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Asthma, rhinitis, and atopic dermatitis (AD) are interrelated clinical phenotypes that partly overlap in the human interactome. The concept of “one-airway-one-disease,” coined over 20 years ago, is a simplistic approach of the links between upper- and lower-airway allergic diseases. With new data, it is time to reassess the concept. This article reviews (i) the clinical observations that led to Allergic Rhinitis and its Impact on Asthma (ARIA), (ii) new insights into polysensitization and multimorbidity, (iii) advances in mHealth for novel phenotype definitions, (iv) confirmation in canonical epidemiologic studies, (v) genomic findings, (vi) treatment approaches, and (vii) novel concepts on the onset of rhinitis and multimorbidity. One recent concept, bringing together upper- and lower-airway allergic diseases with skin, gut, and neuropsychiatric multimorbidities, is the “Epithelial Barrier Hypothesis.” This review determined that the “one-airway-one-disease” concept does not always hold true and that several phenotypes of disease can be defined. These phenotypes include an extreme “allergic” (asthma) phenotype combining asthma, rhinitis, and conjunctivitis.

Pharmacists are trusted health care professionals. Many patients use over-the-counter (OTC) medications and are seen by pharmacists who are the initial point of contact for allergic rhinitis management in most countries. The role of pharmacists in integrated care pathways (ICPs) for allergic diseases is important. This paper builds on existing studies and provides tools intended to help pharmacists provide optimal advice/interventions/strategies to patients with rhinitis. The Allergic Rhinitis and its Impact on Asthma (ARIA)-pharmacy ICP includes a diagnostic questionnaire specifically focusing attention on key symptoms and markers of the disease, a systematic Diagnosis Guide (including differential diagnoses), and a simple flowchart with proposed treatment for rhinitis and asthma multimorbidity. Key prompts for referral within the ICP are included. The use of technology is critical to enhance the management of allergic rhinitis. However, the ARIA-pharmacy ICP should be adapted to local healthcare environments/situations as regional (national) differences exist in pharmacy care.

Pharmacists are trusted health care professionals. Many patients use over-the-counter (OTC) medications and are seen by pharmacists who are the initial point of contact for allergic rhinitis management in most countries. The role of pharmacists in integrated care pathways (ICPs) for allergic diseases is important. This paper builds on existing studies and provides tools intended to help pharmacists provide optimal advice/interventions/strategies to patients with rhinitis. The Allergic Rhinitis and its Impact on Asthma (ARIA)-pharmacy ICP includes a diagnostic questionnaire specifically focusing attention on key symptoms and markers of the disease, a systematic Diagnosis Guide (including differential diagnoses), and a simple flowchart with proposed treatment for rhinitis and asthma multimorbidity. Key prompts for referral within the ICP are included. The use of technology is critical to enhance the management of allergic rhinitis. However, the ARIA-pharmacy ICP should be adapted to local healthcare environments/situations as regional (national) differences exist in pharmacy care. 74 7 1219 1236

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 quasiexperimental) 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.

Objetivos: Quantificar as consultas relacionadas com DPOC dos utentes inscritos em Médicos Sentinela (MS) entre 2007 e 2009, avaliar os principais motivos de consulta relacionadas com DPOC e estimar a incidência da doença nessa população e caraterizar a terapêutica utilizada na DPOC pelos MS. Tipo de estudo: Coorte dinâmica. Local: Multicêntrico. População: Utentes com idade igual ou superior a 45 anos inscritos nas listas dos MS de 2007 a 2009. Métodos: Análise das consultas relacionadas com DPOC durante o período referido quanto à frequência e motivos de consulta e ao tratamento farmacológico instituído. Cálculo da taxa de incidência e extrapolação para a população portuguesa. Utilização dos testes qui-quadrado (comparação de proporções) e t-student (comparação de médias). Resultados: No conjunto dos três anos, a população sob observação na Rede Sentinela foi de 106.953 indivíduos. Foram notificadas 2.916 consultas relacionadas com DPOC (62,5% no sexo masculino), e 173 novos casos com idade igual ou superior a 45 anos (59,5% no sexo masculino), com média de idades de 66,9 anos, sem diferença significativa relativamente à idade entre os sexos. Calculou-se uma taxa de incidência média anual de 161,8/100.000 (IC 95%: 139,4-187,7/100.000), superior no sexo masculino. Os principais motivos de consulta notificados foram: renovação de medicação (61,9%), consultas de seguimento (22,9%) e exacerbação de sintomas (15,6%). Foi prescrita medicação em 87,3% das consultas, com predomínio de fármacos broncodilatadores de uso inalatório: anticolinérgicos (25,1%) e ß-adrenérgicos (20,3%). Conclusões: A frequência de consultas e taxa de incidência foram maiores no sexo masculino, estando o valor obtido desta última aquém do esperado, presumivelmente pelo subdiagnóstico da doença e pela exclusão dos doentes que não frequentam as consultas dos CSP. O padrão de prescrição foi concordante com as recomendações da Global Initiative for Chronic Obstructive Lung Disease. Objectives: To determine the number of chronic obstructive pulmonary disease (COPD)-related consultations among patients registered in the Portuguese Sentinel Practice Network (PSPN) between 2007 and 2009, to calculate the reasons for visits related to COPD, to estimate the incidence of COPD, and to characterize COPD-related therapy. Study design: Dynamic cohort. Setting: Muticentric. Participants: Patients = 45 years old from the lists of general practitioners in the PSPN between 2007 and 2009. Methods: A study of COPD-related consultations over a three-year period, reporting the frequency, the reasons for consultation and treatments was conducted. The estimated incidence rate of COPD was calculated and extrapolated to the Portuguese population. The chi-square test to compare proportions and the t-student test for comparison of means were used. Results: During the study period, the population under observation was 106,953 individuals and 2,916 consultations related to COPD were reported. Of these, 62.5% were for males. New cases of COPD were reported in 173 persons = 45 years old, of which 59.5% were males, with a median age of 66.9 years,. No significant age difference was found between genders. We calculated an annual incidence rate of 161.8/100,000 (95% CI: 139.4-187.7), higher in men. The reasons for consulting were renewal of prescriptions (61.9%), follow-up appointments (22.9%) and exacerbation of symptoms (15.6%). Medication was prescribed in 87.3% of consultations, mainly for inhaled bronchodilators, including anti-cholinergic drugs (25.1%) and ß adrenergic agonists (20.3%). Conclusions: There were more COPD-related visits and a higher incidence rate of COPD for men, though the value observed was lower than expected. This was probably due to under-diagnosis or to the fact that patients who do not attend Primary Health Care clinics were excluded. The prescription pattern found was consistent with the recommendations of the Global Initiative for Chronic Obstructive Lung Disease.

Tese de doutoramento em Medicina (área de especialização em Medicina), Asthma is a common condition in general practice but is frequently under-diagnosed. There is wide variation in the reported incidence and prevalence rates of asthma but these rates are believed to be increasing. Research on the magnitude of this problem has met with methodological obstacles because it has been difficult to define and diagnose asthma in epidemiological terms. There is evidence that the control of asthma involving self-assessment by patients and a stronger doctor-patient relationship can improve compliance to therapeutic plans and lead to better outcomes for patients. Evidence is lacking on the influence of the level of patient empowerment on the quality of life and level of control of asthma. The objectives of the three studies in the present thesis were to assess how physicians in a sentinel practice network perform using standardized diagnostic criteria, to estimate the true prevalence of asthma by gender and age groups in the population of the area covered by one urban Health Centre in Portugal, to assess the severity of asthma, medication use, asthma control, the level of patient enablement and the quality of life in a population of asthmatic patients treated in primary care, and to study the relationship between enablement and the quality of life of asthma patients. Methods In the first of three studies conducted for this thesis the incidence of asthma was calculated. Patients consulting physicians from the Portuguese Sentinel Practice Network with complaints suggestive of asthma were enrolled in the study over a four year period. Frequencies of symptoms and diagnoses of asthma were tabulated. Diagnostic accuracy was computed by dividing the rate of asthma diagnosis by the true rate using established diagnostic criteria. In the second survey, an observational study was conducted in 2009 at the Horizonte Family Health Unit in Matosinhos, Portugal to calculate the prevalence of asthma. A random sample of 590 patients, stratified by age and gender was obtained from the practice database of registered patients. Data was collected using a patient questionnaire based on respiratory symptoms and the physician’s best knowledge of the patient’s asthma status. The prevalence of asthma was calculated by age and gender. The third survey was a cross-sectional study conducted in an urban population in northern Portugal to assess the relationships between patient empowerment, asthma control and quality of life. Data were collected from both clinical records and questionnaires administered to a stratified random sample of asthma patients treated in this clinic. The patient enablement instrument (PEI) was used to assess enablement and the asthma quality of life questionnaire (AQLQ) was used to assess quality of life. Asthma control was assessed using the asthma control test (ACT). Pulmonary function was assessed by measuring peak expiratory flow (PEF) and forced expiratory volume at one second (FEV1). The associations between patient empowerment, asthma control and quality of life were tested using linear and logistic regression models. Results In the first study 43 physicians followed 32,103 patients for 4 years and diagnosed asthma in 310 patients. The diagnosis was confirmed in 260 cases giving a true incidence rate of 2.02/ 1000/ year (95% confidence interval 2.12 to 2.46) and an accuracy of diagnosis of 84%. In the second study, data were obtained from 576 patients with a 97.6% response rate. The mean age for patients with asthma was 27.0 years (95% CI: 20.95 to 33.16). Asthma was diagnosed in 59 persons giving a prevalence of 10.24% (95% CI: 8.16 to 12.32). There was no statistically significant difference in the prevalence of asthma by gender. The third study included 180 patients. 68% of the patients were female. Over half of the patients (57%) had forms of persistent asthma and 43% had intermittent asthma. The mean patient enablement (PEI) scores were significantly higher for patients with intermittent asthma compared to those with persistent forms (p, A asma é frequentemente sub-diagnosticada existindo grande variação nas taxas de incidência e prevalência que se pensa estarem a aumentar, mas a investigação sobre a sua magnitude tem encontrado obstáculos metodológicos, uma vez que tem sido difícil de definir e diagnosticar asma em termos epidemiológicos. Existe evidência de que o controlo da asma envolvendo autoavaliação pelos doentes e uma forte relação médico-doente podem melhorar a adesão aos planos terapêuticos e levar a melhores resultados. Há pouca evidência sobre a influência do nível de capacitação do doente sobre a qualidade de vida e o nível de controle da asma. Os objectivos dos estudos incluídos na presente tese foram: avaliar como os médicos de uma rede sentinela diagnosticam asma usando critérios padronizados de diagnóstico, estimar a prevalência de asma por sexo e grupo etário na população de um Centro de Saúde urbano em Portugal, avaliar a gravidade da asma, o uso de medicamentos, o controle da asma, o nível de capacitação do doente e a qualidade de vida numa população de doentes asmáticos em cuidados primários e estudar a relação entre capacitação e qualidade de vida nestes doentes. Métodos No primeiro estudo da tese calculou-se a incidência de asma. Os doentes que consultaram um dos médicos da Rede Médicos Sentinela com queixas sugestivas de asma foram incluídos no estudo por um período de quatro anos. As frequências de sintomas e os diagnósticos de asma foram calculados. A precisão diagnóstica foi calculada dividindo-se a taxa de diagnóstico de asma pela taxa real usando critérios diagnóstico estabelecidos. O segundo trabalho foi um estudo observacional tendo sido realizado em 2009 na Unidade de Saúde Familiar Horizonte, em Matosinhos. Foi obtida uma amostra aleatória de 590 pessoas, estratificada por idade e sexo a partir da base de dados de inscritos na USF. Os dados foram obtidos através de questionários dirigidos a doentes e a médicos baseados na presença de sintomas respiratórios e no melhor conhecimento do médico do estado de asma do paciente. A prevalência de asma foi calculado por idade e sexo. O terceiro estudo foi um estudo transversal realizado numa população urbana no norte de Portugal. Os dados foram recolhidos a partir dos registos clínicos e de questionários aplicados a uma amostra aleatória estratificada de pacientes com asma tratados na USF. O Patient Enablement Instrument (PEI) foi usado para avaliar a capacitação e o Asthma Quality of Life Questionnaire (AQLQ) foi usado para avaliar a qualidade de vida. O controlo da asma foi avaliado pelo Teste de Controle da Asma (ACT). A função pulmonar foi avaliada pelo débito expiratório máximo instantâneo (PEF) e o volume expiratório forçado no primeiro segundo (FEV1). As associações entre capacitação do doente, o controle da asma e a qualidade de vida foram testados usando modelos de regressão linear e logística. Resultados No primeiro estudo 43 médicos seguiram 32.103 utentes durante quatro anos tendo diagnosticado asma em 310. O diagnóstico foi confirmado em 260 casos, obtendo-se assim uma taxa de incidência de 2,02 /1000 /ano (IC 95%: 2,12-2,46) e uma precisão de diagnóstico de 84%. No segundo estudo os dados foram obtidos a partir de 576 pacientes (97,6% taxa de resposta). A idade média dos doente com asma foi 27,0 anos (IC 95%: 20,95-33,16). Foi diagnosticada asma a 59 pessoas dando uma prevalência de 10,24% (IC 95%: 8,16-12,32). Não houve diferenças estatisticamente significativas na prevalência de asma por sexo. O terceiro estudo incluiu 180 doentes, 68% do sexo feminino. Mais de metade dos doentes (57%) tinham formas de asma persistente e 43% intermitente. As pontuações médias do PEI foram significativamente maiores em doentes com asma intermitente em comparação com as formas persistentes (p

Introduction: The aim of this review is to assess whether there is a relationship between Helicobacter pylori infection and gastric cancer. Method: We searched the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and the NHS Database of Abstracts of Reviews of Effectiveness; MEDLINE; EMBASE, Biological Abstracts and Science Citation Index-Expanded. We used the search terms Helicobacter pylori and (gastric or stomach) and (cancer$ or neoplasm$) and (systematic review$ or meta-anal$), and searched for articles in all languages and limited the search to humans. Evaluation of the Level of Evidence: We used the rating system of the American Family Physician journal: Level A (randomized controlled trial/meta-analysis); Level B (other evidence); and C (consensus/expert opinion). Results: H. pylori increases the odds ratio of gastric cancer in various studies. H. pylori is associated with the development of both types of gastric adenocarcinoma. On average only three per cent of those who carry H. pylori develop gastric carcinoma. The risk of gastric cancer is also increased if the individual has polymorphisms that result in the expression of higher than average levels of the cytokine IL-1β. There is no evidence that nutritional supplements prevent gastric cancer. Conclusions: Gastric cancer is preceded by a long latency period. Infection with H. pylori is a primary cause of the precancerous cascade from gastritis to dysplasia, and eradicating H. pylori by antibiotic therapy results in a modest retardation of the cancerous process. The research to date reviewed above suggests that the best strategy is twofold. Firstly, focus on high risk individuals with known risk factors of H. pylori exposure treat them for H. pylori and screen them endoscopically for the development of early gastric cancers which can be ideally resected endoscopically. Secondly, screen younger individuals (< 45 years) at risk for H. pylori who have not been exposed to H. pylori for as long and treat them., O objectivo da presente revisão é avaliar se existe uma relação entre a infecção por Helicobacter pylori e cancro gástrico. Pesquisámos o Cochrane Central Register of Controlled Trials, o Cochrane Database of Systematic Reviews e o NHS Database of Abstracts of Reviews of Effectiveness; MEDLINE; EMBASE; Silver- Platter, Biological Abstracts and Science Citation Index-Expanded. Usámos os termos de pesquisa Helicobacter pylori e (gastric or stomach) and (cancer$ or neoplasm$) e (systematic review$ or meta-anal$), e pesquisámos artigos de todas as línguas limitando a pesquisa a humanos. Avaliação do Nível de Evidência: usámos o sistema de classificação da revista American Family Physician: Nível A (ensaios clínicos aleatorizados/meta-análises). Nível B (outras fontes de evidência). Nível C (consensos/opinião de peritos). O H. Pylori aumenta a OR para cancro de estômago em vários estudos. O H. Pylori está associado ao desenvolvimento de ambos os tipos de adenocarcinoma gástrico. Em média, apenas três por cento dos portadores de H. Pylori desenvolvem carcinoma gástrico. O risco de cancro de estômago está igualmente aumentado se o indivíduo tem polimorfismos que resultam numa expressão maior do que os níveis médios da citocina IL-1β. Não existe evidência que os suplementos nutricionais previnam o cancro gástrico. O cancro gástrico é precedido por um longo período de latência. A infecção por H. pylori é uma causa primária da cascata pré-cancerosa da gastrite à displasia e a erradicação do H. pylori por terapêutica antibiótica resulta num atraso moderado do processo canceroso. A investigação apresentada revista até hoje sugere que a melhor estratégia é, primeiro, incidir nos indivíduos de alto risco com factores de risco conhecidos de exposição ao H. pylori e rastreá-los endoscopicamente para o desenvolvimento de cancros gástricos iniciais que podem ser ressecados endoscopicamente; seguidamente, rastrear indivíduos mais novos (< 45 anos) em risco para H. pylori que não foram expostos ao H. pylori por um período tão longo e tratá-los.

The aim of this review is to assess whether a screening programme for Helicobacter pylori will be both successful and cost-effective. Method: We searched the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and the NHS Database of Abstracts of Reviews of Effectiveness; MEDLINE; EMBASE; SilverPlatter, Biological Abstracts and Science Citation Index-Expanded. We used the search terms Helicobacter pylori and (diagnos$ or identif$ or find$) and (systematic review$ or meta-anal$), and searched for articles in all languages and limited the search to humans. Evaluation of the Level of Evidence: We used the rating system of the American Family Physician journal: Level A (randomized controlled trial/meta-analysis); Level B (other evidence); and C (consensus/expert opinion). Results: Serological tests: Antibody levels persist in serum for many years and do not permit us to distinguish between past and present infection or to identify treatment failures. Saliva and urine tests: A saliva test had sensitivity of 81% and specificity of 73%. A urine test had sensitivity of 86-89% and specificity of 69-91%. Breath urea tests: The tests have a high sensitivity and specificity but require expensive equipment. Stool tests: showed a high sensitivity and specificity. The European Helicobacter study group recommends either the breath urea or stool antibody tests in the initial diagnosis of H. pylori. Tests for specific gene sequences showed a high sensitivity and specificity. Endoscopy: is invasive, uncomfortable for patients, and expensive. The cost-effectiveness of tests for H. pylori: The better accuracy of the stool and breath tests, despite their greater cost, make them more cost-effective than the serology or near-patient tests. Conclusions: Tests with good sensitivity and specificity are available. The costs of non-invasive diagnostic tests acceptable to patients have been worked out, and the cost-effective dominance of stool and particularly urea breath tests over serological tests has been determined in a systematic review. What remains is to implement and test further the cost-effectiveness of national testing strategies.

RESUMO - A medicina geral e familiar em Portugal institucionaliza-se nos princípios da década de 80. Como referências importantes deste período inicial estão o seminário sobre «o papel do clínico geral em cuidados de saúde primários» (Escola Nacional de Saúde Pública, 1979), a criação da carreira de generalista (1980), o início do internato da especialidade (1981), a criação dos institutos de clínica geral (1981-1983) e do Colégio de Clínica Geral na Ordem dos Médicos (1982) e a realização em Évora do «Encontro Internacional de Clínica Geral» (1984) organizado pela APMC. Desta forma, a medicina geral e familiar portuguesa estabeleceu muito cedo no seu processo de desenvolvimento uma formulação explícita e amplamente aceite do seu perfil profissional e dos seus requisitos de formação. Por outro lado, estando a investigação em cuidados de saúde primários numa fase inicial de desenvolvimento, é ainda necessário criar as condições indispensáveis para poder aspirar a um progresso rápido nesta área — financiamento, integração no trabalho corrente, bases de dados de fácil acesso, identificação de áreas prioritárias, estabelecimento de redes de investigação e de estruturas de apoio e acompanhamento. A adopção de sistemas retributivos melhor adaptados à prática da medicina geral e familiar, privilegiando o trabalho organizado em equipas multidisciplinares, baseando-se no princípio da «discriminação positiva» — pagar melhor a quem trabalhar melhor —, e a reorganização dos centros de saúde que se perspectiva («centros de saúde de terceira geração») podem constituir as bases de uma reforma estrutural do sistema de saúde necessárias para assegurar à carreira de clínica geral as condições de exercício que é possível encontrar hoje em muitos países europeus. ABSTRACT - In Portugal general practice as a recognised medical specialty «took off» during the early 80’. From 1980 to 1984, the new medical specialty was approved, a new vocational training programme in general practice was adopted and initiated, three institutes for general practice were established by the ministry of Health, a college of general practice was established by the Portuguese Medical Association, an association of general/ family physician was organised and held its first international meeting on the role of general practice. In practically four years it was possible to establish the key elements of this profession’s reference framework — professional profile, regulatory mechanisms, training requirements and institutional basis and appropriate organisational setting for the profession. Although some important developments can also be found in the area of general practice research it is however recognised that important support mechanisms in this area are not yet available. The recent adoption of general practice paying schemes with performance related components on one hand and current initiatives to reform primary health care organisational infrastructures on the other, are very likely to create new opportunities for the development of the profession in Portugal. info:eu-repo/semantics/publishedVersion

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