Primary care physicians' ability to diagnose the most prevalent respiratory diseases.

BACKGROUND: There are few reports on the ability of primary care physicians (PCPs) to diagnose acute and chronic respiratory diseases. We assessed the agreement between PCPs and pulmonologists in diagnosing pulmonary tuberculosis (TB), chronic obstructive pulmonary disease (COPD), asthma and acute respiratory infections (ARI). SETTING: Metropolitan Region of Belo Horizonte, State of Minas Gerais, Brazil. METHODS: PCPs filled out a symptom-based questionnaire for adult patients presenting with respiratory symptoms. Their diagnoses were compared to those of three pulmonologists who reviewed the data independently without seeing the patients. Agreement between PCP decisions and those of the pulmonologists was assessed. RESULTS: Among a total of 554 patients, 60 PCPs correctly diagnosed 42.4% as having ARI, 17.3% asthma, 15.7% COPD and 12.4% suspected TB. Agreement between the PCPs and the pulmonologists was as follows: 0.53 for asthma (95%CI 0.45-0.60), 0.53 (95%CI 0.46-0.60) for ARI, 0.45 (95%CI 0.34-0.57) for TB and 0.40 (95%CI 0.29-0.50) for COPD. CONCLUSION: Only reasonable to moderate agreement was found between PCPs and pulmonologists in diagnosing the most prevalent respiratory conditions. This result emphasises the need to adopt measures and provide tools to improve the diagnostic skills of PCPs for patients presenting with respiratory symptoms.

ARIA 2016: Care pathways implementing emerging technologies for predictive medicine in rhinitis and asthma across the life cycle.

The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative commenced during a World Health Organization workshop in 1999. The initial goals were (1) to propose a new allergic rhinitis classification, (2) to promote the concept of multi-morbidity in asthma and rhinitis and (3) to develop guidelines with all stakeholders that could be used globally for all countries and populations. ARIA-disseminated and implemented in over 70 countries globally-is now focusing on the implementation of emerging technologies for individualized and predictive medicine. MASK [MACVIA (Contre les Maladies Chroniques pour un Vieillissement Actif)-ARIA Sentinel NetworK] uses mobile technology to develop care pathways for the management of rhinitis and asthma by a multi-disciplinary group and by patients themselves. An app (Android and iOS) is available in 20 countries and 15 languages. It uses a visual analogue scale to assess symptom control and work productivity as well as a clinical decision support system. It is associated with an inter-operable tablet for physicians and other health care professionals. The scaling up strategy uses the recommendations of the European Innovation Partnership on Active and Healthy Ageing. The aim of the novel ARIA approach is to provide an active and healthy life to rhinitis sufferers, whatever their age, sex or socio-economic status, in order to reduce health and social inequalities incurred by the disease.

Integrated care pathways for airway diseases (AIRWAYS-ICPs).

The objective of Integrated Care Pathways for Airway Diseases (AIRWAYS-ICPs) is to launch a collaboration to develop multi-sectoral care pathways for chronic respiratory diseases in European countries and regions. AIRWAYS-ICPs has strategic relevance to the European Union Health Strategy and will add value to existing public health knowledge by: 1) proposing a common framework of care pathways for chronic respiratory diseases, which will facilitate comparability and trans-national initiatives; 2) informing cost-effective policy development, strengthening in particular those on smoking and environmental exposure; 3) aiding risk stratification in chronic disease patients, using a common strategy; 4) having a significant impact on the health of citizens in the short term (reduction of morbidity, improvement of education in children and of work in adults) and in the long-term (healthy ageing); 5) proposing a common simulation tool to assist physicians; and 6) ultimately reducing the healthcare burden (emergency visits, avoidable hospitalisations, disability and costs) while improving quality of life. In the longer term, the incidence of disease may be reduced by innovative prevention strategies. AIRWAYSICPs was initiated by Area 5 of the Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing. All stakeholders are involved (health and social care, patients, and policy makers).

Severe chronic allergic (and related) diseases: a uniform approach--a MeDALL--GA2LEN--ARIA position paper.

Concepts of disease severity, activity, control and responsiveness to treatment are linked but different. Severity refers to the loss of function of the organs induced by the disease process or to the occurrence of severe acute exacerbations. Severity may vary over time and needs regular follow-up. Control is the degree to which therapy goals are currently met. These concepts have evolved over time for asthma in guidelines, task forces or consensus meetings. The aim of this paper is to generalize the approach of the uniform definition of severe asthma presented to WHO for chronic allergic and associated diseases (rhinitis, chronic rhinosinusitis, chronic urticaria and atopic dermatitis) in order to have a uniform definition of severity, control and risk, usable in most situations. It is based on the appropriate diagnosis, availability and accessibility of treatments, treatment responsiveness and associated factors such as comorbidities and risk factors. This uniform definition will allow a better definition of the phenotypes of severe allergic (and related) diseases for clinical practice, research (including epidemiology), public health purposes, education and the discovery of novel therapies.

Reference values for peak nasal inspiratory flow in children and adolescents in Brazil.

STATEMENT OF THE PROBLEM: Allergic rhinitis is a global public health issue. Peak nasal inspiratory flow (PNIF) can help in the assessment of patients with allergic rhinitis. However, reference values in the literature for PNIF in school children and adolescents are limited. THE AIM OF THIS STUDY was to identify reference values of PNIF among children and adolescents. METHODS: We conducted a cross-sectional study to identify reference values of PNIF among healthy school children and adolescents aged from eight to fifteen years old, selected from 14 randomly selected public schools. Participants performed measurements of PNIF using the In-check-inspiratory flow meter (Clement Clarke, Harlow, England). PNIF values were correlated to gender, age, height, weight and body mass index. RESULTS: A total of 526 subjects participated in the study. The final linear regression model for PNIF allowed obtaining the following equation for subjects aged from eight to 15 years old: PNIF (l/m) = height (centimeters) x 0.7 + 11.2, for boys and PNIF (l/m) = height (centimeters) x 0.7, for girls. CONCLUSION: the equations of the final regression model resulted in a simple formula to obtain reference values of PNIF for subjects aged from 8 to 15 years old.

Monitoring adherence to beclomethasone in asthmatic children and adolescents through four different methods.

BACKGROUND: Suboptimal adherence to inhaled steroids is a known problem in children and adolescents, even when medications are administered under parental supervision. This study aimed to verify the adherence rate to beclomethasone dipropionate (BDP) by four currently available methods. METHODS: In this concurrent cohort study, 102 randomly selected asthmatic children and adolescents aged 3-14 years were followed for 12 months. Adherence rate was assessed every 2 months by self and/or parent report, pharmacy dispensing data, electronic device (Doser); Meditrack Products, Hudson, MA, USA) monitor, and canister weight. RESULTS: Mean adherence rates to BDP by self and/or parent report, pharmacy records, Doser, and canister weight were 97.9% (95% CI 88.0-98.6), 70.0% (95% CI 67.6-72.4), 51.5% (95% CI 48.3-54.6), and 46.3% (95% CI 44.1-48.4), respectively. Agreement analysis between (Doser) and canister weight revealed a weighted kappa equal to 0.76 (95% CI 0.65-0.87). CONCLUSIONS: Adherence was a dynamic event and rates decreased progressively for all methods over the 12-month follow-up. Canister weight and electronic monitoring measures were more accurate than self/parent reports and pharmacy records. Rates obtained by these two methods were very close and statistical analysis also showed a substantial agreement between them. As measurements by canister weight are less costly compared with currently available electronic devices, it should be considered as an alternative method to assess adherence in both clinical research and practice.

Incidence rate and factors related to post-bronchoalveolar lavage fever in children.

BACKGROUND: Post-bronchoscopy and bronchoalveolar lavage (BAL) fever in children has been described by several authors. OBJECTIVES: This study aimed at assessing the occurrence of fever after these examinations and associated risk factors. METHODS: The study was performed in the Bronchoscopy Unit of Hôpital Necker-Enfants Malades, Paris, France, from June 2004 to July 2005. 148 children who underwent fiberoptic bronchoscopy and BAL, and remained in the Unit for 24 h, were included. RESULTS: 37.8% of the patients presented post-BAL fever. In the multivariate analysis of the selected factors (age, immunodeficiency, general or local anesthesia, mucosal biopsy, inflammation and suppuration at the moment of the examination, abnormal bronchoalveolar fluid cellularity and infection), only age <2 years and presence of infection remained associated with fever. CONCLUSIONS: The occurrence of fever is a frequent event in children who underwent BAL. In order to reduce post-BAL fever, antibiotic strategies should be devised based on prospective studies assessing identification of predictive air-way infection criteria and/or rapid bacteriological result analysis.

Assessing correlations between spirometry and Shwachman-Kulczycki score in children and adolescents.

A retrospective observational study was carried out to analyze the correlations between formal pulmonary function tests and the Shwachman-Kulczycki (SK) score. Forty-six Brazilian cystic fibrosis (CF) patients, clinically stable, aged 7-19 years, were included. Clinical and radiological findings of the SK score system and spirometry variables were assessed by independent observers in a blinded manner. The strongest correlation (r = 0.75; 95% CI, 0.59-0.85; P < 0.001) was found for forced expiratory volume in 1 sec (FEV1). Despite some peculiarities of our patients, the results are in agreement with studies undertaken in industrialized countries, showing good correlation between FEV1 and SK score and its usefulness in managing CF. Accordingly, in countries where pulmonary function testing is not available, the SK score remains a valuable parameter on which to base treatment results.

[Diagnosis of meningitis with reagent strips] / Diagnóstico das meningites através de fitas reagentes.

OBJECTIVE: To determine the usefulness of reagent strips in the evaluation of pleocytosis, cerebrospinal fluid glucose and protein levels for early and rapid diagnosis of meningitis in children. METHODS: We included cerebrospinal fluid samples of 164 children admitted to the outpatient clinic of Communicable Diseases of the General Pediatric Center (Fundação Hospitalar do Estado de Minas Gerais, CGP-FHEMIG) during the daytime hours from May of 1997 to May 1999, and who presented with clinical suspicion of meningitis. Patients ranged in age from one month to 12 years (median 12 months). Results from the cytological and biochemical assay (cellularity, cerebrospinal fluid glucose and protein levels) were obtained from 154 patients. These results were subsequently compared with the reaction of cerebrospinal fluid in reagent strips. RESULTS: The cytological and biochemical assay identified 43 cases of probable bacterial meningitis, 19 of probable viral meningitis, and 83 with no alterations. According to the reagent strips, there were 41 cases of probable bacterial meningitis, 2 of probable viral meningitis, and 71 with no alterations. By comparing the results of reagent strips and those of the cytological and biochemical assay, we obtained values for sensitivity, specificity, positive and negative predictive values, and accuracy (respectively 90.7; 98.1; 95.1; 96.4; and 96.1). Statistical analysis using McNemer test did not indicate significant differences between the two methods in the diagnosis of bacterial meningitis (P=0.68). Kappa statistics indicated a high level of agreement between the tests (P<0.0001). CONCLUSIONS: Our results suggest that reagent strips may be a useful additional resource in the diagnosis of bacterial meningitis, especially when it is difficult to collect a sufficient amount of cerebrospinal fluid or to indicate the initial treatment.

Prognostic aspects of cystic fibrosis in Brazil.

Selected prognostic factors were assessed in a cohort of 111 Brazilian children with cystic fibrosis diagnosed between 1 June 1970 and 31 December 1994 and followed in the Pediatric Pulmonology Unit of the Federal University of Minas Gerais Hospital. A standardized protocol was used to collect information retrospectively from medical charts which included date of birth, age at diagnosis, gender, ethnic group, predominant mode of presentation, duration of follow-up, status on 31 December 1994, date of death or date of the last clinical evaluation. The risk of death (univariate and multivariate) was assessed using Cox's proportional hazard model. Mean age at death was higher in males (5.10 years), when the diagnosis was made before the age of 12 months (3.10 years), when clinical presentation was other than respiratory (4.01 years old) and in 'non-whites' (4.86 years old). Age at diagnosis was the only factor associated with death in this population, with both Cox's univariate (RH: 19.4) and multivariate analyses (RH: 17.6; 95% CI: 4.8-64.1). The increased risk of dying in children diagnosed before 12 months of age found in our analysis indicates that they should receive differentiated and intensive multi-professional care.

[Aerosol deposition and clinical performance verified with a spacer device made in Brazil] / Deposição pulmonar de radioaerossol e desempenho clínico verificados com espaçador fabricado no Brasil.

OBJECTIVE: To assess the lung deposition pattern of radioaerosol and the clinical performance of a spacer developed and made in Brazil. METHODS: Qualitative - in a patient with cystic fibrosis - and semi-quantitative - in two healthy volunteers - assessment of pulmonary deposition of (99)mtechnetium was done using the Aerogama Medical oxigen driven nebulizer system attached to the spacer and a gama-camera (Siemens, model Orbiter) connected to a microcomputer. In the next step, clinical assessment was carried out in 50 asthmatic children, aged from four months to 13 years old with an acute attack, using conventional doses of albuterol through a metered dose inhaler attached to the spacer device. RESULTS: Qualitative assessment revealed a lung silhouette comparable with those obtained in the inhalation scintigraphy and semiquantitative assessment reveals that 7.5% to 8.0% of the inhaled (99m)technetium reached the volunteers lungs. Statistically significant differences (p < 0.001) were observed comparing clinical scores at admission with those verified 20 and 40 minutes after albuterol inhalation; conversely, no significance was obtained for scores taken at 60 and 80 minutes. CONCLUSIONS: Although we used an alternative method, the scintigraphic assessment reveals an expected pattern of pulmonary deposition. Similarly, clinical performance in the treatment of an acute attack showed results comparable with those obtained with other spacers devices.

[Accuracy of MiniWright peak expiratory flow meters] / Acurácia de medidores do pico do fluxo expiratório (peak-flow)da marca MiniWright.

OBJECTIVE: To evaluate the accuracy of the Mini-Wright (Clement Clarke International Ltd.) peak-flow meters. METHODS: Twenty of those meters were checked by use of electronic calibration syringe (Jones Flow-Volume Calibrator(R)). Nine of them had an old scale, with values displayed equidistantly, and eleven had a new mechanical scale with non-equidistant values. Each device was connected in series to the calibration syringe to perform eight hand-driven volume injections, with flows ranging from 100 to 700 l/min. Absolute and relative differences between meters and syringe were calculated, the syringe values taken as standard. The accuracy of the twenty Mini-Wright devices was validated by the American Thoracic Society criteria (-/+ 10% or -/+ 20 l/min), and/or European Respiratory Society criteria (-/+ 5% or -/+ 5 l/ min). RESULTS: New scale instruments were more accurate than old scale meters (p < 0.001), by both ATS and ERS criteria. Every meter was rechecked after 600 measurements. Both the old, and the new scale instruments maintained the same level of performance after this evaluation. CONCLUSIONS: Results suggest that new scale meters were accurate and can be safely used in clinical practice. The authors strongly recommend that they are rechecked regularly to ensure that they are within the ATS and ERS variation limits.

[Prevalence of symptoms related to asthma in school children of Campos Gerais, Brazil]. / Prevalencia de síntomas relacionados con el asma en escolares de Campos Gerais (MG), Brasil.

Asthma is the most common chronic disease among children and adolescents, and in recent decades dramatic increases in its prevalence have been reported around the world. However, previous studies have been based on a variety of methodological approaches, making it difficult to compare the results. That situation led a group of international researchers to prepare a standardized self-administered questionnaire to carry out cooperative international studies for the International Study of Asthma and Allergies in Childhood (ISAAC). During April 1996 a cross-sectional study using the ISAAC questionnaire was performed in the city of Campos Gerais, Minas Gerais, Brazil, to determine the prevalence of wheezing and other signs and symptoms related to bronchial asthma among schoolchildren. Two medical students interviewed a randomly selected sample of 200 adolescents 13-14 years old registered in public schools in the city. The sample was equally distributed by sex and age. Of the schoolchildren, 28.5% (95% CI: 22.3%-35.3%) had had wheezing or whistling in the chest at some point in the past. In the preceding 12 months, 6% of them (95% CI: 3.1%-10.5%) had had at least one wheezing episode. A comparison of these results with ones from larger Brazilian cities studied showed that higher prevalence rates were associated with higher population densities and greater urbanization and industrialization. These results strengthen theories supporting an association between asthma and environmental factors. From this it follows that it is necessary to deal with asthma as an important public health problem in Brazil.

[Use of prophylactic medication in persistent asthma] / Emprego de medicação profilática na asma persistente.

OBJECTIVE: To assess the proportion of patients with moderate or severe persistent asthma who are on prophylactic therapy when first evaluated at a specialized outpatient center. METHODS: Descriptive study of 306 patients with persistent asthma and ages ranging from four to fifteen years old, seen from June/1995 to August/1998, at the Respiratory and Allergic Diseases section of the Child and Adolescent Institute, an outpatient reference center located in the town of Juiz de Fora (MG), Brazil. Data from the Institute's registry, chiefly those related to the use of prophylactic medications, such as inhaled steroids, sodium chromoglycate, nedocromil sodium, sustained-release theophylline, long acting inhaled beta2-agonist and ketotifen were used to fill in a standardized protocol. RESULTS: Of the 306 patients, 87.3% had persistent moderate and 12.7% had persistent severe asthma. Only 14.4% were on some kind of controller medication. When only the use of inhaled antiinflammatory drugs (sodium cromolyn, nedocromil sodium and steroids) was considered, this proportion decreased to 4.6%. There was not statistical significance (p<0.05) between the use or not of prophylactic regimens in relation to gender, weight, height, asthma severity, hospital admissions, age of onset, age when first evaluated at the outpatient center and household smoking. CONCLUSIONS: The rate of utilization of prophylactic regimens in this population of persistent asthmatic patients was unsatisfactory, a finding particularly stressed by the low rate of subjects on inhaled antiinflammatory drugs. It is necessary to emphasize such measures to face the magnitude that asthma represents in our country.

Interobserver agreement in assessing plain radiographs of maxillary sinus.

Interrater agreement of six observers in interpreting maxillary sinus plain X-ray films was assessed. Patients aged 1-15 years old were enrolled and X-rays in the Caldwell and Waters's views were requested to confirm diagnosis of sinusitis or after antimicrobial therapy for a pre-existing sinusitis. One-hundred and one pairs of maxillary sinus radiographs from 101 patients were submitted to an independent and blind interpretation by three radiologists and three pediatricians. Each maxillary sinus was separately analyzed. Kappa statistic was used to measure interobserver agreement. A fair degree of agreement among the six raters was found on analyzing these films: 0.39 (95% CI, 0.36-0.41) for the right maxillary sinus and 0.37 (95% CI, 0.34-0.39) for the left one. These results stress literature data on the limits of plain radiographs for diagnosing maxillary sinusitis. The necessity of knowing the clinical findings while interpreting the exams also was depicted.

Survival analysis for cystic fibrosis in Minas Gerais State, Brazil.

A survival analysis was carried out on cystic fibrosis (CF) patients diagnosed and followed at the General Hospital, Federal University of Minas Gerais, Brazil. The study cohort consisted of 111 children, admitted to the Pediatric Pulmonology Section from 1 June 1970 to 31 December 1994. The survival curve and table, constructed by the Kaplan-Meier (product limit) method, show a mean survival age of 12.6 years. This life expectancy resembles the median survival age observed in developed countries by 1970. This study shows that problems relating to health system organization and unfavourable social and economic conditions in developing countries may directly affect the ultimate survival of CF patients.

Benzathine penicillin for unilateral lobar or segmental infiltrates presumptively caused by Streptococcus pneumoniae in children 2-12 years old.

A randomized controlled study was carried out to assess the efficacy of a single dose of benzathine penicillin for treating children 2-12 years old with presumed S. pneumoniae pneumonia. One-hundred-and-seventy-six children screened at self-referral pediatric emergency services in Belo Horizonte, Brazil, were randomized to only one injection of benzathine penicillin (n = 93, case-group) or a 7-day procaine penicillin regimen (n = 83, control-group), upon diagnosis of pneumococcal pneumonia based on clinical and radiological characteristics. Follow-up was carried out on the second day after treatment and around the 7th and/or 14th day after treatment allocation. No statistical significant difference was found for sociodemographic, clinical, laboratory or radiographic characteristics among the two groups. Evident or total radiographic clearing was demonstrated for 92.3 and 95.1 per cent of the benzathine penicillin and procaine penicillin groups, respectively (P = 0.54). Benzathine penicillin may be considered an alternative to classic regimens for treating pneumonia due to sensitive strains of S. pneumoniae among children 2-12 years old. Other benefits are its lower cost, better compliance and low rates of adverse reactions.

Latex particle agglutination test in the diagnosis of Haemophilus influenzae type B, Streptococcus pneumoniae and Neisseria meningitidis A and C meningitis in infants and children.

The knowledge of purulent meningitis etiology is essential in deciding the immediate therapy; in developing countries, however, the etiological agent identification does not reach 60% of the cases. A comparative study using the latex particle agglutination test (LPAT) in cerebrospinal fluid (CSF) for the diagnosis of meningitis due to Haemophilus influenzae type b, Streptococcus pneumoniae or Neisseria meningitidis A and C was carried out in Belo Horizonte MG, Brazil. CSF culture was used as a gold-standard. Two hundred and ninety-nine children, ranging from 3 months to 14 years of age, were included in the investigation. One hundred and forty-four presented a positive CSF culture for the above mentioned bacteria; the remaining presented meningitis due to other organisms (other bacteria or viral) or a normal CSF. The sensitivity and the specificity of LPAT was 95.7 and 100.0% for N. meningitidis C, 95.2 and 100.0% for H. influenzae type b and 86.5 and 100.0% for S. pneumoniae, respectively. When all three organisms were considered simultaneously, the sensitivity and the specificity was 93.0 and 100.0%, respectively. Taking into consideration a realistic estimate of disease prevalence in the community where the diagnostic test is being used, the positive predictive value and the posttest probability were estimated as 36.7 and 47.1% for children < 5 years and as 21.3 and 35.1% for children < 14 years of age, respectively. LPAT is a useful diagnostic test for meningitis due to the studied pathogens, especially in developing countries where laboratory facilities are limited.

[Prevalence of rheumatic fever in children from a public high school in Belo Horizonte]. / Prevalência da febre reumática em crianças de uma escola da rede pública de Belo Horizonte.

PURPOSE: To determine the prevalence of rheumatic fever (RF) among children of a public high school in Belo Horizonte, Brazil. METHODS: The study was performed from March to December/92, and involved high school students coming from families of the medium and low-medium social classes. Considering the total of 1,400 students registered in a public school and the estimated RF prevalence in the developing country, 729 students were randomly chosen to be interviewed and examined by a researcher. The children suspected of being affect by RF were submitted to echocardiography in order to find any cardiac lesions. RESULTS: Due to several different factors, only 550 students aging from 10 to 20 years were admitted in this study. Four children, previously under secondary prophylactics, had already had the diagnosis of RF. Among these children, only one had heart disease (combined mitral incompetence and stenosis, and aortic incompetence). From the other three children, only one had the diagnosis of RF confirmed according to the Jones criteria. CONCLUSION: From the ata obtained, the prevalence of RF was calculated in 3.6/1000.