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The Global Initiative for Asthma (GINA) was established in 1993 by the World Health Organization and the US National Heart Lung and Blood Institute to improve asthma awareness, prevention and management worldwide. GINA develops and publishes evidence-based, annually updated resources for clinicians. GINA guidance is adopted by national asthma guidelines in many countries, adapted to fit local healthcare systems, practices, and resource availability. GINA is independent of industry, funded by the sale and licensing of its materials. This review summarizes key practical guidance for primary care from the 2022 GINA strategy report. It provides guidance on confirming the diagnosis of asthma using spirometry or peak expiratory flow. GINA recommends that all adults, adolescents and most children with asthma should receive inhaled corticosteroid (ICS)-containing therapy to reduce the risk of severe exacerbations, either taken regularly, or (for adults and adolescents with “mild” asthma) as combination ICS–formoterol taken as needed for symptom relief. For patients with moderate–severe asthma, the preferred regimen is maintenance-and-reliever therapy (MART) with ICS–formoterol. Asthma treatment is not “one size fits all”; GINA recommends individualized assessment, adjustment, and review of treatment. As many patients with difficult-to-treat or severe asthma are not referred early for specialist review, we provide updated guidance for primary care on diagnosis, further investigation, optimization and treatment of severe asthma across secondary and tertiary care. While the GINA strategy has global relevance, we recognize that there are special considerations for its adoption in low- and middle-income countries, particularly the current poor access to inhaled medications.

•Childhood pneumonia hospitalization decreased after PHiD-CV introduction.•Incidence of all non-respiratory admissions remained stable between 2002 and 2012.•This data is an evidence of the health public impact of this new pneumococcal vaccine. Pneumococcal disease is a major public health problem worldwide. From March to September of 2010, 10-valent pneumococcal non-typeable Haemophilus influenzae protein conjugate vaccine (PHiD-CV) was introduced in the Brazilian childhood National Immunization Program (NIP) in all 27 Brazilian states. The aim of the present study is to report national time-trends in incidence of hospital admissions for childhood pneumonia in Brazil before and after two years of introduction of this new pneumococcal conjugate vaccine. Analysis of hospitalization data of children aged 0–4 years in Brazilian public health system with an admission diagnosis of pneumonia from 2002 to 2012 was performed comparing pre (2002–2009) and post-vaccination periods (2011–2012). Hospital number of admission due to pneumonia and all non-respiratory diseases were obtained from DATASUS, the Brazilian government open-access public health database system. Incidence of pneumonia hospitalization was compared to incidence of all non-respiratory admissions. Admission rates for pneumonia decreased steadily from 2010 to 2012. In children aged less than four years, incidence of pneumonia hospitalizations decreased 12.65% when pre (2002–2009) and post-vaccination introduction periods (2011–2012) were compared and adjusted for seasonality and secular-trend (p<0.001). On the other hand, non-respiratory admission rates remained stable comparing both periods (p=0.39). Childhood pneumonia hospitalization rates were fluctuating prior to 2010 and decreased significantly in the two years after PHiD-CV introduction. Conversely, rate of non-respiratory admissions has shown no decrease. These data are an evidence of the effectiveness and public health impact of this new pneumococcal vaccine.

It remains unclear whether premature birth, in the absence of neonatal respiratory disease, results in abnormal growth and development of the lung. We previously reported that a group of healthy infants born at 32-34 weeks' gestation and without respiratory complications had decreased forced expiratory flows and normal forced vital capacities at 2 months of age. Our current study evaluated whether these healthy infants born prematurely exhibited improvement or \"catch-up\" in their lung function during the second year of life. Longitudinal measurements of forced expiratory flows by the raised volume rapid thoracic compression technique were obtained in the first and the second years of life for infants born prematurely at 32.7 (range, 30-34) weeks' gestation (n = 26) and infants born at full term (n = 24). Healthy infants born prematurely demonstrate decreased forced expiratory flows and normal forced vital capacities in the first and second years of life. In addition, the increases in lung function with growth were similar to full-term infants. Persistently reduced flows in the presence of normal forced vital capacity and the absence of catch-up growth in airway function suggest that premature birth is associated with altered lung development.

To explore the relationship between prematurity, gender and chorioamnionitis as determinants of early life lung function in premature infants. Placenta and membranes were collected from preterm deliveries (<37 weeks gestational age) and evaluated for histological chorioamnionitis (HCA). Patients were followed and lung function was performed in the first year of life by Raised Volume-Rapid Thoracic Compression Technique. Ninety-five infants (43 males) born prematurely (median gestational age 34.2 weeks) were recruited. HCA was detected in 66 (69%) of the placentas, and of these 55(58%) were scored HCA Grade 1, and 11(12%) HCA Grade 2. Infants exposed to HCA Grade 1 and Grade 2, when compared to those not exposed, presented significantly lower gestational ages, higher prevalence of RDS, clinical early-onset sepsis, and the use of supplemental oxygen more than 28 days. Infants exposed to HCA also had significantly lower maximal flows. There was a significant negative trend for z-scores of lung function in relation to levels of HCA; infants had lower maximal expiratory flows with increasing level of HCA. (p = 0.012 for FEF50, p = 0.014 for FEF25-75 and p = 0.32 for FEV0.5). Two-way ANOVA adjusted for length and gestational age indicated a significant interaction between sex and HCA in determining expiratory flows (p<0.01 for FEF50, FEF25-75 and p<0.05 for FEV0.5). Post-hoc comparisons revealed that female preterm infants exposed to HCA Grade 1 and Grade 2 had significant lower lung function than those not exposed, and this effect was not observed among males. Our findings show a sex-specific negative effect of prenatal inflammation on lung function of female preterm infants. This study confirms and expands knowledge upon the known association between chorioamnionitis and early life chronic lung disease.

Background Asthma is one of the most prevalent chronic pulmonary diseases, affecting approximately 20 million Brazilian people. Most patients with asthma in Brazil present with uncontrolled disease, leading to high morbidity and mortality rates. Therefore, an effective educational intervention focused on asthma management in primary health care (PHC) is expected to reduce hospitalization rates, emergency visits, and direct public health costs, improving the quality of life of patients. Methods The CuidAR study is a controlled and randomized superiority trial conducted at cluster level, with two arms and a 1:1 allocation ratio. A total of 40 PHC centers will be selected, covering all macro-regions of Brazil. Twenty centers will be randomized to the intervention group (healthcare professional teams will undertake an asthma management program) and the other 20 centers will be randomized to the control group (current standard of care). This study aims to enroll 960 participants aged 6 to 65, all of whom have a physician-diagnosed case of uncontrolled asthma and meet the eligibility criteria. The primary outcome is the asthma-related hospitalization rate. Data collected will be analyzed after all participants have completed a 12-month follow-up period. Discussion Empowering the multidisciplinary healthcare team on asthma management at a national level in the PHC centers, while addressing the substantial burden of asthma in Brazil, holds the potential to reduce asthma hospitalization rates in alignment with global health priorities, ultimately reducing direct public health costs. Trial registration Brazilian Registry of Clinical Trials (ReBEC) RBR-9xtq9p6. Registered on January 16, 2023, https://ensaiosclinicos.gov.br/rg/RBR-9xtq9p6 .

Preterm delivery has been associated with a higher incidence of respiratory morbidity even in infants that do not have significant respiratory disease during the neonatal period. Reduced flows have been reported in children and adolescents born prematurely. The aim of this study was to assess lung function in healthy preterm infants in the first months of life. Preterm infants with less than 48 h of supplemental oxygen were recruited. Lung function was assessed by the raised-volume rapid thoracic compression in the first months of life. The control group consisted of full-term infants without a history of respiratory diseases. Sixty-two preterm (29 male) and 27 full-term (10 male) infants were tested. Adjusting for length, age, and sex, we found a mean significant reduction of 92 ml/s (22%) in FEF(50), 73 ml/s (21%) in FEF(25-75), and 19 ml (28%) in FEV(0.5) in the preterm group. These differences in expiratory flows remained significant using another model that adjusts for lung volume (p < 0.01 for FEF(50), FEF(25-75), and FEV(0.5), and p < 0.05 for FEF(75)). In the preterm group, after adjusting for length, male sex, lower gestational age, and increased weight were significantly and independently associated with reduced flows. Our findings confirm that prematurity is independently associated with reduced lung function and that this is detectable in the first months of life. Male sex, lower gestational age, and weight are important predictors for reduced expiratory flows in this group.

House dust mites (HDM) are the main source of aeroallergens worldwide, yet epidemiological differences between socioeconomic factors in association with this medical condition have not been studied in the south region of Brazil. To assess the prevalence of HDM in two socioeconomically distinct populations of patients with allergic asthma or rhinitis, the differences between samples from houses of high-income families and low-income families were analyzed. Mite samples were collected between July and December 2015, in Porto Alegre, Brazil. The HDM were Dermatophagoides pteronyssinus and Dermatophagoides farinae (Hughes; Acari: Pyroglyphidae). Also, other non-pyroglyphid house mites were identified in dust samples: Tyrophagus putrescentiae (Schrank; Acari: Acaridae), Chortoglyphus arcuatus, and Cheyletus malaccensis. Identification of species was performed through morphological keys with a stereomicroscope and a phase optical microscope. A total of 104 homes was evaluated (low-income group: n = 53; high-income group, n = 51). We found a total of 721 mites, representing 11 species, in 93 (89%) houses. In the remaining houses, no mites were found. We observed no significant differences of species composition between the groups studied. However, the number of mites was significantly higher in the low-income group (P < 0.001). D. pteronyssinus was the predominant species detected, with 286 mites (39.6%). D. farinae was not detected in any sample. Our results show that living-rooms from low-income families present higher numbers of HDM.

IntroductionClinical recommendations for childhood asthma are often based on data extrapolated from studies conducted in adults, despite significant differences in mechanisms and response to treatments. The Paediatric Asthma in Real Life (PeARL) Think Tank aspires to develop recommendations based on the best available evidence from studies in children. An overview of systematic reviews (SRs) on paediatric asthma maintenance management and an SR of treatments for acute asthma attacks in children, requiring an emergency presentation with/without hospital admission will be conducted.Methods and analysisStandard methodology recommended by Cochrane will be followed. Maintenance pharmacotherapy of childhood asthma will be evaluated in an overview of SRs published after 2005 and including clinical trials or real-life studies. For evaluating pharmacotherapy of acute asthma attacks leading to an emergency presentation with/without hospital admission, we opted to conduct de novo synthesis in the absence of adequate up-to-date published SRs. For the SR of acute asthma pharmacotherapy, we will consider eligible SRs, clinical trials or real-life studies without time restrictions. Our evidence updates will be based on broad searches of Pubmed/Medline and the Cochrane Library. We will use A MeaSurement Tool to Assess systematic Reviews, V.2, Cochrane risk of bias 2 and REal Life EVidence AssessmeNt Tool to evaluate the methodological quality of SRs, controlled clinical trials and real-life studies, respectively.Next, we will further assess interventions for acute severe asthma attacks with positive clinical results in meta-analyses. We will include both controlled clinical trials and observational studies and will assess their quality using the previously mentioned tools. We will employ random effect models for conducting meta-analyses, and Grading of Recommendations Assessment, Development and Evaluation methodology to assess certainty in the body of evidence.Ethics and disseminationEthics approval is not required for SRs. Our findings will be published in peer reviewed journals and will inform clinical recommendations being developed by the PeARL Think Tank.PROSPERO registration numbersCRD42020132990, CRD42020171624.

Childhood asthma control largely depends on rigorous and regular monitoring. Although various clinical parameters, biomarkers, and patient-reported outcomes are helpful for monitoring purposes, there is no consensus on the minimum and/or optimal set of parameters and their relative priority. To assess actual and perceived optimal childhood asthma monitoring practices used globally. This international, multistakeholder survey study surveyed health care professionals and clinical academics with a professional interest in and exposure to childhood asthma between April 12 and September 3, 2021, to test for differences between the frequency that different techniques are actually used in practice vs optimal practice, between-group differences, and differences across medical settings and country economies. Outcomes were frequency of duration of asthma monitoring visits as well as actual and perceived optimal use and importance of monitoring tools and domains. A total of 1319 participants with expertise in childhood asthma from 88 countries completed the survey. Participants included 1228 health care professionals with a balanced distribution across different care settings (305 [22.7%] primary care, 401 [29.9%] secondary, and 522 [38.9%] tertiary care) and 91 researchers. Children with mild to moderate asthma attended regular monitoring visits at a median (IQR) of 5.0 (2.5-8.0) months, with visits lasting a median (IQR) of 25 (15-25) minutes, whereas severe asthma required more frequent visits (median [IQR], 2.5 [1.0-2.5] months; median [IQR] duration, 25 [25-35] minutes). Monitoring of symptoms and control, adherence, comorbidities, lung function, medication adverse effects, and allergy were considered to be very high or high priority by more than 75% of the respondents. Different patterns emerged when assessing differences between actual and perceived optimal use of monitoring tools. For some tools, current and optimal practices did not differ much (eg, spirometry), whereas in others, there was considerable space for improvement (eg, standardized control and adherence tests). The largest gap was observed for between-visit monitoring with electronic trackers, apps, and smart devices. Differences across country economies, care settings, and medical specialties were modest. These survey results suggest that pediatric asthma monitoring is performed generally homogeneously worldwide, in most cases following evidence-based standards. Wider use of standardized instruments and the intensification of continuous between-visit monitoring, supported by electronic devices, is needed for further improvement of disease outcomes. The results of this survey, in conjunction with the available evidence base, can inform recommendations toward further optimization.

To explore the relationship between prematurity, gender and chorioamnionitis as determinants of early life lung function in premature infants. Placenta and membranes were collected from preterm deliveries (<37 weeks gestational age) and evaluated for histological chorioamnionitis (HCA). Patients were followed and lung function was performed in the first year of life by Raised Volume-Rapid Thoracic Compression Technique. Ninety-five infants (43 males) born prematurely (median gestational age 34.2 weeks) were recruited. HCA was detected in 66 (69%) of the placentas, and of these 55(58%) were scored HCA Grade 1, and 11(12%) HCA Grade 2. Infants exposed to HCA Grade 1 and Grade 2, when compared to those not exposed, presented significantly lower gestational ages, higher prevalence of RDS, clinical early-onset sepsis, and the use of supplemental oxygen more than 28 days. Infants exposed to HCA also had significantly lower maximal flows. There was a significant negative trend for z-scores of lung function in relation to levels of HCA; infants had lower maximal expiratory flows with increasing level of HCA. (p = 0.012 for FEF.sub.50, p = 0.014 for FEF.sub.25-75 and p = 0.32 for FEV.sub.0.5). Two-way ANOVA adjusted for length and gestational age indicated a significant interaction between sex and HCA in determining expiratory flows (p<0.01 for FEF.sub.50, FEF.sub.25-75 and p<0.05 for FEV.sub.0.5). Post-hoc comparisons revealed that female preterm infants exposed to HCA Grade 1 and Grade 2 had significant lower lung function than those not exposed, and this effect was not observed among males. Our findings show a sex-specific negative effect of prenatal inflammation on lung function of female preterm infants. This study confirms and expands knowledge upon the known association between chorioamnionitis and early life chronic lung disease.