Nelson Augusto Rosário

International consensus on (ICON) pediatric asthma

Asthma is the most common chronic lower respiratory disease in childhood throughout the world. Several guidelines and/or consensus documents are available to support medical decisions on pediatric asthma. Although there is no doubt that the use of common systematic approaches for management can considerably improve outcomes, dissemination and implementation of these are still major challenges. Consequently, the International Collaboration in Asthma, Allergy and Immunology (iCAALL), recently formed by the EAACI, AAAAI, ACAAI, and WAO, has decided to propose an International Consensus on (ICON) Pediatric Asthma. The purpose of this document is to highlight the key messages that are common to many of the existing guidelines, while critically reviewing and commenting on any differences, thus providing a concise reference. The principles of pediatric asthma management are generally accepted. Overall, the treatment goal is disease control. To achieve this, patients and their parents should be educated to optimally manage the disease, in collaboration with healthcare professionals. Identification and avoidance of triggers is also of significant importance. Assessment and monitoring should be performed regularly to re‐evaluate and fine‐tune treatment. Pharmacotherapy is the cornerstone of treatment. The optimal use of medication can, in most cases, help patients control symptoms and reduce the risk for future morbidity. The management of exacerbations is a major consideration, independent of chronic treatment. There is a trend toward considering phenotype‐specific treatment choices; however, this goal has not yet been achieved.

Pathogenesis, prevalence, diagnosis, and management of exercise-induced bronchoconstriction: a practice parameter

Chief Editors: John M. Weiler, MD, MBA, President, CompleWare Corporation, Professor Emeritus, University of Iowa, Iowa City, Iowa; Sandra D. Anderson, PhD, DSc, Clinical Professor, Sydney Medical School, Royal Prince Alfred Hospital, Department of Respiratory and Sleep Medicine, Camperdown NSW 2050, Australia; Christopher Randolph, MD, Clinical Professor of Pediatrics, Yale Affiliated Programs, Waterbury Hospital, Center for Allergy, Asthma and Immunology, Waterbury, Connecticut

Meteorological conditions, climate change, new emerging factors, and asthma and related allergic disorders. A statement of the World Allergy Organization

The prevalence of allergic airway diseases such as asthma and rhinitis has increased dramatically to epidemic proportions worldwide. Besides air pollution from industry derived emissions and motor vehicles, the rising trend can only be explained by gross changes in the environments where we live. The world economy has been transformed over the last 25 years with developing countries being at the core of these changes. Around the planet, in both developed and developing countries, environments are undergoing profound changes. Many of these changes are considered to have negative effects on respiratory health and to enhance the frequency and severity of respiratory diseases such as asthma in the general population.Increased concentrations of greenhouse gases, and especially carbon dioxide (CO2), in the atmosphere have already warmed the planet substantially, causing more severe and prolonged heat waves, variability in temperature, increased air pollution, forest fires, droughts, and floods – all of which can put the respiratory health of the public at risk. These changes in climate and air quality have a measurable impact not only on the morbidity but also the mortality of patients with asthma and other respiratory diseases. The massive increase in emissions of air pollutants due to economic and industrial growth in the last century has made air quality an environmental problem of the first order in a large number of regions of the world. A body of evidence suggests that major changes to our world are occurring and involve the atmosphere and its associated climate. These changes, including global warming induced by human activity, have an impact on the biosphere, biodiversity, and the human environment. Mitigating this huge health impact and reversing the effects of these changes are major challenges.This statement of the World Allergy Organization (WAO) raises the importance of this health hazard and highlights the facts on climate-related health impacts, including: deaths and acute morbidity due to heat waves and extreme meteorological events; increased frequency of acute cardio-respiratory events due to higher concentrations of ground level ozone; changes in the frequency of respiratory diseases due to trans-boundary particle pollution; altered spatial and temporal distribution of allergens (pollens, molds, and mites); and some infectious disease vectors. According to this report, these impacts will not only affect those with current asthma but also increase the incidence and prevalence of allergic respiratory conditions and of asthma. The effects of climate change on respiratory allergy are still not well defined, and more studies addressing this topic are needed. Global warming is expected to affect the start, duration, and intensity of the pollen season on the one hand, and the rate of asthma exacerbations due to air pollution, respiratory infections, and/or cold air inhalation, and other conditions on the other hand.

Validation of a questionnaire for epidemiologic studies of wheezing in infants

Large international studies on asthma and allergies in childhood have found notorious variation in prevalence and temporal trend among countries. However, there is no international studies on the epidemiologic characteristics of wheezing in the first year of life. The aim of this study was to validate a questionnaire to assess the prevalence of wheezing in infants from Latin America, Spain, and Portugal. This study was undertaken in pediatric emergency rooms (PER). A randomized sample of parents visiting PER because lower respiratory illness, answered a questionnaire on wheezing developed by the International Study of Wheezing in Infants. During visit, all infants were examined by one of the authors (blind) who reported, or not, the presence of wheezing on chest auscultation. Sensitivity, specificity, predictive positive value, predictive negative value, and agreement level were calculated from parent and physician reports. Two hundred and nine infants aged 12–15 months participated in the study. Fifty‐six parents reported current wheezing and 43 were confirmed by physician; 153 parents did not report current wheezing and 146 had not wheezing at physical examination (agreement = 0.74, CI 95% 0.64–0.85). This questionnaire showed high sensitivity (86%), specificity (91.8%), positive predictive value (76.8%) and predictive negative value (95.4%). Regardless of previous experience with wheezing episodes, parents can reliably inform when their infants are currently wheezing. A simple and convenient questionnaire confirmed by physical examination produce an accurate tool to asses the prevalence of asthma symptoms in infants.

Precautionary labelling of foods for allergen content: are we ready for a global framework?

Food allergy appears to be on the rise with the current mainstay of treatment centred on allergen avoidance. Mandatory allergen labelling has improved the safety of food for allergic consumers. However an additional form of voluntary labelling (termed precautionary allergen labelling) has evolved on a wide range of packaged goods, in a bid by manufacturers to minimise risk to customers, and the negative impact on business that might result from exposure to trace amounts of food allergen present during cross-contamination during production. This has resulted in near ubiquitous utilisation of a multitude of different precautionary allergen labels with subsequent confusion amongst many consumers as to their significance. The global nature of food production and manufacturing makes harmonisation of allergen labelling regulations across the world a matter of increasing importance. Addressing inconsistencies across countries with regards to labelling legislation, as well as improvement or even banning of precautionary allergy labelling are both likely to be significant steps forward in improved food safety for allergic families. This article outlines the current status of allergen labelling legislation around the world and reviews the value of current existing precautionary allergen labelling for the allergic consumer. We strongly urge for an international framework to be considered to help roadmap a solution to the weaknesses of the current systems, and discuss the role of legislation in facilitating this.

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.

Prevalence of recurrent wheezing in infants

OBJECTIVE To identify the prevalence of recurrent wheezing in infants in the city of Curitiba, PR, Brazil. METHODS A cross-sectional study carried out by means of administering questionnaires to the parents of infants aged 12 to 15 months attending health centers for immunization during the period between August 2005 and December 2006. This is a standardized and validated instrument consisting of questions on demographic characteristics, wheezing, respiratory infections and risk factors. At the time of the study the City Health Department had 107 health centers, 35 of which were selected by lots and distributed homogeneously across the municipal territory. RESULTS A total of 1,364 infants (45.4%) had episodes of wheezing during their first 12 months of life, with onset at 5.5+/-3.1 months (mean +/- standard deviation), and 678 (22.6%) had had three or more episodes. In 84.6% of the wheezing children treatment was with .2-agonists, with inhaled corticosteroids in 18.5%, oral corticosteroids in 24.3% and leukotriene receptor antagonists were used with 5.4%. The wheezing children exhibited nocturnal symptoms, intense difficulty breathing and visits to emergency services in the proportions of 58.9, 46.2 and 57.6%, respectively; 12.7% were admitted to hospital for asthma and 10.9% had had a medical diagnosis of asthma. Nocturnal symptoms, visits to emergency, severity of symptoms, hospital admissions for asthma and medical diagnoses of asthma were all more common among those who had suffered three or more crises (p < 0.001). CONCLUSIONS There is an elevated prevalence of wheezing among the infants of Curitiba, with early onset and elevated morbidity. It is possible that these infants represent a large contingent of asthmatics.

Anaphylaxis in Latin America: a report of the online Latin American survey on anaphylaxis (OLASA)

OBJECTIVES: The aims of the Online Latin American Survey of Anaphylaxis (OLASA) were to identify the main clinical manifestations, triggers, and treatments of severe allergic reactions in patients who were seen by allergists from July 2008 to June 2010 in 15 Latin American countries and Portugal (n = 634). RESULTS: Of all patients, 68.5% were older than 18 years, 41.6% were male, and 65.4% experienced the allergic reaction at home. The etiologic agent was identified in 87.4% of cases and predominantly consisted of drugs (31.2%), foods (23.3%), and insect stings (14.9%). The main symptom categories observed during the acute episodes were cutaneous (94.0%) and respiratory (79.0%). The majority of patients (71.6%) were treated initially by a physician (office/emergency room) within the first hour after the reaction occurred (60.2%), and 43.5% recovered in the first hour after treatment. Most patients were treated in an emergency setting, but only 37.3% received parenteral epinephrine alone or associated with other medication. However, 80.5% and 70.2% were treated with corticosteroids or antihistamines (alone or in association), respectively. A total of 12.9% of the patients underwent reanimation maneuvers, and 15.2% were hospitalized. Only 5.8% of the patients returned to the emergency room after discharge, with 21.7% returning in the first 6 hours after initial treatment. CONCLUSION: The main clinical manifestations of severe allergic reactions were cutaneous. The etiologic agents that were identified as causing these acute episodes differed according to age group. Following in order: drugs (31.2%), foods (23.3% and insect stings (14.9%) in adults with foods predominance in children. Treatment provided for acute anaphylactic reactions was not appropriate. It is necessary to improve educational programs in order to enhance the knowledge on this potentially fatal emergency.

Asthma and Rhinitis in South America: How Different They are From Other Parts of the World

Asthma and rhinitis epidemiology has wide variations around the world. The aim of this review was verify the prevalence of asthma and rhinitis in South America and report differences from other regions of the world. We reviewed studies with International Study of Asthma and Allergies in Childhood (ISAAC) methodology in South America, Phases I and III. In South America the ISAAC Phase I ranked four countries among top ten in prevalence of asthma and three countries among top ten in prevalence of rhinoconjunctivitis. ISAAC Phase III showed little changes in asthma and rhinitis prevalence in South American countries. The prevalence increases of asthma and rhinitis in South American centers indicate that the burden of both is continuing to rise, but the differences in prevalence are lessening.

Prevalência de sibilância recorrente em lactentes

OBJECTIVE: To identify the prevalence of recurrent wheezing in infants in the city of Curitiba, PR, Brazil. METHODS: A cross-sectional study carried out by means of administering questionnaires to the parents of infants aged 12 to 15 months attending health centers for immunization during the period between August 2005 and December 2006. This is a standardized and validated instrument consisting of questions on demographic characteristics, wheezing, respiratory infections and risk factors. At the time of the study the City Health Department had 107 health centers, 35 of which were selected by lots and distributed homogeneously across the municipal territory. RESULTS: A total of 1,364 infants (45.4%) had episodes of wheezing during their first 12 months of life, with onset at 5.5±3.1 months (mean ± standard deviation), and 678 (22.6%) had had three or more episodes. In 84.6% of the wheezing children treatment was with β2-agonists, with inhaled corticosteroids in 18.5%, oral corticosteroids in 24.3% and leukotriene receptor antagonists were used with 5.4%. The wheezing children exhibited nocturnal symptoms, intense difficulty breathing and visits to emergency services in the proportions of 58.9, 46.2 and 57.6%, respectively; 12.7% were admitted to hospital for asthma and 10.9% had had a medical diagnosis of asthma. Nocturnal symptoms, visits to emergency, severity of symptoms, hospital admissions for asthma and medical diagnoses of asthma were all more common among those who had suffered three or more crises (p < 0.001). CONCLUSIONS: There is an elevated prevalence of wheezing among the infants of Curitiba, with early onset and elevated morbidity. It is possible that these infants represent a large contingent of asthmatics.