Biomarkers of treatment benefit with atezolizumab plus vemurafenib plus cobimetinib in BRAFV600 mutation-positive melanoma.

BACKGROUND: The phase III IMspire150 study (NCT02908672) demonstrated significantly improved progression-free survival (PFS) with atezolizumab, vemurafenib, and cobimetinib (atezolizumab group) versus placebo, vemurafenib, and cobimetinib (control group) in patients with BRAFV600-mutated advanced melanoma. We report exploratory biomarker analyses to optimize targeting of patients who are more likely to benefit from triplet combination therapy. PATIENTS AND METHODS: Five hundred fourteen patients were randomized to atezolizumab (n = 256) or control (n = 258). Outcomes were evaluated in subgroups defined by key biomarkers, including programmed death-ligand 1 (PD-L1) expression, lactate dehydrogenase (LDH) level, tumor mutational burden (TMB), and interferon-γ (IFN-γ) gene signature. Exploratory recursive partitioning analysis was then used to model associations between PFS and baseline covariates, including key biomarkers. RESULTS: PFS benefit for atezolizumab versus control was greater in patients with high TMB [≥10 mutations/Mb; hazard ratio (HR) 0.73; 95% confidence interval (CI) 0.52-1.02; P = 0.067] versus low TMB (<10 mutations/Mb; HR 0.92; 95% CI 0.65-1.30; P = 0.64) and similar between patients with strong IFN-γ (≥median; HR 0.76; 95% CI 0.54-1.06) versus weak IFN-γ (

A laboratory study of the scouting ability of two reciprocating glide path instruments in mesial root canals of extracted mandibular molars.

AIM: To evaluate in a laboratory setting the performance of two reciprocating glide path systems, WaveOne Gold Glider (WO) and R-Pilot (RP), to create a glide path in mesial root canals of mandibular molars and to assess the torsional resistance of instruments after performing the glide path. METHODOLOGY: A total of 60 mesial root canals of extracted human mandibular molars were divided into two groups (n = 30) according to the glide path system to be used. The data from the volume of each canal, acquired by microcomputed tomography (micro-CT), were validated statistically for the anatomical pairing of the groups. Preparation time, frequency in gaining apical patency, plastic deformation rate of instruments, and canal transportation and centring ability were recorded and compared statistically. The torsional fatigue of the instruments after use was also evaluated. Data were analysed using Fisher's exact test and Mann-Whitney U-test with a 5% significance level. RESULTS: No significant differences were found between groups regarding the time required to perform the glide path, the frequency distributions of the canals classified as patent and the instruments with plastic deformation after use (P > 0.05). No significant differences were found between groups regarding the degree of canal transportation and centring ability at the cervical, middle and apical thirds (P > 0.05). The RP groups had significantly greater maximum torsional strength values compared with the WO groups (P < 0.05). The used WO group had greater angular deflection to fracture when compared to the new WO group (P < 0.05). A significant difference was also found in the percentage of loss of angular deflection in a comparison of the WO group with the RP group (P < 0.05). CONCLUSIONS: The WO and RP instruments performed the same in terms of preparation time, plastic deformation, gaining apical patency, degree of canal transportation and centring ability. The RP instruments had greater torsional strength, less angular deflection and lower percentage of loss in angular deflection than the WO. The used WO group had the greatest angular deflection values.

Whole-Genome Enrichment Provides Deep Insights into Vibrio cholerae Metagenome from an African River.

The detection and typing of Vibrio cholerae in natural aquatic environments encounter major methodological challenges related to the fact that the bacterium is often present in environmental matrices at very low abundance in nonculturable state. This study applied, for the first time to our knowledge, a whole-genome enrichment (WGE) and next-generation sequencing (NGS) approach for direct genotyping and metagenomic analysis of low abundant V. cholerae DNA (<50 genome unit/L) from natural water collected in the Morogoro river (Tanzania). The protocol is based on the use of biotinylated RNA baits for target enrichment of V. cholerae metagenomic DNA via hybridization. An enriched V. cholerae metagenome library was generated and sequenced on an Illumina MiSeq platform. Up to 1.8 × 107 bp (4.5× mean read depth) were found to map against V. cholerae reference genome sequences representing an increase of about 2500 times in target DNA coverage compared to theoretical calculations of performance for shotgun metagenomics. Analysis of metagenomic data revealed the presence of several V. cholerae virulence and virulence associated genes in river water including major virulence regions (e.g. CTX prophage and Vibrio pathogenicity island-1) and genetic markers of epidemic strains (e.g. O1-antigen biosynthesis gene cluster) that were not detectable by standard culture and molecular techniques. Overall, besides providing a powerful tool for direct genotyping of V. cholerae in complex environmental matrices, this study provides a 'proof of concept' on the methodological gap that might currently preclude a more comprehensive understanding of toxigenic V. cholerae emergence from natural aquatic environments.

The effects of repetitive haemarthrosis on postural balance in children with haemophilia.

Sensory information from visual, vestibular and proprioceptive systems is necessary to control posture and balance. Impairment in proprioception due to repetitive joints bleeding may lead to a deficit in postural balance which, in turn, leads to high joint stress and risk of bleeding recurrence. Despite the increase in attention in this field during the past few years, the data concerning to how bleeds can affect postural control in children with haemophilia (CWH) remain scarce. This study aimed to evaluate the postural balance in CWH. Twenty CWH Haemophilia Group (HG) and 20 age-matched children Control Group (CG) were recruited to this study. A force plate was used to record centre of pressure (COP) displacement under four different postural conditions during quiet standing: eyes open on firm surface, eyes open on foam surface, eyes closed on firm surface and eyes closed on a foam surface. Variables of COP as sway area and mean velocity and in anterior-posterior (y) medio-lateral (x) direction were processed and for each variable sensory, quotients were calculated and compared between groups. No differences were found in visual and vestibular quotients variables between groups. A higher value was found in sway area variable on proprioception quotient in the HG when compared with CG (P = 0.042). CWH with repetitive joint bleed on lower limbs showed differences in postural balance when compared with non-haemophiliac children. The identification of early balance impairments in CWH can help us understand better the effects of bleeds inside joints on postural control and plan a more effective preventive and rehabilitative treatment.

Postural adjustment after an unexpected perturbation in children with haemophilia.

Children with haemophilia often bleed inside joints and muscles, which may impair postural adjustments. These postural adjustments are necessary to control postural balance during daily activities. The inability to quickly recover postural balance could elevate the risk of bleeding. To determine whether children with haemophilia have impaired postural adjustment after an unexpected perturbation compared with healthy children. Twenty children with haemophilia comprised the haemophilic group (HG), and 20 healthy, age-paired children comprised the control group (CG). Subjects stood on a force plate, and 4% of the subjects' body weight was applied via a pulley system to a belt around the subjects' trunks. The centre of pressure (COP) displacement was measured after the weight was unexpectedly released to produce a controlled postural perturbation followed by postural adjustment to recover balance. The subjects' postural adjustments in eight subsequent intervals of 1 s (t1-t8), beginning with the moment of weight removal, were compared among intervals and between groups. The applied perturbation magnitudes were the same for both groups, and no difference was observed between the groups in t1. However, the COP displacement in t2 in the HG was significantly higher than in the CG. No differences were observed between the groups in the other intervals. Within-group analysis showed that the COP was higher in t2 than in t4 (P = 0.016), t5 (P = 0.001) and t8 (P = 0.050) in the HG. No differences were observed among intervals in the CG. Children with haemophilia demonstrated differences in postural adjustment while undergoing unexpected balance perturbations when compared with healthily children.

Potentially adverse interactions between haloperidol and valerian.

This study was designed to determine whether the treatment with haloperidol (HP), valerian or both in association impairs the liver or kidney functions. Valerian alone did not affect oxidative stress parameters in the liver or kidney of rats. HP alone only increased glutathione (GSH) depletion in liver, but not in kidney. However, when HP was associated with valerian, an increase in lipid peroxidation levels and dichlorofluorescein (DCFH) reactive species production was observed in the hepatic tissue. Superoxide dismutase (SOD) and Catalase (CAT) activities were not affected by the HP plus valerian treatment in the liver and kidney of rats. HP and valerian when administered independently did not affect the activity of hepatic and renal delta-aminolevulinate dehydratase (delta-ALA-D), however, these drugs administered concomitantly provoked an inhibition of hepatic delta-ALA-D activity. The delta-ALA-D reactivation index was higher in rats treated with HP plus valerian than other treated groups. These results strengthen the view that delta-ALA-D can be considered a marker for oxidative stress. Serum aspartate aminotransferase (AST) activity was not altered by any treatment. However, serum alanine aminotransferase (ALT) activity was higher in the HP group and HP plus valerian group. Our findings suggest adverse interactions between haloperidol and valerian.

Ilex paraguariensis has antioxidant potential and attenuates haloperidol-induced orofacial dyskinesia and memory dysfunction in rats.

Tardive dyskinesia (TD) is a syndrome associated with administration of antipsychotics drugs and may be a consequence of a free radical increase. Ilex paraguariensis (IP), rich in polyphenols, is used to prepare a tea-like beverage, the "mate", and has been investigated for its antioxidant action. Here, we examined the aqueous extract of IP on in vitro TBARS production and in vivo study, using two behavioral models, i.e., haloperidol-induced orofacial dyskinesia (evaluated measuring vacuous chewing movements, VCMs) and memory dysfunction, evaluated in a water-maze task. In vitro, we examine different concentrations of IP against the basal, Fe(II) and sodium nitruproside-induced TBARS production in rat brain homogenate. IP extract was able to prevent the basal formation of TBARS (IC50 = 6.6 mg/ml) and TBARS induced by SNP (IC50 = 3.7 mg/ml) and Fe(II) (IC50= 4.8 mg/ml). Haloperidol administration (12 mg/kg/week, im, x4 weeks) increased VCMs (p <0.001). Rats treated with mate (50 g/l, ad libitum, 60 days) did not exhibit the increase in VCMs observed in control rats treated with haloperidol (p <0.001). In the water maze task, haloperidol treated animals displayed an impairment in memory acquisition (p <0.05) compared to rats treated with vehicle. The "mate" prevented the effects of haloperidol in this behavioral paradigm. Our results indicate that IP exhibits an antioxidant role probably related to the presence of polyphenols. The benefit of IP is possibly related to an indirect modulation of oxidative stress.

Dexmedetomidine decreases the inflammatory response to myocardial surgery under mini-cardiopulmonary bypass.

Cardiopulmonary bypass (CPB) with extracorporeal circulation produces changes in the immune system accompanied by an increase in proinflammatory cytokines and a decrease in anti-inflammatory cytokines. We hypothesize that dexmedetomidine (DEX) as an anesthetic adjuvant modulates the inflammatory response after coronary artery bypass graft surgery with mini-CPB. In a prospective, randomized, blind study, 12 patients (4 females and 8 males, age range 42-72) were assigned to DEX group and compared with a conventional total intravenous anesthesia (TIVA) group of 11 patients (4 females and 7 males). The endpoints used to assess inflammatory and biochemical responses to mini-CPB were plasma interleukin (IL)-1, IL-6, IL-10, interferon (INF)-γ, tumor necrosis factor (TNF)-α, C-reactive protein, creatine phosphokinase, creatine phosphokinase-MB, cardiac troponin I, cortisol, and glucose levels. These variables were determined before anesthesia, 90 min after beginning CPB, 5 h after beginning CPB, and 24 h after the end of surgery. Endpoints of oxidative stress, including thiobarbituric acid reactive species and delta-aminolevulinate dehydratase activity in erythrocytes were also determined. DEX+TIVA use was associated with a significant reduction in IL-1, IL-6, TNF-α, and INF-γ (P<0.0001) levels compared with TIVA (two-way ANOVA). In contrast, the surgery-induced increase in thiobarbituric acid reactive species was higher in the DEX+TIVA group than in the TIVA group (P<0.01; two-way ANOVA). Delta-aminolevulinate dehydratase activity was decreased after CPB (P<0.001), but there was no difference between the two groups. DEX as an adjuvant in anesthesia reduced circulating IL-1, IL-6, TNF-α, and INF-γ levels after mini-CPB. These findings indicate an interesting anti-inflammatory effect of DEX, which should be studied in different types of surgical interventions.

Large-scale whole genome sequencing of M. tuberculosis provides insights into transmission in a high prevalence area.

To improve understanding of the factors influencing tuberculosis transmission and the role of pathogen variation, we sequenced all available specimens from patients diagnosed over 15 years in a whole district in Malawi. Mycobacterium tuberculosis lineages were assigned and transmission networks constructed, allowing ≤10 single nucleotide polymorphisms (SNPs) difference. We defined disease as due to recent infection if the network-determined source was within 5 years, and assessed transmissibility from forward transmissions resulting in disease. High-quality sequences were available for 1687 disease episodes (72% of all culture-positive episodes): 66% of patients linked to at least one other patient. The between-patient mutation rate was 0.26 SNPs/year (95% CI 0.21-0.31). We showed striking differences by lineage in the proportion of disease due to recent transmission and in transmissibility (highest for lineage-2 and lowest for lineage-1) that were not confounded by immigration, HIV status or drug resistance. Transmissions resulting in disease decreased markedly over time.

Factors associated with emergency department visits due to acute asthma.

It is important to identify characteristics related to poor disease control and frequent visits to the emergency department (ED). The objective of the present study was to compare the characteristics of patients attending the adult ED for treatment of asthma exacerbation with those attending an asthma specialist clinic (AC) in the same hospital, and to determine the factors associated with frequent visits to the ED. We conducted a cross-sectional survey of consecutive patients (12 years and older) attending the ED (N = 86) and the AC (N = 86). Significantly more ED patients than AC patients reported ED visits in the past year (95.3 vs 48.8%; P < 0.001) and had difficulty performing work (81.4 vs 49.4%; P < 0.001. Significantly more AC than ED patents had been treated with inhaled corticosteroids (75.6 vs 18.6%; P < 0.001) used to increase or start steroid therapy when an attack was perceived (46.5 vs 20.9%; P < 0.001) and correctly used a metered-dose inhaler (50.0 vs 11.6%; P < 0.001). The history of hospital admissions (odds ratio, OR, 4.00) and use of inhaled corticosteroids (OR, 0.27) were associated with frequent visits to the ED. In conclusion, ED patients were more likely than AC patients to be dependent on the acute use of the ED, were significantly less knowledgeable about asthma management and were more likely to suffer more severe disease. ED patients should be considered an important target for asthma education. Facilitating the access to ambulatory care facilities might serve to reduce asthma morbidity.

[Opiates in pain management: correct or underestimated use? Data from a university hospital]. / Opióides no manejo da dor--uso correto ou subestimado? Dados de um hospital universitário.

OBJECTIVE: Opiates use, mainly in the treatment of acute intense pain (post-surgical patients) and chronic pain in oncologic patients has been usually underestimated in general clinical practice. This paper has the objective to assess the pattern of opiates use (Meperidin and Morphine), that is being used in Hospital de Clínicas de Porto Alegre, Rio Grande do Sul (Brazil). MATERIAL AND METHOD: Medical teams prescriptions were analyzed using the following parameters: pattern of use, dose, interval and the use of concomitant analgesics. 1,107 prescriptions were analyzed, related to 445 inpatients, in the period from May to July of 1993. RESULTS AND DISCUSSION: Only 6.5% of all prescriptions were considered correct. The pattern if necessary was responsible for 74% of all prescriptions. CONCLUSIONS: Pain, either acute or chronic, is not being adequately managed in our hospital.

Dexmedetomidine decreases the inflammatory response to myocardial surgery under mini-cardiopulmonary bypass

Cardiopulmonary bypass (CPB) with extracorporeal circulation produces changes in the immune system accompanied by an increase in proinflammatory cytokines and a decrease in anti-inflammatory cytokines. We hypothesize that dexmedetomidine (DEX) as an anesthetic adjuvant modulates the inflammatory response after coronary artery bypass graft surgery with mini-CPB. In a prospective, randomized, blind study, 12 patients (4 females and 8 males, age range 42-72) were assigned to DEX group and compared with a conventional total intravenous anesthesia (TIVA) group of 11 patients (4 females and 7 males). The endpoints used to assess inflammatory and biochemical responses to mini-CPB were plasma interleukin (IL)-1, IL-6, IL-10, interferon (INF)-γ, tumor necrosis factor (TNF)-α, C-reactive protein, creatine phosphokinase, creatine phosphokinase-MB, cardiac troponin I, cortisol, and glucose levels. These variables were determined before anesthesia, 90 min after beginning CPB, 5 h after beginning CPB, and 24 h after the end of surgery. Endpoints of oxidative stress, including thiobarbituric acid reactive species and delta-aminolevulinate dehydratase activity in erythrocytes were also determined. DEX+TIVA use was associated with a significant reduction in IL-1, IL-6, TNF-α, and INF-γ (P<0.0001) levels compared with TIVA (two-way ANOVA). In contrast, the surgery-induced increase in thiobarbituric acid reactive species was higher in the DEX+TIVA group than in the TIVA group (P<0.01; two-way ANOVA). Delta-aminolevulinate dehydratase activity was decreased after CPB (P<0.001), but there was no difference between the two groups. DEX as an adjuvant in anesthesia reduced circulating IL-1, IL-6, TNF-α, and INF-γ levels after mini-CPB. These findings indicate an interesting anti-inflammatory effect of DEX, which should be studied in different types of surgical interventions.

Factors associated with uncontrolled asthma in Porto Alegre, Brazil.

The prevalence of uncontrolled and controlled asthma, and the factors associated with uncontrolled asthma were investigated in a cross-sectional study. Patients aged 11 years with confirmed asthma diagnosis were recruited from the outpatient asthma clinic of Hospital de Clínicas de Porto Alegre, Brazil. Patients were excluded if they had other chronic pulmonary disease. They underwent an evaluation by a general questionnaire, an asthma control questionnaire (based on the 2006 Global Initiative for Asthma guidelines), assessment of inhaled device technique and pulmonary function tests. Asthma was controlled in 48 of 275 patients (17.5%), partly controlled in 74 (26.9%) and uncontrolled in 153 (55.6%). In the univariate analysis, asthma severity was associated with asthma control (P < 0.001). Availability of asthma medications was associated with asthma control (P = 0.01), so that most patients who could purchase medications had controlled asthma, while patients who depend on the public health system for access to medications had lower rates of controlled asthma. The use of inhaled corticosteroid was lower in the uncontrolled group (P < 0.001). Logistic regression analysis identified three factors associated with uncontrolled asthma: severity of asthma (OR = 5.33, P < 0.0001), access to medications (OR = 1.97, P = 0.025) and use of inhaled corticosteroids (OR = 0.17, P = 0.030). This study showed a high rate of uncontrolled asthma in patients who attended an outpatient asthma clinic. Severity of asthma, access to medications and adequate use of inhaled corticosteroids were associated with the degree of asthma control.

Lung distensibility and airway function in intermediate alpha 1-antitrypsin deficiency (Pi MZ).

We examined the role of intermediate alpha 1-antitrypsin deficiency in predisposing to abnormalities of lung distensibility and airway function in 20 heterozygotes (Pi MZ) who were individually matched with a control Pi M subject of similar age, height, and smoking habits drawn from the same male, working population. There were no significant differences between the heterozygotes and their controls in the results of spirometry, maximum expiratory flow-volume curves (breathing air), single breath nitrogen test, arterialised capillary blood oxygen pressure, or single breath carbon monoxide transfer. Additional studies were made in 12 of the pairs of Pi MZ and Pi M subjects. Comparison of maximum expiratory flow-volume curves breathing air and 80% helium-20% oxygen showed no differences between the Pi MZ and Pi M subjects. Although airway function was similar in the two groups, four of 12 Pi MZ subjects showed abnormalities of the pressure-volume curve of the lung (reduction in lung recoil pressure, abnormal shape factor, increase in functional residual capacity). Abnormalities of washout of a helium-sulphur hexafluoride gas mixture, of a type previously described as characteristic of emphysema, were found in two of the men with abnormal pressure-volume curves. The results suggest that Pi MZ subjects have an increased susceptibility to alveolar abnormalities without increased abnormalities of airway function; this may explain the increased frequency of emphysema at necropsy despite many studies showing no predisposition to abnormal airway function in life. The functional changes we observed would be unlikely to cause symptoms. The risk of disablement from chronic lung disease appears to be only slightly enhanced by intermediate alpha 1-antitrypsin deficiency.

The diagnosis of Pneumocystis carinii pneumonia by cytologic evaluation of Papanicolaou and Leishman-stained bronchoalveolar specimens in patients with the acquired immunodeficiency syndrome.

The presence of foamy alveolar casts or flocculent material in Papanicolaou and Leishman-stained smears of bronchoalveolar lavage (BAL) fluid is said to be indicative of infection with Pneumocystis carinii. We have investigated the sensitivity and specificity of this method of diagnosing pneumocystis pneumonia in patients with the acquired immunodeficiency syndrome (AIDS). Patients (n = 114) with diffuse lung infiltrates were submitted to fibreoptic bronchoscopy and BAL. Seventy of them were patients with AIDS. The other 44 individuals were not infected by the human immunodeficiency virus (HIV). Pneumocystis carinii organisms were identified on Grocott's methenamine silver (GMS)-stained BAL smears in 30 patients with AIDS. Flocculent material was present in the Papanicolaou and Leishman-stained smears from all of these cases. Conversely, P. carinii were not seen on GMS-stained smears in the remaining 84 individuals with or without AIDS. No flocculent material was observed in Papanicolaou or Leishman-stained smears in these 84 patients. We concluded that the presence of flocculent material in Papanicolaou or Leishman-stained smears of BAL fluid is indicative of P. carinii pneumonia in patients with AIDS.

Factors associated with uncontrolled asthma in Porto Alegre, Brazil

The prevalence of uncontrolled and controlled asthma, and the factors associated with uncontrolled asthma were investigated in a cross-sectional study. Patients aged 11 years with confirmed asthma diagnosis were recruited from the outpatient asthma clinic of Hospital de Clínicas de Porto Alegre, Brazil. Patients were excluded if they had other chronic pulmonary disease. They underwent an evaluation by a general questionnaire, an asthma control questionnaire (based on the 2006 Global Initiative for Asthma guidelines), assessment of inhaled device technique and pulmonary function tests. Asthma was controlled in 48 of 275 patients (17.5 percent), partly controlled in 74 (26.9 percent) and uncontrolled in 153 (55.6 percent). In the univariate analysis, asthma severity was associated with asthma control (P < 0.001). Availability of asthma medications was associated with asthma control (P = 0.01), so that most patients who could purchase medications had controlled asthma, while patients who depend on the public health system for access to medications had lower rates of controlled asthma. The use of inhaled corticosteroid was lower in the uncontrolled group (P < 0.001). Logistic regression analysis identified three factors associated with uncontrolled asthma: severity of asthma (OR = 5.33, P < 0.0001), access to medications (OR = 1.97, P = 0.025) and use of inhaled corticosteroids (OR = 0.17, P = 0.030). This study showed a high rate of uncontrolled asthma in patients who attended an outpatient asthma clinic. Severity of asthma, access to medications and adequate use of inhaled corticosteroids were associated with the degree of asthma control.

Opióides no manejo da dor: uso correto ou subestimado? Dados de um hospital universitário / Opiates in pain management: correct or underestimated use? Data from a university hospital

Objetivo. O uso de opióides, principalmente no tratamento da dor intensa aguda (pacientes no pós-operatório) e da dor crônica em pacientes oncológicos, tem sido subestimado na prática clínica em geral. Este trabalho tem o objetivo de verificar o perfil de prescriçao de opióides (meperidina e morfina) no Hospital de Clínicas de Porto Alegre (HCPA), RS. Materiais e Métodos. Análise da conduta das equipes médicas, pela revisao de 1.107 prescriçoes, relativas a 445 pacientes internados no HCPA, entre 20 de maio e 20 de julho de 1993. Os parâmetros básicos de análise, para conduta, incluíam: padrao de uso, a dose do fármaco, intervalo entre doses e analgésicos simultâneos. Discussao e Resultados. Foram encontradas apenas 6,5 por cento de prescriçoes consideradas adequadas em relaçao aos parâmetros dose, intervalo e padrao, analisados conjuntamente. O padrao se necessário foi responsável por 74 por cento do total de prescriçoes. Conclusoes. Os resultados obtidos durante a realizaçao do trabalho permitem-nos concluir que nao há um manejo adequado da dor, tanto aguda como crônica, nos pacientes internados no HCPA.

Factors associated with emergency department visits due to acute asthma

It is important to identify characteristics related to poor disease control and frequent visits to the emergency department (ED). The objective of the present study was to compare the characteristics of patients attending the adult ED for treatment of asthma exacerbation with those attending an asthma specialist clinic (AC) in the same hospital, and to determine the factors associated with frequent visits to the ED. We conducted a cross-sectional survey of consecutive patients (12 years and older) attending the ED (N = 86) and the AC (N = 86). Significantly more ED patients than AC patients reported ED visits in the past year (95.3 vs 48.8 percent; P < 0.001) and had difficulty performing work (81.4 vs 49.4 percent; P < 0.001. Significantly more AC than ED patents had been treated with inhaled corticosteroids (75.6 vs 18.6 percent; P < 0.001) used to increase or start steroid therapy when an attack was perceived (46.5 vs 20.9 percent; P < 0.001) and correctly used a metered-dose inhaler (50.0 vs 11.6 percent; P < 0.001). The history of hospital admissions (odds ratio, OR, 4.00) and use of inhaled corticosteroids (OR, 0.27) were associated with frequent visits to the ED. In conclusion, ED patients were more likely than AC patients to be dependent on the acute use of the ED, were significantly less knowledgeable about asthma management and were more likely to suffer more severe disease. ED patients should be considered an important target for asthma education. Facilitating the access to ambulatory care facilities might serve to reduce asthma morbidity.