Ana Carla Carvalho Coelho

Obesity and Poor Asthma Control in Patients with Severe Asthma

Background. Asthma is a public health problem as it leads to hospitalization and eventual death, particularly in its severe forms. Many studies have demonstrated an association between obesity and asthma. Objective. The aim of this study was to investigate the relationship between obesity and asthma control in a group of patients at a reference center for severe asthma in Brazil. Methods. This cross-sectional study was conducted in the outpatient central reference clinic of the Program for Control of Asthma in the State of Bahia. It included 508 subjects with severe asthma of both genders and above 18 years of age. All the participants answered a sociodemographic and a clinical questionnaire to collect information on their asthma and comorbidities, such as rhinitis and gastro-esophageal reflux disease (GERD). Participants also completed the Asthma Control Questionnaire, performed a spirometry test, and had their weight, height, and waist and hip circumferences registered. Results. Logistic regression analysis demonstrated a positive association between body mass index (BMI) and uncontrolled asthma [odds ratio (OR) 1.5; 95% confidence interval (CI) 1.02–2.20]. Symptoms of chronic rhinitis and GERD were also significantly associated with uncontrolled asthma (OR 3.68, 95% CI 1.50–9.01; and OR 2.78, 95% CI 1.91–4.03, respectively). There was no correlation between waist-to-hip ratios and asthma control. Conclusion. In our sample of patients with severe asthma, those who were obese were more likely to have uncontrolled asthma than patients with a normal BMI. Nevertheless, this is not conclusive evidence for a direct causal association between obesity and poor asthma control. Future studies are necessary to dissect the relationship between obesity and asthma outcomes.

Comparação entre dois métodos de avaliação do controle da asma baseados na percepção individual

OBJECTIVE: To compare the subjective perception of asthma control reported by the patient with that measured by the score obtained on the Asthma Control Questionnaire 6-item version (ACQ-6) in patients with severe asthma and to determine whether asthma control is associated with the number of emergency room visits in the previous month. METHODS: This was a cross-sectional study involving 528 patients treated at the Bahia State Asthma and Allergic Rhinitis Control Program Central Referral Clinic between August of 2008 and March of 2010, in the city of Salvador, Brazil. The patients completed the ACQ-6 and answered a specific additional question in order to evaluate their own perception of asthma control in the previous week. RESULTS: We evaluated 423 patients who met the inclusion criteria. The sample was predominantly female (81.3%), and 64.3% had an income lower than two times the national minimum wage. The mean age was 49.85 ± 13.71 years, and the duration of asthma symptoms was 32.11 ± 16.35 years. The patients had been regularly treated via the program for 36.65 ± 18.10 months. Based on the subjective perception of asthma control, only 8% of the patients considered their asthma to be uncontrolled, whereas 38.8% had an ACQ-6 score > 1.5, which indicates poor control. The kappa statistic revealed poor concordance between the two methods. There was a direct association between uncontrolled asthma and the number of emergency room visits in the previous month (p < 0.001). CONCLUSIONS: In this sample of patients, the subjective perception of asthma control differed from that measured by the ACQ-6 score, and the patients overestimated their own level of asthma control, which puts them at risk of being undertreated.

The Impacts of Educational Asthma Interventions in Schools: A Systematic Review of the Literature

Objective. To review the literature on the impact of educational asthma interventions in schools regarding the knowledge and morbidity of the disease among children and adolescents. Methods. A systematic review was conducted for controlled clinical trials investigating the effectiveness of educational asthma interventions for students, asthmatic or nonasthmatic, families, and school staff. Databases were CENTRAL, PubMed, LILACS, MEDLINE, and SciELO. Articles published in any language were considered, in the period from 2005 to 2014, according to the PRISMA guidelines. Results. Seventeen articles were selected (N = 5,879 subjects). 94% of the interventions (16 of 17 studies) were applied in developed countries that were led by health professionals and most of them targeted asthmatics. Asthma education promotes the improvement of knowledge about the disease in at least one of the evaluated areas. 29% of the interventions (5 of 17 studies) showed a reduction of the asthma symptoms, 35% (6 of 17 studies) reduction of the hospitalization instances and emergency visits, 29% (5 of 17 studies) reduction of school absenteeism, and 41% (7 of 17 studies) increase in the quality of life of the individuals. Conclusions. Educational interventions in schools raise the awareness of asthma and weaken the impact of morbidity indicators.

Validation of scores of use of inhalation devices: valoration of errors

Abstract Objective: To validate two scores quantifying the ability of patients to use metered dose inhalers (MDIs) or dry powder inhalers (DPIs); to identify the most common errors made during their use; and to identify the patients in need of an educational program for the use of these devices. Methods: This study was conducted in three phases: validation of the reliability of the inhaler technique scores; validation of the contents of the two scores using a convenience sample; and testing for criterion validation and discriminant validation of these instruments in patients who met the inclusion criteria. Results: The convenience sample comprised 16 patients. Interobserver disagreement was found in 19% and 25% of the DPI and MDI scores, respectively. After expert analysis on the subject, the scores were modified and were applied in 72 patients. The most relevant difficulty encountered during the use of both types of devices was the maintenance of total lung capacity after a deep inhalation. The degree of correlation of the scores by observer was 0.97 (p < 0.0001). There was good interobserver agreement in the classification of patients as able/not able to use a DPI (50%/50% and 52%/58%; p < 0.01) and an MDI (49%/51% and 54%/46%; p < 0.05). Conclusions: The validated scores allow the identification and correction of inhaler technique errors during consultations and, as a result, improvement in the management of inhalation devices.

School intervention in asthma for adolescents: it is time to act

Asthma is a public health problem that is responsible for significant symptomatology and in extreme cases, premature deaths among adolescents. Lack of knowledge of the disease contributes to both its morbidity and mortality. In this manuscript, we discuss school interventions in asthma, in particular their impacts on improving knowledge of the disease and their ability to both make the school environment safer and reduce morbidity indicators. These interventions have been successful when implemented in higher income countries. Thus, to address the lack of interventions in low and middle income countries, we present an example of an alternative asthma intervention in the school curriculum developed in South America. The model has been proven to be both feasible and relatively inexpensive. It is easily structured by utilizing the staff of the school itself and is capable of being adapted to other countries.

Asthma hospitalization in Brazil: how much was it cost in the last fifteen years?

Results We recorded a total cost up to 660 million dollars in the whole period of study, from asthma hospitalization. The annual cost in Brazil is about 44 million dollars/ year, which represents about 164.13 dollars for each event. Duration of a hospitalization in our country means 3,2 days per event, varying from 2,7 to 4,4 days. These costs varied from USD 50,476,829 in 2000 to USD 34,369,568 in 2012. Comparing the Brazilian regions, only at extreme years 1998 and 2012, the total cost due to asthma hospitalization were, respectively: Midwest (USD 3,246,138 and USD 3,837,184), South (USD 7,726,774 and USD 5,097,261) Southeast (USD 11,330,123 and USD 8,697,415), North (USD 2,762,194 and USD 3,837,184) and Northeast (USD 14,638,311 and USD 14,246,062). Difference between first and last years of analysis suggests decline at cost in all Brazilian regions, except North (one of the poorest region in Brazil). Furthermore, Northeast region presents the biggest spent with asthma hospitalization in Brazil (25,3% of total costs).

80 Asthma Mortality in Brazil (1998–2006).

Background Some countries have virtually abolished asthma deaths, thus demonstrating asthma mortality is largely preventable. Objectives To evaluate the specific mortality due to asthma in Brazil (1998–2006) and its correlation with access to health services and social indicators. Methods Data were obtained from the National Mortality Database from The Ministry of Health of Brazil. Mortality rates for each state and region were evaluated for the period 1998 to 2006 using linear regression models with gamma distribution and log link function. The correlation between human development index (HDI), the Gini index, GDP per capita and number of hospital beds and mortality rates were performed using the Spearman test. Results We recorded 23,758 deaths from asthma from 1998 to 2006. The annual mortality rate per 100,000 inhabitants was 1.68, 1.38, and 1.67, in 1998, 2002 and 2006, respectively (1998–2006 average: 1.51). Comparing only the extremes, 1998 and 2006, mortality rates declined in most economically developed regions of the country: Midwest (−26.11), South (−23.58%), Southeast (−8.83%), and show up rising in the poorest regions in the North (+5.34%) and Northeast (+31.33%). GDP per capita was inversely correlated with asthma mortality rate (rho = −0.378, P = 0.048). In men and women, the asthma mortality rates were respectively, 1.98 and 1.37 in 1998 and 2.01 and 1.30 in 2006. Analysis by age groups, found the coefficients increased with age after adulthood. Individuals over the age of 75 years had the highest rates and greater tendency to increase in the period. Conclusions There was an overall stabilization of asthma mortality in Brazil during the study period. However, a trend toward increasing mortality rates was observed in socio-economically disadvantaged regions, where access to health care and medication is still a problem.

561 Distribution of Asthma Mortality in Various Districts of Salvador, Brazil.

Background Brazil still does not have a national program to combat asthma. Isolated initiatives have been developed in a non-standardized fashion. The Program for Control of Asthma in Bahia (ProAR) was established in Salvador, Bahia, in 2003, aiming for the control of the most severe cases. Objective To analyze time trends in mortality from asthma and its distribution in the districts of Salvador (2000–2009) and to correlate mortality rates with social indicators. Methods Observational study of deaths from asthma registered by the National Database of Mortality according to ICD-10. Mortality rates were calculated per 100,000 inhabitants and analyzed by simple linear regression. The distribution of mortality for asthma in the period was mapped into the 12 health districts of Salvador. The correlation of the number of deaths in Salvador with GDP per capita, HDI and Index Gini was evaluated. Results The average asthma mortality in Salvador between 2000 and 2009 was 1.542/100.000 inhabitants, with a declining trend (R2 = 0.539, b = –11.1, P = 0.016). Deaths occurred more frequently in women than men (66% vs 34%). Asthma mortality rates were higher in subjects > 35 years. There was a reduction at ages younger than 1 year, 5 to 14 years, 25 to 34 years, and 45 to 54 years with a sharp decline between 55 and 64 (–8.14/100,000). The mortality rate (19.68/100,000 inhabitants in 2009) was higher for individuals > 75 years. The highest mortality rates were noted in more populated and poorer areas with less infrastructure and access to health services. It was observed that 78% of the deaths occurred in hospitals or health facilities. Deaths rates for asthma correlated directly with the district Gini index (rho = 0.400, P = 0.505) and inversely with HDI (rho = –0.300, P = 0.624), though not statistically significant. Conclusions Asthma mortality in Salvador is concentrated in the poorest areas with less infrastructure and access to health services, most commonly affecting women and the elderly. There was a reduction in mortality during the study period, possibly related to interventions for asthma control in the municipality. Mortality from asthma behaves differently in each district of the city.