Carlos Antônio Riedi

Programa de triagem neonatal para fibrose cística no estado do Paraná: avaliação após 30 meses de sua implantação

OBJECTIVES To present and analyze the results of the National Neonatal Cystic Fibrosis Screening Program in Paraná, 30 months after its implementation. METHODS This is a descriptive study, with an analysis of the data from the screening of around 98% of all neonates in the period from September 2001 to April 2004, undertaken at the Neonatal Screening Program laboratory of the Fundação Ecumênica de Proteção ao Excepcional do Paraná. Blood samples for the Guthrie test were collected on hospital discharge, ideally between the second and sixth days postpartum, and filter papers were sent for immunoreactive trypsin assay by the immunofluorometric method. Children whose immunoreactive trypsin assay results were > or = 70 ng/ml for two distinct samples during the first 30 days of life, were referred for sweat conductivity testing by the Wescor method. In cases when the result was greater than 50 mMol/l quantitative chlorine and/or sodium in sweat was assayed (iontophoresis with pilocarpine). RESULTS From a total of 456,982 tests, 4,028 (0.9%) children presented a first immunoreactive trypsin assay above the cutoff point set. Four hundred and seventy-eight of these (12.5%) also had a second blood sample assayed with immunoreactive trypsin above 70 ng/ml and 56 (11.7%) of these were referred to specialized clinics after their sweat conductivity test results were above 50 mMol/l and 48 (0.01% of the total number of children screened) had a diagnosis of cystic fibrosis confirmed. The incidence for the state of Paraná was 1:9,520, although some children have not yet been fully investigated. CONCLUSIONS Neonatal screening for cystic fibrosis in the State of Paraná, in accordance with Health Ministry directives, was a pioneering initiative for Brazil. Many patients were diagnosed early, even asymptomatic ones, which is a challenge to improving prognosis with this fatal disease.

Nebulized budesonide to treat acute asthma in children

OBJECTIVE To investigate the efficacy of a single dose of inhaled budesonide as compared to oral prednisone in patients with acute asthma. METHODS Randomized double-blind, double-dummy and placebo-controlled clinical trial. Forty-nine children aged 2 to 7 years with acute asthma were randomized in three groups after receiving nebulized salbutamol (0.15 mg/kg). Group I received placebo both as tablets and nebulization, group II was treated with a single dose of oral prednisone (1 mg/kg) and inhaled placebo, and group III received a single dose of placebo tablet and nebulized budesonide (2 mg). Patients were evaluated in terms of symptom score and transcutaneous hemoglobin saturation. Nebulized salbutamol was repeated in case of increasing symptom score or lower saturation. RESULTS Progressive clinical improvement was observed in all three groups. However, a significant increase in hemoglobin saturation was observed after 2 hours with prednisone, 4 hours with budesonide, and 24 hours with placebo. CONCLUSION A combination of single-dose nebulized budesonide and salbutamol may be as effective as oral prednisone to improve symptom severity, but the latter increases hemoglobin saturation in exacerbation of asthma.

Epidemiology of ocular allergy and co-morbidities in adolescents

OBJECTIVE The prevalence of allergic conjunctivitis (AC) has not been established. Estimates suggest that ocular allergies affect 15% to 20% of the worldwide population, yet most epidemiological studies encompass nasal and ocular allergy symptoms and have not been specific to AC. The aim of this study was to verify the prevalence of ocular allergy symptoms, co-morbidities, and their impact on adolescents. METHODS Adolescents were selected from a sample of schools, and completed in classrooms a previously validated questionnaire on symptoms of AC. AC diagnosis was considered when more than three episodes of ocular itching were reported in the past 12 months. Related symptoms such as tearing, photophobia, foreign body sensation, impact on daily activities, and diagnosis of AC were analyzed. RESULTS Questionnaires were obtained from 3,120 adolescents (mean age 13.3±1.1 years). Ocular itching in the past 12 months occurred in 1,592 (51%). The most frequently associated symptom was tearing (74%), followed by photophobia (50.1%) and foreign body sensation (37.1%). The prevalence of AC was 20.7%, affecting more females than males (56.1% versus 45.9%; p= 0.01). The risks of an adolescent with ocular allergy to present asthma, rhinitis, and atopic eczema were (OR= 5.7; 95% CI: 4.5 to 7.1), (OR=3.6; 95% CI: 3.0 to 4.3), and (OR=2.6; 95% CI: 2.0 to 3.5), respectively. Severe interference in daily activities was reported by 30.5%. CONCLUSIONS Symptoms of ocular allergy are common, frequently associated to other allergic diseases, and impact the daily activities of adolescents.

Early microbial colonization of cystic fibrosis patients identified by neonatal screening, with emphasis on Staphylococcus aureus.

OBJECTIVES To assess bacterial colonization prospectively in patients with cystic fibrosis identified by neonatal screening. To assess susceptibility to antimicrobials and to perform the molecular typing of Staphylococcus aureus strains isolated from the oropharynx of patients during the study. METHODS Twenty-five cystic fibrosis patients receiving regular treatment at the Cystic Fibrosis Outpatient Clinic of Hospital de Clínicas of Universidade Federal do Paraná, Brazil, were included in the study. All patients were identified by trypsin-like immunoreactivity and their diagnosis was confirmed by two or more sweat tests. Oropharyngeal swabs were collected and cultured according to routine methods; bacterial colonies were phenotypically identified and their susceptibility to antimicrobials was tested. S. aureus isolates were submitted to molecular typing using pulsed-field gel electrophoresis. RESULTS Out of 234 oropharyngeal swabs, S. aureus was the most frequently isolated strain (76% of patients, 42% of swabs), followed by Pseudomonas aeruginosa (36% of patients, 16% of swabs) and Haemophilus spp. (76% of patients; 19% of swabs). Seventy-three isolates were obtained from 19 patients colonized with S. aureus, of which 18 were oxacillin-resistant (24.6%), isolated from two patients, with the same electrophoretic profiles as that of the Brazilian clone. The remaining oxacillin-sensitive isolates were distributed into 18 electrophoretic profiles. CONCLUSION There was higher prevalence of S. aureus, with earlier isolation than other pathogens. Multi-sensitive isolates were distributed into different clones, characterizing non-transmissibility among community-acquired strains. The isolated oxacillin-resistant S. aureus showed identical electrophoretic profiles, probably acquired in hospital. P. aeruginosa was not so frequent in the studied population.

Nebulizadores: fonte de contaminação bacteriana em pacientes com fibrose cística?

OBJECTIVE To determine whether nebulizers are a source of microbial contamination in patients with cystic fibrosis, as well as whether the technique and frequency of disinfection of these devices is appropriate. METHODS This was a cross-sectional, uncontrolled observational study. Samples were collected from 28 patients with cystic fibrosis. Samples were collected at the homes of the patients, who were not previously informed of the purpose of the visit. Three samples were collected from each patient: one from the nebulizer chamber, one from the mask/mouthpiece, and one from the patient (oropharyngeal swab /sputum). The samples were properly stored and taken for analyses. The patients, their parents, or their legal guardians completed a questionnaire regarding nebulizer cleaning and disinfecting methods. RESULTS We collected 84 samples from the 28 patients. Of those 28 patients, 15 (53.5%) were male. The median age of the patients was 11 years (range, 1-27 years). Of the 28 patients, 15 presented with positive oropharyngeal swab /sputum sample cultures. The most common bacterial isolates were Staphylococcus aureus (in 8 patients) and Pseudomonas aeruginosa (in 4 patients). Although the samples obtained from the nebulizers presented with various pathogens in culture, no specific species predominated. In 27 cases (96.7%), there were no associations between the samples obtained from the nebulizers and those obtained from the patients in terms of the results of the cultures. Cleaning and disinfection of nebulizers were inappropriate in 22 cases (78.6%). CONCLUSIONS In this sample of patients, despite the inappropriate disinfection techniques, nebulizers were not found to be a source of microbial contamination.

Colonização microbiana precoce de pacientes identificados por triagem neonatal para fibrose cística, com ênfase em Staphylococcus aureus

OBJETIVOS: Avaliar prospectivamente a colonizacao bacteriana de pacientes com fibrose cistica identificados por triagem neonatal. Avaliar a suscetibilidade a antimicrobianos e caracterizar molecularmente as cepas de Staphylococcus aureus isoladas da orofaringe dos pacientes no periodo do estudo. METODOS: Foram estudados 25 pacientes com fibrose cistica, identificados por tripsina imunorreativa e com diagnostico confirmado por duas ou mais provas de suor, atendidos regularmente no ambulatorio de fibrose cistica do Hospital de Clinicas da Universidade Federal do Parana. Foram coletadas amostras de orofaringe com swab e cultivadas por metodos rotineiros; as colonias bacterianas foram identificadas fenotipicamente e testadas quanto a suscetibilidade a antimicrobianos. Os isolados de S. aureus foram submetidos a tipagem molecular por eletroforese em campo pulsado. RESULTADOS: De um total de 234 amostras de orofaringe, S. aureus foi isolado em maior numero (76% dos pacientes, 42% das amostras), seguido de Pseudomonas aeruginosa (36% dos pacientes, 16% das amostras) e Haemophilus spp. (76% dos pacientes; 19% das amostras). Dos 19 pacientes colonizados com S. aureus, foram obtidos 73 isolados, 18 oxacilina-resistentes (24,6%), isolados de dois pacientes, com perfis eletroforeticos identicos ao do clone brasileiro. Os demais isolados oxacilina-sensiveis distribuiram-se entre 18 perfis eletroforeticos distintos. CONCLUSAO: Observou-se uma maior prevalencia de S. aureus, com isolamento mais precoce em relacao aos outros patogenos pesquisados. Os isolados multissensiveis distribuiram-se em clones distintos, caracterizando a nao transmissibilidade entre as cepas comunitarias. Os S. aureus resistentes a oxacilina isolados apresentaram perfis eletroforeticos identicos, provavelmente adquiridos no ambiente hospitalar. P. aeruginosa foi pouco frequente na populacao estudada.

A workshop on asthma management programs and centers in Brazil: reviewing and explaining concepts

Objective: To report the results of a workshop regarding asthma management programs and centers (AMPCs) in Brazil, so that they can be used as a tool for the improvement and advancement of current and future AMPCs. Methods: The workshop consisted of five presentations and the corresponding group discussions. The working groups discussed the following themes: implementation of asthma management strategies; human resources needed for AMPCs; financial resources needed for AMPCs; and operational maintenance of AMPCs. Results: The workshop involved 39 participants, from all regions of the country, representing associations of asthma patients (n = 3), universities (n = 7), and AMPCs (n = 29). We found a direct relationship between a lack of planning and the failure of AMPCs. Based on the experiences reported during the workshop, the common assumptions about AMPCs in Brazil were the importance of raising awareness of managers; greater community participation; interdependence between primary care and specialized care; awareness of regionalization; and use of medications available in the public health system. Conclusions: Brazil already has a core of experience in the area of asthma management programs. The implementation of strategies for the management of chronic respiratory disease and their incorporation into health care system protocols would seem to be a natural progression. However, there is minimal experience in this area. Joint efforts by individuals with expertise in AMPCs could promote the implementation of asthma management strategies, thus speeding the creation of treatment networks, which might have a multiplier effect, precluding the need for isolated centers to start from zero.

Allergic conjunctivitis in asthmatic children: as common as underreported

Allergens can directly affect the eye’s surface and promote the development of local allergic inflammatory disorders. Epidemiologic studies have demonstrated that more than 75% of patients with allergic rhinitis and 20% of patients with asthma have ocular symptoms, such as itching, tearing, and redness.1–3 Contrary to settled epidemiology of allergic rhinoconjunctivitis, there are few data on the occurrence of allergic conjunctivitis in childhood. The aim of this study was to assess the reported frequency of allergic conjunctivitis in asthmatic children attending a tertiary specialty outpatient clinic. We performed a cross-sectional study using clinical data obtained from a standardized allergy workup form that includes oriented questions on common allergic diseases. At the initial visit parents were asked about their children’s symptoms of allergic skin and respiratory conditions and we reviewed the patients’ systems. An asthma diagnosis was considered for recurrent wheezers with 3 or more episodes, according to the Global Initiative for Asthma. Asthmatic patients seen at their first visit to the pediatric allergy unit, from January 2001 to January 2006, were selected for analysis. Diagnosis of allergic conjunctivitis was based on the presence of 1 or more ocular symptoms (itching, tearing, and redness). Allergic sensitization was assessed by skin prick tests with glycerinated allergenic extracts (IPI-ASAC, São Paulo, Brazil) of Dermatophagoides pteronyssinus, Blomia tropicalis, Blattella germanica, Lolium perenne, and dog and cat danders. This panel consists of common sensitizing aeroallergens to our population based on regional prevalence.4 A test result was considered positive if the wheal cross-diameter was 3 mm or greater. Data entered in MS-Excel and categorical variables were analyzed with the nonparametric 2 test. Sensitivity, specificity, odds ratios, and 95% confidence intervals were also obtained using the statistical software Statistica, version 9.1 (StatSoft Inc, Tulsa, Oklahoma). The institutional review board approved this protocol. A total of 1549 asthmatic children (59% male; mean [SD] age, 4.3 [3.5] years) provided complete medical record information. A physician diagnosis of conjunctivitis was registered in 245 medical records (15.8%), but 681 (43.9%) had at least 1 ocular symptom that suggested ocular allergy. A higher number of children had repor-

Respiratory allergy to moth: the importance of sensitization to Bombyx mori in children with asthma and rhinitis ,

OBJECTIVE this study aimed to prepare a silkworm moth (Bombyx mori) antigenic extract and to perform skin prick tests with this extract in patients with allergic respiratory diseases; to evaluate serum specific immunoglobulin E (IgE) to Bombyx mori using ImmunoCAP® system and to report the frequency of positivity between the two methods and with clinical data. METHODS this was a cross-sectional study with 99 children and adolescents diagnosed with asthma and/or allergic rhinitis, who had skin reactivity to at least one of the six aeroallergens tested. Clinical data were evaluated: skin prick tests with Bombyx mori in-house extract, and total and specific IgE analysis using ImmunoCAP® were performed. RESULTS the frequency of Bombyx mori specific IgE was found to be 52.5% and 60% using the skin prick test and ImmunoCAP®, respectively. An association between a positive skin test for Bombyx mori and the presence of allergic rhinitis, atopic dermatitis, and urticaria was observed, but the same was not true for asthma or allergic conjunctivitis. There was no relation with the severity of asthma or rhinitis symptoms. CONCLUSIONS a high frequency of sensitization to Bombyx mori was observed in a selected population of patients with respiratory allergic diseases in the city of Curitiba, state of Paraná, Brazil. The extract prepared from the wings of this moth species is effective in demonstrating this sensitivity.

Polyphasic characterisation of Burkholderia cepaciacomplex species isolated from children with cystic fibrosis

Cystic fibrosis (CF) patients with Burkholderia cepacia complex (Bcc) pulmonary infections have high morbidity and mortality. The aim of this study was to compare different methods for identification of Bcc species isolated from paediatric CF patients. Oropharyngeal swabs from children with CF were used to obtain isolates of Bcc samples to evaluate six different tests for strain identification. Conventional (CPT) and automatised (APT) phenotypic tests, polymerase chain reaction (PCR)-recA, restriction fragment length polymorphism-recA, recAsequencing, and matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) were applied. Bacterial isolates were also tested for antimicrobial susceptibility. PCR-recA analysis showed that 36 out of the 54 isolates were Bcc. Kappa index data indicated almost perfect agreement between CPT and APT, CPT and PCR-recA, and APT and PCR-recA to identify Bcc, and MALDI-TOF and recAsequencing to identify Bcc species. The recAsequencing data and the MALDI-TOF data agreed in 97.2% of the isolates. Based on recA sequencing, the most common species identified were Burkholderia cenocepacia IIIA (33.4%),Burkholderia vietnamiensis (30.6%), B. cenocepaciaIIIB (27.8%), Burkholderia multivorans (5.5%), and B. cepacia (2.7%). MALDI-TOF proved to be a useful tool for identification of Bcc species obtained from CF patients, although it was not able to identify B. cenocepacia subtypes.