Clinical standards for the diagnosis and management of asthma in low- and middle-income countries

BACKGROUND: The aim of these clinical standards is to aid the diagnosis and management of asthma in low-resource settings in low- and middle-income countries (LMICs).METHODS: A panel of 52 experts in the field of asthma in LMICs participated in a two-stage Delphi process to establish and reach a consensus on the clinical standards.RESULTS: Eighteen clinical standards were defined: Standard 1, Every individual with symptoms and signs compatible with asthma should undergo a clinical assessment; Standard 2, In individuals (>6 years) with a clinical assessment supportive of a diagnosis of asthma, a hand-held spirometry measurement should be used to confirm variable expiratory airflow limitation by demonstrating an acute response to a bronchodilator; Standard 3, Pre- and post-bronchodilator spirometry should be performed in individuals (>6 years) to support diagnosis before treatment is commenced if there is diagnostic uncertainty; Standard 4, Individuals with an acute exacerbation of asthma and clinical signs of hypoxaemia or increased work of breathing should be given supplementary oxygen to maintain saturation at 94-98%; Standard 5, Inhaled short-acting beta-2 agonists (SABAs) should be used as an emergency reliever in individuals with asthma via an appropriate spacer device for metered-dose inhalers; Standard 6, Short-course oral corticosteroids should be administered in appropriate doses to individuals having moderate to severe acute asthma exacerbations (minimum 3-5 days); Standard 7, Individuals having a severe asthma exacerbation should receive emergency care, including oxygen therapy, systemic corticosteroids, inhaled bronchodilators (e.g., salbutamol with or without ipratropium bromide) and a single dose of intravenous magnesium sulphate should be considered; Standard 8, All individuals with asthma should receive education about asthma and a personalised action plan; Standard 9, Inhaled medications (excluding dry-powder devices) should be administered via an appropriate spacer device in both adults and children. Children aged 0-3 years will require the spacer to be coupled to a face mask; Standard 10, Children aged <5 years with asthma should receive a SABA as-needed at step 1 and an inhaled corticosteroid (ICS) to cover periods of wheezing due to respiratory viral infections, and SABA as-needed and daily ICS from step 2 upwards; Standard 11, Children aged 6-11 years with asthma should receive an ICS taken whenever an inhaled SABA is used; Standard 12, All adolescents aged 12-18 years and adults with asthma should receive a combination inhaler (ICS and rapid onset of action long-acting beta-agonist [LABA] such as budesonide-formoterol), where available, to be used either as-needed (for mild asthma) or as both maintenance and reliever therapy, for moderate to severe asthma; Standard 13, Inhaled SABA alone for the management of patients aged >12 years is not recommended as it is associated with increased risk of morbidity and mortality. It should only be used where there is no access to ICS.The following standards (14-18) are for settings where there is no access to inhaled medicines. Standard 14, Patients without access to corticosteroids should be provided with a single short course of emergency oral prednisolone; Standard 15, Oral SABA for symptomatic relief should be used only if no inhaled SABA is available. Adjust to the individual's lowest beneficial dose to minimise adverse effects; Standard 16, Oral leukotriene receptor antagonists (LTRA) can be used as a preventive medication and is preferable to the use of long-term oral systemic corticosteroids; Standard 17, In exceptional circumstances, when there is a high risk of mortality from exacerbations, low-dose oral prednisolone daily or on alternate days may be considered on a case-by-case basis; Standard 18. Oral theophylline should be restricted for use in situations where it is the only bronchodilator treatment option available.CONCLUSION: These first consensus-based clinical standards for asthma management in LMICs are intended to help clinicians provide the most effective care for people in resource-limited settings.

Fungal Allergy: Pattern of sensitization over the past 11 years

INTRODUCTION AND OBJECTIVES

Although the prevalence of sensitization to fungi is not precisely known, it can reach 50% in inner cities and has been identified as a risk factor in the development of asthma. Whereas the prevalence of allergic diseases is increasing, it is unclear whether the same occurs with sensitization to fungi.

PATIENTS AND METHODS

A retrospective study was performed at the "Hospital Infantil de México Federico Gómez". From skin tests taken between 2004 and 2015, information was gathered about Alternaria alternata, Aspergillus fumigatus, Candida albicans, Cladosporium herbarum, Mucor mucedo and Penicillium notatum. The participating patients were 2-18 years old, presented some type of allergic condition, and underwent immediate hypersensitivity tests to the fungi herein examined. Descriptive analysis and chi-squared distribution were used.

RESULTS

Of the 8794 patients included in the study, 14% showed a negative result to the entire panel of environmental allergens. The remaining 7565 individuals displayed sensitization to at least one fungus, which most frequently was Aspergillus, with a rate of 16.8%. When the patients were divided into age groups, the same trend was observed. The highest percentage of sensitization (58%) toward at least one type of fungus was found in 2014, and the lowest percentage (49.8%) in 2008.

CONCLUSION

The rate of sensitization to at least one type of fungus was presently over 50%, higher than that detected in other medical centers in Mexico. This rate was constant over the 11-year study, and Aspergillus exhibited the greatest frequency of sensitization among the patients.

Study of the relationship between acetaminophen and asthma in Mexican children aged 6 to 7 years in 3 Mexican cities using ISAAC methodology

OBJECTIVE

To establish the relationship between the use of acetaminophen and the frequency of asthma in Mexican children in 3 Mexican cities.

METHODS

Ours was a multicenter, observational, descriptive, cross-sectional study. Patients from 6 to 7 years of age participating in Phase Three B of the ISAAC (International Study of Asthma and Allergies in Children) living in the north of Mexico City, Victoria City, and Merida were included. After adjusting for confounders, we calculated the odds ratios (OR) for the presence of wheezing ever, wheezing in the last 12 months, asthma ever, and the use of acetaminophen in the first year of life and during the last 12 months.

RESULTS

The ORs for wheezing ever, wheezing in the last year, and asthma ever with respect to use of acetaminophen in the first year of life were not statistically significant (P > .05) in Mexico City, but they were significant in Victoria City (P < .05) and Merida (P < .05). The ORs (95% confidence intervals) for wheezing ever, wheezing in the last year, and asthma ever with respect to use of acetaminophen in the last year were 3.44 (2.96-4.0), 7.97 (5.89-10.78), and 6.10 (3.30-8.81) (P < .05) in Mexico City. Values forVictoria City were 1.36 (1.13-1.63), 3.80 (2.88-5.05), and 2.18(1.57-3.01) (P < .05). Those for Merida were 1.61 (1.40-1.85), 2.07 (1.73-2.48), and 1.53 (1.29-1.82) (P < .05).

CONCLUSION

The use of acetaminophen is associated with the presence of wheezing and asthma in 3 different cities in Mexico.

Mexican anthropometric percentiles for ages 10–18

OBJECTIVE

To elaborate Mexican growth charts based on international methodology.

DESIGN

Data were obtained from the Mexican National Health Survey. The survey was stratified and probabilistic representative of all the country.

SETTING

Nationwide open population living in urban and rural areas.

SUBJECTS

Boys (8545) and girls (9983) from 10 to 18 years participating in the survey.

METHODS

Age, weight and height were recorded. Empirical percentiles were calculated and smoothed. Smoothed curves were approximated using least-mean square estimation.

RESULTS

Tables and figures for percentile values of weight, height and body mass index (BMI) for age, as well as percentile values of weight and BMI for height for both genders are presented. Regarding 50th BMI for age percentiles, Mexicans had higher levels than the Americans in the Centers for Disease Control and Prevention growth charts; Mexicans were lower but had similar weights than the Americans. Owing to the high BMI, the percentile corresponding to an overweight level (25 kg/m(2)) at 18 years was 74.5 in boys and 72.5 in girls, whereas obesity level (30 kg/m(2)) at 18 years was 97.3 and 97.4 in boys and girls, respectively.

CONCLUSIONS

The present growth charts are snapshots of a Mexican population. Because of the high median BMI compared to US and World Health Organization standards, we must be cautious in establishing an upper normal cutoff for clinical normality, not merely selecting the 85th and 95th percentiles as equivalents of overweight and obesity, respectively. Therefore, we proposed percentiles 74.5 in boys and 72.5 in girls as the action points of overweight as they are the percentiles corresponding to BMI 25 kg/m(2) at 18 years.

SPONSORSHIP

The survey was supported by the Mexican Minister of Health. Statistical analyses were sponsored by Dr Del-Rio-Navarro.

Immunostimulants for preventing respiratory tract infection in children

BACKGROUND

Acute respiratory tract infections (ARTIs) are a major cause of childhood morbidity and mortality. Immunostimulants (IS) may reduce the incidence of ARTIs.

OBJECTIVES

To determine the efficacy and safety of IS in preventing ARTIs in children.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005); MEDLINE (January 1966 to January 2006); and EMBASE (January 1990 to January 2006); PASCAL (up to January 2006); SciSearch (up to January 2006); and IPA (up to January 2006) for reports of trials. Investigators in the field were also contacted. Ongoing studies were searched in the trial registration web site, metaRegister of Controlled Trials.

SELECTION CRITERIA

All comparative trials which enrolled patients less than 18 years of age were included. The intervention of interest was the use of an IS medication administered by any method for preventing ARTIs. Clinical trials using random or quasi-random allocation and comparing IS medication or medications to placebo were included.

DATA COLLECTION AND ANALYSIS

The outcome on ARTIs was analyzed both as the mean number of ARTIs by group and as a percent change in the rate of ARTIs. Meta-analysis was undertaken using a random-effects model and results were presented as weighted mean differences (WMD) with 95% confidence intervals (CI). The trials search, quality assessment and data extraction were undertaken independently by two authors. A funnel plot suggested there may be publication bias in the trials identified.

MAIN RESULTS

Thirty-four placebo controlled trials (3877 participants) provided data in a form suitable for inclusion in the meta-analysis. When compared with placebo, the use of IS was shown to reduce ARTIs measured as the total numbers of ARTIs (WMD -1.27; 95% CI -1.58 to -0.97) and the difference in ARTIs rates (WMD -39.68%; 95% CI -47.27% to -32.09%). The trial quality was generally poor and a high level of statistical heterogeneity was evident. The subgroup analysis of bacterial IS studies produced similar results, with lower heterogeneity. No difference in adverse events was evident between the placebo and IS groups

AUTHORS' CONCLUSIONS

This review showed that IS reduces the incidence of ARTIs in children, by 40% on average. However, due to significant heterogeneity and the poor quality of the trials this positive result should be interpreted with caution. The safety profile of IS appears to be good. Further high-quality trials are needed and we encourage national health authorities to conduct large, multicenter, double-blind, placebo-controlled trials on the role of IS in the prevention of ARTIs.

The relationship between asthma symptoms and anthropometric markers of overweight in a Hispanic population

BACKGROUND

Previous studies have revealed the relationship between asthma and obesity, but the relationship with other markers of overweight and obesity has not yet been investigated.

OBJECTIVE

To establish the relationship between asthma symptoms and simple anthropometric indexes (BMI, waist circumference (WC), and waist-to-hip ratio (WHR)) as markers of overweight in an adult Hispanic population.

METHODS

The data were obtained from the PRIT (Prevalence of Cardiovascular Risks in General Hospital Workers) 2001 survey. The participants were workers at the Hospital General de México in Mexico City and included 135 men and 398 women aged 43.8 +/- 11.9 and 43.0 +/- 10.5, respectively. Odds ratios for asthma symptoms at different BMI, WC, and WHR cutoff points associated with excessive weight were calculated. The likelihood ratios for having asthma symptoms in participants with various cutoff values of BMI, WC, and WHR also were calculated.

RESULTS

Asthma symptoms were not related to anthropometric markers of overweight or obesity in men, while they were associated in women with WC cutoff levels of 80 and 85 cm, and BMI of 25 and 27 kg/m2. No level of WHR was related to asthma symptoms in women. In women, the likelihood ratio for asthma symptoms increased proportionally from WC levels of 73.5 cm up to 86 cm, while this risk increased significantly from BMI levels of 22 up to 29 kg/m2.

CONCLUSION

Overweight as assessed by BMI and WC (but not WHR) was related to asthma symptoms in women in the studied population.

Use of Broncho-Vaxom in private practice: phase IV trial in 587 children

We conducted a Phase IV, open-label clinical trial to test the efficacy and safety of the immunomodulating agent Broncho-Vaxom in private practice. The trial comprised 587 children younger than 12 years of age who had an acute respiratory tract infection at entry and a history of recurrent respiratory tract infections. The patients were given one capsule daily, 10 days per month, for 3 consecutive months. During the acute phase of the disease the patients also received antibiotic therapy. Comparing the infection present at entry with previous infections, the time to improvement (mean +/- SD) decreased from 6.77 +/- 4.42 days to 3.76 +/- 2.18 days, while the time to cure decreased from 11.86 +/- 8.41 days to 7.36 +/- 4.93 days. During the 3 months of therapy, the number of infections decreased from 1.79 +/- 0.96 1 month before treatment to 0.24 +/- 0.46 in the third month of treatment; absenteeism decreased from 3.17 +/- 3.07 days to 0.16 +/- 0.63 days; and the number of antibiotic treatments decreased from 1.71 +/- 1.06 to 0.16 +/- 0.51. In the patients who experienced a recurrent respiratory tract infection during the study, the time to improvement decreased from 5.46 +/- 3.28 days before treatment to 2.79 +/- 1.36 days after treatment, and the time to cure decreased from 8.71 +/- 3.96 days to 4.54 +/- 2.26 days. Adverse events included asthenia and adynamia in 3 patients, diarrhea in 3, rash in 2, fever in 2, exacerbation of symptoms in 2, adenitis in 1, and flulike syndrome in 1. We conclude that Broncho-Vaxom is effective and safe for the treatment of acute episodes of respiratory tract infections and for preventing recurrences.