Differences between patients who achieved asthma control and those who remain uncontrolled after standardized severe asthma care strategy.

OBJECTIVE: To assess clinical, functional, and inflammatory patterns of children and adolescents with severe uncontrolled asthma, and investigate the differences between patients who achieved asthma control and those who remain uncontrolled after standardized asthma care strategy. METHODS: Screening all children and adolescents with asthma from the Pediatric Pulmonology Outpatient Clinic of Unicamp, Brazil, and included those with severe uncontrolled asthma according to GINA guidelines criteria. Patients were assessed at baseline and after by demographic and medication data, questionnaires (Asthma Control Test and Pediatric Asthma Quality of Life Questionnaire), Six-Minute Walk Test, skin prick test, spirometry, induced sputum, and blood collection (total immunoglobulin E and eosinophil count). Cytokine dosage was analyzed in sputum supernatant and serum by Cytometric Bead Array. RESULTS: Thirty-three patients with severe uncontrolled asthma were included (median age 10.9 [7.00-17.60] years). All patients presented satisfactory adherence to treatment and 50% of them achieved good asthma control after six-month follow-up (p < 0.001). Patients who achieved asthma control reported higher intervals since their last exacerbation episode (p = 0.008) and higher quality of life scores (p < 0.001) as compared to patients who remained uncontrolled. We found no changes in lung function markers, inflammatory biomarkers, or cytokine levels between patients with uncontrolled and controlled asthma. CONCLUSION: Participation of six months in a structured outpatient clinic for children with severe asthma had a notable improvement in control and quality of life of patients. This demonstrates the importance of a global assessment, focused on peculiarities presented by patients with severe uncontrolled asthma.

Risk factors for recurrent wheezing in preterm infants who received prophylaxis with palivizumab.

OBJECTIVE: To determine the prevalence of recurrent wheezing (RW) in preterm infants who received prophylaxis against severe infection with respiratory syncytial virus (RSV) and to identify genetic susceptibility (atopy or asthma) and risk factors for RW. METHODS: This was a cross-sectional study involving preterm infants who received prophylaxis with palivizumab at a referral center in Brazil during the first two years of age. A structured questionnaire was administered in a face-to-face interview with parents or legal guardians. RESULTS: The study included 410 preterm infants (median age = 9 months [0-24 months]). In the sample as a whole, 111 children (27.1%; [95% CI, 22.9-31.5]) had RW. The univariate analysis between the groups with and without RW showed no differences regarding the following variables: sex, ethnicity, maternal level of education, gestational age, birth weight, breastfeeding, number of children in the household, day care center attendance, pets in the household, and smoking caregiver. The prevalence of RW was twice as high among children with bronchopulmonary dysplasia (adjusted OR = 2.08; 95% CI, 1.11-3.89; p = 0.022) and almost five times as high among those with a personal/family history of atopy (adjusted OR = 4.96; 95% CI, 2.62-9.39; p < 0.001) as among those without these conditions. CONCLUSIONS: Preterm infants who received prophylaxis with palivizumab but have a personal/family history of atopy or bronchopulmonary dysplasia are more likely to have RW than do those without these conditions.

Risk factors for recurrent wheezing in preterm infants who received prophylaxis with palivizumab / Fatores de risco para sibilância recorrente em crianças pré-termo que receberam profilaxia com palivizumabe

ABSTRACT Objective: To determine the prevalence of recurrent wheezing (RW) in preterm infants who received prophylaxis against severe infection with respiratory syncytial virus (RSV) and to identify genetic susceptibility (atopy or asthma) and risk factors for RW. Methods: This was a cross-sectional study involving preterm infants who received prophylaxis with palivizumab at a referral center in Brazil during the first two years of age. A structured questionnaire was administered in a face-to-face interview with parents or legal guardians. Results: The study included 410 preterm infants (median age = 9 months [0-24 months]). In the sample as a whole, 111 children (27.1%; [95% CI, 22.9-31.5]) had RW. The univariate analysis between the groups with and without RW showed no differences regarding the following variables: sex, ethnicity, maternal level of education, gestational age, birth weight, breastfeeding, number of children in the household, day care center attendance, pets in the household, and smoking caregiver. The prevalence of RW was twice as high among children with bronchopulmonary dysplasia (adjusted OR = 2.08; 95% CI, 1.11-3.89; p = 0.022) and almost five times as high among those with a personal/family history of atopy (adjusted OR = 4.96; 95% CI, 2.62-9.39; p < 0.001) as among those without these conditions. Conclusions: Preterm infants who received prophylaxis with palivizumab but have a personal/family history of atopy or bronchopulmonary dysplasia are more likely to have RW than do those without these conditions.

RESUMO Objetivo: Determinar a prevalência de sibilância recorrente (SR) em crianças pré-termo que receberam profilaxia contra infecção grave pelo vírus sincicial respiratório (VSR) e identificar susceptibilidade genética (atopia ou asma) e fatores de risco para SR. Métodos: Estudo transversal envolvendo crianças pré-termo que receberam profilaxia com palivizumabe em um centro de referência no Brasil durante os primeiros dois anos de vida. Um questionário estruturado foi aplicado em entrevista presencial com os pais ou responsáveis. Resultados: O estudo incluiu 410 crianças pré-termo (mediana de idade = 9 meses [0-24 meses]). Na amostra total, 111 crianças (27,1%; IC95%: 22,9-31,5) apresentavam SR. A análise univariada entre os grupos com e sem SR não mostrou diferenças em relação às seguintes variáveis: sexo, etnia, escolaridade materna, idade gestacional, peso ao nascer, aleitamento materno, número de crianças no domicílio, frequência em creche, presença de animais de estimação no domicílio e cuidador tabagista. A prevalência de SR foi duas vezes maior entre crianças com displasia broncopulmonar (OR ajustada = 2,08; IC95%: 1,11-3,89; p = 0,022) e quase cinco vezes maior entre aquelas com história pessoal/familiar de atopia (OR ajustada = 4,96; IC95%: 2,62-9,39; p < 0,001) do que entre aquelas sem essas condições. Conclusões: Crianças pré-termo que receberam profilaxia com palivizumabe, mas apresentam história pessoal/familiar de atopia ou displasia broncopulmonar, têm maior probabilidade de apresentar SR do que aquelas sem essas condições.

Reference values for spirometry in Brazilian children.

OBJECTIVE: To generate reference values for spirometry in Brazilian children 3-12 years of age and to compare those values with the values employed in the equations currently in use in Brazil. METHODS: This study involved healthy children, 3-12 years of age, recruited from 14 centers (primary data) and spirometry results from children with the same characteristics in six databases (secondary data). Reference equations by quantile regressions were generated after log transformation of the spirometric and anthropometric data. Skin color was classified as self-reported by the participants. To determine the suitability of the results obtained, they were compared with those predicted by the equations currently in use in Brazil. RESULTS: We included 1,990 individuals from a total of 21 primary and secondary data sources. Of those, 1,059 (53%) were female. Equations for FEV1, FVC, the FEV1/FVC ratio, FEF between 25% and 75% of the FVC (FEF25-75%) and the FEF25-75%/FVC ratio were generated for white-, black-, and brown-skinned children. The logarithms for height and age, together with skin color, were the best predictors of FEV1 and FVC. The reference values obtained were significantly higher than those employed in the equations currently in use in Brazil, for predicted values, as well as for the lower limit of normality, particularly in children with self-reported black or brown skin. CONCLUSIONS: New spirometric equations were generated for Brazilian children 3-12 years of age, in the three skin-color categories defined. The equations currently in use in Brazil seem to underestimate the lung function of Brazilian children 3-12 years of age and should be replaced by the equations proposed in this study.

Assessment of asthma control among different measures and evaluation of functional exercise capacity in children and adolescents with asthma. / Avaliação do controle da asma entre diferentes medidas e avaliação da capacidade de exercício funcional em crianças e adolescentes com asma.

Objective To assess the agreement among asthma control measures and functional exercise capacity in children and adolescents with uncontrolled and controlled asthma. Methods Children and adolescents with asthma from 7-17 years old were selected, and they were attended in the "Pediatric Pulmonology Outpatient Clinic of State University of Campinas", in Brazil. All patients had asthma control level assessed by Global Initiative for Asthma questionnaire (GINAq), Asthma Control Test (ACT), spirometry and six-minute-walk-test (6MWT). Patients were classified as uncontrolled or controlled asthma in each test and agreement among measures was assessed by kappa statistics. The ROC curve was calculated for the 6MWT. The spirometric index obtained from spirometry was composed by FEV1, FEV1/FVC and FEF25-75%. Spirometry and 6MWT results were compared between uncontrolled and controlled asthma group by GINAq. Results Of the 138 subjects included, 78 (56.5%) were male with median age of 11 (7-17) years old. GINAq detected 68.8% of patients with uncontrolled asthma. Moderate agreement (p < 0.001; k = 0.56) and high specificity (100%) was observed between GINAq and ACT. In 6MWT, the cut-off point of 82.03% of predicted distance was able to distinguish patients with controlled and uncontrolled asthma. Spirometric index presented 73.4% of sensitivity according to GINAq. The results for 6MWT in patients with uncontrolled asthma were the worst of all. Conclusion This study highlights the importance of assessing more than one measure to differentiate asthma control level. GINAq identified more patients with uncontrolled asthma and presented moderate agreement with ACT. Spirometric index was associated with uncontrolled asthma according to GINAq. 6MWT was a suitable measure to distinguish patients with controlled and uncontrolled asthma.

Safety, Tolerability, and Effects of Sodium Bicarbonate Inhalation in Cystic Fibrosis.

BACKGROUND: Among the many consequences of loss of CFTR protein function, a significant reduction of the secretion of bicarbonate (HCO3-) in cystic fibrosis (CF) is a major pathogenic feature. Loss of HCO3- leads to abnormally low pH and impaired mucus clearance in airways and other exocrine organs, which suggests that NaHCO3 inhalation may be a low-cost, easily accessible therapy for CF. OBJECTIVE: To evaluate the safety, tolerability, and effects of inhaled aerosols of NaHCO3 solutions (4.2% and 8.4%). METHODS: An experimental, prospective, open-label, pilot, clinical study was conducted with 12 CF volunteer participants over 18 years of age with bronchiectasis and pulmonary functions classified as mildly to severely depressed. Sputum rheology, pH, and microbiology were examined as well as spirometry, exercise performance, quality-of-life assessments, dyspnea, blood count, and venous blood gas levels. RESULTS: Sputum pH increased immediately after inhalation of NaHCO3 at each clinical visit and was inversely correlated with rheology when all parameters were evaluated: [G' (elasticity of the mucus) = - 0.241; G″ (viscosity of the mucus) = - 0.287; G* (viscoelasticity of the mucus) = - 0.275]. G* and G' were slightly correlated with peak flow, forced expiratory volume in 1 s (FEV1), and quality of life; G″ was correlated with quality of life; sputum pH was correlated with oxygen consumption (VO2) and vitality score in quality of life. No changes were observed in blood count, venous blood gas, respiratory rate, heart rate, peripheral oxygen saturation of hemoglobin (SpO2), body temperature, or incidence of dyspnea. No adverse events associated with the study were observed. CONCLUSION: Nebulized NaHCO3 inhalation appears to be a safe and well tolerated potential therapeutic agent in the management of CF. Nebulized NaHCO3 inhalation temporarily elevates airway liquid pH and reduces sputum viscosity and viscoelasticity.

Volumetric capnography versus spirometry for the evaluation of pulmonary function in cystic fibrosis and allergic asthma.

OBJECTIVE: To compare the values of the markers for volumetric capnography and spirometry and their ability to classify children and adolescents with asthma, cystic fibrosis (CF), and healthy controls. METHODS: This was a cross-sectional study that included 103 patients with controlled persistent allergic asthma, 53 with CF and a healthy control group with 40 volunteers (aged 6 to 15 years), of both sexes. The individuals underwent volumetric capnography and spirometry. RESULTS: Phase III slope (SIII), SIII standardized by exhaled tidal volume (SIII/TV) and capnographic index (SIII/SII)×100 (KPIv) were different among the three groups assessed, with highest values for CF. The relation between the forced expiratory volume in one second and the forced vital capacity (FEV1/FVC) was the only spirometric marker that presented difference on the three groups. On individuals with normal spirometry, KPIv and FEV1/FVC were different among the three groups. The ROC curve identified the individuals with asthma or CF from the control group, both through volumetric capnography (better to identify CF in relation to the control using KPIv) and through spirometry (better to identify asthma in relation to the control). KPIv was the best parameter to distinguish asthma from CF, even in individuals with normal spirometry. CONCLUSION: Volumetric capnography and spirometry identified different alterations in lung function on asthma, CF, and healthy controls, allowing the three groups to be distinguished.

Respiratory physical therapy techniques recommended for patients with cystic fibrosis treated in specialized centers.

BACKGROUND: Respiratory therapy is a part of the treatment of patients with cystic fibrosis (CF). However, there is no information about the main factors influencing the recommendation of the use of different techniques or devices by physical therapists from different specialized centers. OBJECTIVE: To determine the respiratory therapy techniques recommended for the treatment of patients with CF seen in specialized treatment centers in Brazil. METHODS: This is a descriptive study including a sample of Brazilian CF specialized treatment centers. Data on demographics, spirometric variables, and recommended respiratory therapy treatment techniques were collected. RESULTS: Twelve specialized treatment centers with a total of 974 patients were included (13.5±11.3 years old and FEV1 (%) 75.7±27.9). The most recommended techniques were huffing (61.1% of patients), high frequency oral oscillation (HFOO) (52.0%), and positive expiratory pressure (PEP) (45.3%). Most often, recommendation was to perform treatment once (54.8% of patients) or twice (34%) a day. There was great variability in the recommendation among the different states. When data were separated by age, there was a predominance of performing conventional and manual techniques in infants and preschool children. There were no significant variations according to pulmonary function. Based on the literature, techniques based on volume, huffing, and PEP were most prevalently performed in international centers. CONCLUSION: The most recommended treatment techniques for patients with CF in Brazil are huffing, HFOO, and PEP, followed by volume-based techniques. There were geographical variations in the preferred treatment techniques, as well as based on patient age, but not based on the level of pulmonary function.

Reference values for spirometry in Brazilian children / Valores de referência de espirometria para crianças brasileiras

ABSTRACT Objective: To generate reference values for spirometry in Brazilian children 3-12 years of age and to compare those values with the values employed in the equations currently in use in Brazil. Methods: This study involved healthy children, 3-12 years of age, recruited from 14 centers (primary data) and spirometry results from children with the same characteristics in six databases (secondary data). Reference equations by quantile regressions were generated after log transformation of the spirometric and anthropometric data. Skin color was classified as self-reported by the participants. To determine the suitability of the results obtained, they were compared with those predicted by the equations currently in use in Brazil. Results: We included 1,990 individuals from a total of 21 primary and secondary data sources. Of those, 1,059 (53%) were female. Equations for FEV1, FVC, the FEV1/FVC ratio, FEF between 25% and 75% of the FVC (FEF25-75%) and the FEF25-75%/FVC ratio were generated for white-, black-, and brown-skinned children. The logarithms for height and age, together with skin color, were the best predictors of FEV1 and FVC. The reference values obtained were significantly higher than those employed in the equations currently in use in Brazil, for predicted values, as well as for the lower limit of normality, particularly in children with self-reported black or brown skin. Conclusions: New spirometric equations were generated for Brazilian children 3-12 years of age, in the three skin-color categories defined. The equations currently in use in Brazil seem to underestimate the lung function of Brazilian children 3-12 years of age and should be replaced by the equations proposed in this study.

RESUMO Objetivo: Gerar valores de referência para espirometria em crianças brasileiras de 3-12 anos de idade e comparar os resultados obtidos com as equações em uso no Brasil. Métodos: Foram incluídas crianças sadias de 3-12 anos recrutadas em 14 centros (dados primários) e resultados de espirometria de crianças com as mesmas características de seis bancos de dados (dados secundários). As equações quantílicas foram geradas após transformações logarítmicas dos dados espirométricos e antropométricos. A classificação por cor da pele foi autodeclarada. Os resultados obtidos foram comparados com os previstos nas equações em uso no Brasil para testar sua adequação. Resultados: Foram incluídos 1.990 indivíduos de 21 fontes de dados primários e secundários, sendo 1.059 (53%) do sexo feminino. Equações para VEF1, CVF, VEF1/CVF, FEF25-75% e FEF25-75%/CVF foram geradas para crianças brancas e para crianças negras e pardas. Os logaritmos da estatura e da idade e a cor da pele foram os melhores preditores para VEF1 e CVF. Os resultados obtidos foram significativamente maiores do que as estimativas geradas pelas equações em uso no Brasil, tanto para valores previstos quanto para o limite inferior da normalidade, particularmente em crianças negras e pardas. Conclusões: Novas equações espirométricas foram geradas para crianças brasileiras de 3-12 anos de cor branca, negra e parda. As equações atualmente em uso no Brasil parecem subestimar a função pulmonar de crianças brasileiras menores de 12 anos de idade e deveriam ser substituídas pelas equações propostas neste estudo.

Avaliação do controle da asma entre diferentes medidas e avaliação da capacidade de exercício funcional em crianças e adolescentes com asma / Assessment of asthma control among different measures and evaluation of functional exercise capacity in children and adolescents with asthma

RESUMO Objetivo Avaliar a concordância entre as medidas de controle da asma e a capacidade de exercício funcional em crianças e adolescentes com asma não controlada e controlada. Métodos Selecionamos crianças e adolescentes com asma de 7 a 17 anos, que foram atendidos no Ambulatório de Pneumologia Pediátrica da Universidade Estadual de Campinas. Todos os pacientes tiveram nível de controle da asma avaliado pelo questionário da Global Initiative for Asthma (GINAq), Teste de Controle da Asma (TCA), espirometria e teste de caminhada de seis minutos (TC6M). Os pacientes foram classificados como asma não controlada ou controlada em cada teste e a concordância entre as medidas foi avaliada pelas estatísticas do Kappa. A curva ROC foi calculada para o TC6M. O índice espirométrico da espirometria foi composto por FEV1, FEV1/FVC e FEF25-75%. Os resultados da espirometria e do TC6M foram comparados entre o grupo de asma não controlada e controlada pela GINAq. Resultados Dos 138 sujeitos incluídos, 78 (56,5%) eram do sexo masculino com idade média de 11,00 (7-17) anos. O GINAq detectou 68,8% dos pacientes com asma não controlada. Foi observada concordância moderada (p<0,001; k=0,56) e alta especificidade (100%) entre o GINAq e o TCA. No TC6M, o ponto de corte de 82,03% da distância prevista possibilitou a distinção de pacientes com asma controlada e não controlada. O índice espirométrico apresentou 73,4% de sensibilidade com o GINAq. Foram observados resultados piores no TC6M em pacientes com asma não controlada. Conclusões Este estudo destaca a importância de avaliar mais de uma medida para diferenciar o nível de controle da asma. O GINAq identificou mais pacientes com asma não controlada e apresentou concordância moderada com o TCA. O índice espirométrico foi associado à asma não controlada de acordo com o GINAq. O TC6M foi uma boa medida para distinguir pacientes com asma controlada e não controlada.

ABSTRACT Objective To assess the agreement among asthma control measures and functional exercise capacity in children and adolescents with uncontrolled and controlled asthma. Methods Children and adolescents with asthma from 7-17 years old were selected, and they were attended in the "Pediatric Pulmonology Outpatient Clinic of State University of Campinas", in Brazil. All patients had asthma control level assessed by Global Initiative for Asthma questionnaire (GINAq), Asthma Control Test (ACT), spirometry and six-minute-walk-test (6MWT). Patients were classified as uncontrolled or controlled asthma in each test and agreement among measures was assessed by kappa statistics. The ROC curve was calculated for the 6MWT. The spirometric index obtained from spirometry was composed by FEV1, FEV1/FVC and FEF25-75%. Spirometry and 6MWT results were compared between uncontrolled and controlled asthma group by GINAq. Results Of the 138 subjects included, 78 (56.5%) were male with median age of 11 (7-17) years old. GINAq detected 68.8% of patients with uncontrolled asthma. Moderate agreement (p < 0.001; k = 0.56) and high specificity (100%) was observed between GINAq and ACT. In 6MWT, the cut-off point of 82.03% of predicted distance was able to distinguish patients with controlled and uncontrolled asthma. Spirometric index presented 73.4% of sensitivity according to GINAq. The results for 6MWT in patients with uncontrolled asthma were the worst of all. Conclusion This study highlights the importance of assessing more than one measure to differentiate asthma control level. GINAq identified more patients with uncontrolled asthma and presented moderate agreement with ACT. Spirometric index was associated with uncontrolled asthma according to GINAq. 6MWT was a suitable measure to distinguish patients with controlled and uncontrolled asthma.

Identificação, Prevenção e Tratamento da Síndrome Mão-Pé Induzida por Quimioterapia: Revisão Sistemática / Identification, Prevention and Treatment of Hand-Foot Syndrome Induced by Chemotherapy: Systematic Review / Identificación, Prevención y Tratamiento de la Enfermedad Mental por Quimioterapia: Revisión Sistemática

Introdução: A síndrome mão-pé é uma reação adversa experimentada por vários pacientes em tratamento para o câncer e fator preditor de morbidade e mortalidade. Objetivo: Avaliar as evidências científicas relacionadas à identificação, prevenção e tratamento da síndrome mão-pé induzida por agentes quimioterápicos, identificar os principais sinais e sintomas que possibilitam o reconhecimento da síndrome e, ainda, discutir a ocorrência de onicomicoses no contexto da síndrome mão-pé. Método: Trata-se de uma revisão sistemática na MEDLINE/PubMed, Biblioteca Virtual da Saúde e Scopus, incluindo literatura cinzenta e busca manual. Os 29 estudos incluídos na revisão foram analisados e classificados segundo a hierarquia dos níveis de evidência Grading of Recommendations Assessment, Development and Evaluations (GRADE) e a confiabilidade entre os examinadores (coeficiente Kappa) foi calculada. Resultados: Foram identificados estudos que demonstraram eficácia na prevenção da síndrome mão-pé com o uso da crioterapia e hidroterapia. Evidenciaram-se resultados satisfatórios com o uso do creme de ureia na prevenção e tratamento, e o uso de piridoxina não apresentou resultados conclusivos. Foram encontrados mecanismos para identificação da síndrome e para classificação dos agentes indutores. O grupo dos taxanos predominou entre os medicamentos indutores da síndrome mão-pé. Conclusão: Existem evidências consistentes, porém não contemplam todos os fármacos indutores da síndrome e não exploram outras manifestações relacionadas às onicólises e onicomicoses. O estudo apresentou resultados que poderão auxiliar os prescritores na identificação da síndrome mão-pé, além de alternativas para prevenção e tratamento. Contudo, vale destacar a necessidade de pesquisas futuras para elucidar a etiologia e protocolos de tratamento.

Introduction: Hand-foot syndrome is an adverse reaction experienced by many cancer patients and a predictor of morbidity and mortality. Objective:To evaluate the scientific evidence related to the identification, prevention and treatment of chemotherapeutic-induced hand-foot syndrome, to identify the main signs and symptoms that enable the recognition of the syndrome, and to discuss the occurrence of onychomycosis in the context of the hand-foot syndrome. Method: This is a systematic review at MEDLINE/PubMed, Virtual Health Library and Scopus, including gray literature and manual search. The 29 studies included in the review were analyzed and graded according to the hierarchy of evidence levels Grading of Recommendations Assessment, Development and Evaluations (GRADE) and reliability among examiners (Kappa coefficient) was calculated. Results:It were identified studies that demonstrated efficacy in preventing hand-foot syndrome using cryotherapy and hydrotherapy. Satisfactory results were evidenced with the use of urea cream for prevention and treatment, and the use of pyridoxine showed inconclusive results. Mechanisms for identification of the syndrome and classification of inducing agents were found. The taxane group predominated among hand-foot syndrome inducing drugs. Conclusion: There are consistent evidences but do not include all drugs inducing the syndrome and do not explore other manifestations related to onycholysis and onychomycosis. The study presented results that may help prescribers to identify hand-foot syndrome, as well as alternatives for prevention and treatment. However, it is worth highlighting the need for future studies to elucidate the etiology and treatment protocols.

Introducción: El síndrome de pies y manos es una reacción adversa experimentada por muchos pacientes con cáncer y un predictor de morbilidad y mortalidad. Objetivo: Evaluar la evidencia científica relacionada con la identificación, prevención y tratamiento del síndrome de pies y manos inducido por quimioterapia, identificar los principales signos y síntomas que permiten el reconocimiento del síndrome y analizar la aparición de onicomicosis en el contexto del síndrome mano-pie. Método:Esta es una revisión sistemática en MEDLINE/PubMed, Virtual Health Library y Scopus, que incluye literatura gris y búsqueda manual. Los 29 estudios incluidos en la revisión se analizaron y clasificaron de acuerdo con la jerarquía de los niveles de evidencia Grading of Recommendations Assessment, Development and Evaluations (GRADE). Resultados: Identificamos estudios que demostraron eficacia en la prevención del síndrome mano-pie usando crioterapia e hidroterapia. También mostraron resultados satisfactorios con el uso de crema de urea en la prevención y el tratamiento, y el uso de piridoxina no mostró resultados concluyentes. Se encontraron mecanismos para la identificación del síndrome y la clasificación de los agentes inductores. El grupo de taxanos predominó entre los fármacos inductores del síndrome mano-pie. Conclusión: Existe evidencia consistente pero no incluye todas las drogas que inducen el síndrome y no explora otras manifestaciones relacionadas con la onicólisis y la onicomicosis. El estudio presentó resultados que pueden ayudar a los prescriptores a identificar el síndrome de manos y pies, así como alternativas para la prevención y el tratamiento. Sin embargo, vale la pena destacar la necesidad de futuras investigaciones para dilucidar la etiología y los protocolos de tratamiento.

Evaluation of continuous constant current and continuous pulsed current in sweat induction for cystic fibrosis diagnosis.

BACKGROUND: The sweat test (ST) is the gold standard for the diagnosis of cystic fibrosis (CF). However, little is known about sweat induction using different types of currents and waves. In this context, our objective was to develop a device to induce sweat and compare the use of continuous constant current (CCC) and continuous pulsed current (CPC) in individuals with CF and healthy controls. METHODS: A prospective cross-sectional study with experimental intervention. The variables of gender, ethnicity, age, and body mass index (BMI) were considered. The method of Gibson and Cooke was used, and the following markers were evaluated: sweat weight, electrical impedance, sufficient sweat amount, and CF diagnosis. Triangular (TPC) or sinusoidal (SPC) pulsed current was applied to the right arm, and CCC was applied to the left arm. RESULTS: The study analyzed 260 individuals, 141/213 (54.2%) were female participants, 135/260 (51.9%) were Caucasians. The distribution of individuals by concentration of chloride at the ST was: (CF) 26/260 (10%); (borderlines) 109/260 (41.9%); (healthy) 97/260 (37.3%); (insufficient weight in sweat) 28/260 (10.8%). No association was observed between the sufficient sweat amount to perform the ST when we compared the currents. However, the SPC showed a higher amount of sweat weight. Using Bland and Altman plot considering the agreement between the sweat chloride values achieved from CPC [SPC and TPC] and CCC, there was no proportional bias and mean values are unrelated and only explain less than 8% of the variation. Moreover, TPC presented higher electrical impedance when compared with SPC and CCC. SPC presented lower electrical impedance and higher sweat weight than CCC. Male participants presented lower electrical impedance and higher sweat weight with CCC and TPC, and higher sweat weight with SPC. CONCLUSIONS: The evaluated currents are safe and able to induce and produce sweat in sufficient quantities for the ST. SPC presented lower electrical impedance when compared with other currents. The use of SPC is recommended to induce sweat in patients with sweat problems. Finally, ethnicity, gender, age and BMI did not influence sweat induction at the ST, and no side effect was observed in our study.

Protocolo de atendimento e seguimento fisioterapêutico na fibrose cí­stica / Protocol for physical therapy follow-up and monitoring in cystic fibrosis patients

A Fibrose Cí­stica (FC) requer uma abordagem multidisciplinar culminando em um complexo regime terapêutico. A fisioterapia tem papel fundamental na depuração das vias aéreas, melhora da ventilação pulmonar e da tolerância ao exercí­cio. No entanto, aspectos como acompanhamento da evolução clí­nica do paciente, identificação de perí­odos de exacerbação pulmonar e avaliação da adesão ao tratamento também fazem parte da rotina fisioterapêutica. Com o objetivo de contemplar os principais instrumentos disponí­veis que auxiliam em um melhor controle, acompanhamento e avaliação de pacientes com FC, elaborou-se o PASFIC - Protocolo de Atendimento e Seguimento Fisioterapêutico na Fibrose Cí­stica. Este protocolo inclui 10 critérios: 1) fisioterapia respiratória, 2) escore de gravidade, 3) escores de exacerbação pulmonar, 4) avaliação do peso e da estatura, 5) avaliação respiratória, 6) espirometria, 7) coleta de secreção das vias respiratórias, 8) aderência, 9) habilidades funcionais, 10) anormalidades posturais. A finalidade do PASFIC é caracterizar a população, identificar as alterações clí­nicas e acompanhar a evolução clí­nica e o atendimento fisioterapêutico de pacientes com FC, viabilizando suporte assistencial individualizado, uma melhor adesão ao tratamento e intervenção precoce durante as agudizações pulmonares, facilitando a monitorização pela equipe multiprofissional, otimizando o atendimento de pacientes com FC. (AU)

Cystic Fibrosis (CF) requires multidisciplinary approach culminating in a complex treatment regimen. Physical therapy is an important factor for better management of the disease, playing a key role in airway clearance, lung ventilation and exercise tolerance improvement. However, aspects such as monitoring of patients clinical evolution, identification of periods of acute pulmonary exacerbations and assessment of treatment adherence are also part of the physical therapy routine. In order to cover all instruments that help improve control, monitoring and evaluation of CF patients, a systematic protocol has been developed to qualify and quantify CF patients` interventions data. It includes 10 criteria: 1) Monitoring of physiotherapy techniques, 2) Application of severity score, 3) Application of pulmonary exacerbation scores, 4) Weight and height measurements, 5) Evaluation of respiratory system, 6) Systematic spirometry, 7) Airway secretion collection and register, 8) Monitoring of adherence to treatment, 9) Assessment of functional abilities, and 10) Postural abnormalities. The aim is to characterize the CF population, to identify clinical alterations and to follow up on the disease evolution and physiotherapy assistance for CF patients, as well as to allow individualized care and support, better treatment adherence, and early intervention for pulmonary exacerbations. (AU)

Experiência Subjetiva com Medicamentos de Pacientes convivendo com o Câncer de Mama: um Fotovoz / Subjective Experience with Medications of Patients living with Breast Cancer: a Photovoice / Experiencia subjetiva con Medicamentos de Pacientes conviviendo con el cáncer de Mama: un Fotovoz

Introdução: A experiência subjetiva com medicamentos deve ser compreendida e explorada no dia a dia da prática clínica. Objetivo: Compreender a experiência subjetiva com medicamentos de mulheres convivendo com o câncer de mama. Método: Estudo qualitativo com orientação teórico-metodológica da Experiência Subjetiva com Medicamentos, proposta por Ramalho de Oliveira & Shoemaker, e do fotovoz na perspectiva de Wang & Burris, de um hospital oncológico em Minas Gerais, entre agosto e novembro de 2017. A amostra com três participantes foi estabelecida no momento em que a inclusão de novos participantes não acrescentava nada de novo à pesquisa e os objetivos foram alcançados. O critério de inclusão foi intencional entre mulheres acompanhadas pelo serviço de Gerenciamento da Terapia Medicamentosa e que aceitaram participar da pesquisa. As participantes utilizaram fotografias para retratar as suas experiências com o uso de medicamentos. Essas fotografias foram discutidas e interpretadas nos fotodiálogos, que foram gravados e transcritos, e cujos dados foram interpretados pela análise indutiva dos dados. Resultados: A experiência com o uso de medicamentos foi definida em quatro unidades temáticas: 1. Quimioterapia e a ideia de perda de cabelo; 2. Implicações da experiência subjetiva com medicamentos nas relações familiares e de trabalho; 3. Valorizando o uso da terapia endócrina: adesão ao tratamento. 4. Resposta do corpo às reações da quimioterapia! Conclusão: Os temas do estudo validaram a importância da atenção farmacêutica operacionalizada pelo gerenciamento da terapia medicamentosa no contexto da mulher com câncer de mama.

AbstractIntroduction: The subjective experience with medication must be understood and explored in the day-to-day clinical practice. Objective:To understand the subjective experience with the medications of women living with breast cancer. Method: Qualitative study with the theoretical and methodological orientation of the Subjective Experience with Medications proposed by Ramalho de Oliveira & Shoemaker and Photovoice from the perspective of Wang and Burris from a cancer hospital in Minas Gerais between August and November 2017. The sample of three participants was established at the time when the inclusion of new participants did not add anything new to the research and the objectives were achieved. The inclusion criterion was intentional among women accompanied by the Medication Therapy Management services and who accepted to participate in the study. Participants used photographs to portray their experiences with the use of medications. These photographs were discussed and interpreted in photodialogue; these were recorded and transcribed whose data were interpreted by the inductive data analysis. Results: The experience with the use of medications was defined in four thematic units: 1. Chemotherapy and the idea of hair loss; 2. Implications of subjective experience with medications in family and work relationships; 3. Valuing the use of endocrine therapy: adherence to treatment. 4. The body's response to chemotherapy reactions! Conclusion: The themes of the study validated the importance of Pharmaceutical Care operationalized by the Medication Therapy Management in the context of women with breast cancer.

Introducción: la experiencia subjetiva con medicamentos debe ser comprendida y explotada en el día a día de la práctica clínica. Objetivo: comprender la experiencia subjetiva con medicamentos de mujeres conviviendo con el cáncer de mama. Método: estudio cualitativo, con orientación teórico-metodológica de la experiencia subjetiva con Medicamentos propuesta por ramalho de oliveira & shoemaker y del Fotovoz en la perspectiva de Wang y Burris de un hospital oncológico en Minas Gerais entre agosto y noviembre de 2017. la muestra de tres participantes se estableció en el momento en que la inclusión de nuevos participantes no añadía nada nuevo a la investigación y los objetivos se alcanzaron. el criterio de inclusión fue intencional entre mujeres acompañadas por el servicio de Gestión de la terapia Medicamentosa y que aceptaron participar en la investigación. las participantes utilizaron fotografías para retratar sus experiencias con el uso de medicamentos. estas fotografías fueron discutidas e interpretadas en los fotodiálogos; estos fueron grabados y transcritos cuyos datos fueron interpretados por el análisis inductivo de los datos. Resultados: la experiencia con el uso de medicamentos fue definida en cuatro unidades temáticas: 1. Quimioterapia y la idea de pérdida de cabello; 2. implicaciones de la experiencia subjetiva con medicamentos en las relaciones familiares y de trabajo; 3. Valorizando el uso de la terapia endocrina: adhesión al tratamiento. 4. respuesta del cuerpo a las reacciones de la quimioterapia! Conclusión: los temas del estudio validaron la importancia de la atención Farmacéutica operacionalizada por la Gestión Gestión integral de la Farmacoterapia en el contexto de la mujer con cáncer de mama.

Experiência do cônjuge diante da mulher com câncer de mama e em quimioterapia: estudo de caso qualitativo / Experience of the spouse of a woman with breast cancer undergoing chemotherapy: a qualitative case study

Objective: To identify the meaning attributed to the experience of a spouse of a woman with breast cancer undergoing chemotherapy. Methods: Descriptive study, with a theoretical-methodological orientation based on medical anthropology and utilizing an ethnographic case study strategy. Data were collected through semi-structured interviews and participant observation. Results: The meanings revealed that the diagnosis cause suffering. Chemotherapy was seen as giving hope of healing the wife's cancer. During this process, the spouse had to deal with the strong adverse effects of the treatment and subordinate to his wife to reduce the conflict experienced by the couple, which violated the rules of his masculinity. Religion and family were important support networks on this path. Final considerations and implications for practice: The results showed the importance of considering cultural aspects of spouses when they are faced with disease in their wives. The way spouses deal with breast cancer will depend on their cultural systems. Nursing care must be comprehensive and extend to spouses whose wives have breast cancer.

Objetivo: Identificar sentidos atribuidos a experiencia del cónyuge de mujer con cáncer de mama en quimioterapia. Método: Estudio descriptivo, orientación teórico-metodológica de antropología médica, estudio de caso etnográfico. Datos recolectados mediante entrevistas semiestructuradas y observación participante. Resultados: Se revela un diagnóstico sufrido. La quimioterapia fue recibida como esperanza de cura al cáncer de la esposa. Durante el tratamiento debió lidiar con los fuertes efectos adversos, e inclusive, subordinarse a la esposa para disminuir los conflictos de pareja, violando las normas de su masculinidad. Durante ese período, religión y familia constituyeron importantes redes de apoyo. Consideraciones finales e implicaciones para práctica: Los resultados evidenciaron la importancia de considerar aspectos culturales del compañero ante el padecimiento de la esposa, la forma en que enfrentará al cáncer de mama dependerá de su sistema cultural. Se requerirá atención de enfermería integral, extendiendo el cuidado al cónyuge de la mujer con cáncer de mama.

Objetivo: Identificar os sentidos atribuídos à experiência do cônjuge diante da mulher com câncer de mama e em quimioterapia. Método: Estudo descritivo, com orientação teórico-metodológica da antropologia médica e estratégia de estudo de caso etnográfico. Os dados foram coletados utilizando entrevistas semiestruturadas e observação participante. Resultados: Os sentidos revelaram um diagnóstico sofrido. A quimioterapia foi recebida como esperança de cura para o câncer da esposa. Na trajetória, precisou lidar com os fortes efeitos adversos do tratamento e ainda se subordinar à esposa para diminuir os conflitos do casal, violando então as regras da sua masculinidade. Nesse percurso, a religião e a família foram importantes redes de apoio. Considerações finais e implicações para prática: Os resultados evidenciaram a importância de se considerar os aspectos culturais do parceiro diante do adoecimento da esposa, a forma como lidará com o câncer de mama dependerá do seu sistema cultural. A assistência de enfermagem deve ser integral e estender o cuidado também ao cônjuge da mulher que tem câncer de mama.

Impact of a medication therapy management service offered to patients in treatment of breast cancer

ABSTRACT Cancer has high morbidity and mortality rates related to medication use and produce a costly impact in health care. Thus, patients require constant monitoring and proper coordination of care between different professionals. This study aimed to evaluate the impact generated by a Medication Therapy Management service (MTM) offered to patients with breast cancer in use of polypharmacy. Observational, exploratory, descriptive and retrospective study of a MTM service that included 93 patients. Sociodemographic and clinical data related to pharmacotherapy and the processes associated with the systematization of the service were collected and analyzed. Patients were followed-up by the MTM service on average for 18 months (±4.31) and 185 drug-related problems (DRP) were identified, an average of two DRP per patient. Of these DRP, 48.11% were resolved and 49.73% were in the resolution process. The most common DRP were in the categories of Indication (37.84%), followed by Safety (23.78%). The safety category showed the highest resolution rate (59.09%). The study revealed an increased risk of DRP for patients with three or more comorbidities and using 5 or more medications. The process of systematization of a MTM service in oncology was associated with positive outcomes.

Teste de caminhada de seis minutos em pediatria: discutindo evidências em situações específicas / Six minutes walk test in pediatrics: discussing evidence in specific situations

Teste de caminhada de seis minutos (TC6) tem se mostrado uma ferramenta bem tolerada, confiá- vel e de baixo custo para monitorar a capacidade funcional de crianças e adolescentes saudáveis e em diferentes situações clínicas. Objetivo: Verificar e discutir as evidências científicas do TC6 utilizado em 4 situações específicas da criança com: 1) asma; 2) fibrose cística 3) obesidade e 4) higidez. Método: A busca nas bases de dados foi conduzida utilizando-se as palavras-chaves: teste de caminhada de seis minutos, crianças, adolescentes, obesos, fibrose cística e asma. Consultou-se as bases Pubmed (Medline), Lilacs e PEDro. Foram considerados os ensaios clínicos em português, inglês e espanhol, publicados no período de 2005 a 2016 e incluídos os estudos que abordam o TC6como método de avaliação, monitorização e prognóstico de crianças e adolescentes saudáveis, com diagnósticos de asma, fibrose cística e obesidade. Resultados: Identificou-se 97 artigos, sendo 48 duplicados. Conduziu-se a pré-seleção de 43 estudos dos quais 6foram excluídos, pelo título ou resumo, por não atenderem aos critérios de inclusão. A seleção final totalizou 39 manuscritos para a apreciação na íntegra e discussão na presente revisão. Conclusão: TC6 é reprodutível e validado para a população pediátrica, sendo considerado um instrumento importante para avaliar as implicações das doenças crônicas na capacidade funcional. 1) TC6 tem se mostrado útil pra identificação do prejuízo das atividades de vida diária durante a crise de asma e fora dela, assim como do comprometimento da capacidade funcional diante do hábito de vida sedentário. 2) É adequado para avaliação de programas de reeducação alimentar na obesidade. 3) Na fibrose cística é uma boa ferramenta para avaliação de programas de reabilitação pulmonar e acompanhamento da progressão da doença. 4) Entre os saudáveis observa-se a busca por valores de referência e falta de um consenso sobre a forma de aplicabilidade do teste

The six-minute walk test (6MWT) is regarded as a well-tolerated, reliable and cost-effective tool to monitor the functional capacity of healthy children and adolescents and in different clinical situations. Objective: To verify and discuss the scientific evidence of the 6MWT in four specific situations of children with: 1) asthma; 2) cystic fibrosis 3) obesity and 4) healthy controls. Method: A search was conducted in Pubmed (Medline), Lilacs and PEDro databases with the key words: sixminute walk test, children, adolescents, obesity, cystic fibrosis and asthma. The selected articles were those that reported clinical trials in Portuguese, English or Spanish, published between 2005- 2016 that included studies that assessed the 6MWT as a method of evaluation for monitoring and prognosis of healthy or diseased children and adolescents. Results: We identified 97 articles, 48 of them were duplicate. A pre-selection of 43 remaining studies based on title or summary excluded 6 articles for not meeting the inclusion criteria. Finally, 39 manuscripts were included in this review. Conclusion: 6MWT is reproducible and validated for the pediatric population and is considered an important instrument to assess the implications of chronic diseases on functional status. 1) 6MWT has proven useful to identify function losses to the activities of daily living during or in-between asthma attacks, as well as the functional jeopardy of sedentary habit; 2) It is suitable for assessing nutritional education programs in obesity; 3) In cystic fibrosis, it is a good tool for evaluating pulmonary rehabilitation programs and monitoring of the disease progression; and 4) Among healthy subjects, however, there is still lack of consensus of a reference as well as the most suitable applicability of this test

Sweat test and cystic fibrosis: overview of test performance at public and private centers in the state of São Paulo, Brazil.

OBJECTIVE:: The sweat test (ST) measures chloride levels in sweat and is considered the gold standard for the diagnosis of cystic fibrosis (CF). However, the reliability of a ST depends on their being performed by experienced technicians and in accordance with strict guidelines. Our aim was to evaluate how sweat stimulation, sweat collection, and chloride measurement are performed at 14 centers (9 public centers and 5 private centers) that routinely perform STs in the state of São Paulo, which has the highest frequency of CF in Brazil. METHODS:: This was a cross-sectional cohort study, using a standardized questionnaire administered in loco to the staff responsible for conducting STs. RESULTS:: No uniformity regarding the procedures was found among the centers. Most centers were noncompliant with the international guidelines, especially regarding the collection of sweat (the samples were insufficient in 10-50% of the subjects tested); availability of stimulation equipment (which was limited at 2 centers); modernity and certification of stimulation equipment (most of the equipment having been used for 3-23 years); and written protocols (which were lacking at 12 centers). Knowledge of ST guidelines was evaluated at only 1 center. CONCLUSIONS:: Our results show that STs largely deviate from internationally accepted guidelines at the participating centers. Therefore, there is an urgent need for standardization of STs, training of qualified personnel, and acquisition/certification of suitable equipment. These are essential conditions for a reliable diagnosis of CF, especially with the increasing demand due to newborn screening nationwide, and for the assessment of a possible clinical benefit from the use of modulator drugs. OBJETIVO:: O teste do suor (TS) mede os níveis de cloro no suor e é considerado o padrão ouro para o diagnóstico da fibrose cística (FC). Contudo, a confiabilidade do TS depende de sua realização por técnicos experientes e segundo diretrizes rígidas. Nosso objetivo foi avaliar como são realizadas a estimulação e coleta do suor e a dosagem de cloro em 14 centros (9 públicos e 5 privados) que realizam TS rotineiramente no estado de São Paulo, que possui a maior frequência de FC do Brasil. MÉTODOS:: Estudo de coorte transversal utilizando um questionário padronizado aplicado in loco ao pessoal responsável pela realização dos TS. RESULTADOS:: Não houve uniformidade entre os centros quanto aos procedimentos. A maioria dos centros não era aderente às diretrizes internacionais, especialmente quanto à coleta do suor (amostras insuficientes em 10-50% dos indivíduos testados), disponibilidade de equipamentos de estimulação (limitada em 2 centros), modernidade e certificação dos mesmos (a maioria utilizada há 3-23 anos) e protocolos escritos (ausentes em 12 centros). Avaliou-se o conhecimento sobre diretrizes para TS em apenas 1 centro. CONCLUSÕES:: Nossos resultados mostram que, nos centros participantes, os TS estão muito distantes das diretrizes internacionalmente aceitas. Portanto, há necessidade urgente de padronização dos TS, de treinamento de pessoal qualificado e de aquisição/certificação de equipamentos adequados. Essas são condições essenciais para um diagnóstico confiável de FC, especialmente com a crescente demanda resultante da triagem neonatal em todo o país, e para a avaliação do possível benefício clínico do uso de moduladores.

Sweat test and cystic fibrosis: overview of test performance at public and private centers in the state of São Paulo, Brazil / Teste do suor e fibrose cística: panorama da realização do teste em centros públicos e privados do estado de São Paulo

ABSTRACT Objective: The sweat test (ST) measures chloride levels in sweat and is considered the gold standard for the diagnosis of cystic fibrosis (CF). However, the reliability of a ST depends on their being performed by experienced technicians and in accordance with strict guidelines. Our aim was to evaluate how sweat stimulation, sweat collection, and chloride measurement are performed at 14 centers (9 public centers and 5 private centers) that routinely perform STs in the state of São Paulo, which has the highest frequency of CF in Brazil. Methods: This was a cross-sectional cohort study, using a standardized questionnaire administered in loco to the staff responsible for conducting STs. Results: No uniformity regarding the procedures was found among the centers. Most centers were noncompliant with the international guidelines, especially regarding the collection of sweat (the samples were insufficient in 10-50% of the subjects tested); availability of stimulation equipment (which was limited at 2 centers); modernity and certification of stimulation equipment (most of the equipment having been used for 3-23 years); and written protocols (which were lacking at 12 centers). Knowledge of ST guidelines was evaluated at only 1 center. Conclusions: Our results show that STs largely deviate from internationally accepted guidelines at the participating centers. Therefore, there is an urgent need for standardization of STs, training of qualified personnel, and acquisition/certification of suitable equipment. These are essential conditions for a reliable diagnosis of CF, especially with the increasing demand due to newborn screening nationwide, and for the assessment of a possible clinical benefit from the use of modulator drugs.

RESUMO Objetivo: O teste do suor (TS) mede os níveis de cloro no suor e é considerado o padrão ouro para o diagnóstico da fibrose cística (FC). Contudo, a confiabilidade do TS depende de sua realização por técnicos experientes e segundo diretrizes rígidas. Nosso objetivo foi avaliar como são realizadas a estimulação e coleta do suor e a dosagem de cloro em 14 centros (9 públicos e 5 privados) que realizam TS rotineiramente no estado de São Paulo, que possui a maior frequência de FC do Brasil. Métodos: Estudo de coorte transversal utilizando um questionário padronizado aplicado in loco ao pessoal responsável pela realização dos TS. Resultados: Não houve uniformidade entre os centros quanto aos procedimentos. A maioria dos centros não era aderente às diretrizes internacionais, especialmente quanto à coleta do suor (amostras insuficientes em 10-50% dos indivíduos testados), disponibilidade de equipamentos de estimulação (limitada em 2 centros), modernidade e certificação dos mesmos (a maioria utilizada há 3-23 anos) e protocolos escritos (ausentes em 12 centros). Avaliou-se o conhecimento sobre diretrizes para TS em apenas 1 centro. Conclusões: Nossos resultados mostram que, nos centros participantes, os TS estão muito distantes das diretrizes internacionalmente aceitas. Portanto, há necessidade urgente de padronização dos TS, de treinamento de pessoal qualificado e de aquisição/certificação de equipamentos adequados. Essas são condições essenciais para um diagnóstico confiável de FC, especialmente com a crescente demanda resultante da triagem neonatal em todo o país, e para a avaliação do possível benefício clínico do uso de moduladores.