Ana Carla Sousa de Araujo

Investigação de fatores associados à asma de difícil controle

OBJECTIVE To determine the prevalence of factors associated with difficult-to-control asthma. METHODS Patients with severe asthma were selected from the outpatient asthma clinic of the Ribeirão Preto School of Medicine Hospital das Clínicas. The patients were divided into two groups: controlled severe asthma and difficult-to-control severe asthma. After new attempts to optimize the severe asthma treatment, a questionnaire was applied, and additional tests for factors associated with difficult-to-control asthma, such as environmental and occupational exposure, smoking history, social factors, rhinitis/sinusitis, gastroesophageal reflux disease (GERD), obstructive sleep apnea, congestive heart failure (CHF), pulmonary embolism, cystic fibrosis, vocal cord dysfunction, alpha-1 antitrypsin deficiency, and Churg-Strauss syndrome, were performed. RESULTS 77 patients with severe asthma were selected, of which 47 suffered from hard-to-control asthma, being 68.1% female, with mean age of 44.4 years (+/-14.4), and forced expiratory volume in one second of 54.7% (+/-18.3). The most factors most often associated with difficult-to-control asthma were noncompliance with treatment (68%), rhinitis/sinusitis (57%), GERD (49%), environmental exposure (34%), occupational exposure (17%), smoking history (10%), obstructive sleep apnea (2%), and CHF (2%). At least one of these factors was identified in every case. CONCLUSIONS Noncompliance with treatment was the factor most often associated with difficult-to-control asthma, underscoring the need to investigate comorbidities in the evaluation of patients with this form of the disease.

Development and validation of an asthma knowledge questionnaire for use in Brazil

OBJECTIVE To develop and validate an asthma knowledge questionnaire for use in adult asthma patients in Brazil. METHODS A 34-item self-report questionnaire was constructed and administered to adult asthma patients and adult controls. The maximum total score was 34. RESULTS The questionnaire was shown to be discriminatory, with good reliability and reproducibility. The mean score for asthma patients and controls was, respectively, 21.47 +/- 4.11 (range: 9-31) and 17.27 +/- 5.11 (range: 7-28; p < 0.001). The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.53, and the Bartletts test of sphericity demonstrated a satisfactory suitability of the data to factor analysis (p < 0.001). There was no significant difference between the total scores obtained in the first and in the second application of the questionnaire within a two-week interval (p = 0.43). The internal consistency reliability (KR-20 coefficient) was 0.69. CONCLUSIONS This study has validated an asthma knowledge questionnaire for use in Brazil.

Efeito da acidificação esofágica na obstrução brônquica de pacientes asmáticos com refluxo gastroesofágico

BACKGROUND: The relationship between asthma and gastroesophageal reflux is, as yet, not completely understood. Among the mechanisms thought to be responsible for gastroesophageal reflux-related worsening of asthma symptoms are the vagovagal reflex and microaspiration. OBJECTIVE: To assess forced expiratory volume in one second after acid infusion. METHOD: This study investigated the effect of acid infusion in 13 volunteers with moderate asthma and gastroesophageal reflux. Spirometry was performed before and after insertion of an 8F nasogastric tube and a pH meter. After 15 minutes of saline solution infusion into the midpoint between the upper esophageal sphincter and lower esophageal sphincter, and again after 15 minutes of esophageal acidification (with hydrochloric acid) of the same area, forced expiratory volume in one second was reassessed. Acidification was repeated every 5 minutes until forced expiratory volume in one second values stabilized (variation: < 5%). RESULTS: Mean forced expiratory volume in one second values remained stable during the tube insertion, saline infusion, initial hydrochloric acid infusion and subsequent hydrochloric acid infusion procedures (p = 0.72). Lower forced expiratory volume in one second values were seen resulting from the tube insertion in two patients (drops of 11% and 22%, respectively), after saline infusion in another two (drops of 13% and 14%) and after acid infusion in 1 (a drop of 22%). CONCLUSION: Esophageal acidification over short periods does not lead to spirometric alterations in a group of asthmatics with gastroesophageal reflux. However, in some cases, simple esophageal procedures or infusions result in bronchospasm.

Efficacy and safety of the use of omalizumab in a patient with difficult-to-control severe asthma and antiphospholipid antibody syndrome

Results Female, 36-year-old patient, with uncontrolled asthma, dependent on oral corticosteroid. Patient had a history of cough, wheezing and dyspnea since childhood with worsening in the past few years, with dyspnea on minimal activities and use of rescue albuterol 3-10 times a day. She had a history of intensive care unit admission and intubation for asthma on two occasions. Associated conditions were: APS (thrombosis of the leg, miscarriage, stillbirth and positive lupus anti-coagulant, use of aspirin, depression, GERD, and allergic rhinitis. She was on Formoterol/Budesonide 12/400mcg plus inhaled Beclomethasone 800mcg twice daily; Montelukast 10mg a day; Prednisone 5mg daily; Fluoxetine 40mg daily; nasal Budesonide 50mcg twice a day; Omeprazole 20mg once a day. Her initial spirometry showed an FEV1 of 47% predicted, with response to bronchodilator (21% and 300mL reversibility). This pattern remained throughout her follow up in our Clinic. Her total IgE was 120kU/L, and she presented positive skin prick tests to Dermatophagoides pteronyssinus, D. farinae and Trichophyton and negative to Aspergillus. Chest tomography and bronchoscopy were unremarkable. Despite correct use of medications, the patient had frequent exacerbations and need for increasing doses of oral prednisone up to 80mg daily, with weight gain of 18kg in 3 years. Omalizumab was started, and within two weeks the patient showed marked improvement of symptoms, making it possible to withdraw prednisone. There was reduction in use of rescue albuterol, improvement in quality of life and weight loss. After 9 months, treatment with omalizumab was discontinued due to supply problems, with worsening of asthma and return of oral corticosteroids. Provision of omalizumab was restored after 6 months, and the patient again had improvement of symptoms and discontinuation of oral corticosteroids. Currently, she uses rescue bronchodilator 2 times a week, lost 20kg and practices physical activity.

A systematic intervention for assistance of patients with asthma in Brazil: partnership between university and public health system

Methods A group of 16 allergists/immunologists developed a capacitating program in 11 Public Health Units in the city of Ribeirao Preto, Brazil. The program comprised lectures on asthma and hands-on training on spirometry and use of inhalation devices; production of didactic material; and development of a protocol on management of asthma. Spacers and spirometry were provided. Each researcher visited one Health Unit 2-4 times a month, to accompany the non-specialist on patients’ visits to the clinic, perform case discussions, and deliver short lectures to the health professionals. Records of asthma medications provided to patients upon physicians’ prescription in the North Region were compared to those from three other Regions with no intervention.

Health outcomes, education, healthcare delivery and quality – 3051. Profiles of diagnosis and treatment of asthma in the public health system in Brazil

Health outcomes, education, healthcare delivery and quality – 3051. Profiles of diagnosis and treatment of asthma in the public health system in Brazil Janaina M Melo, Adriana S Moreno, Virginia PL Ferriani, Elcio Vianna, Marcos Borges, Persio Roxo Jr, Ana Carla S Araujo, Luane M Mello, Rosa Ferreira, Jorgete M Silva, Patricia Stefanelli, Marcos R Goncalves, Larissa P Oliveira, Andrea Cetlin, Luana B Queiroz, Rosangela Villela, Davi C Aragon, L Karla Arruda