Transcript عوامل الخطورة للربو - Risk factors for asthma in Syria

‫_الدكتورة يسر محمد‬
‫الرعاية األولية ‪2015-6-14‬‬
‫عوامل الخطورة للربو‬
‫الساليدات الثالثة التالية تعرف الربو‬
‫ألية الربو ‪ :‬مرض مزمن اتسدادي عكوس‬
‫المواد المحرضة لنوب الربو‬
‫اسأل املريض عنها؟‬
I Feel breathless?????
‫تقسم عوامل خطورة الربو الى المسببات‬
‫والمحرضات والعوامل المساعدة‬
‫ المسببات‪ :‬العوامل التي تؤدي لحدوث الربو عند شخص حتى اآلن ال يعاني منه ‪.‬‬‫وراثة‪،‬تأتب محسسات ‪ ،‬مهنة ‪ ،‬تدخين سلبي‬
‫ المحرضات‪ :‬المسببات ولكن اضافة لها توجد مواد ال تسبب بحدوث الربو ولكن تحرض‬‫النوب عند المريض الربوي‪:‬منظفات‪ ،‬تلوث مناخ‬
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‫العوامل المساعدة‪:‬‬
‫المستوى الثقافي‬
‫الوضع االقتصادي‪ GNP Per capita‬يزداد الحدوث‬
‫ التغذية‬‫الجنس‪ :‬الذكور حتى سن البلوغ ثم يتساوى مع االناث‬
‫االدوية‬
‫غياب االرضاع الوالدي‬
‫البدانه ونقص النشاط الفيزيائي‬
‫االستعداد الوراثي‬
‫• نعرف أن وجود ربو أو تحسس عند االبوين يؤهب ‪ ،‬كما أن‬
‫وجود رشح تحسسي أو اكزيما عند الشخص نفسه يؤهب للربو اذ‬
‫مورثات التأتب واحدة (‪)IgE‬‬
‫• بينت الدراسات ‪Genome Wide Association‬‬
‫• بينت وجود مورثات صامته عند المؤهبين لربو ‪ :‬تعاد برمجتها‬
‫ويظهر التحسس والربو عند التعرض للمحسسات أو التدخين‬
‫السلبي ويسمى هذا ‪Epigenetics‬‬
‫• بعد هذا تتفعل المناعة التي تميز الربو‪:‬‬
‫‪ ،IgE mediated Immunity‬فرط االستثارة القصبية‬
‫تفعيل المورثات الصامته ‪Epigenetics:‬‬
‫اعادة البرمجة‬
‫للمورثات بعد التعرض لمحسس أو تدخين •‬
‫سلبي سواء في المنزل أو العمل‬
‫المحسس‬
‫التدخين السلبي‬
149 chemicals in ETS narghile
4700 Chemicals in ETS cigarette
‫سنتحدث عن التدخين السلبي والمحسسات‬
Genetically predetermined
Passive smoking
• Environmental tobacco Smoke (ETS)
• Second Hand Smoke (SHS)
• Is composed of Side Stream Smoke(SSS)
At the top of cigarette, and Exhaled main stream
smoke(EMSS). Rejected by the smoker.
• For Narghile it is essentially EMSS
Mechanisms
• Particles present in ETS are of smaller size (0.1
µ) which allows them to penetrate deeply into
the lungs resulting in oxidative stress and the
liberation of Oxidative Reactive Substances,
which are among the most aggressive
mechanisms for airway inflammation
• Wirth, in a general review , reported cigarette
ETS to be more toxic than MSS for several
reasons. ETS has a low ignition temperature
(600C0 instead of 800C0).In addition, several
toxic substances such as carbon monoxide,
nicotine, volatile organic compounds, and
benzopyrenes are present in higher
concentrations.
Epigenetics
• There are susceptibility genes for asthma in
predisposed individuals , however clinical expression
might not be apparent unless there is appropriate
environmental exposure such as inhalation of
parental ETS by children or exposure to allergens.
This exposure to ETS leads to epigenetic changes.
Epigenetic changes are defined as heritable changes
that affect gene expression without altering the DNA
sequence.(DNA methylation, histone modifications, RNA-associated silencing
by small non-coding RNAs, phosphorylation, and ubiquitylation )
Immunity
• ETS seems to influence innate immunity
predisposing to Th2-associated respiratory
diseases and increasing the risk for IgEmediated sensitization ,which could lead to
the inflammatory and structural changes seen
in allergic diseases, especially asthma.
‫المحسسات ‪:‬نفس اآللية‬
‫• وجود حد أدنى من المحسس ال بد منه لحدوث التأتب( فرط‬
‫افراز ال‪ ،)IgE‬والذي ال بد منه لحدوث الرشح التحسسي أو‬
‫االكزيما والربو كخط ثان‪.‬‬
‫• ولكن ال توجد عالقة كمية‬
‫المحسسات ‪ :‬نفس اآللية‬
‫العت البحري‬
‫الصرصور‬
‫حبيبات طلع‬
: ‫فطور‬Moulds
‫دور الفيروسات والجراثيم‬
‫‪• Respiratory sentitial virus:‬‬
‫يؤهب للربو‬
‫‪• The hygiene hypothesis‬‬
‫يزداد حدوث الربو في العالم المتحضر وقد تكون ازدياد مكافحة‬
‫انتانات الطفولة األولى سبب في ذلك‪،‬كما يقل في السل واذا‬
‫زاد عدد األوالد‬
‫‪• Endotoxin from gram negative bacteria: In‬‬
‫يزيد حدوث الربو …… ‪humidifiers, plants‬‬
‫‪Thelper 1‬االنتانات تحول الى‬
‫العوامل المؤثرة والتي ال دور بيولوجي لها‬
‫الوضع االقتصادي‬
‫أكل الطعام الجاهز‪ :‬همبرغر‪ ،‬دربي‪..........‬‬
‫درجة الثقافة ‪......‬‬
‫االرضاع الوالدي‬
‫البدانة وعدم النشاط الفيزيائي ‪.....‬‬
Obesity
• Relationship of asthma and, exercise and
Mediterranean diet in Spanish
schoolchildren. 2010
• Mediterranean diet protect
• Obesity is risk factor
‫البدانة‬
‫• هناك تناسب طردي بين البدانه عند األطفال وحدوث الربو ‪ ،‬وشدته‪:‬‬
‫‪ metaanalysis:‬كان الربو أكثر حدوثا عند البدين ‪:‬‬
‫)‪(odds ratio 1.5, 95% CI 1.271.80‬‬
‫‪• The incidence of asthma increased as the BMI‬‬
‫‪increased.‬‬
‫كما كان الربو أكثر شدة عند البدبن‬
‫تلوث البيئة‬
‫‪International Study of Asthma and Allergies in‬‬
‫‪Childhood(ISAAC): 98 countries, 233 centers:‬‬
‫تبين أن حدوث الربو عند األطفال يزداد بعالقة احصائية مع‬
‫تكرار مرور الشاحنات قرب المنزل‬
‫‪-‬أما بالنسبة لتلوث الهواء‪ :‬فثبين أنه يزيد من خطورة الهجمات‬
‫التعرض لحيوانات المزرعة‬
‫سواء في بطن امه أو في السنة األولى من الحياة يزيد من‬
‫حوث الربو ‪:‬‬
‫)‪OR 1.27(CI: 2-3‬‬
Breast feeding
‫االرضاع الوالدي‬
• Protect from asthma
Medications
• Antibiotics during pregnancy, or first year of
life.
• Acetaminophene( Sytamol), during pregnancy,
or first year of life
• Aspirine
‫الغذاء‬
‫• فيتامين ‪E,D‬يحمي من الربو‬
‫• الطعام لحوض المتوسط يحمي من الربو‬
‫• الطعام الجاهز من همبرغر ودربي يزيد حدوث الربو‬
‫األبحاث السورية الوطنية‬
• Asthma triggers in the East Mediterranean
Journal : Yousser Mohammad, Debra
Myers.Questionnaire study of self reported
asthma triggers: A case series of East —
Mediterranean Syrian patients.
Pak J Chest Med Dec 2007;13(4):3-10.
• International Study of Asthma and Allergies in
Childhood – Syria 2002
TABLE 1; PROPORTION OF PATIENTS REPORTING EACH USUAL
COMMON TRIGGER or OCCUPATIONAL TRIGGER.
Mandatory questions
Men
N=171 (100%)
Women
N=329 (100%)
All patients
N= 500 (100%)
ETS
110 (64%)
242 (73.5%)
352 (70.4%)
Household dust
116 (68%)
218 (66.2%)
334 (67%)
Fumes, heating
11 (6.4%)
16 (4.8%)
27 (5.4%)
Pets
5 (2.9%)
8 (2.4%)
13 (2.6%)
Weather change
77 (45%)
139 (42%)
216 (43.2%)
Trafic fumes
62 (36%)
104 (32%)
166 (33%)
Pollens
57 (33%)
101 (31%)
158 (31.6%)
Humidity
50 (29%)
88 (26.5%)
138 (27.6%)
Infection
75 (44%)
150 (46%)
225 (45%)
Exersion
49 (29%)
74 (22.5%)
123 (24.6%)
Psychology
4 (2.3%)
30 (9%)
34 (6.8 %)
Aspirine
4 (2.3%)
8 (2.4%)
12 (2.4%)
Wool
6 (3.5%)
13 (7%)
19 (3.8%)
Occupation
31 (18%)
29 (8%)
60 (12%)
Triggers
TABLE 2 : PROPORTION OF PATIENTS REPORTING
EACH OTHER PARTICULAR TRIGGER /500 patient
Free communications
Particular triggers
Total responses
(N=374).
% OF TRIGGERED
(74.8%)
1.INDOORS
Frying smells
153
31%
Perfumes
74
15%
Perfumed Detergent
36
7%
Detergent (NaOCl)
27
5.5%
Narguile - passive
21
4.2%
Chopping Red hot Pepper
5
1%
Household Spray
3
0.6%
Paints
11
2.2%
Seasonal sandstorm
10
2%
Gaseuse insecticide
2
0.4%
Hay
19
3.8%
Cow
18
3.6%
Poultry
11
2.2%
Working in Green House
10
2%
9
1.8%
8
1.6%
5
1%
2.OUTDOORS
3.AGRICULTURE
Smell of Orange Flower
Harvest
of
Dusty
olives,and eggplants
sheep
Crops:
Pesticides
5
1%
Fertilizers
2
0.4%
ACEinhibitor
8
1.6%
Antibiotic
2
0.4%
Others (Parlodel, Tenormin,
Diestradiol)
5.FOODS AND DRINKS
5
1%
17
3%
9
2%
4.DRUGS
6.LAUGH
International Study of Asthma and Allergies
in Childhood – Syria 2002
• 200 Centers from 150 countries participated, 3
centers from Syria.
• A questionnaire about asthma symptoms
prevalence and risk factors was validated for.
• In Syria prevalence of asthma symptoms was:
5.2% in children 6-7 years old.
www.isaac.auckland.ac.nz
Methodes
• Parents of children aged 6–7 years completed
core written questionnaires about the prevalence
of symptoms of asthma and rhinitis,
• and an environmental questionnaire for
other risk factors, including exposure to parental
Environmental cigarette smoking .
• We added questions about exposure to narghile
Environmental smoke to the questionnaire. Because
it is of concern in our region
Results
• Among 2 734 pupils (49% females) surveyed,
• we found an association between exposure to ETS of
the mother smoking cigarette or narghile and ever
wheezing,
nocturnal cough and severe wheeze; however, the
strongest association was found when the mother
smoked narghile.
• Mother smoking narghile was also
associated with exercise wheeze
For all : (P<0.05), OR>1
• Father smoking narghile, but not cigarettes,
was associated with nocturnal
cough, severe wheeze and exercise wheeze.
• The association with current wheeze became
significant when mother smoked both
cigarettes and narghile P<0.05 and OR>1
• however, the effect was adititive and not
synergic.
CONCLUSION From Syria ISAAC Study
• : We recommend that international studies
investigating ETS include questions on narghile.
If not it is a confounder , bias
• This was published in a highly scored journal
and recognized for international Data.
•
Mohammad Y, Shaaban R, Hassan M,Yassine F, Mohammad S, Tessier JF, Ellwood P4 .
Respiratory effects in children from passive smoke of cigarettes and narghile: ISAAC Phase
Three in Syria.The International Journal of . Tuberculosis and Lung Diseases. 18(11):1279–
1284
Institutions of Authors for Syria ISAAC
• Y. Mohammad,*†‡ R. Shaaban,* M. Hassan,* F. Yassine,* S. Mohammad,†
J. F. Tessier,§ P. Ellwood¶
• *National Research Center for Chronic Respiratory Diseases, Tishreen
University School of Medicine, Lattakia,
• †Faculty of Medicine, Syrian Private University, Damascus, ‡Department of
Pulmonary, Internal Medicine, Damascus
• University, Damascus, Syria; §Institut de Sante´ Publique, d’Epide´miologie
et de De´veloppement, Universite´ de
• Bordeaux, France; ¶Faculty of Medical and Health Sciences, The University
of Auckland, Auckland, New Zealand