environments. METHODS: A cross-sectional analysis of two adult cohorts, a Brazilian (ProAR) and a European (U-BIOPRED). U-BIOPRED comprised of 311 non-smoking with Severe Asthma (SAn), 110 smokers or ex-smokers with SA (SAs) and 88 mild to moderate asthmatics (MMA) while ProAR included 544 SA and 452 MMA. Although these projects were independent, there were similarities in objectives and methodology, with ProAR adopting operating procedures of U-BIOPRED. RESULTS: Among SA subjects, age, weight, proportion of former smokers and FEV1 pre-bronchodilator were similar. The proportion of SA with a positive skin prick tests (SPT) to aeroallergens, the scores of sino-nasal symptoms and quality of life were comparable. In addition, blood eosinophil counts (EOS) and the % of subjects with EOS > 300 cells/µl were not different. The Europeans with SA however, were more severe with a greater proportion of continuous oral corticosteroids (OCS), worse symptoms and more frequent exacerbations. FEV1/FVC pre- and post-bronchodilator were lower among the Europeans. The MMA cohorts were less comparable in control and treatment, but similar in the proportion of allergic rhinitis, gastroesophageal reflux disease and EOS >3%. CONCLUSIONS: ProAR and U-BIOPRED cohorts, with varying severity, ethnicity and environment have similarities, which provide the basis for global external validation of asthma phenotypes. This should stimulate collaboration between asthma consortia with the aim of understanding SA, which will lead to better management.

Tipos craniofaciais e relação com a síndrome da apneia obstrutiva do sono / Craniofacial types and relation to obstructive sleep apnea syndrome

Introdução: fatores anatômicos, como obesidade e alterações craniofaciais, interagem na etiologia e na expressão da Síndrome da Apneia Obstrutiva do Sono. Dimensões cranianas e faciais são usadas para classificar os diferentes fenótipos mediante duas medidas antropométricas: o índice craniano e o índice facial. Objetivo: avaliar a possível associação dos tipos cranianos e faciais ao risco da Síndrome da Apneia Obstrutiva do Sono, obtido pelo questionário de Berlim. Metodologia: participaram do estudo 34 indivíduos (76,5% mulheres), com mediana de idade = 59,0 (56,8 ­ 65,0) anos, avaliados quanto ao risco da Síndrome da Apneia Obstrutiva do Sono, através do questionário de Berlim e medidas antropométricas: índice de massa corporal, circunferência cervical, circunferência abdominal, índice craniano e índice facial. Resultados: foram encontradas as medidas índice de massa corporal = 30,3 (24,7 ­ 37,4) kg /m², circunferência cervical = 37,6 (33,9 ­ 41,6) cm e circunferência abdominal = 102,0 (91,8 ­ 116,1) cm. No grupo de alto risco para essa Síndrome, houve predominância do tipo craniano braquicefálico = 40,7%, e do tipo facial euriprosópico = 37,0%. Conclusão: através do presente estudo foi possível observar que idade, obesidade, tipo craniano braquicefálico e face euriprosópica associaram-se ao alto risco de Síndrome da Apneia Obstrutiva do Sono.

Introduction: anatomical factors such as obesity and craniofacial alterations interact in the etiology and expression of Obstructive Sleep Apnea Syndrome. Cranial and facial dimensions are used to classify the different phenotypes through two anthropometric measurements: the cranial and facial indexes. Objective: to evaluate the possible association of cranial and facial types with Obstructive Sleep Apnea Syndrome risk obtained by the Berlin questionnaire. Methodology: the study included thirty-four individuals (76,5% women), with a median age = 59,0 (56,8 ­ 65,0) years, who were evaluated for Obstructive Sleep Apnea Syndrome risk through the Berlin questionnaire and anthropometric measurements: body mass index, cervical circumference, abdominal circumference, cranial index and facial index. Results: the following measurements were found: body mass index = 30,3 (24,7 ­ 37,4) kg/m², cervical circumference = 37,6 (33,9 ­ 41,6) cm and abdominal circumference = 102,0 (91,8 ­ 116,1) cm. In the high-risk group for this Syndrome there was a predominance of brachycephalic cranial type = 40,7%, and euryprosopic facial type = 37,0%. Conclusion: through the present study, it was possible to observe that age, obesity, brachycephalic cranial type and euryprosopic face were associated with the high-risk for Obstructive Sleep Apnea Syndrome.

Rural to urban migration contributes to the high burden of asthma in the urban area.

INTRODUCTION: It is unknown whether rural-urban migration contributes to worse the burden of asthma in the cities. OBJECTIVES: The aim of this study was to evaluate whether subjects with asthma that migrated from rural areas to a large urban center in Brazil have more severe disease than asthmatic subjects that was born and always lived in the urban area. METHODS: This is a case-control study. We enrolled two groups of subjects with asthma currently living in a large urban center in Brazil: 486 subjects with moderate-severe asthma and 432 subjects with mild asthma. RESULTS: Rural-urban migrants had higher odds of moderate-severe asthma [adjusted OR 1.57, 95% CI (1.18-2.01)] and uncontrolled symptoms of asthma [adjusted OR 1.80, 95% CI (1.16-2.76)] than urban-born subjects. CONCLUSIONS: Rural-urban migrants in Brazil have more severe asthma than urban-born subjects. Our results suggest that rural-urban migration is associated with the high burden of asthma in the urban area.

Tendência temporal das internações por pneumonia em adultos e idosos na cidade do Salvador-Bahia, no período de 2003 a 2016 / Temporal trend of hospitalizations for pneumonia in adults and elderly in the city of Salvador-Bahia, from 2003 to 2016

Introdução: a pneumonia é uma doença infecciosa aguda do sistema respiratório que representa um grave problema de saúde pública no Brasil e no mundo. Objetivo: descrever a distribuição das internações por pneumonia em indivíduos residentes no município de Salvador, Estado da Bahia, no período de 2003 a 2016, conforme custo, sexo e faixa etária. Metodologia: estudo observacional descritivo e exploratório sobre internações por pneumonia (CID: J12-18) na cidade do Salvador, Bahia. Os dados foram obtidos no Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH-SUS), disponibilizados pelo Departamento de Informação do Sistema Único de Saúde (DATASUS), tabulados e tratados no Microsoft Excel 2016. Resultados: o número de internações por pneumonia totalizou 224.173. O sexo feminino correspondeu a 51,25% das internações. Em contrapartida, o sexo masculino apresentou os maiores custos médios de internação, tendo sido o mais elevado o de R$2.416,40 em 2016. Para ambos os sexos, as faixas etárias de maior ocorrência de internação foram as de 70-79 e a igual ou superior a 80 anos. O ano de 2015 apresentou a mais alta taxa de internação (97,1/100 mil hab.) e o mais alto custo médio (R$2.309,61). Conclusão: os dados revelam declínios pontuais das internações e elevação dos custos em termos nominais. Acompanhar a evolução da morbidade em série temporal contribui para questionar mudanças de gestão pública e avaliar o impacto da doença na coletividade.

Introduction: pneumonia is an acute infectious disease of the respiratory system that represents a serious public health problem in Brazil and in the world. Objective: describe the distribution of hospitalizations for pneumonia in individuals residents in the municipality of Salvador, State of Bahia, in the period from 2003 to 2016, as cost, sex and age group. Methodology: descriptive and exploratory observational study on hospitalizations for pneumonia (CID: J12-18) in the city of Salvador, Bahia. The data were obtained from the Hospital Information System of the Unified Health System (SIH-SUS), provided by the Department of Information of the Unified Health System (DATASUS), tabulated and treated in Microsoft Excel 2016. Results: the number of hospitalizations for pneumonia totaled 224,173. Females accounted for 51.25% of hospitalizations. On the other hand, the male sex showed the highest average costs of hospitalization, and the highest was of R$2.416,40 in 2016. For both sexes, the age groups of greater occurrence of hospitalization were those of 70-79 and the same or over 80 years of age. The year 2015 showed the highest rate of hospitalization (97.1/100 000 inhab.) and the highest average cost (R$2.309,61). Conclusion: the data reveal individual declines of hospitalizations and raise of costs in nominal terms. Follow the evolution of morbidity in temporal series contributes to question public management changes and assess the impact of the disease in the community.

Effects of upper limb resistance exercise on aerobic capacity, muscle strength, and quality of life in COPD patients: a randomized controlled trial.

OBJECTIVE:: To evaluate the effects of upper limb resistance exercise on the functional capacity, muscle function, and quality of life in patients with chronic obstructive pulmonary disease. SETTING:: Clinical School of Physiotherapy in a Public University of Brazil. SUBJECTS:: 58 patients were recruited; of these, 7 were excluded and 51 individuals were enrolled. INTERVENTION:: Control group performed warm-up, aerobic exercise, inspiratory muscle training, and session stretching, followed by massage therapy. The treatment group performed warm-up, aerobic exercise, inspiratory muscle training, three sets of upper limb resistance exercise, and session stretching, followed by massage therapy. Total three sessions per week for eight weeks. PRIMARY OUTCOME MEASURES:: 6-minute walk test, respiratory and peripheral muscle strength, dyspnea, and quality of life. Normality of the data was tested using the Shapiro-Wilk test; paired analysis of variance was used for intergroup analyses. RESULTS:: 51 patients (25 in the control group and 26 in the treatment group); 41% of the subjects were men. Mean forced expiratory volume was 2.6 ± 0.6 L, and mean body mass index was 27.3 ± 7.0 kg/m2. The upper limb resistance exercise resulted in significantly greater benefit in terms of exercise capacity (88.5 ± 81.9 m, P = 0.043), inspiratory muscle strength (22.9 ± 24.2 cm H2O, P = 0.001), upper limb muscle strength (2.3 ± 3.1 kg, P = 0.027), and quality of life scores (-15.3 ± 10.9 points, P = 0.000). CONCLUSION:: Upper limb resistance exercise improved the exercise capacity, respiratory muscle strength, and quality of life.

Obesity and asthma: clinical and laboratory characterization of a common combination.

OBJECTIVE: To evaluate the relationship between obesity and asthma. METHODS: This was a preliminary cross-sectional analysis involving 925 subjects with mild-to-moderate or severe asthma evaluated between 2013 and 2015. Obesity was defined on the basis of body mass index (BMI) and abdominal circumference. We collected clinical, laboratory, and anthropometric parameters, as well as pulmonary function test results and data regarding comorbidities. The subjects also completed asthma control and quality of life questionnaires. RESULTS: Obese individuals had a significantly higher number of neutrophils in peripheral blood than did nonobese individuals (p = 0.01). Among the obese individuals, 163 (61%) had positive skin-prick test results, as did 69% and 71% of the individuals classified as being overweight or normal weight, respectively. Obese individuals showed lower spirometric values than did nonobese individuals, and 32% of the obese individuals had uncontrolled asthma, a significantly higher proportion than that found in the other groups (p = 0.02). CONCLUSIONS: Obese individuals with asthma seem to present with poorer asthma control and lower pulmonary function values than do nonobese individuals. The proportion of subjects with nonatopic asthma was higher in the obese group. Our results suggest that obese individuals with asthma show a distinct inflammatory pattern and are more likely to present with difficult-to-control asthma than are nonobese individuals.

Anafilaxia em serviços de emergência: constante desafio para clínicos e equipe de saúde / Anaphylaxis in emergency services: a constant challenge for clinicians and health staff

Introdução: a anafilaxia é uma reação alérgica sistêmica grave, de início rápido e potencialmente fatal. A despeito da gravidade e da intensidade das reações anafiláticas, os sinais e sintomas desta síndrome são subestimados e não são reconhecidos por pacientes e por médicos. Objetivo: revisar os aspectos principais da epidemiologia, diagnóstico e tratamento da anafilaxia em sala de emergências. Metodologia: foi realizada busca de estudos publicados na língua inglesa, nas bases de dados PUBMED/ MEDLINE que discorressem sobre o tema anafilaxia. Os estudos foram selecionados após a definição dos DeCS e MeSH: alergia, hipersensibilidade, choque anafilático, emergência e morte. Estes termos foram cruzados por meio do chaveador boleano (AND). Os dados foram coletados no período de maio de 2017 a agosto de 2017. Conclusão: a anafilaxia caracteriza-se por ser uma síndrome sistêmica, multiorgânica, potencialmente fatal porem ainda de difícil diagnóstico. Epinefrina constitui-se o tratamento de escolha na emergência.

Introduction: anaphylaxis is a serious, early-onset and potentially fatal systemic allergic reaction. Despite the severity and intensity of anaphylactic reactions, the signs and symptoms of this syndrome are underestimated and are not recognized by patients and physicians. Objective: to review the main aspects of epidemiology, diagnosis and treatment of anaphylaxis in an emergency room. Methodology: a search was made for studies published in the English language, in PUBMED / MEDLINE databases that discuss the topic of anaphylaxis. The studies were selected after the definition of DeCS and MeSH: allergy, hypersensitivity, anaphylactic shock, emergency and death. These terms were crossed by the boolean switch (AND). The data were collected from May 2017 to August 2017. Conclusion: anaphylaxis is characterized by a systemic, multiorganic syndrome, potentially fatal but difficult to diagnose. Epinephrine is the treatment of choice in the emergency room.

Curricular intervention increases adolescents' knowledge about asthma: a randomized trial / Intervenção curricular eleva o conhecimento dos adolescentes sobre a asma: um ensaio randomizado

Abstract Objectives To evaluate the impact of a curricular intervention concerning the knowledge about asthma among adolescents from a public school. Methods This was a randomized, controlled trial study on a curricular intervention in asthma, carried out with asthmatic and non-asthmatic adolescents. The study participants were divided into a curricular intervention group for asthma (IG), and a control group with traditional curriculum (CG). Topics related to asthma were included in the curriculum, such as the disease concept, triggering factors, treatment, symptoms, action plan, and beliefs in popular myths about the disease. These topics were evaluated through a questionnaire with scores ranging from 0 to 20 points, expressed by the mean score. The acquisition of knowledge was evaluated 90 days and 540 days after the start of the intervention (baseline), by applying the mixed linear model for analysis of associations. Results 181 students participated in the study (IG = 101 and CG = 80). As shown by their scores before the intervention; the students were unaware about asthma (IG: x=10.7±2.9 vs. CG: x=11.5±2.7 points), its treatment (IG: x=1.6±0.9 vs. CG: x=1.6±0.8 points), and reported beliefs in popular myths about the disease (IG: x=1.5±1.1 vs. CG: x=1.7±1.1 points). After the intervention, the IG showed higher overall knowledge (GI: x=15.5±3.1 points), as well as knowledge about the treatment (GI: x=2.5±1.0 points), and two times more knowledge in the field "beliefs in popular myths about the disease" when compared to the CG. A greater probability of achieving satisfactory knowledge about asthma was noted in the IG (RR = 3.5), with NTT = 2.0. Conclusion The inclusion of the asthma topic in the curriculum improved knowledge about the disease in a subgroup of students.

Resumo Objetivo Avaliar o impacto de uma intervenção curricular sobre o conhecimento em asma dos adolescentes de um colégio público. Métodos Ensaio controlado e randomizado de uma intervenção curricular em asma, conduzido com adolescentes, asmáticos e não asmáticos, alocados em: grupo intervenção curricular em asma (GI) e grupo controle com currículo tradicional (GC). Foram inseridos no currículo tópicos relacionados à asma, tais como conceito, fatores desencadeantes, tratamento, sintomas, plano de ação e crenças em mitos populares sobre a doença, avaliados por meio de um questionário com escore de 0-20, expressos em média de acertos. Avaliou-se a apreensão do conhecimento 90 dias e 540 dias após o início da intervenção (baseline), aplicou-se o modelo linear misto para análise das associações. Resultados 181 estudantes participaram do estudo (GI = 101 e GC = 80). Os estudantes desconheciam a asma, como revelam os seus escores anteriores à intervenção (GI: x= 10,7±2,9 vs. GC: x= 11,5±2,7 acertos), seu tratamento (GI: x= 1,6±0,9 vs. GC: x= 1,6±0,8 acertos) e relataram crenças em mitos populares sobre a doença (GI: x=1,5±1,1 vs. GC: x=1,7±1,1 acertos). Após a intervenção, o GI apresentou maior conhecimento geral (GI: x= 15,5±3,1 acertos); sobre o tratamento (GI: x= 2,5±1,0 acertos) e duas vezes mais conhecimento no domínio "crenças em mitos populares sobre a doença" comparado com o GC. Maior probabilidade de alcançar conhecimento satisfatório sobre a asma foi observado no GI (RR = 3,5), com NNT = 2,0. Conclusão A inserção do tema asma no currículo é capaz de elevar o conhecimento sobre a doença em um subgrupo de estudantes.

Doença pulmonar obstrutiva crônica: atividade de vida diária e qualidade de vida / Chronic obstructive pulmonary disease: daily life activity and quality of life

Introdução: A qualidade de vida (QV) é um instrumento relevante para o contexto funcional na doença pulmonar obstrutiva crônica (DPOC), a escala London Chest Activity of Daily Living (LCADL) avalia a atividade de vida diária (AVD) em pacientes com DPOC. Objetivo: avaliar a capacidade em realizar AVD e a QV dos pacientes com DPOC que buscam serviço público de reabilitação pulmonar (RP). Métodos: Pesquisa transversal, realizada de 2014 até 2017, 27 pacientes diagnósticados DPOC leve a grave de acordo os critérios GOLD, de ambos os sexos, estáveis, sem exacerbações recentes. Foi utilizado ANOVA para analisar diferença entre as médias de LCADL e Saint George's Respiratory Questionnaire (SGRQ) em seguida o teste pos- HOC de Turkey para delimitar o impacto de cada preditor separadamente. Utilizou-se o teste de Spearmann para correlacionar LCADL e SGRQ. Resultados: Encontrada limitação leve para todos os domínios da escala LCADL 22,7 ± 8,4 pontos com 30,2% de limitação. A QV é impactada em todos os domínios (31,2 ± 11,6 pontos) de forma moderada a grave com 41,6% de redução. A dispnéia e a fadiga interferem de forma correlata na AVD, r = 0,78 (p < 0,05). O escore LCADL correlaciona-se diretamente com a QV, r =0,59 (p < 0,05). Conclusão: Os pacientes apresentam limitação na atividade de vidade diária e impacto na qualidade de vida, além de forte correlação entre o índice de dispneia da escala LCADL e seus domínios. [AU]

Introduction: Quality of life (QoL) is an important tool for the functional context in chronic obstructive pulmonary disease (COPD), the scale London Chest Activity of Daily Living (LCADL) evaluates the activities of daily living (ADL) in patients with COPD. Objective: to evaluate the ability to perform ADL and QoL of patients with COPD seeking public pulmonary rehabilitation (PR) service. Methods: Cross-sectional study, carried out from 2014 to 2017, 27 patients diagnosed COPD mild to severe according to the GOLD criteria, of both sexes, stable, without recent exacerbations. ANOVA was used to analyze difference between the means of LCADL and Saint George's Respiratory Questionnaire (SGRQ) followed by Turkey's post-HOC test to delimit the impact of each predictor separately. The Spearmann test was used to correlate LCADL and SGRQ. Results: Light limitation was found for all domains of the LCADL scale, 22.7 ± 8.4 points with a 30.2% limitation. QoL is affected in all domains (31.2 ± 11.6 points) in a moderate to severe manner, with a 41.6% reduction. Dyspnea and fatigue correlate with ADL, r = 0.78 (p <0.05). The LCADL score correlated directly with the QoL, r = 0.59 (p <0.05). Conclusion: Patients present a limitation in daily activity and impact on quality of life, as well as a strong correlation between the dyspnea index of the LCADL scale and its domains. [AU]