Clinical standards for the diagnosis and management of asthma in low- and middle-income countries.

BACKGROUND: The aim of these clinical standards is to aid the diagnosis and management of asthma in low-resource settings in low- and middle-income countries (LMICs).METHODS: A panel of 52 experts in the field of asthma in LMICs participated in a two-stage Delphi process to establish and reach a consensus on the clinical standards.RESULTS: Eighteen clinical standards were defined: Standard 1, Every individual with symptoms and signs compatible with asthma should undergo a clinical assessment; Standard 2, In individuals (>6 years) with a clinical assessment supportive of a diagnosis of asthma, a hand-held spirometry measurement should be used to confirm variable expiratory airflow limitation by demonstrating an acute response to a bronchodilator; Standard 3, Pre- and post-bronchodilator spirometry should be performed in individuals (>6 years) to support diagnosis before treatment is commenced if there is diagnostic uncertainty; Standard 4, Individuals with an acute exacerbation of asthma and clinical signs of hypoxaemia or increased work of breathing should be given supplementary oxygen to maintain saturation at 94-98%; Standard 5, Inhaled short-acting beta-2 agonists (SABAs) should be used as an emergency reliever in individuals with asthma via an appropriate spacer device for metered-dose inhalers; Standard 6, Short-course oral corticosteroids should be administered in appropriate doses to individuals having moderate to severe acute asthma exacerbations (minimum 3-5 days); Standard 7, Individuals having a severe asthma exacerbation should receive emergency care, including oxygen therapy, systemic corticosteroids, inhaled bronchodilators (e.g., salbutamol with or without ipratropium bromide) and a single dose of intravenous magnesium sulphate should be considered; Standard 8, All individuals with asthma should receive education about asthma and a personalised action plan; Standard 9, Inhaled medications (excluding dry-powder devices) should be administered via an appropriate spacer device in both adults and children. Children aged 0-3 years will require the spacer to be coupled to a face mask; Standard 10, Children aged <5 years with asthma should receive a SABA as-needed at step 1 and an inhaled corticosteroid (ICS) to cover periods of wheezing due to respiratory viral infections, and SABA as-needed and daily ICS from step 2 upwards; Standard 11, Children aged 6-11 years with asthma should receive an ICS taken whenever an inhaled SABA is used; Standard 12, All adolescents aged 12-18 years and adults with asthma should receive a combination inhaler (ICS and rapid onset of action long-acting beta-agonist [LABA] such as budesonide-formoterol), where available, to be used either as-needed (for mild asthma) or as both maintenance and reliever therapy, for moderate to severe asthma; Standard 13, Inhaled SABA alone for the management of patients aged >12 years is not recommended as it is associated with increased risk of morbidity and mortality. It should only be used where there is no access to ICS.The following standards (14-18) are for settings where there is no access to inhaled medicines. Standard 14, Patients without access to corticosteroids should be provided with a single short course of emergency oral prednisolone; Standard 15, Oral SABA for symptomatic relief should be used only if no inhaled SABA is available. Adjust to the individual's lowest beneficial dose to minimise adverse effects; Standard 16, Oral leukotriene receptor antagonists (LTRA) can be used as a preventive medication and is preferable to the use of long-term oral systemic corticosteroids; Standard 17, In exceptional circumstances, when there is a high risk of mortality from exacerbations, low-dose oral prednisolone daily or on alternate days may be considered on a case-by-case basis; Standard 18. Oral theophylline should be restricted for use in situations where it is the only bronchodilator treatment option available.CONCLUSION: These first consensus-based clinical standards for asthma management in LMICs are intended to help clinicians provide the most effective care for people in resource-limited settings.

Patient socioeconomic status as a prognostic factor for allo-SCT.

The aim of the present study was to assess the influence of socioeconomic status (SeS) on the outcome of allo-SCT at a Brazilian SCT center. In total, 201 patients receiving HLA-identical related allo-SCTs were studied. The median age was 30 years. Overall, 163 patients had malignancies (CML 68, ALL/AML 63, myelodysplastic syndrome 12 and others 20). SeS was defined according to the Brazilian Association of Market Research Agencies classification, where people are clustered in groups A-E (richest to poorest). In total, 146 patients (72%) were classified as richest (A+B+C) and 55 (28%) as poorest (D+E). The D+E SeS group was associated with a higher incidence of chronic GVHD and acute GVHD (hazard ratio (HR)=2.61; P=0.001 and HR=2.62; P=0.001, respectively), better platelet and neutrophil engraftment (HR=1.94; P=<0.001 and HR=2.12; P=0.001) and with a higher TRM in multivariate analysis (HR=1.92; P=0.039). Estimated overall survival at 5 years was 55.2%. A D+E SeS (HR=2.13; P=0.001) was associated with a worse survival on multivariate analysis. In conclusion, a lower SeS is a strong prognostic factor in patients undergoing allo-SCT in Brazil, influencing engraftment, TRM and overall survival.

Prevalence of symptoms of asthma, rhinitis, and atopic eczema in Brazilian adolescents related to exposure to gaseous air pollutants and socioeconomic status.

OBJECTIVES: To evaluate the relationship between exposure to gaseous air pollutants (ozone [O3], carbon monoxide [CO], nitrogen dioxide [NO2], and sulfur dioxide [SO2]) socioeconomic status and the prevalence of symptoms of asthma, rhinitis and atopic eczema in adolescents. SUBJECTS AND METHODS: A sample of 16 209 adolescents from São Paulo West (SPW), São Paulo South (SPS), Santo André (SA), Curitiba (CR), and Porto Alegre (PoA) were enrolled. Data on air pollutants and socioeconomic status were compared to prevalence of symptoms with the Spearman correlation coefficient. RESULTS: Socioeconomic status was quite similar in all cities. The levels of O3 in SPW, SPS, and SA, and of CO in SA were higher than the acceptable ones. In relation to O3 and CO exposures, adolescents from SPW and SA had a significant risk of current wheezing, whereas living in SPW was associated with a high risk of rhinoconjunctivitis, eczema, and flexural eczema and living in CR to rhinitis. Exposure to NO2 was associated with a high risk of current wheezing in SPW and SA, and of severe asthma in SPW and PoA. Exposure to SO2 was associated with a high risk of current wheezing in SPW and SA, severe asthma in SPW and PoA, and nighttime cough, eczema, flexural eczema and severe eczema in SPW. Living in SPW, CR, or PoA was associated with a high risk of rhinitis, rhinoconjunctivitis, and severe rhinitis. CONCLUSIONS: Although we did not detect a characteristic pattern for all symptoms evaluated or a specific air pollutant, our data suggest a relationship between higher exposure to photochemical pollutants and high prevalence or risk of symptoms of asthma, rhinitis, and atopic eczema.

Changes in the prevalence of asthma and allergic diseases among Brazilian schoolchildren (13-14 years old): comparison between ISAAC Phases One and Three.

The present study is aimed to describe the changes in the prevalence of symptoms of asthma, rhinitis and eczema among Brazilian adolescents (AD, 13-14 years old) between Phases 1 and 3 of the International Study of Asthma and Allergies in Childhood (ISAAC). The prevalence of self-reported symptoms of asthma, rhinitis and eczema in AD from five Brazilian cities (Curitiba, Porto Alegre, Recife, Salvador and São Paulo), obtained during ISAAC Phase 1 (n = 15 419) and Phase 3 (n = 15 684), was compared to determine the trend of prevalence in a 7-year interval. There was a trend to reduction in the current prevalence of wheezing and increasing of nocturnal cough when averaging figures from the five cities. The prevalence of wheezing in the last 12 months was 27.7 vs. 19.9% (p < 0.01); asthma ever 14.9 vs. 14.7% (p > 0.05); severe episode of wheezing 5.2 vs. 5.2%; nocturnal cough 32.6 vs. 34.9% (p < 0.01); exercise wheezing 23.6 vs. 23.0% (p > 0.05) and awake with wheezing 11.8 vs. 11.2% (p > 0.05). Similar things were observed with the prevalence of current symptoms of rhinitis and eczema. In Brazil, there was a small but significant mean decrease in the prevalence of two asthma-related symptoms, wheezing and nocturnal cough, though this trend was not consistent in the surveyed cities. The prevalence of asthma symptoms in Brazil, despite its mean trend to a decrease, is still one of the highest in Latin America.

[Association between gastroesophageal reflux and dips in the oxygen transcutaneous saturation of the hemoglobin in infants with chronic obstructive ventilatory disease] / Associação entre refluxo gastroesofágico e quedas da saturação transcutânea de oxigênio da hemoglobina em lactentes com doença ventilatória obstrutiva crônica.

OBJECTIVE: To verify the association between oxygen desaturation episodes and the dips in pH in infants with chronic obstructive respiratory symptoms. METHOD: Cross-sectional study with children 24 months old or younger hospitalized for investigation of chronic obstructive respiratory symptoms from 1997 to 1999. The patients underwent esophageal pH monitoring associated with transcutaneous oxygen saturation during the night. The patients were included in the study according to their need to be hospitalized and availability of equipment. The indices used to measure this association were reflux index, total number of refluxes, number of refluxes longer than 5 minutes, Euler index, ZMD index, 24-hour mean pH, and mean pH of desaturation. RESULTS: We studied 44 children. The mean age was 7.5 months, and 20% had desaturation below 93% during pH monitoring. We used the t test to compare the occurrence of desaturation with the pH monitoring parameters. We found higher significance with the reflux index (RI), number of episodes longer than 5 minutes, ZMD index, 24-hour mean pH, and mean pH of desaturation. The bivariate analysis, taking into account possible confounding factors and RI, showed PR equal to 6.61 (IC 95% 1.67 - 26.12) for an RI higher than 4%. CONCLUSION: Oxygen saturation monitoring associated with pH monitoring may be a useful tool to establish an association between GER and respiratory problems in patients with chronic or recurrent wheeze.

Respiratory syncytial virus (RSV) bronchiolitis: comparative study of RSV groups A and B infected children.

The grouping characteristics of 29 respiratory syncytial virus (RSV) present in nasopharyngeal cells collected from hospitalized children with bronchiolitis during the 1990 RSV season in Porto Alegre, RS, were analysed. Twenty-two were grouped as belonging to group A and 7 to group B. Cyanosis, oxygen therapy, cough, length of hospitalization and atelectasis were observed to be more frequently found within group B infected children. Other clinical signs and symptoms were similarly found in both groups.

Intoxicacao por metoclopramida. / Intoxication by metoclopramide

Sao analisados 13 casos de intoxicacao por metoclopramida, internados na Emergencia do Hospital da Crianca Santo Antonio, no periodo de janeiro de 1981 a dezembro de 1982. Sao considerados a dose, a via de administracao, o tempo de inicio dos sintomas e as manifestacoes clinicas. E enfatizado o cuidado necessario quanto a via de administracao e, principalmente, a dose maxima, que nao deve exceder a 0,5mg/kg/ dia.