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Borges AL, Brito M, Ambrósio P, Condeço R, Pinto P, Ambrósio B, Mahomed F, Gama JMR, Bernardo MJ, Gouveia AI, Djokovic D. Prospective external validation of IOTA methods for classifying adnexal masses and retrospective assessment of two-step strategy using benign descriptors and ADNEX: a Portuguese multicenter study. Ultrasound Obstet Gynecol 2024. [PMID: 38477149 DOI: 10.1002/uog.27641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 02/06/2024] [Accepted: 02/22/2024] [Indexed: 03/14/2024]
Abstract
OBJECTIVE This study aimed to externally and prospectively validate the International Ovarian Tumor Analysis (IOTA) Simple Rules (SRs), Logistic Regression model 2 (LR2) and Assessment of Different NEoplasias in the adneXa (ADNEX) in a Portuguese population, comparing them with operator subjective assessment (SA), Risk-of-Malignancy Index (RMI), as well as with each other. This study also aimed to retrospectively validate IOTA two-step strategy, using modified benign descriptors (MBDs) followed by the application of ADNEX in cases where MBDs were not applicable (MBDs + ADNEX). METHODS In this multicenter diagnostic accuracy study, conducted between January 2016 and December 2021, three tertiary referral centers prospectively included consecutive patients with ultrasound diagnosis of at least one adnexal tumor who underwent surgery. All ultrasound assessments were performed by level II or III sonologists with IOTA certification. Patient clinical data and serum cancer antigen (CA125) levels were collected from the hospital databases. Each adnexal mass was classified as benign or malignant using SA, RMI, IOTA SRs, LR2 and ADNEX (with and without CA125). The reference standard was histopathological diagnosis. In the second phase, all adnexal tumors were retrospectively classified using the two-step strategy (MBDs + ADNEX). The sensitivity, specificity, positive (PPV) and negative predictive value (NPV), positive (LR+) and negative likelihood ratio (LR-) as well as overall accuracy were determined for SA, RMI, IOTA SRs, LR2, ADNEX and two-step strategy (MBDs + ADNEX). Receiver-operator characteristic curves were constructed and corresponding areas under the curve (AUC) determined for RMI, LR2 and ADNEX and two-step strategy (MBDs + ADNEX). The ADNEX calibration plots were constructed and estimated by LOESS smoother. RESULTS Of the 571 included patients, 428 had benign disease, 42 borderline ovarian tumors, 93 primary invasive adnexal cancers and 8 metastatic tumors in adnexa (malignancy prevalence: 25.0%). The operator SA had an overall sensitivity of 97.9% and a specificity of 83.6% for distinguishing between benign and malignant lesions. RMI showed high specificity (95.6%) but very low sensitivity (58.7%), with an AUC of 0.913. The IOTA SRs were applicable in 80.0% of patients, with a sensitivity of 94.8% and a specificity of 98.6%. LR2 revealed a sensitivity of 84.6%, a specificity of 86.9% and an AUC of 0.939, at the malignancy risk cut-off of 10%. At the same cut-off, ADNEX with and without CA125 had a sensitivity of 95.8% and 98.6%, respectively, and a specificity of 82.5% and 79.7%, respectively. The AUC of ADNEX with vs. without CA125 was 0.962 vs. 0.960. The ADNEX model provided heterogeneous results in distinguishing between benign and different subtypes of malignancy, with the highest AUC (0.991) for discriminating benign masses from primary adnexal cancer stage II-IV, and the lowest AUC (0.696) for distinguishing primary adnexal cancer stage I and metastatic lesion in adnexa. The ADNEX calibration plots suggested an underestimation of the predicted risk in relation with the observed proportion of malignancies. The MBDs were applicable in 26.3% of cases (150/571 tumors, none of which were malignant). Similar to the ADNEX model applied in all patients, the two-step strategy using ADNEX in the second step only, with and without CA125, had an AUC of 0.964 and 0.961, respectively. CONCLUSIONS Our results showed a good to excellent performance of the IOTA methods in the studied Portuguese population, outperforming RMI. ADNEX was superior in accuracy, but interpretation of its ability to distinguish malignant subtypes was fundamentally limited not only by sample size but also by large differences in the prevalence of tumor subtypes. The IOTA MBDs have been shown to be reliable in identifying benign disease. The two-step strategy based on the application of MBDs, followed by the ADNEX model if MBDs are not applicable, has proven to be suitable for daily practice circumventing the need to use electronic support in all patients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- A L Borges
- Hospital de São Francisco Xavier, Ginecologia e Obstetrícia, Lisboa, Portugal
- Universidade da Beira Interior, Faculdade de Ciências da Saúde, Covilhã, Portugal
| | - M Brito
- Maternidade Doutor Alfredo da Costa, Ginecologia e Obstetrícia, Lisboa, Portugal
| | - P Ambrósio
- Maternidade Doutor Alfredo da Costa, Ginecologia e Obstetrícia, Lisboa, Portugal
| | - R Condeço
- Maternidade Doutor Alfredo da Costa, Ginecologia e Obstetrícia, Lisboa, Portugal
| | - P Pinto
- Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Ginecologia Oncológica, Lisboa, Portugal
- Charles University, First Faculty of Medicine, Praha, Czech Republic
| | - B Ambrósio
- Hospital de Vila Franca de Xira, Ginecologia e Obstetrícia, Vila Franca de Xira, Portugal
| | - F Mahomed
- Maternidade Doutor Alfredo da Costa, Ginecologia e Obstetrícia, Lisboa, Portugal
| | - J M R Gama
- Universidade da Beira Interior, Faculdade de Ciências da Saúde, Centro de Matemática e Aplicações, Covilhã, Portugal
| | - M J Bernardo
- Maternidade Doutor Alfredo da Costa, Ginecologia e Obstetrícia, Lisboa, Portugal
| | - A I Gouveia
- Universidade da Beira Interior, Faculdade de Ciências da Saúde, Covilhã, Portugal
- Universidade de Lisboa, Instituto de Biofísica e Engenharia Biomédica, Lisboa, Portugal
- Universidade da Beira Interior, Faculdade de Ciências Sociais e Humanas, Núcleo de Investigação em Ciências Empresariais, Covilhã, Portugal
| | - D Djokovic
- Maternidade Doutor Alfredo da Costa, Ginecologia e Obstetrícia, Lisboa, Portugal
- Universidade Nova de Lisboa, Faculdade de Ciências Médicas de Lisboa, Ginecologia e Obstetrícia, Lisboa, Portugal
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Cardoso EM, Lourenço-Gomes V, Esgalhado AJ, Reste-Ferreira D, Oliveira N, Amaral AS, Martinho A, Gama JMR, Verde I, Lourenço O, Fonseca AM, Buchli R, Arosa FA. HLA-A23/HLA-A24 serotypes and dementia interaction in the elderly: Association with increased soluble HLA class I molecules in plasma. HLA 2023; 102:660-670. [PMID: 37400938 DOI: 10.1111/tan.15149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/16/2023] [Accepted: 06/22/2023] [Indexed: 07/05/2023]
Abstract
MHC class I molecules regulate brain development and plasticity in mice and HLA class I molecules are associated with brain disorders in humans. We investigated the relationship between plasma-derived soluble human HLA class I molecules (sHLA class I), HLA class I serotypes and dementia. A cohort of HLA class I serotyped elderly subjects with no dementia/pre-dementia (NpD, n = 28), or with dementia (D, n = 28) was studied. Multivariate analysis was used to examine the influence of dementia and HLA class I serotype on sHLA class I levels, and to compare sHLA class I within four groups according to the presence or absence of HLA-A23/A24 and dementia. HLA-A23/A24 and dementia, but not age, significantly influenced the level of sHLA class I. Importantly, the concurrent presence of HLA-A23/A24 and dementia was associated with higher levels of sHLA class I (p < 0.001). This study has shown that the simultaneous presence of HLA-A23/HLA-A24 and dementia is associated with high levels of serum sHLA class I molecules. Thus, sHLA class I could be considered a biomarker of neurodegeneration in certain HLA class I carriers.
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Affiliation(s)
- Elsa M Cardoso
- ESS-IPG, School of Health Sciences, Polytechnic of Guarda, Guarda, Portugal
- CICS-UBI, Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal
- FCS-UBI, Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
| | | | - André J Esgalhado
- CICS-UBI, Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal
| | - Débora Reste-Ferreira
- CICS-UBI, Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal
| | - Nádia Oliveira
- CICS-UBI, Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal
| | - Ana Saraiva Amaral
- CICS-UBI, Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal
| | - António Martinho
- Molecular Genetics Laboratory, Coimbra Blood and Transplantation Center, Coimbra, Portugal
| | - Jorge M R Gama
- Centre of Mathematics and Applications, Faculty of Sciences, University of Beira Interior, Covilhã, Portugal
| | - Ignácio Verde
- CICS-UBI, Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal
- Centre of Mathematics and Applications, Faculty of Sciences, University of Beira Interior, Covilhã, Portugal
| | - Olga Lourenço
- CICS-UBI, Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal
- FCS-UBI, Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
| | - Ana M Fonseca
- CICS-UBI, Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal
- FCS-UBI, Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
| | - Rico Buchli
- Pure Protein LLC, Oklahoma City, Oklahoma, USA
| | - Fernando A Arosa
- CICS-UBI, Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal
- FCS-UBI, Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
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Arrais MLT, Maricoto TJP, Lulua OM, Quifica FGS, Gama JMR, Brito MD, Taborda-Barata L. Factors associated with poor asthma symptom control in adult Angolan regularly seen at an outpatient respiratory clinic. Afr Health Sci 2023; 23:672-682. [PMID: 38357136 PMCID: PMC10862642 DOI: 10.4314/ahs.v23i3.78] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
Background Asthma is one of the most common chronic respiratory diseases and one of the most frequent causes of hospital care. Objectives To describe the clinical characteristics of asthma and factors associated with its control. Methods A cross-sectional study was conducted at the Military Hospital in Luanda, from April 2018 to March 2019. Data collection was performed using questionnaires on asthma symptoms and treatment, socio-demographic and environmental questions, and a Global Initiative for Asthma (GINA) questionnaire to assess the level of asthma control. Ordinal logistic regression analyses were performed. We estimated odds ratios, for higher categories of asthma control. P<0.05 was considered significant. Results The sample consisted of 305 asthmatics ≥18-years-old, 56% women, with a mean age of 41.3 years. About 28% of patients had controlled asthma, 36% partially controlled and 35% uncontrolled. Poor asthma control was associated with frequent use of short-acting beta-2 agonists [OR 5.70 (95%CI 2.37;13.7)], oral corticosteroids [OR 3.68 (95%CI 2.24;6.04)], and incorrect inhaler technique [OR 4.08 (95%CI 1.25;13.3)]. Conclusions A significant number of adults living in Luanda have uncontrolled asthma due to the under-use of inhaled corticosteroid therapy. It is necessary to develop strategic management and prevention plans to improve Angolan asthmatics' medical care.
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Affiliation(s)
- Margarete L T Arrais
- Department of Pulmonology, Military Hospital Luanda, Angola
- Centro de Investigação em Saúde de Angola - CISA, Caxito, Bengo, Angola
| | - Tiago J P Maricoto
- Aveiro Healthcare Centre, Aradas Family Health Unit, Aveiro, Portugal
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
- UBIAir - Clinical & Experimental Lung Centre, UBIMedical, University of Beira Interior, Covilhã, Portugal
| | - Ofélia M Lulua
- Department of Pulmonology, Military Hospital Luanda, Angola
| | | | - Jorge M R Gama
- Centre of Mathematics and Applications, Faculty of Sciences, University of Beira Interior, Covilhã, Portugal
| | - Miguel D Brito
- Centro de Investigação em Saúde de Angola - CISA, Caxito, Bengo, Angola
- Health and Technology Research Centre - H&TRC, Escola Superior de Tecnologia da Saúde de Lisboa, Instituto Politécnico de Lisboa, Portugal
| | - Luis Taborda-Barata
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
- UBIAir - Clinical & Experimental Lung Centre, UBIMedical, University of Beira Interior, Covilhã, Portugal
- Department of Allergy & Clinical Immunology, Cova da Beira University Hospital Centre, Covilhã, Portugal
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Bernardo LFA, Teixeira MM, De Domenico D, Gama JMR. Improved Equations for the Torsional Strength of Reinforced Concrete Beams for Codes of Practice Based on the Space Truss Analogy. Materials (Basel) 2022; 15:ma15113827. [PMID: 35683127 PMCID: PMC9181826 DOI: 10.3390/ma15113827] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 02/04/2023]
Abstract
Design codes provide the necessary tools to check the torsional strength of reinforced concrete (RC) members. However, some researchers have pointed out that code equations still need improvement. This study presents a review and a comparative analysis of the calculation procedures to predict the torsional strength of RC beams from some reference design codes, namely the Russian, American, European, and Canadian codes for RC structures. The reliability and accuracy of the normative torsional strengths are checked against experimental results from a broad database incorporating 202 RC rectangular beams tested under pure torsion and collected from the literature. The results show that both the readability and accuracy of the codes' equations should be improved. Based on a correlation study between the experimental torsional strengths, and geometrical and mechanical properties of the beams, refined yet simple equations are proposed to predict torsional strength. It is demonstrated that the proposed formulation is characterized by a significant improvement over the reference design codes. The efficiency of the proposed formulae is also assessed against another equation earlier proposed in the literature, and an improvement is noted as well. From the results, it can be concluded that the proposed equations in this study can contribute to a more accurate and economical design for practice.
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Affiliation(s)
- Luís F. A. Bernardo
- Centre of Materials and Building Technologies (C-MADE), Department of Civil Engineering and Architecture, University of Beira Interior, 6201-001 Covilhã, Portugal;
- Correspondence:
| | - Mafalda M. Teixeira
- Centre of Materials and Building Technologies (C-MADE), Department of Civil Engineering and Architecture, University of Beira Interior, 6201-001 Covilhã, Portugal;
| | - Dario De Domenico
- Department of Engineering, University of Messina, 98166 Messina, Italy;
| | - Jorge M. R. Gama
- Center of Mathematics and Applications (CMA), Department of Mathematics, University of Beira Interior, 6201-001 Covilhã, Portugal;
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Matos-Semedo F, Cruz C, Inácio F, Gama JMR, Nwaru BI, Taborda-Barata L. House dust mite (HDM) and storage mite (SM) molecular sensitisation profiles and association with clinical outcomes in allergic asthma and rhinitis: protocol for a systematic review. BMJ Open 2021; 11:e046519. [PMID: 34312197 PMCID: PMC8314702 DOI: 10.1136/bmjopen-2020-046519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Identification and characterisation of single allergens at molecular level is important. Component-resolved diagnosis offers the possibility of higher diagnostic precision, thereby allowing better patient management. House dust mites (HDM) have a worldwide distribution. Studies from different countries have shown that IgE-mediated allergy to storage mites (SM) is important in rural and urban populations. With the availability of HDM and SM molecular allergen components, studies have investigated whether different molecular sensitisation profiles are associated with clinical disease outcomes. However, no previous systematic review has synthesised the underlying evidence. METHODS AND ANALYSIS We will search Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Methodology Register), MEDLINE, EMBASE, CINAHL, AMED, ISI Web of Science (Science and Social Science Index) from inception to March 2020. Unpublished and ongoing work, as well as research in progress will be searched in www.ClinicalTrials.gov; www.controlledtrials.com and wwwanzctrorgau. We will contact an international panel of experts in this field. No language restrictions will apply; translations will be undertaken where necessary. The Critical Appraisal Skills Programme quality assessment tool will be used to appraise the methodological quality of included studies. A descriptive summary with data tables will be constructed, and if adequate, meta-analysis using random effects will be performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist will be followed for reporting. ETHICS AND DISSEMINATION Since this systematic review will be only based on published and retrievable literature, no ethics approval is required. We will publish the systematic review in an international peer-reviewed journal. TRIAL REGISTRATION NUMBER reviewregistry959.
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Affiliation(s)
- Filipa Matos-Semedo
- Department of Immunoallergy, Hospital da Luz, Lisbon, Portugal
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
| | - Cíntia Cruz
- Department of Immunoallergy, Hospital da Luz, Lisbon, Portugal
| | - Filipe Inácio
- Department of Immunoallergology, Hospital de São Bernardo, Centro Hospitalar de Setúbal, Setúbal, Portugal
| | - Jorge M R Gama
- Mathematics, Centre of Mathematics and Applications, University of Beira Interior, Covilhã, Portugal
| | - Bright I Nwaru
- Krefting Research Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Luís Taborda-Barata
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
- CICS-Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal
- Department of Immunoallergology, Cova da Beira University Hospital Centre, Covilhã, Portugal
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Lourenço O, Cardoso A, Mónico B, Gama JMR, Neiva HP, Marinho DA. β2-adrenergic agonists and doping: Where do we stand? Allergy 2021; 76:2320-2321. [PMID: 34192372 DOI: 10.1111/all.14830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/01/2021] [Accepted: 03/23/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Olga Lourenço
- Faculty of Health Sciences University of Beira Interior Covilhã Portugal
- CICS‐UBI Health Sciences Research Centre University of Beira Interior Covilhã Portugal
| | - Ana Cardoso
- Faculty of Health Sciences University of Beira Interior Covilhã Portugal
| | - Beatriz Mónico
- Faculty of Health Sciences University of Beira Interior Covilhã Portugal
| | - Jorge M. R. Gama
- Centre of Mathematics and Applications (CMA‐UBI) University of Beira Interior Covilhã Portugal
| | - Henrique P. Neiva
- Department of Sport Sciences University of Beira Interior Covilhã Portugal
- Research Center in Sports Sciences Health Sciences and Human DevelopmentCIDESD Covilhã Portugal
| | - Daniel A. Marinho
- Department of Sport Sciences University of Beira Interior Covilhã Portugal
- Research Center in Sports Sciences Health Sciences and Human DevelopmentCIDESD Covilhã Portugal
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Cardoso A, Mónico B, Gama JMR, Neiva HP, Marinho DA, Lourenço O. β2-adrenergic agonists do not improve physical performance in healthy individuals. Allergy 2021; 76:2201-2203. [PMID: 32901942 DOI: 10.1111/all.14588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/26/2020] [Accepted: 08/31/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Ana Cardoso
- Faculty of Health Sciences University of Beira Interior Covilhã Portugal
| | - Beatriz Mónico
- Faculty of Health Sciences University of Beira Interior Covilhã Portugal
| | - Jorge M. R. Gama
- Centre of Mathematics and Applications (CMA‐UBI) University of Beira Interior Covilhã Portugal
| | - Henrique P. Neiva
- Department of Sport Sciences University of Beira Interior Covilhã Portugal
- Research Center in Sports Sciences, Health Sciences and Human Development CIDESD Covilhã Portugal
| | - Daniel A. Marinho
- Department of Sport Sciences University of Beira Interior Covilhã Portugal
- Research Center in Sports Sciences, Health Sciences and Human Development CIDESD Covilhã Portugal
| | - Olga Lourenço
- Faculty of Health Sciences University of Beira Interior Covilhã Portugal
- CICS ‐ UBI Health Sciences Research Centre University of Beira Interior Covilhã Portugal
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Arrais M, Lulua O, Quifica F, Rosado-Pinto J, Gama JMR, Cooper PJ, Taborda-Barata L, Brito M. Lack of Consistent Association between Asthma, Allergic Diseases, and Intestinal Helminth Infection in School-Aged Children in the Province of Bengo, Angola. Int J Environ Res Public Health 2021; 18:ijerph18116156. [PMID: 34200291 PMCID: PMC8201383 DOI: 10.3390/ijerph18116156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 12/02/2022]
Abstract
Epidemiological studies have shown conflicting findings on the relationship between asthma, atopy, and intestinal helminth infections. There are no such studies from Angola; therefore, we aimed to evaluate the relationship between asthma, allergic diseases, atopy, and intestinal helminth infection in Angolan schoolchildren. We performed a cross-sectional study of schoolchildren between September and November 2017. Five schools (three urban, two rural) were randomly selected. Asthma, rhinoconjunctivitis, and eczema were defined by appropriate symptoms in the previous 12 months: atopy was defined by positive skin prick tests (SPT) or aeroallergen-specific IgE; intestinal helminths were detected by faecal sample microscopy. In total, 1023 children were evaluated (48.4% female; 57.6% aged 10–14 years; 60.5% urban). Asthma, rhinoconjunctivitis, or eczema were present in 9%, 6%, and 16% of the studies children, respectively. Only 8% of children had positive SPT, but 64% had positive sIgE. Additionally, 40% were infected with any intestinal helminth (A. lumbricoides 25.9%, T. trichiura 7.6%, and H. nana 6.3%). There were no consistent associations between intestinal helminth infections and asthma, allergic diseases, or atopy, except for A. lumbricoides, which was inversely associated with rhinoconjuctivitis and directly associated with aeroallergen-specific IgE. We concluded that, overall, intestinal helminth infections were not consistently associated with allergic symptoms or atopy. Future, preferably longitudinal, studies should collect more detailed information on helminth infections as part of clusters of environmental determinants of allergies.
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Affiliation(s)
- Margarete Arrais
- Department of Pulmonology, Military Hospital, Luanda 12195, Angola; (M.A.); (O.L.); (F.Q.)
- CISA—Centro de Investigação em Saúde de Angola/Health Research Center of Angola, Caxito 9999, Angola;
| | - Ofélia Lulua
- Department of Pulmonology, Military Hospital, Luanda 12195, Angola; (M.A.); (O.L.); (F.Q.)
| | - Francisca Quifica
- Department of Pulmonology, Military Hospital, Luanda 12195, Angola; (M.A.); (O.L.); (F.Q.)
| | - José Rosado-Pinto
- Department of Immunoallergology, Hospital da Luz, 1500-650 Lisbon, Portugal;
| | - Jorge M. R. Gama
- Center of Mathematics and Applications, Faculty of Sciences, University of Beira Interior, 6201-001 Covilhã, Portugal;
| | - Philip J. Cooper
- Institute of Infection and Immunity, St George’s University of London, London SW17 0RE, UK;
- School of Medicine, International University of Ecuador, 170411 Quito, Ecuador
| | - Luis Taborda-Barata
- Department of Immunoallergology, Cova da Beira University Hospital Centre, 6200-001 Covilhã, Portugal
- CICS—Centro de Investigação em Ciências da Saúde/Health Sciences Research Centre, University of Beira Interior, 6200-506 Covilhã, Portugal
- Correspondence: ; Tel.: +351-275329003
| | - Miguel Brito
- CISA—Centro de Investigação em Saúde de Angola/Health Research Center of Angola, Caxito 9999, Angola;
- Health and Technology Research Center (H&TRC), The Lisbon Higher School of Health Technology, The Polytechnic Institute of Lisbon, 1990-096 Lisbon, Portugal
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Arrais M, Dias W, Gama JMR, Brito M. Physicians' perceptions of their knowledge and the preparedness of health facilities in Angola to diagnose and manage COVID-19. Int Health 2021; 14:103-110. [PMID: 33845486 PMCID: PMC8083292 DOI: 10.1093/inthealth/ihab017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 01/26/2021] [Accepted: 03/10/2021] [Indexed: 12/23/2022] Open
Abstract
Background Healthcare professionals represent a vulnerable group in terms of responding to COVID-19. Knowledge can influence healthcare professionals through adoption of the correct attitudes and practices. The aim of this study was to evaluate, by a questionnaire, the perceptions of physicians about their level of knowledge as well as conditions in their workplaces for dealing with COVID-19. Methods A cross-sectional study of Angolan physicians took place from 11 May to 23 June 2020. A questionnaire was electronically shared across social media and via email. Results The sample consisted of 637 valid questionnaires; 53% of respondents were female, 41% were aged 31–40 y and 79% were from Luanda province. About 51% of physicians perceived that they had adequate knowledge about COVID-19 and 64% used personal protective equipment. These figures were higher among specialists from the province of Luanda. About 81% stated that their health units lacked the technical capacity to diagnose COVID-19. Only 35% of health units have chest tomography equipment; 44% are prepared for the care and/or isolation of patients. Only 33% of units are running intensive care units. The main concerns of physicians were training opportunities and limited access to personal protective equipment. Conclusion The results show that it is necessary to strengthen physicians’ knowledge about COVID-19, as well as to improve the conditions of the health units, so as to promote safe practices.
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Affiliation(s)
- Margarete Arrais
- Department of Pulmonology , Military Hospital, Luanda, Angola.,CISA - Health Research Centre of Angola, Caxito, Bengo, Angola
| | | | - Jorge M R Gama
- Centre of Mathematics and Applications, Faculty of Sciences, University of Beira Interior, Covilhã, Portugal
| | - Miguel Brito
- CISA - Health Research Centre of Angola, Caxito, Bengo, Angola.,Health and Technology Research Centre (H&TRC), Escola Superior de Tecnologia da Saúde de Lisboa, Instituto Politécnico de Lisboa, Portugal
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Arrais M, Maricoto T, Cooper P, Gama JMR, Nwaru BI, Brito M, Taborda-Barata L. Helminth infections, atopy, asthma and allergic diseases: protocol for a systematic review of observational studies worldwide. BMJ Open 2020; 10:e038085. [PMID: 32457081 PMCID: PMC7252955 DOI: 10.1136/bmjopen-2020-038085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Childhood infections, particularly those caused by helminths are considered to be important environmental exposures influencing the development of allergic diseases. However, epidemiological studies focusing on the relationship between helminth infections and risk of allergic diseases, performed worldwide, show inconsistent findings. Previous systematic reviews of observational studies published 10 or more years ago showed conflicting findings for effects of helminths on allergic diseases. Over the past 10 years there has been growing literature addressing this research area and these need to be considered in order to appreciate the most contemporary evidence. The objective of the current systematic review will be to provide an up-to-date synthesis of findings of observational studies investigating the influence of helminth infections on atopy, and allergic diseases. METHODS AND ANALYSIS This systematic review protocol was registered at PROSPERO. We will search Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, ISI Web of Science, WHO Global Health Library, Scielo, IndMed, PakMediNet, KoreaMed, Ichushi for published studies from 1970 to January 2020. Bibliographies of all eligible studies will be reviewed to identify additional studies. Unpublished and ongoing research will also be searched in key databases. There will be no language or geographical restrictions regarding publications. Critical Appraisal Skills Programme quality assessment tool will be used to appraise methodological quality of included studies. A descriptive summary with data tables will be constructed, and if adequate, meta-analysis using random-effects will be performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist will be followed for reporting of the systematic review. ETHICS AND DISSEMINATION Since this systematic review will be only based on published and retrievable literature, no ethics approval will be sought. The multidisciplinary team performing this systematic review will participate in relevant dissemination activities. Findings will be presented at scientific meetings and publish the systematic review in international, peer-reviewed, open-access journals. PROSPERO REGISTRATION NUMBER CRD42020167249.
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Affiliation(s)
- Margarete Arrais
- Department of Pulmonology, Military Hospital Luanda, Luanda, Angola
- CISA - Health Sciences Research Center of Angola, Caxito, Bengo, Angola
| | - Tiago Maricoto
- ACeS Baixo Vouga, Aveiro-Aradas Family Health Unit, Aveiro, Portugal
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
| | - Philip Cooper
- Institute of Infection and Immunity, St George's University of London, London, UK
- School of Medicine, International Univeristy of Ecuador, Quito, Ecuador
| | - Jorge M R Gama
- Centre of Mathematics and Applications, Faculty of Sciences, University of Beira Interior, Covilhã, Portugal
| | - Bright I Nwaru
- Krefting Research Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Miguel Brito
- CISA - Health Sciences Research Center of Angola, Caxito, Bengo, Angola
- Health and Technology Research Center (H&TRC), Lisbon Higher School of Health Technology, Polytechnic Institute of Lisbon, Lisbon, Portugal
| | - Luís Taborda-Barata
- Department of Allergy & Clinical Immunology, Cova da Beira University Hospital Centre, Covilhã, Portugal
- CICS - Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal
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11
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Laia-Dias I, Lozoya-Ibáñez C, Skypala I, Gama JMR, Nurmatov U, Lourenço O, Taborda-Barata L. Prevalence and risk factors for food allergy in older people: protocol for a systematic review. BMJ Open 2019; 9:e029633. [PMID: 31446411 PMCID: PMC6719770 DOI: 10.1136/bmjopen-2019-029633] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Studies suggest that the prevalence of food allergy may be increasing worldwide. Results regarding the prevalence and features of adverse food reactions older people have, however, scarcely been analysed in the literature. Thus, the objective of the present systematic review will be to describe the prevalence of food allergy in older individuals, its risk factors, clinical features, as well as the most frequently and commonly involved foods. METHODS AND ANALYSIS We will conduct a systematic review and meta-analysis of the incidence, prevalence and risk factors for food allergy in older individuals. We will search international electronic databases including MEDLINE, EMBASE, Cochrane Library, CINAHL, AMED and ISI Web of Science for published, unpublished and ongoing studies from 1980 toJanuary 2019. There will be no restriction on the language or geography of publication. We will use the critical appraisal skills programme quality assessment tool to appraise the methodological quality of included studies. A descriptive summary with data tables will be elaborated, and if deemed clinically relevant and statistically adequate, meta-analysis using random-effects modelling will be carried out, given the expected clinical, methodological and statistical heterogeneity of studies. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist will guide reporting of the systematic review. ETHICS AND DISSEMINATION Since this systematic review will be solely based on published and retrievable literature, no ethics approval will be obtained. This study will allow us to draw up-to-date estimates of the prevalence of adverse food reactions in older individuals, worldwide, besides allowing the identification of its major risk factors, clinical manifestations and predominant foods responsible for such reactions. A multidisciplinary team has been assembled for this systematic review and will participate in relevant dissemination activities, namely reports, publications and presentations. PROSPERO REGISTRATION NUMBER CRD42018102140.
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Affiliation(s)
- Inês Laia-Dias
- Faculty of Health Sciences, Universidade da Beira Interior, Covilhã, Portugal
| | - Carlos Lozoya-Ibáñez
- Department of Allergy and Clinical Immunology, Hospital Amato Lusitano, Castelo Branco Local Health Unit, Castelo Branco, Portugal
| | - Isabel Skypala
- Royal Brompton Hospital, Royal Brompton & Harefield NHS Trust, London, UK
| | - Jorge M R Gama
- Centre of Mathematics and Applications, Faculty of Sciences, Universidade da Beira Interior, Covilhã, Portugal
| | - Ulugbek Nurmatov
- Division of Population Medicine, School of Medicine, Cardiff University, Wales, UK
| | - Olga Lourenço
- Faculty of Health Sciences, Universidade da Beira Interior, Covilhã, Portugal
- CICS - Health Sciences Research Centre, NuESA - Environment and Health Study Group, Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
| | - Luís Taborda-Barata
- CICS - Health Sciences Research Centre, NuESA - Environment and Health Study Group, Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
- Department of Allergy and Clinical Immunology, Cova da Beira University Hospital Centre, Covilhã, Portugal
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12
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Coutinho Costa J, Machado JN, Ferreira C, Gama JMR, Almeida T, Arrobas AM. Immunotherapy in Allergic Asthma - 5 year analysis: Is it a curative approach? Pulmonology 2019; 25:183-185. [PMID: 30862426 DOI: 10.1016/j.pulmoe.2019.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 01/28/2019] [Indexed: 11/16/2022] Open
Affiliation(s)
- J Coutinho Costa
- Pneumology B Unit, University Hospital Centre of Coimbra - Hospital Geral, Coimbra, Portugal.
| | - J N Machado
- Pneumology B Unit, University Hospital Centre of Coimbra - Hospital Geral, Coimbra, Portugal
| | - C Ferreira
- Pneumology B Unit, University Hospital Centre of Coimbra - Hospital Geral, Coimbra, Portugal
| | - J M R Gama
- Centre of Mathematics and Applications, University of Beira Interior, Covilhã, Portugal
| | - T Almeida
- Pneumology B Unit, University Hospital Centre of Coimbra - Hospital Geral, Coimbra, Portugal
| | - A M Arrobas
- Pneumology B Unit, University Hospital Centre of Coimbra - Hospital Geral, Coimbra, Portugal
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Freitas Ferreira E, Pascoal A, Silva P, Lourenço O, Valente S, Valente MJ, Loureiro M, Gama JMR, Fonseca JA, Taborda-Barata L. Inhaler training and asthma knowledge are associated with a higher proportion of patients with correct inhaler technique in young but not in elderly asthmatic patients. J Asthma 2019; 57:556-566. [PMID: 30810421 DOI: 10.1080/02770903.2019.1582063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: Incorrect inhaler usage is frequent, particularly in elderly asthmatic patients. This study aimed at comparing inhaler technique errors and their determinants, as well inhaler technique self-perception versus real performance, between elderly and non-elderly asthmatics. Methods: Cross-sectional assessment of 92 elderly and 100 non-elderly asthmatics followed at specialty clinics. A standardized questionnaire was applied and inhaler technique demonstration was requested. Errors were assessed using checklists based on manufacturers' instructions and inhaler technique was graded as correct, acceptable or incorrect. Chi-Square Test and Fischer's Exact Test were used for comparative analysis of nominal variables. A p value equal to or less than 0.05 was considered statistically significant. Results: Inhaler technique was correct in a minority of elderly and young patients, without significant differences between study groups. Only 11.1% of the elderly who classified their inhaler as easy and 12.7% who stated their technique was correct had no errors. Previous regular inhaler training was associated with better actual performance in young but not in elderly patients. Conclusion: Our study showed that in spite of regular follow up at specialized outpatient clinics, inhaler devices are associated with a high frequency of errors in elderly and non-elderly asthmatics. In addition, most patients tend to overestimate their technique as correct. Finally, previous, frequent training was associated with a significantly higher percentage of patients showing correct or acceptable technique but only in non-elderly asthmatics, which suggests that elderly asthmatics may need specifically tailored inhaler education programs.
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Affiliation(s)
- Eduardo Freitas Ferreira
- NuESA - Health Environment Study Group, Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
| | - Adriana Pascoal
- NuESA - Health Environment Study Group, Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal.,Centro de Medicina de Reabilitação da Região Centro Rovisco Pais, Tocha, Portugal
| | - Patrícia Silva
- NuESA - Health Environment Study Group, Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal.,Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
| | - Olga Lourenço
- NuESA - Health Environment Study Group, Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal.,CICS - UBI - Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal
| | - Salete Valente
- CHUCB - Department of Pulmonology, Cova da Beira University Hospital Centre, Covilhã, Portugal
| | - Maria Jesus Valente
- CHUCB - Department of Pulmonology, Cova da Beira University Hospital Centre, Covilhã, Portugal
| | | | - Jorge M R Gama
- Center of Mathematics and Applications, Faculty of Sciences, University of Beira Interior, Covilhã, Portugal
| | - João A Fonseca
- Centre for Research in Health Technologies and Information Systems, Faculty of Medicine, University of Porto, Porto, Portugal.,Allergy Unit, CUF Porto Institute and Hospital, Porto, Portugal
| | - Luís Taborda-Barata
- NuESA - Health Environment Study Group, Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal.,CICS - UBI - Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal.,CHUCB - Department of Allergy & Clinical Immunology, Cova da Beira University Hospital Centre, Covilhã, Portugal
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Maricoto T, Monteiro L, Gama JMR, Correia-de-Sousa J, Taborda-Barata L. Inhaler Technique Education and Exacerbation Risk in Older Adults with Asthma or Chronic Obstructive Pulmonary Disease: A Meta-Analysis. J Am Geriatr Soc 2018; 67:57-66. [PMID: 30291745 DOI: 10.1111/jgs.15602] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 01/01/2018] [Accepted: 01/01/2018] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To evaluate the effect of inhaler education programs on clinical outcomes and exacerbation rates in older adults with asthma or chronic obstructive pulmonary disease (COPD). DESIGN Systematic review and meta-analysis. SETTING AND PARTICIPANTS Older adults with asthma or COPD, either in primary or secondary health care and pharmacy setting. MEASUREMENTS We searched the Medline, Embase, and Central databases according to the main eligibility criteria for inclusion: systematic reviews, meta-analysis, clinical trials and quasi-experimental studies; participants aged 65 and older; education on inhaler technique and reporting of disease control and exacerbation rates. We used the Grading of Recommendations, Assessment, Development and Evaluations scale for quality assessment and used a random-effect model with Mantel-Haenszel adjustment to perform a meta-analysis. RESULTS We included 8 studies (4 randomized, 4 quasi-experimental) with a total of 1,812 participants. The most frequent type of intervention was physical demonstration of inhaler technique, training with placebo devices. Five studies showed significant reduction in exacerbation rates (pooled risk ratio=0.71, 95% confidence interval=0.59-0.86; p < .001), although effect on disease control and quality of life showed high discrepancy in the reported results, and all randomized studies revealed uncertainty in their risk of bias assessment. CONCLUSION All interventions seemed to improve inhaler performance and clinically relevant outcomes, but a placebo device could be the most effective. There is evidence that interventions reduce exacerbation risk in older adults, although to an overall moderate degree. J Am Geriatr Soc 67:57-66, 2019.
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Affiliation(s)
- Tiago Maricoto
- Aveiro-Aradas Family Health Unit Aveiro Healthcare Centre, Aveiro, Portugal.,Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
| | - Luís Monteiro
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal.,Esgueira + Family Health Unit Aveiro Healthcare Centre, Aveiro, Portugal
| | - Jorge M R Gama
- Centre of Mathematics and Applications, Faculty of Sciences, University of Beira Interior, Covilhã, Portugal
| | - Jaime Correia-de-Sousa
- Life and Health Sciences Research Institute/3B's-PT Government Associate Laboratory, University of Minho, Braga, Portugal.,Horizonte Family Health Unit, Unidade Local de Saúde, Matosinhos, Portugal
| | - Luís Taborda-Barata
- CICS-Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal.,NuESA-Environment and Health Study Group, Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal.,Department of Allergy and Clinical Immunology, Cova da Beira University Hospital Centre, Covilhã, Portugal
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Mónico B, Gama JMR, Pastorinho MR, Lourenço O. Tobacco smoke as a risk factor for allergic sensitization in adults: Conclusions of a systematic review and meta-analysis. J Allergy Clin Immunol 2018; 143:417-419. [PMID: 30205187 DOI: 10.1016/j.jaci.2018.07.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 06/19/2018] [Accepted: 07/27/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Beatriz Mónico
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal; CICS - UBI Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal
| | - Jorge M R Gama
- CMA - UBI Centre of Mathematics and Applications, University of Beira Interior, Covilhã, Portugal
| | - M Ramiro Pastorinho
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal; CICS - UBI Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal
| | - Olga Lourenço
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal; CICS - UBI Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal.
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Arrais M, Lulua O, Quifica F, Rosado-Pinto J, Gama JMR, Taborda-Barata L. Prevalence of asthma and allergies in 13-14-year-old adolescents from Luanda, Angola. Int J Tuberc Lung Dis 2018; 21:705-712. [PMID: 28482967 DOI: 10.5588/ijtld.16.0530] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING The few epidemiological studies on asthma and allergic diseases performed in Africa have shown that the prevalence of these diseases is high or increasing. No such studies have been performed in Angola. OBJECTIVE To determine the prevalence of asthma and other allergic diseases in Angolan adolescents. DESIGN This was a descriptive, observational, cross-sectional study in the province of Luanda, Angola, using the International Study of Asthma and Allergies in Childhood study methodology in adolescents aged 13 and 14 years. Twenty-three (12%) public schools were randomly selected. Data were analysed using the Statistical Package for the Social Sciences version 22.0 software. RESULTS A total of 3128 adolescents were included. The prevalence of asthma (wheezing in the previous 12 months) was 13.4%. The prevalence of rhinitis (sneezing, runny or blocked nose in the previous 12 months) was 27% and that of eczema (itchy skin lesions in the previous 12 months) was 20%; both were more prevalent in girls. Rhinitis was associated with a greater number of episodes of night cough in adolescents with asthma. Rhinitis and eczema, a split-type air conditioning system, and frequent intake (more than once per month) of paracetamol were associated with a higher risk of having asthma. CONCLUSION Asthma and related allergic diseases are a public health problem in adolescents from Luanda. Preventive and control measures should be implemented.
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Affiliation(s)
- M Arrais
- Military Hospital, Luanda, Angola
| | - O Lulua
- Military Hospital, Luanda, Angola
| | | | - J Rosado-Pinto
- Department of Immunoallergology, Hospital da Luz, Lisbon
| | - J M R Gama
- Department of Mathematics, Faculty of Sciences, University of Beira Interior, Covilhã
| | - L Taborda-Barata
- Department of Allergy & Clinical Immunology, Cova da Beira Hospital, Covilhã, Centro de Investigação em Ciências da Saúde, University of Beira Interior, Covilhã, Portugal
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