Characteristics and correlates of asthma in a university clinic population

Circadian rhythm disturbances in patients with Alzheimer's disease: a review

Circadian Rhythm Disturbances (CRDs) affect as many as a quarter of Alzheimer's disease (AD) patients during some stage of their illness. Alterations in the suprachiasmatic nucleus and melatonin secretion are the major factors linked with the cause of CRDs. As a result, the normal physiology of sleep, the biological clock, and core body temperature are affected. This paper systematically discusses some of the causative factors, typical symptoms, and treatment options for CRDs in patients with AD. This paper also emphasizes the implementation of behavioral and environmental therapies before embarking on medications to treat CRDs. Pharmacotherapeutic options are summarized to provide symptomatic benefits for the patient and relieve stress on their families and professional care providers. As of today, there are few studies relative to CRDs in AD. Large randomized trials are warranted to evaluate the effects of treatments such as bright light therapy and engaging activities in the reduction of CRDs in AD patients.

Pharmacology I: effects on sleep of commonly used ICU medications

Critically ill patients are almost universally administered medications to treat their acute illnesses and to maximize their comfort. The effects of many of these medications on their sleep, however, may be important. It is known that critically ill patients have severely disrupted sleep and that this disrupted sleep has a negative impact on ICU outcomes. This article reviews how some commonly used ICU medications may affect patients' sleep.

Paediatric asthma and obesity

None of the explanations proposed for the increase in paediatric asthma have been adequate. It is becoming apparent that the cause of the increase in asthma must be multi-factorial. Increasing attention has been focused on the role of lifestyle in the development of asthma. Lifestyle changes that have occurred in children are those in diet and decreased physical activity, with obesity being the product of these changes. The increase in asthma, obesity and a sedentary lifestyle have occurred together. However, a temporal relationship between asthma, obesity and decreased physical activity has not been determined in the paediatric literature. Limited data suggest that decreased physical activity could be playing a role in the aetiology of asthma independent of obesity. Furthermore, there has been substantial research on the benefits of exercise programmes for paediatric patients with asthma. Longitudinal trials monitoring physical activity, obesity and the development of asthma are needed.

Is the treatment of acute COPD exacerbations in Finland shifting to general practitioners?

OBJECTIVE

To examine changes in the numbers of inpatient episodes and inpatient days and length of stay in acute exacerbations of COPD (chronic obstructive pulmonary disease) by specialization and by age group and sex distribution relative to the total population in the years 1995-2001.

DESIGN

A register-based study.

SUBJECTS

Data on inpatient episodes for patients aged 45 years or over with a principal diagnosis of COPD beginning in 1995-2001 and lasting less than 90 days were extracted from the hospital discharge register of the Finnish National Research and Development Centre for Welfare and Health.

MAIN OUTCOME MEASURES

Numbers of inpatient episodes and days by age and sex in the specialties of general practice, pulmonary medicine, and internal medicine.

RESULTS

The annual number of inpatient episodes increased by 10.9% from 1995 to 2001. The number of emergency treatment episodes supervised by a general practitioner increased by 36.8% during the same period and the number of such episodes supervised by a pulmonary specialist by 17.8%. The increase in age-adjusted emergency treatment episodes for men was 0.8% and that for women 18.5%. The average hospital stay shortened from 8.0 (SD 8.0) to 6.5 (SD 6.2) for men and from 8.7 (SD 8.5) to 7.3 (SD 6.8) for women.

CONCLUSIONS

The greater increase in inpatient episodes for exacerbations of COPD in relation to the total population among women than among men may be attributed to differences in smoking habits and ageing between the sexes. Responsibility for COPD cases is clearly shifting to general practitioners. This is due partly to the national programme for the treatment of obstructive pulmonary diseases and the associated in-service training provided for general practitioners and partly to financial reasons. More detailed investigations should be made into the quality of the treatment.

Is mild asthma really 'mild'?

Current evidence suggests that patients with mild asthma are often under-recognised, and those that are diagnosed can remain with this initial classification and be treated accordingly, despite worsening of their condition. There is considerable overlap between mild and more severe asthma in terms of the underlying pathophysiology and poorly reversible airway changes, such as subepithelial fibrosis and airway wall remodelling, which are present very early in the progression of asthma in patients with normal lung function. Life-threatening exacerbations can also occur in patients with mild asthma. In view of these factors and given that asthma is a two-component disease (airway inflammation and smooth muscle dysfunction), recent studies have examined the effects of both early intervention with steroids and combination therapy comprising an inhaled steroid and a long acting beta(2)-agonist. These studies suggest that early intervention is likely to provide better asthma control and possibly prevent or delay the worsening of disease and fatalities in patients considered to be mild asthmatics.

Relationship between asthma severity and obesity

The prevalence of both obesity and asthma has risen in recent years. We sought to investigate whether obesity may be related to asthma. We undertook a retrospective medical record review of patient records at an inner-city academic asthma center. Obesity was defined as a body mass index (BMI) greater than 30. Asthma severity was defined by using the National Heart Lung and Blood Institute 1997 guidelines. Adults with a history of cigarette smoking or other lung disease were excluded. A total of 143 individuals aged 18-88 with a mean age of 43.9 met the entry criteria. There were 113 females and 30 males. Seventy-two percent of the sample was obese. The Spearman correlation coefficient showed a linear relationship between asthma severity and BMI (r = 0.40, p < 0.0001). Females with asthma were significantly more overweight than males, mean BMI 35.9 vs. 32.14, respectively (p = 0.01). The prevalence of obesity in the 13 patients on long-term oral corticosteroids was 100%. Prevalence of obesity increases with increasing asthma severity in adults. The association of asthma severity with obesity suggests that obesity may be a potentially modifiable risk factor for asthma or asthma-like symptoms.

Childhood obesity

The pediatrician's approach to overweight was best summarized by Bruch 25 years ago: The pediatrician plays an important role in the prevention of obesity. From birth on, feeding a child always involves a dual task--namely, offering food in appropriate amounts and gearing it to the child's expression of his needs. Only in this way can he develop discriminating awareness and become active in establishing self-regulation.... If a child is fed when he is hungry, played with when he needs attention, and encouraged to be active when he is restless, he is not likely to grow up inhibited and passive or overstuffed and helpless, unable to control his eating because every discomfort is misinterpreted as a need to eat.

Beyond administrative data: characterizing cardiorespiratory disease episodes among patients visiting the emergency department

We attempted to address deficiencies in administrative health service data during a study of cardiorespiratory emergency department visits. From 1994-1996, we obtained data on 9,264 visits and conducted 1,772 follow-up interviews. The median interval between symptoms and visit ranged from 0.8 days (95% CI 0-1.7) for cardiac conditions to 4.0 days for chronic obstructive pulmonary disease (COPD) (95% CI 2.7-5.3) and respiratory infections (95% CI 3.5-4.5). Infection was the most common trigger of respiratory visits. Although most had improved at follow-up, symptoms persisted following the visit for a mean of 4.5 days (95% CI 3.8-5.4) for cardiac conditions to 8.4 days (95% CI 7.2-9.5) for COPD. Among adults aged < 70, the mean number of reduced activity days per episode ranged from 4.7 (95% CI 3.9-5.4) for asthma to 6.6 (95% CI 5.9-7.4) for respiratory infections. Our data assist in interpreting epidemiological studies based on administrative data, and illustrate the broad impacts of cardiorespiratory disease episodes.

Is there a relationship between smoking and asthma in adults?

A case-control study was carried out to investigate the possibility of a relationship between smoking and asthma in adults. The study group of 141 asthmatic adults and 423 age- and sex-matched non-asthmatic controls were selected from 4341 men and women aged 18 years and over, who were registered with a family practice. Both groups were interviewed by telephone about past and present smoking habits. Current smokers constituted 22% of the asthmatic group and 15% of the controls (not significantly different). The prevalence of those who had given up smoking (quitters) was significantly higher in asthmatics than in controls (8.5% versus 3.6%). Asthma began at younger ages in smokers than in quitters and non-smokers. In smokers, the duration of smoking was associated with the duration of asthma. No other significant differences in or associations between smoking habits and asthma were found. No major relationship between smoking and asthma was demonstrated.

Childhood obesity

Approximately 10% of children are obese. Twin and adoption studies demonstrate a large genetic component to obesity, especially in adults. However, the increasing prevalence of obesity over the last 20 years can only be explained by environmental factors. In most obese individuals, no measurable differences in metabolism can be detected. Few children engage in regular physical activity. Obese children and adults uniformly underreport the amount of food they eat. Obesity is particularly related to increased consumption of high-fat foods. BMI is a quick and easy way to screen for childhood obesity. Treating childhood obesity relies on positive family support and lifestyle changes involving the whole family. Food preferences are influenced early by parental eating habits, and when developed in childhood, they tend to remain fairly constant into adulthood. Children learn to be active or inactive from their parents. In addition, physical activity (or more commonly, physical inactivity) habits that are established in childhood tend to persist into adulthood. Weight loss is usually followed by changes in appetite and metabolism, predisposing individuals to regain their weight. However, when the right family dynamics exist--a motivated child with supportive parents--long-term success is possible.

Features that distinguish those who die from asthma from community controls with asthma

To evaluate risk factors for asthma mortality, an unmatched case-control study was undertaken in the Canadian prairie provinces of Alberta, Saskatchewan, and Manitoba. Those between the ages of 5 and 50 (inclusive) who died from an acute exacerbation of asthma were compared to a control group of people with asthma from the same geographical areas who were contacted using random-digit dialing. Because no deaths occurred among residents less than 15 years old, this analysis was limited to cases and controls between 15 and 50 years old. Of the 38 deaths that occurred between November 1992 and October 1995, data were obtained from next of kin for 35 (92.1%). Of the 210 potential controls that were identified, 142 returned completed questionnaires (67.6%). Cases were more likely than controls to have asthma reported to be severe, to have experienced nocturnal symptoms, to have had cardiopulmonary resuscitation (CPR)/intubation, and to have had more healthcare utilization in the previous year. Medication use was also more common among cases compared to controls. Specific asthma triggers were reported more often for cases than controls; weather changes, excitement, depression, and stress showed the greatest case control differences. Although a number of very strong risk factors for death from asthma were identified, death from asthma is so rare in this age group that it is not possible to label an individual as "likely" to die from asthma. Nonetheless, patients, caregivers, and health professionals should be aware of indicators that would suggest greater risk.

Questionnaire items that predict asthma and other respiratory conditions in adults

The International Union Against Tuberculosis and Lung Disease questionnaire is widely used in epidemiologic studies of adult asthma. We examined whether the symptom questions could be classified into groups that represent different "syndromes," and whether some questions are better for predicting asthma than others. We analyzed questionnaire data from a population sample of 1,527 adults aged 18 to 55 years using factor analyses to classify the 17 respiratory symptom questions into four different groups that we termed asthma, cough, breathlessness, and urgent medical visit. The urgent medical visit was a subset of asthma. These four "syndromes" had good validity when measured against airway responsiveness to histamine, atopy to common allergens, lung function, smoking status, and body mass index. Questions that predicted asthma syndrome were those that asked about wheeze at rest or following exercise, asthma attack, chest tightness, and shortness of breath at rest. Questions about cough identified a different group of subjects who apparently did not have asthma. Questions of breathlessness did not aggregate with "asthma" or with "cough syndrome." The identification of particular questions that measure different respiratory conditions is important for epidemiologic studies when short questionnaires or more precise definitions are required.

Assessment of an ambulatory care asthma program

In response to rising asthma morbidity and mortality, numerous comprehensive asthma programs have been developed. However, few studies have examined critically the effectiveness of such programs or the means by which treatment or outcome is altered. To assess the role of a specialized ambulatory asthma care program, we reviewed the interventions recommended to 344 patients referred for the assessment of asthma. A subset of 127 made return visits 6-12 months following their initial assessment, thereby allowing assessment of behavioral and physiological outcomes. At the initial consultation, the recommended medication changes were: inhaled beta-agonists +6% (p < 0.01), inhaled steroids +58% (p < 0.001), intranasal steroids +8% (p < 0.001), dry powdered formulations +13% (p < 0.01), theophylline -7% (p < 0.001). The percentage of patients using spacer devices increased 8% (p < 0.001). Comparing preassessment values to those at a visit at 6-12 months following assessment, a further 25% of patients taking inhaled steroids at the initial assessment had a change to either the dose, device, or frequency of administration. Mean FEV1 improved from 2.41 +/- 0.08 liters at the initial assessment to 2.64 +/- 0.09 liters at the 6-12-month visit (p < 0.001). There was an increase in the number of patients considered mild and not obstructed, with a corresponding decrease in the number considered moderately and severely obstructed (p < 0.05). The number of emergency room visits was reduced by more than 60% (p < 0.001) in patients followed for at least 6 months. We conclude that an ambulatory asthma program marked by increased use of inhaled anti-inflammatory medications and decreased use of theophylline can produce significant decreases in asthma exacerbations requiring hospital care, emergency room care, or systemic steroids while reducing the prevalence and severity of airflow limitation.

Asthma-related hospital use among Finnish asthmatics of working age

The aim was to examine asthma-related use of hospital services among persons of working age (15-64 years) in Finland on the basis of hospital discharge registers over a period of 15 years. A total of 155,080 asthma-induced treatment periods and 1,270,453 hospitalisation days were observed in the working-age population during the period concerned. Although the use of hospital services was found to be smallest in the second youngest male age-group (25-34 years), the numbers of treatment periods and hospitalisation days observed among men relative to population were found to increase by age. Middle-aged (35-44) female asthmatics tend to use hospital services more often than men of the same age, but no difference was observed between the sexes in the oldest age-group (55-64 years). The long-term monitoring and guidance of asthmatics and the specialist services required should be coordinated within the basic health care system as in the case of other chronic diseases. The long-term monitoring of asthmatics should be performed by general practitioners, and in the light of the present findings special emphasis should be placed on subjects aged 35 years and older.

Exercise-induced bronchospasm in nonasthmatic obese children

The frequency, degree, and pattern of bronchial reactivity to exercise were compared in 13 obese and 14 control children, ages 6 to 10 years, with no history of asthma. Spirometry was performed before and every three minutes after a seven-minute exercise challenge on a treadmill. There were 11 obese children and 6 controls who had at least a 15% fall in at least one of three monitored pulmonary function parameters (P < .05). The group mean percentage falls in FEV1 and FEF25%-75% were significantly greater in the obese group than in the controls. The pattern of bronchospasm, occurring soon after the exercise challenge, is consistent with that found in the known asthmatic population. A significant correlation was found between triceps skin-fold thickness and degree of fall in FEF25%-75% (r = .55, P < .005). This study demonstrated that significantly greater frequency and degree of bronchospasm of the smaller airways occur in obese children, partially related to the amount of subcutaneous fat. Whether exercise-induced bronchospasm leads to exercise avoidance and obesity or whether obesity causes or enhances bronchial hyperreactivity to exercise requires further study.