Demographic characteristics of patients experiencing near-fatal and fatal asthma: results of a regional survey of 400 asthma specialists [see comment]

A Randomized, Double-Blind, Placebo-Controlled Trial of Escitalopram in Patients with Asthma and Major Depressive Disorder

BACKGROUND

Depression is common in asthma and is associated with poor outcomes. However, antidepressant therapy in depressed patients with asthma has been the topic of little research.

OBJECTIVE

This study examined the impact of antidepressant treatment with escitalopram versus placebo on the Hamilton Rating Scale for Depression (HRSD), Inventory of Depressive Symptomatology-Self Report (IDS-SR), Asthma Control Questionnaire (ACQ), and oral corticosteroid use in patients with asthma and major depressive disorder (MDD).

METHODS

Single-site 12-week, randomized, double-blind, placebo-controlled, parallel-group trial of escitalopram (10 mg/d) was conducted in 139 outpatients with asthma and MDD. Randomization was stratified by oral corticosteroid use (≥3 bursts in past 12 months, yes or no) and baseline depressive symptom severity (HRSD score ≥ 20) (higher severity, n = 42) versus less than 3 bursts, HRSD score less than 20, or both (lower severity, n = 97). The primary data analysis was conducted using hierarchical linear modeling Version 7.01 on the higher and lower severity samples and post hoc was conducted on the combined sample.

RESULTS

Among the higher severity completers (n = 21), a significant reduction in the ACQ score (P = .04) and oral corticosteroid use (P = .04) was observed with escitalopram. In the combined sample, no significant differences were observed, but a trend toward greater reduction in the IDS-SR score was observed with escitalopram (P = .07). Side effects were comparable across groups.

CONCLUSIONS

The findings suggest that patients with more severe asthma and depression symptomatology may have a positive response, in terms of both asthma and depressive symptom reduction, to antidepressant treatment.

Slow-onset asthma deaths have more eosinophils and health care utilization than rapid-onset deaths

RATIONALE

Patients with fatal asthma have been hypothesized as representing two distinct subgroups according to the onset of symptoms prior to death.

OBJECTIVES

To determine if these two groups may be reliably identified and determine if they differ clinically and pathologically.

METHODS

Patients with autopsies, 2-34 years of age, dying from asthma were classified slow-onset (Type 1) or rapid-onset (Type 2). The consistency of classification by two independent observers was determined. Clinical and pathologic data was compared between groups.

MAIN RESULTS

Among 37 subjects there were 21 Type 1 and 16 Type 2 mortalities. Inter-observer agreement was good; kappa 0.63 (95% CI 0.38, 0.87). Subjects did not differ by age, race, sex, presence of obesity, insurance status, or use of corticosteroids. Type 1 mortalities were hospitalized more (2.5+1.3 versus 0.1+0.1; p=0.048) and made more emergency room visits (10.5+4.9 versus 0.8+0.2; p=0.023) in the year prior to death than Type 2 mortalities. At autopsy, bronchial eosinophils (p<0.025) and bronchiolar basement membrane thickening (p<0.05) were more predominant in Type 1 mortalities compared with Type 2. Airway wall neutrophils were uncommon in both groups.

CONCLUSION

Good inter-observer agreement exists in classifying patients dying from asthma according to whether the onset of symptoms was slow or rapid in onset. Slow-onset patients had a predominance of eosinophils and basement membrane thickening and higher health care utilization. These differences support the validity of classifying asthma mortalities into these distinct subgroups.

Feasibility of a national fatal asthma registry: more evidence of IRB variation in evaluation of a standard protocol

PURPOSE

Approximately 4,500 Americans die from asthma each year. Our objective was to determine the feasibility of creating a national fatal asthma registry to better understand this problem.Methods. Using a standard questionnaire, 18 state vital statistics departments and 22 medical examiners offices were contacted in 2001 to assess availability of fatal asthma data. Funding was obtained in 2002 to implement a fatal asthma registry. During 2003, the project was put on hold due to uncertainty about the impact of the Health Insurance Portability and Accountability Act (HIPAA). The project was revived in 2004 when a standard protocol was submitted to Institutional Review Boards (IRBs) in four different states.

RESULTS

All vital statistics departments reported that they were able to identify the decedent's name and demographic characteristics. Contact information for a relative or doctor was available in all states. Demographic characteristics and autopsy findings were available from 100% of the medical examiners offices. However, IRBs at the four institutions required major protocol modifications, including language and approach for contacting next of kin.

CONCLUSION

Availability of demographic and clinical data across states is consistent. The creation of a national fatal asthma registry appears feasible, but different IRB interpretations of what is permissible preclude a standard approach across states.

Fatal asthma in Finnish children and adolescents 1976-1998: validity of death certificates and a clinical description

Several studies show that asthma mortality in children and adolescents increased until the mid-1990s, after which it has slightly decreased worldwide. The objective of this study was to describe the mortality rates of childhood asthma in Finland, and to analyze patient characteristics to identify predisposing factors for fatal asthma exacerbation among children and adolescents during 1976-1998 (2004). All death certificates where asthma or related respiratory tract disease was coded as the underlying cause of death were reviewed for those under 20 years of age. Health care records and autopsy reports were evaluated to validate the cause of death and to identify any predisposing factors. In all, there had been 28 asthma deaths. The validity of the death certificates proved to be good as only 7% were misclassified. Death occurred either in the very young children or adolescents: the median age in the group of <12 years (n = 15) was 3.3 years while the median age in the group of >12 years (n = 13) was 18.1 years. The fatal exacerbations occurred mostly during summer and early autumn. Clinical triggers, recorded for 14/22 patients with available patient records, included respiratory infection, (12) use of ibuprofen despite known allergy (1), and exercise after visiting a horse stable (1). The severity of the disease was discernible in 21 patients: severe in 15, moderate in 5, and mild in 1 patient. Inhaled corticosteroids were not used as maintenance or periodic therapy in 12/22 patients, of whom 4 had died during the 1990s. In conclusion, asthma mortality in Finnish children and adolescents was rare and its incidence remained stable. The validity of the death certificate diagnoses proved to be good. Poor asthma management and non or undertreatment with inhaled corticosteroids were risk factors for fatal asthma.

Effectiveness of nebulizer use-targeted asthma education on underserved children with asthma

OBJECTIVE

To determine the effectiveness of a home-based asthma education intervention in increasing appropriate nebulizer use and reducing symptom frequency, emergency department (ED) visits, and hospitalizations over 12 months.

DESIGN

A randomized clinical trial. Settings Pediatric primary care, pulmonary/allergy, and ED practices associated with the University of Maryland Medical System and The Johns Hopkins Hospital, Baltimore.

PARTICIPANTS

Children with persistent asthma, aged 2 to 9 years, with regular nebulizer use and an ED visit or hospitalization within the past 12 months. Children were randomized into the intervention (n = 110) or control (n = 111) group. Follow-up data were available for 95 intervention and 86 control children.

INTERVENTION

Home-based asthma education, including symptom recognition, home treatment of acute symptoms, appropriate asthma medication, and nebulizer practice.

MAIN OUTCOME MEASURES

Estimates of mean differences in asthma symptom frequency, number of ED visits and hospitalizations and appropriate quick relief, controller medication, and nebulizer practice over 12 months.

RESULTS

Of the 221 children, 181 (81.9%) completed the study. There were no significant differences in home nebulizer practice, asthma morbidity, ED visits, or hospitalizations between groups (P range, .11-.79). Although most children received appropriate nonurgent asthma care (mean, 2 visits per 6 months), more than one third of all children received at least 6 quick-relief medication prescriptions during 12 months, with no difference by group.

CONCLUSIONS

A nebulizer education intervention had no effect on asthma severity or health care use. Of concern is the high quick-relief and low controller medication use in young children with asthma seen nearly every 3 months for nonurgent care.

Contribution of aspirin-intolerant asthma to near fatal asthma based on a questionnaire survey in Niigata Prefecture, Japan

OBJECTIVE

Prevention of deaths due to asthma is one of the most important issues in asthma management. However, there are few epidemiological studies of asthma deaths in Japan.

METHODOLOGY

Over an 8-week period in Niigata Prefecture, Japan, a questionnaire on asthma control and emergency episodes was administered to adult asthmatic patients. A questionnaire was also given to the patients' physicians to obtain further clinical information. Patients who became unconscious during episodes of asthma, or who required intubation and ventilation, were allocated to a near-fatal asthma group (NFA). Patients who did not fulfill these criteria were allocated to the non-NFA group. The NFA group was divided into two subgroups, based on the date of their last NFA episode (old NFA>or= 5 years and recent NFA<4 years).

RESULTS

Characteristic features of the NFA group included severe disease (23.1%vs 7.6%) with more aggressive patient management, including inhaled corticosteroid use (84.3%vs 72.0%). Multiple regression analysis confirmed that aspirin-intolerant asthma (AIA) was strongly associated with NFA. There was no difference in the incidence of AIA between the recent and old NFA patients. This suggests the incidence of AIA in NFA did not improve over time.

CONCLUSIONS

A history of AIA may be a useful indicator of potential NFA and allow preventative methods to be introduced. It is therefore important to obtain a history of AIA and to be aware of the risk of NSAID administration to these patients.

Severity of allergic complaints: the importance of depressed mood

OBJECTIVE

To evaluate the prevalence of depressive symptoms in patients with different kinds of allergic diseases and the connection of depressive symptoms with the severity, type and seasonality of allergic complaints.

METHODS

Data was obtained via a cross-sectional multicenter questionnaire survey of 528 patients aged 16-60 years attending six regional in- and outpatient allergy clinics in Hungary in June to July 1998. Consecutive patients completed a structured, self-administered questionnaire containing questions about their current and past allergic complaints. Depressive symptoms were measured by the Shortened Beck Depression Inventory (BDI).

RESULTS

32.2% of patients scored above the normal level (> or =10) and 12.5% had clinically significant depressive symptomatology (> or =19) by the BDI. These rates were significantly higher than those found in the control group from a national representative population sample (22.4% and 8.3%). Patients with asthma and with perennial symptoms had significantly higher depression scores than patients with other types of allergic diseases. There was a significant association between the severity of depressive symptoms and the severity of allergic complaints independently from age, sex, type and seasonality of the allergic disease, and other current physical illnesses and symptoms tested by the General Linear Model (GLM).

CONCLUSIONS

Our results draw attention that patients even with mild depressive symptoms have significantly more severe allergic complaints and assess general health state as much worse than those without depressive symptoms in any types of allergic diseases. Diagnosis and treatment of depressive symptoms in allergic patients is of great concern from both a clinical and an economical point of view.

Rate and place of death from asthma among different ethnic groups in Israel: national trends 1980 to 1997

STUDY OBJECTIVES

To compare the trends of asthma mortality and place of death in young patients (ages 5 to 34 years) from different major population groups in Israel.

DESIGN

Retrospective study.

PATIENTS AND PARTICIPANTS

Patients who died from asthma between the years 1980 and 1997 according to the death record of the National Israeli Health Registry.

RESULTS

During the period studied, 100 asthma mortality cases were reported, which yields a mean mortality rate of 0.226 per 100,000 population. There were no significant changes in the mortality rates over the years. The mean (+/- SD) age of death was 23 +/- 7 years. Of this population, 84.5% were Jews and 15.5% were Arabs, which is proportionate to the general Israeli population. In 52% of the cases, the patients died outside a hospital. There was no significant difference in the place of death between Jews and Arabs. Significantly more men (62.5%) than women (40%) died outside the hospital (p = 0.025).

CONCLUSIONS

The asthma mortality rate in Israel during the years 1980 to 1997 was low and stable. Most of the patients still died outside the hospital. There was no difference in the asthma death rate and place of death between Jews and Arabs, suggesting that in our population genetic predisposition is not likely to be a risk factor for mortality.

Fatal asthma from powdering shark cartilage and review of fatal occupational asthma literature

BACKGROUND

Work-related asthma (WRA) is the most common work-associated respiratory disease in developed countries.

METHOD

We report shark cartilage dust as a new potential cause of occupational asthma (OA) in the context of other fatal OA case reports.

RESULTS

A 38-year-old white male worked for 8 years in a facility which primarily granulated and powdered various plastics. Sixteen months prior to his death, the plant began grinding shark cartilage. After 10 months of exposure, he reported chest symptoms at work in association with exposure to shark cartilage dust and a physician diagnosed asthma. Six months later, he complained of shortness of breath at work and died from autopsy-confirmed asthma. The latency from onset of exposure to symptoms and from symptom onset to death was shorter than 10 previously reported OA fatalities.

CONCLUSION

Recognition of occupational causes and triggers of asthma and removal of affected individuals from these exposures is critical and can prevent progression to irreversible or even fatal asthma.

Activated, cytotoxic CD8(+) T lymphocytes contribute to the pathology of asthma death

This study investigates the presence of CD8(+) T lymphocytes and their possible association with viral infection in bronchi of victims of fatal asthma. Postmortem samples from the peribronchial region of the lung were obtained from seven patients who died an asthma death (AD), seven asthmatic patients who died of unrelated causes (AUC), and seven postmortem cases with no history of lung disease (control subjects). Using immunohistochemical techniques, the CD8(+) cytotoxic T-cell population in peribronchial tissue was characterized in three patient groups. The percentage of CD8(+) cells expressing the activation marker CD25 was higher in the AD group than in both the AUC and control groups (11.91 +/- 1.92% versus 3.93 +/- 1.63% and 1.09 +/- 0.56%, respectively (p < 0.001). Perforin expression, a marker of cytotoxicity, was highest in the AD group (9.16 +/- 1.5%) compared with 1.39 +/- 0.9; 1.8 +/- 0.6% in the AUC and control groups respectively (p < 0.001). Expression of interleukin-4 (IL-4) and interferon gamma (IFN-gamma) by CD8(+) T cells was higher in the AD group than the control group (p < 0.05). Furthermore, the IFN-gamma/IL-4 ratio in the AD group was less than half that of the control group (1.46 +/- 0.2 versus 3.2 +/- 0.1; p = 0.02). Using polymerase chain reaction (PCR), viral genome for rhinovirus (RV) was detected in lung tissue from three of the seven cases in the AD group. Two of these cases also had detectable respiratory syncytial virus (RSV). Viral genome for RSV was detected in five of the AUC group and in one of these cases, RV was also detected. No viral genome was detected in the lungs of the control group. In conclusion, this study provides novel evidence of an aberrant CD8(+) T-cell population, possibly in response to viral infection in subjects who die of acute asthma.