Respiratory muscles's thermographic analysis in asthmatic youth with and without bronchospasm induced by eucapnic voluntary hyperpnea.

OBJECTIVE: To compare the thermographic pattern of regions of interest (ROI) of respiratory muscles in young asthmatics with and without bronchospasm induced by eucapnic voluntary hyperpnea (EVH). MATERIALS AND METHODS: Cross-sectional study carried out with 55 young (55% male and 45% females) aged 12.5 ± 3.3 years, divided in nine nonasthmatics, 22 asthmatics without exercise-induced bronchospasm compatible response (EIB-cr) and 24 asthmatics with EIB-cr. The diagnosis of EIB was given to subjects with a fall in forced expiratory volume in the first second (FEV1) ≥ 10% compared to baseline. Thermographic recordings of respiratory muscles were delimited in ROI of the sternocleidomastoid (SCM), pectoral, and rectus abdominis intention area. Thermal captures and FEV1 were taken before and 5, 10, 15 and 30 min after EVH. RESULTS: Twenty-four (52.1%) of asthmatics had EIB-cr. There was a decrease in temperature at 10 min after EVH test in the SCM, pectoral and rectus abdominis ROIs in all groups (both with p < 0.05). There was a decrease in temperature (% basal) in asthmatic with EIB-cr compared to nonasthmatics in the rectus abdominis area (p < 0.05). CONCLUSION: There was a decrease in temperature in the ROIs of different muscle groups, especially in asthmatics. The greater drop in FEV1 observed in individuals with EIB-cr was initially associated with a decrease in skin temperature, with a difference between the nonasthmatics in the abdominal muscle area. It is likely that this decrease in temperature occurred due to a temporary displacement of blood flow to the most used muscle groups, with a decrease in the region of the skin evaluated in the thermography.

Obesity is a risk factor for exercise-induced bronchospasm in asthmatic adolescents.

INTRODUCTION: Exercise-induced bronchospasm (EIB) is common in young asthmatics and obesity is becoming an epidemic in this population. Both conditions can give rise to or worsen respiratory symptoms upon exercise and may interfere with recreational and sports activities. OBJECTIVE: To investigate the association between obesity and the risk and severity of EIB in asthmatic children and adolescents. METHODS: This study included data from asthmatic patients aged between 7 and 19 years undergoing treadmill running tests to evaluate EIB, defined as a reduction greater than or equal to 10% in forced expiratory volume in the first second (FEV1 ) compared to baseline. Eutrophic, obese, and overweight individuals were categorized according to body mass index z-score (eutrophic, -0.5 < z ≤ 1; overweight, 1 < z < 2; and obese, z ≥ 2). RESULTS: Of the 156 individuals studied (42% female), 58% were eutrophic, 22% overweight, and 19% obese. Seventy-three individuals (47%) presented with EIB, with higher risk among obese (OR, 2.86; 95% CI, 1.00-8.14; P = .05). Asthma severity was another independent risk factor for EIB (OR, 2.95; 95% CI, 1.36-6.42; P = .006). The number of patients in whom FEV1 returned to baseline values (difference less than 10% from baseline) at the 13th minute after challenge was lower in obese individuals compared to eutrophic and overweight ones (P = .04). Baseline FEV1 , gender, or age were not found to be risk factors for EIB in any of the groups. CONCLUSION: Obese youngsters with asthma present a greater risk for EIB with slower recovery than their nonobese peers. Clinicians should be aware of this association, especially in those with more severe disease, for adequate recognition and treatment.

Asthma in pregnancy: association between the Asthma Control Test and the Global Initiative for Asthma classification and comparisons with spirometry.

OBJECTIVE: The aim of this study was to identify a possible association between the assessment of clinical asthma control using the Asthma Control Test (ACT) and the Global Initiative for Asthma (GINA) classification and to perform comparisons with values of spirometry. STUDY DESIGN: Through this cross-sectional study, 103 pregnant women with asthma were assessed in the period from October 2010 to October 2013 in the asthma pregnancy clinic at the Clinical Hospital of the Federal University of Pernambuco. Questionnaires concerning the level of asthma control were administered using the Global Initiative for Asthma classification, the Asthma Control Test validated for asthmatic expectant mothers and spirometry; all three methods of assessing asthma control were performed during the same visit between the twenty-first and twenty-seventh weeks of pregnancy. RESULTS: There was a significant association between clinical asthma control assessment using the Asthma Control Test and the Global Initiative for Asthma classification (p<0.001). There were also significant associations between the results of the subjective instruments of asthma (the GINA classification and the ACT) and evidence of lung function by spirometry. CONCLUSIONS: This study shows that both the Global Initiative for Asthma classification and the Asthma Control Test can be used for asthmatic expectant mothers to assess the clinical control of asthma, especially at the end of the second trimester, which is assumed to be the period of worsening asthma exacerbations during pregnancy. We highlight the importance of the Asthma Control Test as a subjective instrument with easy application, easy interpretation and good reproducibility that does not require spirometry to assess the level of asthma control and can be used in the primary care of asthmatic expectant mothers.

Mothers impose physical activity restrictions on their asthmatic children and adolescents: an analytical cross-sectional study.

BACKGROUND: Physical activities are important for children and adolescents, especially asthmatics. A significant proportion is considered less active than their non-asthmatic peers and mother's beliefs about asthma are thought to be a determinant factor.The research objectives were to investigate whether mothers try to impose limitations on the physical activity (PA) of their asthmatic children/adolescents; identify associated factors; and explore if this attitude has any impact on children's PA levels. METHODS: In this cross sectional investigation, we studied 115 asthmatics aged between 9 and 19 years and their mothers. Asthma severity, PA level and exercise induced bronchospasm (EIB) were evaluated. Mothers were questioned on their beliefs about physical activity in non-asthmatic and asthmatic children, if they imposed restrictions on their children's physical activity, on EIB perception and personal levels of anxiety and depression. RESULTS: Ninety six percent of the mothers answered that PA are important for children and adolescents. Despite this, 37% of them admitted imposing restrictions to their children's PA. This attitude was associated with mother's negative opinions about asthmatics doing PA, perception of children's dyspnea after running on a treadmill, mother's anxiety level and children's asthma severity. The mother's restrictive attitudes were not associated with children's lower PA levels. CONCLUSION: A high proportion of the mothers said that they restrained their asthmatic children from engaging in physical activity. This fact should be recognized by health professionals and discussed with parents and caregivers as these negative beliefs may lead to conflicts and prejudiced attitudes that could discourage children's involvement in physical activities and sports.

Adverse reactions to foods and food allergy: development and reproducibility of a questionnaire for clinical diagnosis.

Objective. To develop a questionnaire as a screening tool for adverse reactions to foods in children and to assess the technical reproducibility by test-retest. Methods. Reproducibility of the questionnaire was performed by the literature review, preparing the preliminary questionnaire, peer review, pretest, and retest analysis. The study of the test-retest reproducibility was cross-sectional and descriptive. Kappa coefficient was used to study the reproducibility of the questionnaire. The sample consisted of 125 2-4 year-old children from 15 daycare centers in Recife, Brazil, and interviews with parents or caregivers were used to collect data. Results. From the total children, sixty-three were boys (50.4%), forty-six were two years old (36.8%), forty-seven were three years old (37.6%), and thirty-two were four years old (25.6%). Forty caregivers reported that their child had health problems with food. Most frequently reported offending foods were milk, peanuts, shrimp, and chocolate. Nine questions showed a good Kappa index (≥0,6). Conclusions. The questionnaire used needs to be resized and reshaped on the basis of the issues with good internal consistency and reproducibility. The use of a validated and reproducible questionnaire in the children represents an important contribution towards assessing an eventual rise in overt food allergy.

Valores de referência para espirometria em crianças pré-escolares / Reference values for spirometry in preschool children

OBJETIVOS: Valores de referência para testes de função pulmonar diferem em amostras de diferentes países, incluindo valores para pré-escolares. O objetivo principal do presente estudo foi derivar valores de referência em nossa população. MÉTODOS: Foi realizado estudo prospectivo, com aplicação de questionário a 425 crianças pré-escolares com idade variando entre três e seis anos, provenientes de escolas e creches públicas e privadas de uma cidade metropolitana do Brasil. As crianças foram selecionadas por amostragem aleatória simples dos referidos educandários. Foram avaliados: PFE, CVF, VEF1 VEF0,50, FEF25-75 e as relações: VEF1/CVF, VEF0,5/CVF e FEF25-75/CVF. RESULTADOS: Das 425 crianças recrutadas, 321 (75,6%) realizaram os testes. Destas, 135 (42,0%) apresentaram manobras aceitáveis, com curvas expiratórias completas e fizeram parte da análise de regressão para definir os valores de referência. Por análise de regressão linear e logarítmica, a estatura e o sexo influenciaram significativamente nas medidas de CVF. No sexo masculino, o r² se elevou com o modelo logarítmico, para a CVF e VEF1, porém o modelo linear foi mantido, por sua simplicidade. Os limites inferiores foram calculados através das medidas do 5º percentil dos resíduos. CONCLUSÃO: Curvas expiratórias completas são de mais difícil obtenção em pré-escolares. Além da estatura, o sexo também influencia nas medidas de CVF e VEF1. Foram definidos valores de referência para espirometria em crianças pré-escolares, nessa população, aplicáveis a populações semelhantes.

OBJECTIVES: Reference values for lung function tests differ in samples from different countries, including values for preschoolers. The main objective of this study was to derive reference values in this population. METHODS: A prospective study was conducted through a questionnaire applied to 425 preschool children aged 3 to 6 years, from schools and day-care centers in a metropolitan city in Brazil. Children were selected by simple random sampling from the aforementioned schools. Peak expiratory flow (PEF), forced vital capacity (FVC), forced expiratory volumes (FEV1, FEV0.50), forced expiratory flow (FEF25-75) and FEV1/FVC, FEV0.5/FVC and FEF25-75/FVC ratios were evaluated. RESULTS: Of the 425 children enrolled, 321 (75.6%) underwent the tests. Of these, 135 (42.0%) showed acceptable results with full expiratory curves and thus were included in the regression analysis to define the reference values. Height and gender significantly influenced FVC values through linear and logarithmic regression analysis. In males, R2 increased with the logarithmic model for FVC and FEV1, but the linear model was retained for its simplicity. The lower limits were calculated by measuring the fifth percentile residues. CONCLUSION: Full expiratory curves are more difficult to obtain in preschoolers. In addition to height, gender also influences the measures of FVC and FEV1. Reference values were defined for spirometry in preschool children in this population, which are applicable to similar populations.

Reference values for spirometry in preschool children.

OBJECTIVES: Reference values for lung function tests differ in samples from different countries, including values for preschoolers. The main objective of this study was to derive reference values in this population. METHODS: A prospective study was conducted through a questionnaire applied to 425 preschool children aged 3 to 6 years, from schools and day-care centers in a metropolitan city in Brazil. Children were selected by simple random sampling from the aforementioned schools. Peak expiratory flow (PEF), forced vital capacity (FVC), forced expiratory volumes (FEV1, FEV0.50), forced expiratory flow (FEF25-75) and FEV1/FVC, FEV0.5/FVC and FEF25-75/FVC ratios were evaluated. RESULTS: Of the 425 children enrolled, 321 (75.6%) underwent the tests. Of these, 135 (42.0%) showed acceptable results with full expiratory curves and thus were included in the regression analysis to define the reference values. Height and gender significantly influenced FVC values through linear and logarithmic regression analysis. In males, R(2) increased with the logarithmic model for FVC and FEV1, but the linear model was retained for its simplicity. The lower limits were calculated by measuring the fifth percentile residues. CONCLUSION: Full expiratory curves are more difficult to obtain in preschoolers. In addition to height, gender also influences the measures of FVC and FEV1. Reference values were defined for spirometry in preschool children in this population, which are applicable to similar populations.

Asma na gravidez: atualização no manejo / Asthma in pregnancy: current management

A asma é doença crônica frequente na gestação, cujo descontrole encontra-se associado a desfechos maternos e perinatais desfavoráveis. O manejo da doença apresenta desafios, tais como a resistência das pacientes em utilizar medicações durante a gravidez, além de queixas frequentes de dispneia associada ao estado gravídico, não relacionada à asma. O objetivo do presente trabalho foi revisar os conhecimentos atuais sobre asma na gravidez. As fontes de dados foram revisões e artigos originais publicados nos últimos 12 anos e indexados nas bases de dados PubMed, SciELO e Lilacs. As conclusões deste artigo de revisão indicam que o controle adequado da asma juntamente com a vigilância obstétrica cuidadosa devem ser integrados e constituir objetivo global do tratamento de gestantes asmáticas. O tratamento medicamentoso permite o uso de algumas medicações utilizadas em pacientes não gestantes.

Asthma is a common chronic disease during pregnancy, and inappropriate control of this conditionis associated with unfavorable maternal and perinatal outcomes. Management of asthma duringpregnancy presents challenges, including the patients’ resistance to use medications duringpregnancy and frequent complaints of dyspnea associated with pregnancy but not related toasthma. The objective of the present study was to review the current knowledge about asthmain pregnancy. Data sources included reviews and original articles published in the past 12 yearsand indexed in PubMed, SciELO, and Lilacs databases. Our findings indicate that adequate controlof asthma and careful obstetric follow-up should be integrated and constitute a global goal intreating pregnant women with asthma. Pharmacologic treatment allows for the use of somemedications that are used in non-pregnant patients.

Giardia lamblia e alergia respiratória: estudo em uma amostra de crianças de área urbana com frequência elevada da protozoose / Giardia lamblia and respiratory allergies: a study of children from an urban area with a high incidence of protozoan infections

OBJETIVO: Uma elevada incidência de enteroparasitoses é encontrada em regiões urbanas do nordeste brasileiro. As infecções por Giardia lamblia têm sido relacionadas com aumento da prevalência de alergias cutâneas e gastrointestinais. Contudo, ainda existe pouca informação sobre a associação entre a giardíase e doenças alérgicas das vias aéreas. Diante disso, o presente estudo se propôs a verificar a relação entre a infecção por G. lamblia em crianças de área urbana e reatividade alérgica respiratória. MÉTODOS: O estudo incluiu 110 pacientes, de ambos os sexos e idades, entre 5 e 15 anos. Os pacientes foram submetidos a questionários de avaliação dos sintomas clínicos, testes cutâneos de leitura imediata e exames coproparasitológicos e sorológicos. RESULTADOS: Foi verificada uma frequência elevada de crianças infectadas por G. lamblia (45%, 50/110). A infecção pelo protozoário não foi associada com maior risco de alergias respiratórias (p = 0,075), elevação de IgE total (p = 0,701), IgE específica (p = 0,250) ou teste cutâneo positivo para diferentes alérgenos ambientais (p = 0,239). CONCLUSÃO: O estudo demonstrou que a presença dos sintomas de asma, atopia cutânea e marcadores sorológicos não foram associados com a presença de infecção pela G. lamblia nessa amostra de crianças.

OBJECTIVES: There is a high incidence of intestinal parasite infection in urban areas in the Northeast of Brazil. Giardia lamblia infections have been associated with increased prevalence of cutaneous allergies and gastrointestinal disorders. However, little is known about the relationship between giardiasis and allergic diseases of the airways. The present study aimed to investigate the possible association between respiratory allergic diseases and infections by G. lamblia in children from urban areas. METHODS: This study recruited 110 patients of both sexes aged 5-15 years. Patients were administered a questionnaire evaluating clinical symptoms and were given skin tests, parasite tests and serum tests. RESULTS: A high incidence of G. lamblia was observed (45%, 50/110). Infections by this protozoan were not associated with increased risk of respiratory allergy (p = 0.075), high total IgE levels (p = 0.701), positive specific IgE tests (p = 0.250), or positive skin tests for a range of environmental allergens (p = 0.239). CONCLUSION: This study demonstrated that symptoms of asthma, skin allergy and serum markers were not associated with G. lamblia infections in this sample of children from urban areas.

Giardia lamblia and respiratory allergies: a study of children from an urban area with a high incidence of protozoan infections.

OBJECTIVES: There is a high incidence of intestinal parasite infection in urban areas in the Northeast of Brazil. Giardia lamblia infections have been associated with increased prevalence of cutaneous allergies and gastrointestinal disorders. However, little is known about the relationship between giardiasis and allergic diseases of the airways. The present study aimed to investigate the possible association between respiratory allergic diseases and infections by Giardia lamblia in children from urban areas. METHODS: This study recruited 110 patients of both sexes aged 5-15 years. Patients were administered a questionnaire evaluating clinical symptoms and were given skin tests, parasite tests and serum tests. RESULTS: A high incidence of Giardia lamblia was observed (45%, 50/110). Infections by this protozoan were not associated with increased risk of respiratory allergy (p = 0.075), high total IgE levels (p = 0.701), positive specific IgE tests (p = 0.250), or positive skin tests for a range of environmental allergens (p = 0.239). CONCLUSION: This study demonstrated that symptoms of asthma, skin allergy and serum markers were not associated with Giardia lamblia infections in this sample of children from urban areas.

Hallway versus treadmill 6-minute-walk tests in patients with chronic obstructive pulmonary disease.

INTRODUCTION: The 6-min-walk test is widely used for functional evaluation of patients with chronic obstructive pulmonary disease (COPD), but the test requires a 30-m unobstructed hallway, which is not available in all institutions. A treadmill 6-min walk test might be more practical. METHODS: In a crossover study, we compared the results from hallway and treadmill 6-min-walk tests by 19 patients with moderate to very severe COPD. Each patient did 3 hallway tests and 3 treadmill tests. The hallway tests were according to the American Thoracic Society guidelines. RESULTS: The mean hallway walk distance was significantly (102 m, 95% confidence interval 65-139 m) greater than the mean treadmill walk distance. Between the hallway and treadmill tests, agreement was very poor via Bland-Altman analysis, correlation was low (r = 0.48, P = .04), and those differences were not explained by differences in patient effort. The differences between the 3 treadmill tests were greater than those between the 3 hallway tests, and in both the hallway and treadmill tests patient effort progressively diminished, indicating a learning effect. CONCLUSIONS: The hallway and treadmill walk tests are not interchangeable. We need further study and standardization of the treadmill 6-min walk test.

Produção de IL-10 em resposta a aeroalérgenos em crianças e adolescentes de zona urbana com geohelmintíases / IL-10 production in response to aeroallergens by children and teenage from urban areas with geohelminthiasis

Objetivos: A IL-10 pode imunomodular as respostas alérgicas no hospedeiro. A respeito dos geohelmintos, trabalhos divergem quanto à alteração do quadro clínico e/ou testes cutâneos de hipersensibilidade. Pouco é conhecido sobre a produção de IL-10 frente a aeroalérgenos durante as geohelmintíases. Neste estudo, verificamos a produção de IL-10 por células mononucleares de sangue periférico de pacientes com ou sem geohelmíntiases, de zona urbana, em resposta ao Dermatophagoides pteronyssinus ou Blomia tropicalis. Métodos: Estudo experimental, com 21 pacientes de zona urbana, em que foram realizadas 84 determinações de IL-10. Após exames coprológicos, em triplicata, dois grupos foram formados, crianças enteroparasitadas e não-parasitadas. Amostras de sangue foram coleta das para purificação de células mononucleares e cultivo com antígenos de Ascaris sp (Asc), mitógeno concanavalina A (Con A), O. pteronyssinus (Dep) e B. tropicalis (Bt). A IL-10 do sobrenadante celular foi dosada (ELISA). Resultados: Idade dos pacientes variou de 9-12 anos e sem diferença quanto ao sexo. Nos indivíduos parasitados a carga parasitária foi baixa. Frente ao Asc, Con A ou Dep não houve diferença na síntese de IL-10 pelas células do grupo parasitado e não parasitado. Contudo, uma produção significativamente maior de IL-10, frente ao estímulo com Bt, nos não-parasitados foi observada. Conclusões: Pacientes de zona urbana parasitados produzem menos IL-10 frente à B. tropicalis, alérgeno mais prevalente em Recife, podendo levar a predisposição às manifestações alérgicas. Estes dados corroboram a hipótese que baixa carga parasitária de geohelmintos, principalmente Ascaris lumbricoides, pode predispor à asma/sibilância.

Objectives: IL-10 can immunomodulate allergic reactions in the host. Concerning of the geohelminths, the studies diverge about the alteration of clinical allergic disease and/or skin prick test reactivity. IL-10 production in response to aeroallergens during the geohelminths infection is poorly known. In this study, we verified the IL-10 syntheses by peripheral blood mononuclear cells from low parasitic load infected or non-infected patients coming from urban areas, when stimulated with Dermatophagoides pteronyssinus (Dep) or Blomia tropicalis (Bt). Methods: Experimental analysis of 21 patients from urban areas, which was performed 84 IL-10 determinations. After the parasitological exams (Hofmann/Kato-Katz), in triplicate, two groups were obtained, geohelminths infected and non-infected children. Blood sample were harvested for purification of mononuclear cells and culture with Ascaris sp antigen (Asc), concanavalina A mitogen (Con A), Dep and Bt. IL-10 content in cellular supernatant was measured (ELISA). Results: Patients age was among 9-12 years old and without difference in gender. In parasite infected individual the parasite load was low. In response to Asc, Con A or Dep there was not difference in the IL-10 synthesis. However, in response to Bt stimulus, high production of IL-10 by non-parasite infected group was observed. Conclusions: Parasite infected patients from urban areas product less IL-10 to Bt, allergen more prevalent in Recife, could lead to predisposition to allergic manifestation. These finding corroborate the hypotheses that low parasite load of geohelminths, especially Ascaris lumbricoides, can predispose to asth ma/wheezing.

Efeitos relacionados ao uso do esteróide inalado na saúde periodontal que o médico precisa conhecer / Side adverse effects of inhaled steroids on periodontal health that physician needs to know

Objetivo: Revisar a literatura para investigar a associação entre o uso dos esteróides inalados e a presença da doença periodontal. Fontes dos dados: Foi realizada uma revisão consultando a base de dados do Medline acessando o Pubmed; foram também consultadas as fontes de dados 880, Lilacs e Scielo, com as palavras-chaves: periodontal disease (gingivitis and periodontitis) - asthma - inhaled steroids. Síntese dos dados: Os esteróides inalados se constituem na medicação de primeira escolha para o tratamento da asma persistente, sendo bem documentado os efeitos adversos na cavidade bucal, como disfagia, faringite e candidíase. Existem alguns dados sobre os possíveis efeitos deletérios que os esteróides inalados possam causar nos dentes e gengiva, como exacerbação da inflamação gengiva I, perda de inserção clínica periodontal e perda das unidades dentárias. Conclusão: Parece haver uma associação positiva entre o uso de esteróides inalados e alterações periodontais.

Objective: Review the literature to investigate the association between the use of inhaled steroids and the presence of periodontal disease. Source of data: Literature review was carried out in Medline, Lilacs, Scielo and BBO by Pubmed, using the key-words: periodontal disease (gingivitis and periodontitis) - asthma ¬inhaled steroids. Syntheses of data: Inhaled steroids are the main drug in the treatment of persistent asthma. Adverse side effects in the oral cavity are well documented, such as dysphagia, pharyngitis and candidiasis. There are some data on possible negative effects steroids cause to teeth and gums, like gingival inflammation, lack of clinical attachment and loss of teeth. Conclusion: The review suggests there is a positive association between the use of inhaled steroids and periodontal alterations.

Sintomas nasais, depuração muco-ciliar nasal e cloreto de benzalcônio / Nasal symptoms, nasal mucociliar clearance, and benzalkonium chlorideand benzalkonium chloride

Introdução: O cloreto de benzalcônio (CBZ) é considerado um preservativo inócuo, embora seja cada vez mais associado a efeitos colaterais e sintomas clínicos. Objetivos: Verificar o efeito do CBZ na depuração muco-ciliar nasal em voluntários sadios e sua correlação com sintomas. Pacientes e Métodos: O ensaio clínico foi duplo-cego, placebo-controlado, randomizado, cruzado, com três semanas de washout, em 43 voluntários sadios para comparar o efeito de solução salina nasal contendo CBZ a 0,01 % (S+CBZ) com a de solução salina livre de preservativos (SP), usados três vezes ao dia, por três semanas, na depuração muco-ciliar nasal. As avaliações foram realizadas no início e fim de cada período por técnica cintigráfica com estrôncio coloidal marcado com tecnécio99m. Resultados: Dos 43 voluntários apenas um não completou as observações planejadas. Nove indivíduos foram excluídos do estudo por infecção de vias aéreas superiores. Houve redução significante na depuração mucociliar nasal após o período de uso da S+CBZ em relação a SP (1,23 mm.min'l; p < 0.01), apesar de não ter sido referido qualquer sintoma. Não houve efeito carry-over. Conclusão: O CBZ nas concentrações usadas nos medicamentos tópicos nasais causou retardo na depuração muco-ciliar nasal em indivíduos saudáveis após três semanas de uso. Não houve relato de sintomas nasais associados.