Nulma Souto Jentzsch

Methods of assessing adherence to inhaled corticosteroid therapy in children and adolescents: adherence rates and their implications for clinical practice.

Nonadherence to inhaled corticosteroid therapy is common and has a negative effect on clinical control, as well as increasing morbidity rates, mortality rates and health care costs. This review was conducted using direct searches, together with the following sources: Medline; HighWire; and the Latin American and Caribbean Health Sciences Literature database. Searches included articles published between 1992 and 2008. The following methods of assessing adherence, listed in ascending order by degree of objectivity, were identified: patient or family reports; clinical judgment; weighing/dispensing of medication, electronic medication monitoring; and (rarely) biochemical analysis. Adherence rates ranged from 30 to 70%. It is recognized that the degree of adherence determined by patient/family reports or by clinical judgment is exaggerated in comparison with that obtained using electronic medication monitors. Physicians should bear in mind that true adherence rates are lower than those reported by patients, and this should be considered in cases of poor clinical control. Weighing the spray quantifies the medication and infers adherence. However, there can be deliberate emptying of inhalers and medication sharing. Pharmacies provide the dates on which the medication was dispensed and refilled. This strategy is valid and should be used in Brazil. The use of electronic medication monitors, which provide the date and time of each triggering of the medication device, although costly, is the most accurate method of assessing adherence. The results obtained with such monitors demonstrate that adherence was lower than expected. Physicians should improve their knowledge on patient adherence and use accurate methods of assessing such adherence.

Nitric oxide in children with persistent asthma

OBJECTIVE To assess the difference in exhaled nitric oxide levels in atopic and nonatopic asthmatic patients treated with anti-inflammatory drugs, and to compare exhaled nitric oxide measurement with lung function tests. METHODS Cross-sectional study with 45 consecutively selected patients with moderate and severe persistent asthma, aged between 6 and 17 years, and treated with anti-inflammatory drugs for at least 1 year. The patients were split into two groups: atopic ones (with positive skin tests) and nonatopic ones. The clinical and functional assessments and the measurement of exhaled nitric oxide were carried out concomitantly. RESULTS There was a male predominance (62.5%), with an age range between 6 and 13 years (mean of 10.4 years) in 85% of the patients. Neither the symptoms associated with asthma (p = 0.07), allergic rhinitis (p = 0.17), food allergy (p = 0.09), necessity of systemic corticosteroids (p = 0.10), antileukotrienes (p = 0.20) and antihistamines (p = 0.70), nor the three parameters used to assess lung function (FEV(1), FEV(1)/FVC and FEF(25-75%), p > or = 0.14) were statistically significant. The frequency of eczema (p < 0.005) and exhaled nitric oxide levels (p < 0.001) were higher among atopic patients. CONCLUSION Results suggest that clinical and functional stability of asthma among atopic patients does not necessarily reflect an efficient control over the inflammatory process and a higher probability for recurrence after discontinuation of anti-inflammatory therapy.

Unilateral pulmonary agenesis

I read with great interest the article by Malcon et al. reporting the occurrence of unilateral pulmonary agenesis in an 8-year-old asymptomatic male child without other associated malformations, and I congratulate the authors on it. I would like to report that we treated a 3-month-old female infant, from the city of Belo Horizonte, Brazil, who had been born at term and had undergone prenatal testing uneventfully. The infant was taken to the Department of Pediatrics of the São José University Hospital in that same city on March of 2012 with a 4-day-history of cough and fever. Her parents reported that she had no comorbidities or previous hospitalizations. The patient presented with acute respiratory failure and required oxygen by nasal catheter. Examination of the respiratory system revealed diminished breath sounds throughout the left hemithorax, without adventitious sounds. A chest X-ray (Figure 1) showed complete opacification of the left hemithorax, together with deviation of the trachea and mediastinum to the left. The left lung was not seen on chest CT (Figure 2). Doppler echocardiography showed agenesis of the left pulmonary artery, without other cardiac abnormalities, and bronchoscopy revealed complete absence of the left lung and absence of bronchial stump. A diagnosis of left lung agenesis was therefore established. The patients course was satisfactory, and she is under outpatient follow-up. Congenital malformations of the lung are rare and vary widely in their clinical presentation and severity, depending mostly on the degree of lung involvement and their location in the thoracic cavity. The earliest stage of lung development occurs during the first 50 days of gestation and is called embryonic stage: around the 26th day, the anterior part of the foregut invaginates and forms the laryngotracheal bud; subsequently, the two main bronchi are formed. After 48 days of gestation, the segmental and subsegmental bronchi start forming. The pulmonary arteries form from the sixth aortic arch, and the pulmonary veins form from the invagination of the sinoatrial region of the heart. The development of the conducting airways starts early, whereas the respiratory bronchioles, alveolar ducts, and alveoli form later in gestation, in the stages called pseudoglandular, canalicular, saccular, and alveolar. In unilateral pulmonary agenesis, the right or left main bronchus does not develop, and there is absence of bronchi, parenchyma, and pulmonary vessels. The origin of pulmonary agenesis is unknown, and its prevalence, including the bilateral and unilateral forms, is 0.5-1.0 per 10,000 live births. …

Treatment adherence and level of control in moderate persistent asthma in children and adolescents treated with fluticasone and salmeterol

OBJECTIVE There is a scarcity of studies that assessed the association between adherence to combination therapy and asthma control in pediatric patients. The authors investigated the association between adherence to fluticasone propionate/salmeterol xinafoate combination-metered aerosol and the level of asthma control in children. METHODS This was a prospective observational study of 84 patients aged 5-16 years with moderate persistent asthma, who remained uncontrolled despite the use of 1000μg/day of inhaled nonextrafine-hydrofluoric alkane-beclomethasone dipropionate in the three months prior to study enrollment. Participants were prescribed two daily doses of FP (125μg)/salmeterol xinafoate (25μg) combination by metered aerosol/spacer for six months. Adherence rates were assessed using the devices dose counter after the 2nd, 4th, and 6th months of follow up. Asthma control was assessed using a simplified Global Initiative for Asthma 2014 Report classification. RESULTS Mean adherence rates after the second, fourth, and sixth months were 87.8%, 74.9%, and 62.1% respectively, for controlled asthma, and 71.7%, 56.0%, and 47.6% respectively, for uncontrolled asthma (all p-values≤0.03). The proportion of children achieving asthma control increased to 42.9%, 67.9% and 89.3% after the 2nd, 4th and 6th months of follow-up, respectively (p≤0.001). CONCLUSION Adherence rates between 87.8% in the 2nd month and 62.1% in the 6th month were strong determinants of asthma control.