Aproximando a Atenção Especializada da Atenção Primária à Saúde: em busca do cuidado integral ao paciente com asma no Brasil / Aligning Specialized Care with Primary Health Care: in search of comprehensive care for asthma patients in Brazil

A ocorrência de doenças alérgicas e asma ainda cresce em muitos países. Dados mostram que aproximadamente um quarto dos habitantes de países industrializados apresenta algum tipo de alergia, e nos países em desenvolvimento estas doenças podem alcançar proporções ainda maiores da população. No Brasil, embora não exista até o momento uma agenda política nacional de atenção à saúde dos pacientes com alergias e asma, iniciativas individuais em diferentes regiões têm beneficiado milhares de pacientes ao longo das últimas décadas. Estes programas têm como principais objetivos qualificar o cuidado em saúde, melhorar a qualidade de vida (especialmente dos pacientes com asma e rinite alérgica) e reduzir os indicadores de morbimortalidade relacionados às doenças. Com essa finalidade, os programas vêm se ocupando de diversas ações de educação em saúde, capacitação profissional, busca ativa para garantir diagnóstico e tratamento oportuno, e proporcionar acesso a medicamentos de forma gratuita e continuada. Entretanto, a falta de um caráter institucional que garanta o acesso universal a ações cientificamente fundamentadas, impede a equidade e a continuidade do cuidado, além de dificultar a atenção integral em asma e em outras doenças alérgicas.

Allergic diseases and asthma are on the rise in many countries. Data show that approximately 25% of the inhabitants of industrialized countries have some type of allergy, reaching even greater proportions in developing countries. Although a national health care agenda for patients with allergies and asthma has not yet been developed in Brazil, individual initiatives in different regions have benefited thousands of patients in recent decades. The main objectives of these programs are to improve health care, quality of life (especially for patients with asthma and allergic rhinitis), and reduce disease-related morbidity and mortality indicators. To this end, these programs have been engaged in health education actions, professional training, performing active searches to ensure timely diagnosis and treatment, and providing free and continuous access to medication. However, the due to the non-institutional character of these programs, universal access, evidence-based actions, and continuity of care are not guaranteed, and it is difficult to provide comprehensive care for asthma and other allergic diseases.

Exposure to intimate partner violence and lack of asthma control in adults: a cross-sectional study

ABSTRACT BACKGROUND: Asthma is a chronic airway disease that affects 339 million people worldwide. It is a heterogeneous disease with different risks, including in family environments, where intimate partner violence occurs. OBJECTIVE: This study aimed to investigate the possible association between psychosocial factors and asthma control in adults exposed to intimate partner violence. DESIGN AND SETTING: This cross-sectional study was conducted at a Brazilian public higher education institution in Salvador, Bahia, Brazil. METHODS: The study population consisted of adults clinically diagnosed with severe asthma and those with mild/moderate asthma identified at an asthma referral outpatient clinic. The sample comprised 492 participants who underwent clinical evaluation and completed questionnaires to assess asthma control, depression, stress, and resilience. The Conflict Tactics Scale, which measures tactics for managing marital conflicts, was used to estimate the level of intimate partner violence. RESULTS: Of the 492 participants, 76.2% were women and 91% self-referenced color black/brown, 37.8% reported low family income, 87.4% reported low education level, 71.7% reported high stress, 32.5% reported low resilience, 18.5% reported moderate or severe depression, 83.3% reported resolute negotiation, 49.4% reported major psychological aggression, 19.6% reported major physical aggression, 15.5% reported major injury, and 7.3% reported major sexual coercion. Regression analysis revealed that sex was an effect modifier. CONCLUSION: Women in situations of social vulnerability, with low income and poor education, with depression, severe asthma, and those who used aggression to resolve marital conflicts had a profile associated with a lack of asthma control.

A especialidade de Alergia e Imunologia Clínica no Brasil: como começamos a segunda década do século XXI? / The specialty of Allergy and Clinical Immunology in Brazil: how do we start the second decade of the 21st century?

Introdução: É necessário conhecer a situação de alergistas/ imunologistas nos diferentes cenários de atuação, identificando perfis e eventuais dificuldades. O conhecimento destes dados poderá servir de subsídio para fomentar a implementação de políticas que garantam a integralidade na atenção à saúde do paciente com doenças alérgicas e erros inatos da imunidade (EII). Objetivo: Verificar o perfil dos especialistas em Alergia e Imunologia no Brasil, em relação ao local de atuação, acesso a exames, terapias e o impacto da pandemia COVID-19 sobre o seu exercício profissional. Métodos: Estudo descritivo-exploratório, com dados coletados por inquérito on-line, utilizando-se a ferramenta Google Forms. Todos os associados adimplentes da ASBAI foram convidados a participar. O questionário abordou aspectos sociodemográficos e profissionais. As informações foram analisadas no programa SPSS versão 20.0. Resultados: Quatrocentos e sessenta associados responderam ao questionário. Observou-se predomínio de mulheres (73%), com mediana de idade de 47 anos. A maioria dos participantes atua no setor privado (95%), e 47% no setor público. Aproximadamente 80% dos que atendem no setor público referiram ter acesso a algum exame diagnóstico para doenças alérgicas e EII. Apenas 35% dos especialistas do sistema público têm acesso a imunoterapia alérgeno específica, contra 96% dos que atuam no setor privado. Já aos medicamentos imunobiológicos, 53% e 72% dos especialistas que atuam no serviço público e privado, respectivamente, referiram acesso. Mais de 60% dos associados participantes da pesquisa tiveram redução no número de consultas em pelo menos 50%, e 56% tem realizado atendimento por teleconsulta durante a pandemia de COVID-19. Conclusão: Os associados da ASBAI têm incorporado na sua prática clínica os avanços na terapia das doenças imunoalérgicas, mas vários métodos diagnósticos ainda são pouco acessíveis. A presença do especialista em Alergia e Imunologia no SUS, também precisa ser ampliada. A pandemia do coronavírus trouxe a discussão da telemedicina como um método de atendimento clínico em nossa especialidade.

Introduction: It is necessary to know the situation of allergists/ immunologists in different scenarios of action, identifying profiles and possible difficulties. The knowledge of these data can serve as a subsidy to promote the implementation of policies that ensure comprehensive health care for patients with allergic diseases and inborn errors of immunity (IEI). Objective: To verify the profile of specialists in Allergy and Immunology in Brazil, concerning the place of work, access to tests, therapies, and the impact of the pandemic on their professional practice. Methods: Descriptive-exploratory study, with data collected through an online survey, using the Google Forms tool. All compliant ASBAI members were invited to participate. The questionnaire addressed sociodemographic and professional aspects. The information was analyzed using SPSS version 20.0. Results: Four hundred and sixty associates answered the questionnaire. Women were predominant (73%), and the median age was 47 years. Most participants work in the private sector (95%) and 47% in the public sector. Approximately 80% of those who work in the public sector reported having access to some diagnostic tests for allergic diseases and IEI. Only 35% of specialists in the public system have access to specific allergen immunotherapy, against 96% of those working in the private sector. As for immunobiological drugs, 53% and 72% of specialists working in the public and private service, respectively, reported access. More than 60% of the members participating in the survey had a reduction in the number of consultations by at least 50% and 56% have been assisted by teleconsultation during the Covid19 pandemic. Conclusion: ASBAI associates have incorporated advances in the therapy of immune allergic diseases into their clinical practice, but several diagnostic methods are still inaccessible. The presence of specialists in Allergy and Immunology in the Unified Health System (Sistema Único de Saúde - SUS) also needs to be expanded. The coronavirus pandemic brought the discussion of telemedicine as a method of clinical care practice in our specialty.

Asthma mortality in children and adolescents of Brazil over a 20-year period / Mortalidade por asma em crianças e adolescentes no Brasil ao longo de 20 anos

Abstract Objective: To evaluate the number of asthma deaths and the temporal trend of the asthma-specific mortality rate in children and adolescents up to 19 years of age in Brazil. Methods: This is an ecological time-series study of asthma deaths reported in Brazil, in the population up to 19 years of age, between 1996 and 2015. The specific asthma mortality rate and its temporal trend were analyzed. Results: There were 5014 deaths during the 20 years evaluated, with the majority, 68.1%, being recorded in children under 5 years of age. The specific asthma mortality rate ranged from 0.57/100,000 in 1997 to 0.21/100,000 in 2014, with a significant reduction of 59.8%. Regarding the place of death, 79.4% occurred in a hospital setting. In this sample, the adolescents had a 1.5-fold higher chance of death out-of-hospital than children up to nine years of age. There was no significant difference in the temporal trend between the genders and no significant decrease in out-of-hospital deaths. Conclusions: This study found a temporal trend for a reduction in asthma deaths over 20 years in children and adolescents in Brazil. Mortality rates varied across the geographic regions of the country and were higher in the Northeast. The prevalence of deaths under 5 years of age may be associated with the greater vulnerability of this age group in low-income countries. In adolescence, deaths outside the hospital environment are noteworthy. Asthma deaths are rare but unacceptable events, considering the treatable nature of the disease and the presence of avoidable factors in most of fatal outcomes.

Resumo Objetivo: Estimar o número de óbitos por asma e a tendência temporal da taxa de mortalidade por asma em crianças e adolescentes no Brasil. Métodos: Estudo ecológico de séries temporais em que foram avaliados os óbitos por asma ocorridos no Brasil entre 1996 e 2015, na população com até 19 anos. Foram analisadas a taxa de mortalidade específica por asma e a sua tendência temporal. Resultados: Ocorreram 5.014 óbitos, a maioria (68,1%) registrada em menores de cinco anos. Observou-se uma oscilação da taxa de mortalidade específica por asma entre 0,57 e 0,21/100.000 habitantes, o que correspondeu a uma redução de 59,8% no período. Quanto ao local dos óbitos, 79,4% ocorreram em ambiente hospitalar. Nesta amostra o adolescente teve 1,5 vez mais chance de óbito por asma fora do ambiente hospitalar do que as crianças até nove anos. Não foi observada diferença significativa da redução da tendência temporal entre os sexos e dos óbitos fora do ambiente hospitalar. Conclusões: Houve tendência temporal de redução da mortalidade por asma em crianças e adolescentes nos 20 anos avaliados. As taxas de mortalidade variaram nas diversas regiões geográficas do país, foram mais elevadas na Região Nordeste. O predomínio dos óbitos abaixo de cinco anos pode se associar a maior vulnerabilidade desse grupo em países de baixa renda. Na adolescência, ressaltam-se óbitos fora do ambiente hospitalar. As mortes por asma são eventos inaceitáveis, considera-se o caráter tratável da doença e a presença de fatores evitáveis na maioria dos desfechos fatais.

Exposure to secondhand smoke among patients with asthma: a cross-sectional study.

OBJECTIVE: To estimate the frequency of secondhand smoke exposure among patients with asthma. METHODS: A cross-sectional study of asthma patients and non-asthmatic controls using questionnaires to identify secondhand smoke exposure at home, school, work, and public places. RESULTS: We studied 544 severe asthma patients, 452 mild/moderate asthma patients, and 454 non-asthmatic patients. Among severe patients, the mean age was 51.9 years, 444 (81.6%) were female, 74 (13.6%) were living with a smoker, 383 (71.9%) reported exposure in public spaces and, of the 242 (44.5%) who worked/ studied, 46 (19.1%) reported occupational exposure. Among those with mild/moderate asthma, the mean age was 36.8 years, 351 (77.7%) were female, 50 (11.1%) reported living with a smoker, 381 (84.9%) reported exposure in public settings and, of the 330 (73.0%) who worked/ studied, 58 (17.7%) reported occupational exposure. An association between secondhand smoke exposure and disease control was found among patients with mild/moderate asthma. Among those interviewed, 71% of severe asthma patients and 63% of mild/moderate asthma patients avoided certain places due to fear of secondhand smoke exposure. CONCLUSION: Secondhand smoke exposure is a situation frequently reported by a significant proportion of asthma patients. Individuals with asthma are exposed to this agent, which can hamper disease control, exacerbate symptoms and pose unacceptable limitations to their right to come and go in public settings.

Exposure to secondhand smoke among patients with asthma: a cross-sectional study / Exposição à fumaça secundária do cigarro entre pacientes com asma: estudo transversal

ABSTRACT Objective To estimate the frequency of secondhand smoke exposure among patients with asthma. Methods A cross-sectional study of asthma patients and non-asthmatic controls using questionnaires to identify secondhand smoke exposure at home, school, work, and public places. Results We studied 544 severe asthma patients, 452 mild/moderate asthma patients, and 454 non-asthmatic patients. Among severe patients, the mean age was 51.9 years, 444 (81.6%) were female, 74 (13.6%) were living with a smoker, 383 (71.9%) reported exposure in public spaces and, of the 242 (44.5%) who worked/ studied, 46 (19.1%) reported occupational exposure. Among those with mild/moderate asthma, the mean age was 36.8 years, 351 (77.7%) were female, 50 (11.1%) reported living with a smoker, 381 (84.9%) reported exposure in public settings and, of the 330 (73.0%) who worked/ studied, 58 (17.7%) reported occupational exposure. An association between secondhand smoke exposure and disease control was found among patients with mild/moderate asthma. Among those interviewed, 71% of severe asthma patients and 63% of mild/moderate asthma patients avoided certain places due to fear of secondhand smoke exposure. Conclusion Secondhand smoke exposure is a situation frequently reported by a significant proportion of asthma patients. Individuals with asthma are exposed to this agent, which can hamper disease control, exacerbate symptoms and pose unacceptable limitations to their right to come and go in public settings.

RESUMO Objetivo Estimar a frequência de exposição à fumaça secundária do cigarro entre pacientes com asma. Métodos Estudo transversal, que avaliou pacientes com asma e controles sem asma, por meio de questionários, para identificar a exposição secundária à fumaça do cigarro no ambiente domiciliar, escolar, no trabalho e em ambientes públicos. Resultados Estudamos 544 asmáticos graves, 452 com asma leve/moderada e 454 sem asma. Entre os asmáticos graves, a média de idade foi de 51,9 anos, 444 (81,6%) eram do sexo feminino, 74 (13,6%) tinham fumantes em sua residência, 383 (71,9%) relataram exposição em ambientes públicos e, dos 242 (44,5%) que trabalhavam e/ou estudavam, 46 (19,1%) admitiram exposição ocupacional. Entre asmáticos leves/moderados, a média de idade foi de 36,8 anos, 351 (77,7%) eram do sexo feminino, 50 (11,1%) afirmaram haver tabagistas em sua residência, 381(84,9%) relataram exposição em ambientes públicos e, dos 330 (73,0%) que trabalhavam e/ou estudavam, 58 (17,7%) referiram exposição ocupacional. Encontrou-se associação entre exposição à fumaça secundária do cigarro e controle da doença entre pacientes com asma leve/moderada. Entre os entrevistados, 71% dos pacientes asmáticos graves e 63% daqueles com asma leve/moderada relataram evitar frequentar certos ambientes pelo receio da exposição à fumaça secundária do cigarro − relato mais associado aos pacientes com asma grave. Conclusão A exposição secundária à fumaça do cigarro é uma situação frequente e relatada por uma proporção significativa de asmáticos. Indivíduos com asma encontram-se expostos a este agente, que pode dificultar o controle da doença, exacerbar sintomas e lhes impor limitação inaceitável ao direito de ir e vir em ambientes públicos.

Características clínicas e fatores associados à asma grave em Salvador, Brasil / Clinical features and associated factors with severe asthma in Salvador, Brazil

RESUMO Objetivo Descrever características clínicas e identificar fatores associados a maior gravidade da asma, em uma amostra de pacientes acompanhados em um centro de referência em Salvador. Métodos Estudo transversal de 473 adultos, acompanhados regularmente no Programa para Controle da Asma na Bahia (ProAR), reavaliados de forma sistemática entre 2013 e 2015. Os pacientes foram admitidos por preencher critérios anteriores de asma grave e reclassificados de acordo com a definição mais atual, proposta por um documento conjunto da European Respiratory Society/American Thoracic Society (ERS/ATS 2014). Resultados Foram reclassificados como portadores de asma grave pelos critérios da ATS/ERS (AG-ERS/ATS) 88/473 (18%). Destes, 87% eram mulheres, 48% obesos, com mediana do índice de massa corporal (IMC) de 29 kg/m2 (IQ 26-34), 99% tinham sintomas de rinite crônica e 83%, sintomas de doença do refluxo gastroesofágico (DRGE). Nenhum se declarou fumante atual. Os principais corticosteroides inalatórios utilizados foram beclometasona (88%) e budesonida (69%). A maioria relatou adequada adesão (77%) e a minoria das avaliações (0,6%) revelou erros graves na técnica inalatória. A mediana do volume expiratório forçado no primeiro segundo pós-broncodilatador (VEF1pós-BD) foi 67% do predito (IQ 55-80). A mediana do número de eosinófilos no sangue periférico foi menor nos pacientes com AG-ERS/ATS [209 células/mm3 (IQ 116-321)] do que nos demais pacientes estudados [258 células/mm3 (IQ 154-403)]. Sintomas de doença do refluxo gastroesofágico (DRGE) foram associados a mais gravidade [OR = 2,2; IC95% (1,2-4,2)]. Conclusões Neste grupo de pacientes, sintomas de RGE foram associados a AG-ERS/ATS e contagem de eosinófilos > 260 células/mm3 esteve associada a 42% menos chance de AG-ERS/ATS.

ABSTRACT Objective To describe the clinical features and to identify factors associated with significant severe asthma in samples of patients followed in a reference center in Salvador. Methods A cross-sectional study of 473 adults, regularly followed in the "Asthma Control Program" in Bahia (Programa de Controle da Asma e da Rinite Alérgica na Bahia (ProAR)), reassessed systematically between 2013 and 2015. The patients were admitted for meeting previous criteria of severe asthma and were reclassified according to the most current definition proposed by a joint document of the "European Respiratory Society/American Thoracic Society" (ERS/ATS) (ERS/ATS 2014). Results Only 88/473 (18%) were reclassified as having severe asthma by ERS/ATS criteria (SA-ERS/ATS). Among these patients, 87% were women, 48% obese, with a median Body Mass Index (BMI) of 29 kg·m2 (IQ 26-34), furthermore, 99% had symptoms of chronic rhinitis and 83% had symptoms of Gastroesophageal Reflux Disease (GERD). None of the 88 patients claimed to be current smokers. The most frequently corticosteroids were beclomethasone dipropionate (BDP) (88%) and budesonide (BUD) (69%). The majority of the evaluations reported adequate adherence (77%), however, the minority (0,6%) detected serious errors in inhalation techniques. The median Forced Expiratory Volume (FEV1) associated with post-bronchodilator test (post-BD) was 67% predicted (IQ 55-80). The median number of eosinophils in the peripheral blood was lower in patients with SA-ERS/ATS (258 cells/mm3 (IQ 116-321) than in the other patients studied [258 cells/mm3 (IQ 154-403)]. Gastroesophageal reflux symptoms were associated with a higher severity [OR = 2.2 95% CI (1.2-4.2)]. Conclusion In this group of patients, symptoms of GERD were associated with SA-ERS/ATS and eosinophil count > 260 cells/mm3 were associated 42% with less chance SA-ERS/ATS

2020 Brazilian Thoracic Association recommendations for the management of asthma / Recomendações para o manejo da asma da Sociedade Brasileira de Pneumologia e Tisiologia - 2020

ABSTRACT The pharmacological management of asthma has changed considerably in recent decades, as it has come to be understood that it is a complex, heterogeneous disease with different phenotypes and endotypes. It is now clear that the goal of asthma treatment should be to achieve and maintain control of the disease, as well as to minimize the risks (of exacerbations, disease instability, accelerated loss of lung function, and adverse treatment effects). That requires an approach that is personalized in terms of the pharmacological treatment, patient education, written action plan, training in correct inhaler use, and review of the inhaler technique at each office visit. A panel of 22 pulmonologists was invited to perform a critical review of recent evidence of pharmacological treatment of asthma and to prepare this set of recommendations, a treatment guide tailored to use in Brazil. The topics or questions related to the most significant changes in concepts, and consequently in the management of asthma in clinical practice, were chosen by a panel of experts. To formulate these recommendations, we asked each expert to perform a critical review of a topic or to respond to a question, on the basis of evidence in the literature. In a second phase, three experts discussed and structured all texts submitted by the others. That was followed by a third phase, in which all of the experts reviewed and discussed each recommendation. These recommendations, which are intended for physicians involved in the treatment of asthma, apply to asthma patients of all ages.

RESUMO O manejo farmacológico da asma mudou consideravelmente nas últimas décadas, com base no entendimento de que a asma é uma doença heterogênea e complexa, com diferentes fenótipos e endótipos. Agora está claro que o objetivo do tratamento da asma deve ser alcançar e manter o controle da doença e evitar riscos futuros (exacerbações, instabilidade da doença, perda acelerada da função pulmonar e efeitos adversos do tratamento). Isso implica em uma abordagem personalizada, incluindo tratamento farmacológico, educação do paciente, plano de ação por escrito, treinamento para uso do dispositivo inalatório e revisão da técnica inalatória a cada visita ao consultório. Um painel de 22 pneumologistas brasileiros foi convidado a revisar criticamente evidências recentes de tratamento farmacológico da asma e a preparar esta recomendação, um guia de tratamento adaptado à nossa realidade. A escolha dos tópicos ou questões relacionadas às mudanças mais significativas nos conceitos e, consequentemente, no manejo da asma na prática clínica foi realizada por um painel de especialistas. Foi solicitado a cada especialista que revisasse criticamente um tópico ou respondesse a uma pergunta, com base em evidências, para estas recomendações. Numa segunda fase, três especialistas discutiram e estruturaram todos os textos submetidos pelos demais e, na última fase, todos revisaram e discutiram cada recomendação. As presentes recomendações se aplicam a adultos e crianças com asma e destinam-se a médicos envolvidos no tratamento da doença.

Self-reported smoking status and urinary cotinine levels in patients with asthma / Tabagismo entre asmáticos: avaliação por autorrelato e dosagem de cotinina urinária

ABSTRACT Objective: To determine the frequency of active smoking among patients with asthma and individuals without asthma by self-report and urinary cotinine measurement. Methods: This was a cross-sectional study conducted in the city of Salvador, Brazil, and involving 1,341 individuals: 498 patients with severe asthma, 417 patients with mild-to-moderate asthma, and 426 individuals without asthma. Smoking status was determined by self-report (with the use of standardized questionnaires) and urinary cotinine measurement. The study variables were compared with the chi-square test and the Kruskal-Wallis test. Results: Of the sample as a whole, 55 (4.1%) reported being current smokers. Of those, 5 had severe asthma, 17 had mild-to-moderate asthma, and 33 had no asthma diagnosis. Of the 55 smokers, 32 (58.2%) were daily smokers and 23 (41.8%) were occasional smokers. Urinary cotinine levels were found to be high in self-reported nonsmokers and former smokers, especially among severe asthma patients, a finding that suggests patient nondisclosure of smoking status. Among smokers, a longer smoking history was found in patients with severe asthma when compared with those with mild-to-moderate asthma. In addition, the proportion of former smokers was higher among patients with severe asthma than among those with mild-to-moderate asthma. Conclusions: Former smoking is associated with severe asthma. Current smoking is observed in patients with severe asthma, and patient nondisclosure of smoking status occurs in some cases. Patients with severe asthma should be thoroughly screened for smoking, and findings should be complemented by objective testing.

RESUMO Objetivo: Descrever a frequência de tabagismo ativo entre pacientes com asma e indivíduos sem asma, usando questionários padronizados e dosagem da cotinina urinária. Métodos: Estudo transversal realizado em Salvador (BA), com 1.341 indivíduos, sendo 498 com asma grave, 417 com asma leve/moderada e 426 sem asma. O tabagismo foi identificado por meio de autorrelato utilizando questionários e por mensuração da cotinina urinária. Para a comparação das variáveis estudadas, utilizaram-se os testes do qui-quadrado e de Kruskal-Wallis. Resultados: Dos 55 participantes (4,1%) que se declararam tabagistas atuais, 5, 17 e 33 eram dos grupos asma grave, asma leve/moderada e sem asma, respectivamente. Desses 55, 32 (58,2%) eram tabagistas diários e 23 (41,8%) eram tabagistas ocasionais. Observaram-se níveis elevados de cotinina urinária entre não fumantes autodeclarados e tabagistas pregressos, especialmente no grupo asma grave, o que sugere omissão do hábito atual de fumar. A carga tabágica entre os fumantes e a proporção de ex-tabagistas foram maiores no grupo asma grave do que no grupo asma leve/moderada. Conclusões: O tabagismo pregresso esteve associado à asma grave. Tabagismo atual também foi observado em alguns pacientes com asma grave e detectou-se omissão em alguns casos. A investigação de tabagismo deve ser meticulosa em pacientes com asma grave e a entrevista desses deve ser complementada por uma avaliação objetiva.

Self-reported smoking status and urinary cotinine levels in patients with asthma.

OBJECTIVE: To determine the frequency of active smoking among patients with asthma and individuals without asthma by self-report and urinary cotinine measurement. METHODS: This was a cross-sectional study conducted in the city of Salvador, Brazil, and involving 1,341 individuals: 498 patients with severe asthma, 417 patients with mild-to-moderate asthma, and 426 individuals without asthma. Smoking status was determined by self-report (with the use of standardized questionnaires) and urinary cotinine measurement. The study variables were compared with the chi-square test and the Kruskal-Wallis test. RESULTS: Of the sample as a whole, 55 (4.1%) reported being current smokers. Of those, 5 had severe asthma, 17 had mild-to-moderate asthma, and 33 had no asthma diagnosis. Of the 55 smokers, 32 (58.2%) were daily smokers and 23 (41.8%) were occasional smokers. Urinary cotinine levels were found to be high in self-reported nonsmokers and former smokers, especially among severe asthma patients, a finding that suggests patient nondisclosure of smoking status. Among smokers, a longer smoking history was found in patients with severe asthma when compared with those with mild-to-moderate asthma. In addition, the proportion of former smokers was higher among patients with severe asthma than among those with mild-to-moderate asthma. CONCLUSIONS: Former smoking is associated with severe asthma. Current smoking is observed in patients with severe asthma, and patient nondisclosure of smoking status occurs in some cases. Patients with severe asthma should be thoroughly screened for smoking, and findings should be complemented by objective testing.

Obesity and asthma: clinical and laboratory characterization of a common combination / Obesidade e asma: caracterização clínica e laboratorial de uma associação frequente

ABSTRACT 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.

RESUMO Objetivo: Avaliar a relação entre obesidade e asma. Métodos: Análise preliminar transversal de dados de um estudo de caso-controle com 925 pacientes com asma leve a moderada ou grave, avaliados entre 2013 e 2015. A classificação de obesidade levou em conta o índice de massa corpórea (IMC) e a circunferência abdominal. Foram coletados parâmetros clínicos, laboratoriais, medidas antropométricas e de função pulmonar, assim como resultados de questionários de controle da asma e de qualidade de vida e presença de comorbidades. Resultados: Os indivíduos obesos apresentaram um número significativamente maior de neutrófilos no sangue periférico que os não obesos (p = 0,01). Entre os obesos, 163 (55%) apresentaram positividade no teste alérgico, enquanto os grupos com sobrepeso e IMC normal apresentaram positividade em 62% e 67%, respectivamente. Os parâmetros espirométricos dos indivíduos obesos foram mais baixos que os dos não obesos, e 97 obesos (32%) apresentaram asma não controlada, uma proporção significativamente maior do que a observada nos demais grupos de estudo (p = 0,02). Conclusões: Indivíduos asmáticos e obesos têm pior controle da asma e valores mais baixos de parâmetros de função pulmonar que os não obesos. A proporção de pacientes sem atopia entre asmáticos obesos foi maior que entre os não obesos. Nossos resultados sugerem que indivíduos asmáticos obesos podem apresentar um padrão inflamatório diferente do habitual e doença de mais difícil controle quando comparados com indivíduos asmáticos não obesos.

Tendência da asma na adolescência no Brasil: resultados da Pesquisa Nacional de Saúde do Escolar (PeNSE) 2012 e 2015 / Asthma trend in adolescence in Brazil: results of the National Adolescent School-based Health Survey (PeNSE 2012-2015)

RESUMO: Objetivo: Comparar a evolução dos indicadores referentes à asma nas edições da Pesquisa Nacional de Saúde do Escolar (PeNSE) 2012 e 2015. Métodos: Estudo transversal em que foram incluídos escolares do nono ano de escolas públicas e privadas das capitais brasileiras. Para saber se o escolar teve chiado no peito nos 12 meses anteriores ao inquérito, foi feita a pergunta: "Nos últimos 12 meses, você teve chiado (ou piado) no peito?" (sim/não). E para saber se teve asma alguma vez na vida foi questionado: "Você teve asma alguma vez na vida?" (sim/não). Resultados: Verificou-se que 23,52% dos estudantes relataram chiado ou piado no peito nos ultimos 12 meses, variando de 16,80% em Salvador (Bahia) a 27,43% em Porto Alegre (Rio Grande do Sul). Ter asma alguma vez na vida foi relatado por 17,92% dos estudantes, variando de 13,98% em Campo Grande (Mato Grosso do Sul) a 30,35% em Porto Alegre (Rio Grande do Sul). Também foi verificada redução da prevalência de chiado (ou piado) no peito nos últimos 12 meses, entre as duas pesquisas (PeNSE 2012 e 2015) em 20 das 27 capitais do Brasil, com destaque para Belo Horizonte, Florianópolis, Cuiabá e Goiânia. Por outro lado, houve aumento da prevalência daqueles que relataram asma alguma vez na vida em 26 das 27 capitais do país. Conclusão: Houve tendência à redução dos sintomas de asma nos últimos 12 meses, enquanto se observa aumento na proporção de adolescentes em que a asma foi referida alguma vez na vida. De certo que o monitoramento da asma ao longo dos anos é imprescindível para gerar conhecimentos e embasar políticas públicas de controle da asma.

ABSTRACT: Objective: To compare the evolution of asthma indicators in the editions of the National School Health Survey (PeNSE 2012 and 2015). Methods: Cross-sectional study including Brazilian 9th grade students from public and private schools. Wheezing was assessed through the question: "In the past 12 months, did you have wheezing (or chirping) chest? (yes/no)", and to assess lifetime presence of asthma, the question was "Have you ever had asthma? (yes/no)". Results: Of the students, 23,52% reported wheezing or chirping chest in the past 12 months, with prevalences ranging from 16,80% (in Salvador, Bahia) to 27,43% (in Porto Alegre, Rio Grande do Sul). Lifetime presence of asthma was reported by 17,92% of the students, ranging from 13,98% (in Campo Grande, Mato Grosso do Sul) to 30,35% (in Porto Alegre, Rio Grande do Sul). There was also a decrease in the prevalence of self-report of wheezing/chirping chest in the last 12 months between the two editions of the survey (2012/2015) in 20 of the 27 Brazilian state capitals, especially in Belo Horizonte, Florianópolis, Cuiabá and Goiânia. However, prevalence of lifetime diagnostic of asthma increased from 2012 to 2015 in 26 of the 27 Brazilian state capitals. Conclusion: There was a decrease in the prevalence of self-report of asthma symptoms and an increase of self-reported lifetime presence of asthma. Certainly, monitoring indicators of asthma prevalence is of high importance for health knowledge and the development of public policies.

Risk factors for death in patients with severe asthma / Fatores de risco de morte em pacientes portadores de asma grave

OBJECTIVE: To identify risk factors for death among patients with severe asthma. METHODS: This was a nested case-control study. Among the patients with severe asthma treated between December of 2002 and December of 2010 at the Central Referral Outpatient Clinic of the Bahia State Asthma Control Program, in the city of Salvador, Brazil, we selected all those who died, as well as selecting other patients with severe asthma to be used as controls (at a ratio of 1:4). Data were collected from the medical charts of the patients, home visit reports, and death certificates. RESULTS: We selected 58 cases of deaths and 232 control cases. Most of the deaths were attributed to respiratory causes and occurred within a health care facility. Advanced age, unemployment, rhinitis, symptoms of gastroesophageal reflux disease, long-standing asthma, and persistent airflow obstruction were common features in both groups. Multivariate analysis showed that male gender, FEV1 pre-bronchodilator < 60% of predicted, and the lack of control of asthma symptoms were significantly and independently associated with mortality in this sample of patients with severe asthma. CONCLUSIONS: In this cohort of outpatients with severe asthma, the deaths occurred predominantly due to respiratory causes and within a health care facility. Lack of asthma control and male gender were risk factors for mortality. .

OBJETIVO: Identificar os fatores de risco para morte em pacientes com asma grave. MÉTODOS: Estudo caso-controle aninhado a uma coorte de pacientes acompanhados no Ambulatório Central de Referência do Programa para o Controle da Asma na Bahia, em Salvador (BA). No período entre dezembro de 2002 e dezembro de 2010, foram selecionados todos os pacientes com asma grave que foram a óbito e pacientes asmáticos graves vivos como controles na relação 1:4. As informações foram coletadas nos prontuários do serviço e complementadas por meio de visitas domiciliares e atestados de óbitos. RESULTADOS: Foram selecionados 58 óbitos e 232 controles. Os óbitos, na sua maioria, foram atribuídos a causas respiratórias e ocorreram dentro de uma unidade de saúde. Idade avançada, inatividade laboral, presença de rinite, sintomas de doença do refluxo gastroesofágico, tempo prolongado de doença e obstrução ao fluxo aéreo persistente foram aspectos comuns em ambos os grupos. A análise multivariada mostrou que o gênero masculino, VEF1 pré-broncodilatador < 60% do previsto e a ausência de controle dos sintomas da asma foram fatores de risco significativamente e independentemente associados à mortalidade nessa amostra de asmáticos graves. CONCLUSÕES: Nesta coorte ambulatorial de pacientes com asma grave, os óbitos ocorreram predominantemente por causas respiratórias em unidades de saúde. A falta de controle da asma e o gênero masculino foram os fatores de risco para óbito. .

Influence of periodontitis in the development of nosocomial pneumonia: a case control study.

BACKGROUND: Although a number of studies on the role of periodontitis in the development of nosocomial pneumonia (NP) have been published, the debate surrounding the existence and nature of this association continues. The present study investigates the influence of periodontitis in NP. METHODS: This case-control study involved 315 individuals: 85 cases (with NP) and 230 controls (without NP), at a general hospital in Feira de Santana, Bahia, Brazil. Sociodemographic characteristics, health conditions, and lifestyle habits were recorded. A full-mouth periodontal examination was performed and periodontal condition assessed. The diagnosis of NP was made in accordance with established medical criteria, after physical, microbiologic, and/or radiographic examination. Logistic regression was used to calculate the strength of the association between periodontitis and NP. RESULTS: Individuals with periodontitis were three times as likely to present with NP (unadjusted odds ratio [OR unadjusted] = 3.06, 95% confidence interval [95% CI]: 1.82 to 5.15) as those without periodontal disease. After adjusting for age, time between hospitalization and data collection, last visit to dentist, smoking habit, and present occupation, the association measurement had a slight decrease (OR adjusted = 2.88, 95% CI: 1.59 to 5.19), but the results continued to be statistically significant. CONCLUSION: These findings suggest that periodontal infection may influence the development of NP, highlighting that periodontitis is a factor positively associated with this respiratory tract infection.