Misperception of poor asthma control in the outpatients clinic of a tertiary hospital in Rio de Janeiro.

OBJECTIVE: To determine the proportion of patients with asthma with misperception of poor control of their disease. METHODS: A cross-sectional study with a convenience sample of patients with asthma and aged ≥18 years. Asthma control was assessed by the Asthma Control Test and the Global Initiative for Asthma questionnaire. The Kappa coefficient was used to analyze the agreement between the results of these tests and the patients' perception of asthma control, defined by the response to one question of the Asthma Control Test: "How do you evaluate your asthma control during the last 4 weeks?". RESULTS: Among the 71 patients aged 19 to 81 years and a mean of 57.7±13.9 years, there were 27 (38%) controlled, according to the Asthma Control Test, and 18 (25.3%) using the Global Initiative for Asthma questionnaire. The Kappa coefficients of the results of these tests and the perception of control by the patients were 0.4 and 0.29, respectively. Among the 41 (57.7%) patients who considered themselves controlled, 18 (43.9%) had a misperception of their poor control, as per the Asthma Control Test, and 25 (61%) by the Global Initiative for Asthma. CONCLUSION: Applying the Asthma Control Test, it was observed that almost half of the participants had a misperception of their poor control of the disease and, according to the Global Initiative for Asthma questionnaire, more than half of the sample did not notice the lack of asthma control.

Most frequent errors in inhalation technique of patients with asthma treated at a tertiary care hospital.

OBJECTIVE: To demonstrate the most frequent errors in inhalation technique in patients with asthma undergoing treatment at a tertiary care hospital. METHODS: A cross-sectional study with a convenience sample of asthma patients aged 18 years or over, treated at a pulmonology outpatient clinic of a tertiary care hospital. The assessment of inhalation technique of users of the dry powder inhalers Aerolizer®, Aerocaps and Diskus®, or metered-dose inhalers was based on the manufacturer's instructions for use of each inhaler device. Patients demonstrated the inhalation technique with empty inhaler devices, and it was considered correct when all stages were performed properly, or when errors probably did not interfere with the treatment outcome. RESULTS: Among 71 participants, 43 (60.5%) performed inhalation technique incorrectly. Among metered-dose inhalers and dry powder inhalers users, inhalation technique errors were found in 84.2% and 51.9%, respectively (p=0.013). Errors were more frequent at the exhalation stage (67.4%), followed by breathing in (58.1%) and apnea (51.2%). In the group using dry powder inhalers, the most common errors occurred during exhalation and, for those using metered-dose inhalers, the most compromised stage was aspiration. CONCLUSION: Errors were more frequent among those using metered-dose inhalers compared with dry powder inhalers. Misconceptions are more common at the expiration stage among users of dry powder inhalers and in aspiration among those on metered-dose inhalers.

Incorrect use of inhalation devices among patients with bronchial asthma. A hospital-based cross-sectional study in Rio de Janeiro, Brazil.

CONTEXT AND OBJECTIVE: Treatment of asthma implies inhalation of specific drugs to reach high concentrations in the respiratory tree and ensure low drug bioavailability and few adverse effects. This study aimed to evaluate the effectiveness of the inhalation technique among outpatients with asthma. DESIGN AND SETTING: Tertiary-care hospital-based cross-sectional study in Rio de Janeiro. METHODS: We evaluated inhalation practices in a convenience sample. A questionnaire was used to investigate sociodemographic data and assess disease control level, duration of use of the inhalation device, length of treatment and previous instructions provided by the prescribing physician. Patients demonstrated their inhalation technique using empty devices, and their technique was considered correct when all steps were appropriately performed or when errors did not interfere with the treatment outcome. RESULTS: Among the 71 participants, 53 (74.7%) had been using the same inhaler device for at least two years and 41 (57.8%) had been under treatment for two years or more. Twelve (17.1%) said that they had been taught once and 57 (81.4%) at least twice, while one (1.4%) reported not having received any guidance regarding use of inhaler devices. Eighteen patients (25.3%) presented controlled asthma and 28 (39.5%) performed the inhalation technique correctly. Incorrect technique was associated with fewer evaluations of the inhalation technique (P =0.04) and uncontrolled asthma (P = 0.01). CONCLUSIONS: Less than half of the sample performed the inhalation technique correctly. Incorrect inhalation technique was related to lower number of evaluations of the use of the inhalation device and uncontrolled asthma.

Clinical evaluation of the microscopic-observation drug-susceptibility assay for detection of tuberculosis.

BACKGROUND: There is an urgent need for low-cost methods for rapid, accurate detection of Mycobacterium tuberculosis in clinical specimens. The microscopic-observation drug-susceptibility (MODS) assay is a relatively low-cost and simple liquid culture method that has been proposed for use in resource-limited environments. METHODS: This prospective study evaluated the performance of the MODS assay for detection of M. tuberculosis in persons undergoing evaluation for pulmonary tuberculosis in Brazil and Honduras. Respiratory specimens were evaluated using smear microscopy, culture on Lowenstein-Jensen medium, and culture using the MODS assay. A subset of specimens was also cultured using the Mycobacterial Growth Indicator Tube (MGIT) 960 automated system (Becton Dickinson). A study subject was considered to have tuberculosis if at least 1 culture on Lowenstein-Jensen medium was positive for M. tuberculosis. FINDINGS: A total of 1639 respiratory specimens obtained from 854 study subjects were analyzed. On a per-subject basis, MODS sensitivity was 97.5% (95% confidence interval [CI], 95.7-98.6), and specificity was 94.4% (95% CI, 93.1-95.2). Median times to detection were 21 days (interquartile range [IQR], 17-25 days) and 7 days (IQR, 5-10) for culture on Lowenstein-Jensen medium and for the MODS assay, respectively (P<.01). For 64 specimens cultured using the MGIT 960 automated system, median time to growth was similar for the MODS assay (7 days; IQR, 7-10 days) and the MGIT 960 automated system (8 days; IQR, 6-11.5 days; P=.16). The percentage of contaminated cultures was lower for the MODS assay than for culture on Lowenstein-Jensen medium (3.8% vs. 5.8%; P<.01). CONCLUSIONS: The MODS assay is a relatively simple test whose good performance characteristics for detection of pulmonary tuberculosis may make it suitable for resource-limited environments.

Avaliação da técnica inalatória em atendimentos de primeira consulta em ambulatório de asma de hospital terciário / Evaluation of the inhalation technique in first care visits in an asthma outpatient clinic at a tertiary hospital

Introdução: Técnica inalatória (TI) correta é fundamental para o controle da asma. Objetivo: Avaliar TI de pacientes em atendimento de primeira consulta em um ambulatório de asma. Métodos: Estudo observacional transversal com amostra de conveniência de asmáticos com idade ≥ 18 anos, em primeira consulta no ambulatório de asma do Hospital Universitário Antonio Pedro (HUAP) da Universidade Federal Fluminense e em uso de medicamentos disponíveis para uso em aerossol dosimetrado (AD), Aerocaps, Aerolizer ou Diskus. Participantes preencheram questionário com dados sociodemográficos, avaliação de controle da doença segundo o documento GINA, existência de orientações médicas para uso dos dispostivos inalatórios (DI), tempo de uso de DI e especialidade do médico encaminhador. A TI era considerada apropriada quando todas as etapas foram realizadas corretamente baseando-se nas bulas das medicações e foram demonstradas com os DI vazios. Resultados: Entre os 51 pacientes incluídos, 43 (84,3%) tinham TI incorretas e 4 (7,8%) apresentavam asma controlada. Trinta e cinco (70%) referiram orientação prévia quanto ao uso do DI. A TI correta associou-se com tempo de uso maior que 2 anos (p=0,006) e uso de DI de pó seco em detrimento de AD (p=0,019). Conclusão: Somente 16% dos pacientes encaminhados ao ambulatório da pneumologia específico de asma, de um hospital terciário, tinham a TI correta em sua primeira consulta e a quase totalidade não tinha a asma controlada. Atenção deve ser dada sempre a supervisão da qualidade da TI, principalmente dos usuários de AD e dos que usam seus DI há menos de 2 anos.

Introduction: Correct inhalation technique (IT) is essential for asthma control. Objective: To evaluate the IT of patients making their first visit to the asthma outpatient clinic. Methods: Cross-sectional observational study with a convenience sample of asthmatics aged ≥ 18 years, in their first visit to the asthma outpatient clinic of the Hospital Universitário Antonio Pedro (HUAP) of the Universidade Federal Fluminense and using medications available in metered-dose aerosol (DA) , Aerocaps, Aerolizer or Diskus. Participants completed a questionnaire with sociodemographic data, assessment of disease control according to the GINA document, existence of medical guidelines for the use of inhalation devices (IDs), length of ID use, and specialty of the refer-ring clinician. IT was considered appropriate when all steps were performed correctly based on medication package inserts and were demonstrated with empty IDs. Results: Among the 51 patients included, 43 (84.3%) had incorrect IT and 4 (7.8%) had controlled asthma. Thirty-five (70%) reported previous guidance regarding the use of ID. Correct IT was associated with time of use greater than 2 years (p=0.006) and use of dry powder ID rather than DA (p=0.019). Conclusion: Only 16% of the patients referred to the asthma-specific pulmonology outpatient clinic of a tertiary hospital had the correct IT at their first appointment and almost all of them did not have controlled asthma. Attention should always be given to the supervision of IT quality, especially for DA users and those who have been using their ID for less than 2 years.

Misperception of poor asthma control in the outpatients clinic of a tertiary hospital in Rio de Janeiro / Má percepção da falta de controle da asma em ambulatório de hospital terciário do Rio de Janeiro

ABSTRACT Objective To determine the proportion of patients with asthma with misperception of poor control of their disease. Methods A cross-sectional study with a convenience sample of patients with asthma and aged ≥18 years. Asthma control was assessed by the Asthma Control Test and the Global Initiative for Asthma questionnaire. The Kappa coefficient was used to analyze the agreement between the results of these tests and the patients' perception of asthma control, defined by the response to one question of the Asthma Control Test: "How do you evaluate your asthma control during the last 4 weeks?". Results Among the 71 patients aged 19 to 81 years and a mean of 57.7±13.9 years, there were 27 (38%) controlled, according to the Asthma Control Test, and 18 (25.3%) using the Global Initiative for Asthma questionnaire. The Kappa coefficients of the results of these tests and the perception of control by the patients were 0.4 and 0.29, respectively. Among the 41 (57.7%) patients who considered themselves controlled, 18 (43.9%) had a misperception of their poor control, as per the Asthma Control Test, and 25 (61%) by the Global Initiative for Asthma. Conclusion Applying the Asthma Control Test, it was observed that almost half of the participants had a misperception of their poor control of the disease and, according to the Global Initiative for Asthma questionnaire, more than half of the sample did not notice the lack of asthma control.

RESUMO Objetivo Determinar a proporção de pacientes com asma com percepção inadequada do mau controle de sua doença. Métodos Estudo transversal com amostra de conveniência de pacientes com asma e idade ≥18 anos. Avaliou-se o controle da asma por meio do Asthma Control Test e do questionário do Global Initiative for Asthma. Utilizou-se o coeficiente Kappa para análise da concordância entre os resultados desses testes e a percepção do controle da asma pelo paciente, definida pela resposta a uma questão do Asthma Control Test: "Como você avalia o controle da sua asma durante as últimas 4 semanas?". Resultados Entre os 71 pacientes com idades entre 19 e 81 anos e média de 57,7±13,9 anos, existiam 27 (38%) controlados, segundo o Asthma Control Test, e 18 (25,3%) de acordo com o questionário do Global Initiative for Asthma. Os coeficientes de Kappa entre os resultados desses testes e a percepção do controle pelos pacientes foram, respectivamente, 0,4 e 0,29. Entre os 41 (57,7%) pacientes que se consideravam controlados, 18 (43,9%) tinham percepção inapropriada do seu mau controle, de acordo com o Asthma Control Test, e 25 (61%) segundo o Global Initiative for Asthma. Conclusão Aplicando-se o Asthma Control Test, observou-se que quase metade dos participantes tinha percepção inadequada de seu mau controle da doença e, segundo o questionário da Global Initiative for Asthma, mais da metade da amostra não percebeu o descontrole da asma.

Most frequent errors in inhalation technique of patients with asthma treated at a tertiary care hospital / Erros mais frequentes na técnica inalatória de pacientes com asma brônquica em tratamento em hospital terciário

ABSTRACT Objective: To demonstrate the most frequent errors in inhalation technique in patients with asthma undergoing treatment at a tertiary care hospital. Methods: A cross-sectional study with a convenience sample of asthma patients aged 18 years or over, treated at a pulmonology outpatient clinic of a tertiary care hospital. The assessment of inhalation technique of users of the dry powder inhalers Aerolizer®, Aerocaps and Diskus®, or metered-dose inhalers was based on the manufacturer's instructions for use of each inhaler device. Patients demonstrated the inhalation technique with empty inhaler devices, and it was considered correct when all stages were performed properly, or when errors probably did not interfere with the treatment outcome. Results: Among 71 participants, 43 (60.5%) performed inhalation technique incorrectly. Among metered-dose inhalers and dry powder inhalers users, inhalation technique errors were found in 84.2% and 51.9%, respectively (p=0.013). Errors were more frequent at the exhalation stage (67.4%), followed by breathing in (58.1%) and apnea (51.2%). In the group using dry powder inhalers, the most common errors occurred during exhalation and, for those using metered-dose inhalers, the most compromised stage was aspiration. Conclusion: Errors were more frequent among those using metered-dose inhalers compared with dry powder inhalers. Misconceptions are more common at the expiration stage among users of dry powder inhalers and in aspiration among those on metered-dose inhalers.

RESUMO Objetivo: Demonstrar os erros mais frequentes na técnica inalatória de pacientes com asma brônquica em tratamento em hospital terciário. Métodos: Estudo transversal, com amostra de conveniência de pacientes com asma, com 18 anos ou mais, em tratamento em ambulatório de pneumologia de um hospital terciário. A avaliação da técnica inalatória dos usuários dos dispositivos de pó seco Aerolizer ®, Aerocaps® ou Diskus®, ou de aerossóis dosimetrados teve como base as orientações da bula do fabricante de cada dispositivo inalatório. Os pacientes demonstraram a técnica inalatória com dispositivos inalatórios vazios, e ela foi considerada correta quando todas as etapas foram realizadas de forma apropriada, ou quando os equívocos provavelmente não interferiam no resultado do tratamento. Resultados: Entre os 71 participantes, 43 (60,5%) realizaram a técnica inalatória de forma incorreta. Dentre os usuários de aerossóis dosimetrados e dispositivos de pó seco, ocorreram erros de técnica inalatória em 84,2% e 51,9%, respectivamente (p=0,013). Os erros foram mais frequentes na etapa da expiração (67,4%), seguidos da aspiração (58,1%) e da apneia (51,2%). No grupo que usava dispositivos de pó seco, os erros mais comuns aconteceram na expiração e, nos que utilizavam aerossóis dosimetrados, a etapa mais comprometida foi a aspiração. Conclusão: Os erros foram mais frequentes entre os que usavam aerossóis dosimetrados em comparação com dispositivos de pó seco. Os equívocos foram mais comuns na etapa da expiração entre os usuários de dispositivos de pó seco e na aspiração entre os que usavam aerossóis dosimetrados.

Incorrect use of inhalation devices among patients with bronchial asthma. A hospital-based cross-sectional study in Rio de Janeiro, Brazil

ABSTRACT CONTEXT AND OBJECTIVE: Treatment of asthma implies inhalation of specific drugs to reach high concentrations in the respiratory tree and ensure low drug bioavailability and few adverse effects. This study aimed to evaluate the effectiveness of the inhalation technique among outpatients with asthma. DESIGN AND SETTING: Tertiary-care hospital-based cross-sectional study in Rio de Janeiro. METHODS: We evaluated inhalation practices in a convenience sample. A questionnaire was used to investigate sociodemographic data and assess disease control level, duration of use of the inhalation device, length of treatment and previous instructions provided by the prescribing physician. Patients demonstrated their inhalation technique using empty devices, and their technique was considered correct when all steps were appropriately performed or when errors did not interfere with the treatment outcome. RESULTS: Among the 71 participants, 53 (74.7%) had been using the same inhaler device for at least two years and 41 (57.8%) had been under treatment for two years or more. Twelve (17.1%) said that they had been taught once and 57 (81.4%) at least twice, while one (1.4%) reported not having received any guidance regarding use of inhaler devices. Eighteen patients (25.3%) presented controlled asthma and 28 (39.5%) performed the inhalation technique correctly. Incorrect technique was associated with fewer evaluations of the inhalation technique (P =0.04) and uncontrolled asthma (P = 0.01). CONCLUSIONS: Less than half of the sample performed the inhalation technique correctly. Incorrect inhalation technique was related to lower number of evaluations of the use of the inhalation device and uncontrolled asthma.

Tratamento do tabagismo em pacientes com DPOC / Smoking Cessation in patients with COPD

DPOC é uma das doenças pulmonares mais prevalentes no mundo. No Brasil, as prevalências de DPOC e de tabagismo são 15,8% e e 10,4%, respectivamente. Entre 30 e 70% dos pacientes com DPOC permanecem tabagistas. O tratamento destes pacientes é um desafio. Frequentemente apresentam baixa motivação e auto eficácia para a interrupção do tabagismo (IT), elevada dependência de nitcotina e associação com depressão. A investigação destes elementos deve preceder o início do tratamento farmacológico, que deve sempre estar associado a terapia cognitivo comportamental (TCC) e ao tratamento da depressão. O paciente com DPOC deve ser informado sobre a relação do tabagismo com sua doença e a importância da interrupção para o controle dos sintomas e mudança do prognóstico. A TCC inclui e sugere a escolha da data de IT, a identificação de situações de alto risco, o desenvolvimento de comportamentos alternativos e o manejo dos sintomas de abstinência, além de proporcionar apoio e incrementar motivação. Todos os fármacos de primeira linha no tratamento do tabagismo podem ser utilizados no tratamento deste grupo, com as doses e períodos clássicos, mas para os mais dependentes, é frequente a necessidade de se estender o período de tratamento, aumentar doses e associar fármacos.

COPD is one of the most prevalent pulmonary diseases in the world. In Brazil, the prevalence of COPD and smoking is 15.8% and 10.4%, respectively. Between 30 and 70% of COPD patients are smokers. The treatment of these patients is a challenge. Frequently they present low motivation and self-efficacy for smoking cessation (SC), high level of nicotine dependence and association with depression. The investigation of these elements should precede the beginning of pharmacological treatment, which should always be associated with cognitive behavioral therapy (CBT) and with the treatment of depression. The patient with COPD should be informed about relationship of smoking with their disease and the importance of discontinuation for symptom control and change of prognosis. CBT includes and suggests the choice of SC date, the identification of high-risk situations, the development of alternative behaviors and the management of withdrawal symptoms, as well as providing support and increasing motivation. All first-line drugs in the smoking treatment can be used in the treatment of this group, with the classic doses and periods, but for the most dependent, it is often necessary to extend the period of treatment, increase doses and associate drugs.

Clinical evaluation of the microscopic observation drug susceptibility assay for detection of Mycobacterium tuberculosis resistance to isoniazid or rifampin.

This prospective study evaluated the performance of the microscopic observation drug susceptibility (MODS) assay for the direct detection of Mycobacterium tuberculosis drug resistance. MODS assay sensitivity, specificity, and positive and negative predictive values were 96.7% (95% confidence interval [95% CI], 92.1 to 98.8%), 78.4% (95% CI, 73.5 to 80.6%), 82.4% (95% CI, 78.4 to 84.2%), and 95.8% (95% CI, 89.9 to 98.5%), respectively, for isoniazid resistance and 96.0% (95% CI, 90.3 to 98.6%), 82.9% (95% CI, 78.8 to 84.7%), 80.0% (95% CI, 75.2 to 82.1%), and 96.7% (95% CI, 91.9 to 98.8%), respectively, for rifampin resistance. For both rifampin and isoniazid testing, the likelihood ratio for a negative test was < or =0.05, indicating that the MODS assay may be useful for ruling out drug resistance.

Dosagem de bilirrubina para classificar transudato e exsudato pleural / Bilirrubin dosage to separation of transudates from pleural exudates

Introducao: distinção entre resultados e transudatos caracteriza-se por ser a primeira etapa na investigação da síndroma de derrame plural. Essa diferenciação e realizada através da análise bioquímica do liquido pleural. O critério de Light e o mais utilizado nesta classificação , mas alguns casos, especialmente os transudatos , podem ser classificados incorretamente. O objetivo e avaliar a utilidade do critério de Meisel, relação entre a bilirrubina total do liquido pleural e a do soro (Bb-L/Bb-S), para separar exsudatos e transudatos pleurais. Material e métodos: estudo prospectivo com casuística composta por 71 pacientes, com idades entre 9 e 81 anos, atendidos no Ambulatorio de Pesquisa em Pleurologia da Universidade Federal Fluminense, Cidade de Niteroi, Rio de Janeiro, entre marco de 1996 e marco de 2000. Quadro clinico, imagem e o criterio de Light para diagnostico final. Resultados: quarenta e cinco (63) individuos do sexo masculino e 26 (37) do sexo feminino. Quarenta e um (58) casos de tuberculose , 11 (15,5) adenocarcinomas, 3 (4,2) tromboembolismo pulmonar, 2 (3) derrames parapneumonicos, 3 (4,2) empiemas, 3 (4,2) linfomas e 8 (11) transudatos. De acordo com o criterio de Meisel, a relacao Bb-L/Bb-S quando maior e igual a 0,6 caracteriza um derrame pleural exsudativo. Para o diagnostico de exsudatos pleurais, obteve-se: sensibilidade : 89, especificidade: 75, valor preditivo positivo: 97, valor preditivo negativo: 46 , acuracia: 87 (p<0,001). Conclusão: conclui-se que o critério de Meisel e um método auxiliar na diferenciação de derrames pleurais transudativos e exsudativos.

Prevalência de tuberculose pleural no ambulatório de pleurologia do Hospital Universitário Antônio Pedro / Prevalence of tuberculosis pleuritis in unit pleural diseases of the Antônio Pedro Hospital

Introdução: Estudo da prevalência de tuberculose pleural no Ambulatório de Pesquisa em Doenças Pleurais do Hospital Universitário Antônio Pedro, Niterói, RJ, entre março de 1994 e dezembro 1998. Métodos: Todos os pacientes encaminhados para procedimentos e exames que esclarecessem o diagnóstico da causa da síndrome do derrame pleural. Resultados: Um total de 218 pacientes foi avaliado. Tuberculose: 122 pacientes (56,0), limite de idade: 8 - 80 anos; transudato: 27 pacientes (12,0), 42 - 81 anos; adenocarcinoma: 23 pacientes (11,0), 18 - 79 anos; linfomas: 5 pacientes (2,0), 26 - 76 anos; carcinoma indiferenciado: 1 paciente (1,0), 18 anos; carcinoma escamoso: 2 pacientes (1,0), 71 anos cada um; empiema pleural não tuberculoso: 12 pacientes (5,0), 21 - 73 anos; parapneumômico: 10 pacientes (4,0), 9 - 44 anos; infarto pulmonar: 8 pacientes (4,0), 33 - 78 anos; lupus eritematoso sistêmico: 4 pacientes (2,0), 17 - 35 anos; quilotórax: 3 pacientes (1,0), 36 - 44 anos e hemotórax: 1 paciente (1,0) de 35 anos. Conclusão: A prevalência de tuberculose pleural foi de 56,0, com intervalo de confiança, a 95de probabilidade, entre 47,1a 64,8.