Provision of inhaled corticosteroids is associated with decrease in hospital admissions in Brazil: A longitudinal nationwide study

OBJECTIVE

To describe trends of hospital admissions due to asthma from 2008 to 2015 and to evaluate their relationship with trends of inhaled corticosteroids (ICS) provision by the government in Brazil.

METHODS

We used Brazilian Government data to calculate hospital admission rates due to asthma, number of physicians, number of hospital beds, number of subjects that received ICS per 100,000 inhabitants in Brazil and in each of its municipalities for each year of the study. We performed Poisson Multilevel Regression Analyses to evaluate the relationship between the trends of hospital admission rates due to asthma with the trends of the number of subjects that had been receiving ICS during the study period. The analyses were adjusted for the number of physicians and hospital beds.

FINDINGS

The number of patients who received ICS/100,000 inhabitants increased from 2008 to 2015 (943.9-1988.5). Hospital admissions/100,000 inhabitants decreased in patients aged 5-14 years (148.3-110.9) and in patients aged 15-39 years (59.9-32.3); the reduction was greater in municipalities in which ICS provision increased. The number of physicians/100,000 inhabitants increased and the number of hospital beds/100,000 inhabitants decreased in the study period. The increase in the number of physicians and in the number of subjects that received ICS were associated with reduction in hospital admissions.

CONCLUSION

We found that provision of ICS by the Brazilian Government was associated with a decrease of hospital admissions for asthma in the municipalities and country levels from 2008 to 2015.

Exposure to secondhand smoke among patients with asthma: a cross-sectional study

Objective

To estimate the frequency of secondhand smoke exposure among patients with asthma.

Methods

A cross-sectional study of asthma patients and non-asthmatic controls using questionnaires to identify secondhand smoke exposure at home, school, work, and public places.

Results

We studied 544 severe asthma patients, 452 mild/moderate asthma patients, and 454 non-asthmatic patients. Among severe patients, the mean age was 51.9 years, 444 (81.6%) were female, 74 (13.6%) were living with a smoker, 383 (71.9%) reported exposure in public spaces and, of the 242 (44.5%) who worked/ studied, 46 (19.1%) reported occupational exposure. Among those with mild/moderate asthma, the mean age was 36.8 years, 351 (77.7%) were female, 50 (11.1%) reported living with a smoker, 381 (84.9%) reported exposure in public settings and, of the 330 (73.0%) who worked/ studied, 58 (17.7%) reported occupational exposure. An association between secondhand smoke exposure and disease control was found among patients with mild/moderate asthma. Among those interviewed, 71% of severe asthma patients and 63% of mild/moderate asthma patients avoided certain places due to fear of secondhand smoke exposure.

Conclusion

Secondhand smoke exposure is a situation frequently reported by a significant proportion of asthma patients. Individuals with asthma are exposed to this agent, which can hamper disease control, exacerbate symptoms and pose unacceptable limitations to their right to come and go in public settings.

Obesity and asthma: clinical and laboratory characterization of a common combination

OBJECTIVE

To evaluate the relationship between obesity and asthma.

METHODS

This was a preliminary cross-sectional analysis involving 925 subjects with mild-to-moderate or severe asthma evaluated between 2013 and 2015. Obesity was defined on the basis of body mass index (BMI) and abdominal circumference. We collected clinical, laboratory, and anthropometric parameters, as well as pulmonary function test results and data regarding comorbidities. The subjects also completed asthma control and quality of life questionnaires.

RESULTS

Obese individuals had a significantly higher number of neutrophils in peripheral blood than did nonobese individuals (p = 0.01). Among the obese individuals, 163 (61%) had positive skin-prick test results, as did 69% and 71% of the individuals classified as being overweight or normal weight, respectively. Obese individuals showed lower spirometric values than did nonobese individuals, and 32% of the obese individuals had uncontrolled asthma, a significantly higher proportion than that found in the other groups (p = 0.02).

CONCLUSIONS

Obese individuals with asthma seem to present with poorer asthma control and lower pulmonary function values than do nonobese individuals. The proportion of subjects with nonatopic asthma was higher in the obese group. Our results suggest that obese individuals with asthma show a distinct inflammatory pattern and are more likely to present with difficult-to-control asthma than are nonobese individuals.

Eosinophilic asthma, according to a blood eosinophil criterion, is associated with disease severity and lack of control among underprivileged urban Brazilians

BACKGROUND

Asthma is a syndrome with multiple phenotypes. Peripheral blood eosinophil counts might be the ideal biomarker to identify subjects with eosinophilic asthma. It is available, inexpensive, and it is associated with eosinophilia in sputum.

OBJECTIVE

The aim of this study was to evaluate whether blood eosinophilia is associated with asthma severity and to evaluate whether blood eosinophilia is associated with lack of control of asthma symptoms and airway obstruction.

METHODS

Case control study. The cases were subjects recruited from a cohort of patients with severe asthma, in Salvador-BR, demanding continuous inhaled corticosteroids and LABA. There were two control groups: 1) subjects with mild/moderate asthma, 2) subjects with no asthma. Subjects enrolled in the study answered questionnaires, had their blood and stool samples collected, performed spirometry and SPT. We established a cutoff ≥ 260 cells/mm3 for blood eosinophilia.

RESULTS

We evaluated 544 subjects in the case group, 452 subjects with mild to moderate asthma and 450 subjects with no asthma. The subjects of the case group had higher odds of presenting the eosinophilic phenotype in comparison to subjects with mild to moderate asthma [OR 1.60 95CI(1.19-2.16)] and no asthma [OR 3.93; 95CI(2.90-5.33)]. The eosinophilic phenotype, according to blood count, is associated with uncontrolled asthma [OR 1.56; 95CI(1.06-2.28)], but it is not associated with airway obstruction [OR 0.87; 95CI(0.61-1.24)].

CONCLUSION

We conclude that the blood eosinophilia is a biomarker associated with asthma severity and poor symptom control, but we found no association with reduced lung function.

Self-reported smoking status and urinary cotinine levels in patients with asthma

Objective:

To determine the frequency of active smoking among patients with asthma and individuals without asthma by self-report and urinary cotinine measurement.

Methods:

This was a cross-sectional study conducted in the city of Salvador, Brazil, and involving 1,341 individuals: 498 patients with severe asthma, 417 patients with mild-to-moderate asthma, and 426 individuals without asthma. Smoking status was determined by self-report (with the use of standardized questionnaires) and urinary cotinine measurement. The study variables were compared with the chi-square test and the Kruskal-Wallis test.

Results:

Of the sample as a whole, 55 (4.1%) reported being current smokers. Of those, 5 had severe asthma, 17 had mild-to-moderate asthma, and 33 had no asthma diagnosis. Of the 55 smokers, 32 (58.2%) were daily smokers and 23 (41.8%) were occasional smokers. Urinary cotinine levels were found to be high in self-reported nonsmokers and former smokers, especially among severe asthma patients, a finding that suggests patient nondisclosure of smoking status. Among smokers, a longer smoking history was found in patients with severe asthma when compared with those with mild-to-moderate asthma. In addition, the proportion of former smokers was higher among patients with severe asthma than among those with mild-to-moderate asthma.

Conclusions:

Former smoking is associated with severe asthma. Current smoking is observed in patients with severe asthma, and patient nondisclosure of smoking status occurs in some cases. Patients with severe asthma should be thoroughly screened for smoking, and findings should be complemented by objective testing.

Irreversible airway obstruction in asthma: A risk factor for severe exacerbations in spite of proper treatment

OBJECTIVES

To evaluate whether irreversible airway obstruction (IAO) related to asthma is a risk factor for lack of symptoms control, poor quality of life and exacerbations.

METHODS

We evaluated consecutive outpatients with asthma in a one-year cohort study. We excluded subjects with smoke history > 9 pack-years. Definition of IAO was post bronchodilator FEV1/CVF ratio below the lower limit of normality. Subjects received high dose of inhaled medications for asthma. We used logistic regression models, adjusted for the treatment offered during the study, to evaluate whether IAO related to asthma is a risk factor for symptoms control, quality of life, any emergency room visit, number of emergency room visits and hospital admission.

RESULTS

We enrolled 248 subjects in the study. IAO was not a risk factor for poor symptoms control [OR 1.354, 95 CI (0.632-2.899)] or worse asthma related quality of life [OR 0.705, 95 CI (0.413-1.204)]. Subjects with IAO had higher odds of any emergency room visit [OR 2.214, 95 CI (1.300-3.768)] and hospital admission [OR 8.530, 95 CI (1.517-47.978)] and lower odds to reduce emergency room visits in the course of the follow-up period [OR 0.452, 95 CI (0.265-0.769)]. IAO did not predict the number of emergency room visits [OR 1.53, 95 CI (0.71-3.30).

CONCLUSION

IAO is not a risk factor for poor symptoms control or poor quality of life, in a setting of proper treatment. It is a risk factor for emergency room visit and hospital admission. Subjects with IAO have poor response to treatment.