Characterization of Codeine Treatment Responders Among Patients with Refractory or Unexplained Chronic Cough: A Prospective Real-World Cohort Study

PURPOSE

Codeine is a narcotic antitussive often considered for managing patients with refractory or unexplained chronic cough. This study aimed to evaluate the proportion and characteristics of patients who responded to codeine treatment in real-world practice.

METHODS

Data from the Korean Chronic Cough Registry, a multicenter prospective cohort study, were analyzed. Physicians assessed the response to codeine based on the timing and degree of improvement after treatment initiation. Follow-up assessments included the Leicester Cough Questionnaire and cough severity visual analog scale at six months. In a subset of subjects, objective cough frequency was evaluated following the initiation of codeine treatment.

RESULTS

Of 305 patients, 124 (40.7%) responded to treatments based on anatomic diagnostic protocols, while 181 (59.3%) remained unexplained or refractory to etiological treatments. Fifty-one subjects (16.7%) were classified as codeine treatment responders (those showing a rapid and clear response), 57 (18.7%) as partial responders, and 62 (20.3%) as non-responders. Codeine responders showed rapid improvement in objective cough frequency and severity scores within a week of the treatment. At 6 months, responders showed significantly improved scores in cough scores, compared to non-responders. Several baseline parameters were associated with a more favorable treatment response, including older age, non-productive cough, and the absence of heartburn.

CONCLUSIONS

Approximately 60% of chronic cough patients in specialist clinics may require antitussive drugs. While codeine benefits some, only a limited proportion (about 20%) of patients may experience rapid and significant improvement. This underscores the urgent need for new antitussive drugs to address these unmet clinical needs.

Clinical outcomes of mild to moderate coronavirus disease 2019 patients treated with Regdanvimab in delta-variant outbreak: Retrospective cohort study

Regdanvimab is a novel neutralizing antibody agent used for the treatment of coronavirus disease 2019 (COVID-19). However, the effectiveness of regdanvimab in delta-variant patients has rarely been investigated. We examined the clinical outcomes and adverse events in COVID 19 patients treated with regdanvimab in the delta-variant era. Data were collected from laboratory-confirmed COVID-19 hospitalized patients who received regdanvimab in 2021 and categorized into pre-delta and delta variant groups. The primary outcome was the need for oxygen therapy. Rescue therapy, clinical improvement, and adverse events were analyzed. Among 101 patients treated with regdanvimab, 31 (30.7%) were delta patients and 49 (48.5) were pre-delta patients. 64.4% were male, the mean age was 60.3 years, and 70 patients (69%) had at least one underlying disease. The median interval from symptom onset to injection was 4 days. Twenty-three patients (23%) needed oxygen therapy, including 9 (29%) in the delta and 8 (16.3%) in the pre-delta group. (P = .176) The risk of early oxygen supplement was higher in the delta group (adjusted hazard ratio (aHR), 6.75; 95% confidence interval(CI), 1.53-29.8). The in-hospital survival rate was 100%, and no patients were admitted to the intensive care unit. Adverse events occurred in 43% of patients:13 (42%) delta patients and 23 (47%) pre-delta patients had any adverse events (P = .661). Patients treated with regdanvimab 4 days after symptom onset showed a favorable prognosis (aHR, 0.26; 95% CI, 0.26-0.91). We found that the high-risk mild to moderate COVID-19 patients treated with regdanvimab showed similar disease progression in delta-variant patients and pre-delta variants; however, we need to be more closely observed delta-variant patients than those in the pre-delta group despite regdanvimab treatment due to rapid disease aggravation.

Baseline Cohort Profile of the Korean Chronic Cough Registry: A Multicenter, Prospective, Observational Study

PURPOSE

The Korean Chronic Cough Registry study was initiated to characterize patients with chronic cough (CC) and investigate their outcomes in real-world clinical practice. This report aims to describe the baseline cohort profile and study protocols.

METHODS

This multicenter, prospective observational cohort study included newly referred CC patients and those already being treated for refractory or unexplained chronic cough (RUCC). Cough status was assessed using a visual analog scale, the Leicester Cough Questionnaire (LCQ), and the Cough Hypersensitivity Questionnaire (CHQ).

RESULTS

A total of 610 patients (66.9% women; median age 59.0 years) were recruited from 18 centers, with 176 being RUCC patients (28.9%). The median age at CC onset was 50.1 years, and 94.4% had adult-onset CC (≥ 19 years). The median cough duration was 4 years. Compared to newly referred CC patients, RUCC patients had a longer cough duration (6.0 years vs. 3.0 years) but had fewer symptoms and signs suggesting asthma, rhinosinusitis, or gastroesophageal acid reflux disease. Subjects with RUCC had lower LCQ scores (10.3 ± 3.3 vs. 11.6 ± 3.6; P < 0.001) and higher CHQ scores (9.1 ± 3.9 vs. 8.4 ± 4.1; P = 0.024). There were no marked differences in the characteristics of cough between refractory chronic cough and unexplained chronic cough.

CONCLUSIONS

Chronic cough typically develops in adulthood, lasting for years. Cough severity and quality of life impairment indicate the presence of unmet clinical needs and insufficient cough control in real-world clinical practice. Longitudinal follow-up is warranted to investigate the natural history and treatment outcomes.

Clinical Relevance of Staphylococcus aureus Nasal Colonization and Staphylococcal Enterotoxin-Specific IgE Sensitization in Late-Onset Asthma

This prospective observational study examined whether Staphylococcus aureus (SA) nasal colonization and staphylococcal enterotoxin (SE)-specific IgE sensitization synergistically affect clinical outcomes of adults with late-onset asthma (onset age ≥ 40 years). Nasal swabs were taken to evaluate SA colonization. Serum SE-IgE level was measured. Subjects were classified into 4 groups according to SA colonization and SE-IgE sensitization positivity. Among 181 patients with late-onset asthma recruited, the proportions of SA/SE (‒/‒), SA/SE (+ /‒), SA/SE (‒/ +), and SA/SE (+ / +) were 33.7%, 15.5%, 28.2%, and 22.6%, respectively. Severe asthma was more frequent in the SA/SE (+ / +) group than in the SA/SE (‒/‒) group (41.5% vs. 13.1%). The relationship of SA/SE (+ / +) with severe asthma was significant in multivariate logistic regression (vs. SA/SE (‒/‒); adjusted odds ratio: 4.36; 95% confidence intervals: 1.50‒12.73; p = 0.007), whereas SA/SE (+ /‒) or SA/SE (‒/ +) was not. In conclusion, SA nasal colonization and SE-IgE sensitization may synergistically affect disease severity in late-onset asthmatics.

Health-Related Quality of Life and Its Determinants in Chronic Cough: The Korean Chronic Cough Registry Study

PURPOSE

Chronic cough (CC) is associated with health-related quality of life (HRQoL) impairment. However, the determinants of HRQoL are under-investigated.

METHODS

Patients aged 19-80 years with CC were prospectively recruited from 10 referral clinics. Comparisons were made with age- and sex-matched controls (1:4 ratio) selected from a Korean general population survey database; 1) a group without current cough (non-cough controls) and 2) another group without major chronic illnesses (healthy controls). HRQoL was assessed using the EuroQoL 5-dimension (EQ-5D) index. In CC patients, cough-specific patient-reported outcomes (PROs) were additionally measured. Cross-sectional analyses were performed to evaluate demographic and clinical parameters associated with the EQ-5D index of CC patients.

RESULTS

A total of 200 CC patients (137 newly referred with CC and 63 refractory or unexplained CC [RUCC] patients), 800 non-cough controls, and 799 healthy controls were analyzed. The EQ-5D index of CC patients was significantly lower than that of non-cough controls or healthy controls (0.82 ± 0.14 vs 0.92 ± 0.14/0.96 ± 0.08; P < 0.001, respectively). The index was also associated with older age (≥ 60 years), female sex, and comorbidities such as asthma or depression. Among the patients with CC, the index was significantly lower in patients with RUCC than in those with newly referred CC, being treated with codeine or cough neuromodulators, or with cough-related fatigue. In Spearman analyses, the EQ-5D index correlated with cough-specific quality of life and cough severity scores, not with throat sensation or cough trigger scores.

CONCLUSIONS

The HRQoL impairment of CC patients was associated with older age, female sex, and comorbidities but it was also affected by cough severity, complications, treatments, and treatment responses. Longitudinal studies are warranted to further understand and improve the HRQoL of CC patients.

Staphylococcal Enterotoxin-Specific IgE Sensitization: A Potential Predictor of Fixed Airflow Obstruction in Elderly Asthma

PURPOSE

Staphylococcus aureus enterotoxin-specific immunoglobulin E (SE-sIgE) sensitization tends to increase with age and is known to be associated with asthma and severity in older adults. However, the long-term impact of SE-sIgE in the elderly remains unknown. This study aimed to examine the relationships between SE-sIgE and fixed airflow obstruction (FAO) in a cohort of elderly asthmatics.

METHODS

A total of 223 elderly asthmatics and 89 controls were analyzed. Patients were assessed for demographics, history of chronic rhinosinusitis (CRS), asthma duration, acute exacerbation frequency, and lung function at baseline and then were prospectively followed up for 2 years. Serum total IgE and SE-sIgE levels were measured at baseline. Airflow obstruction was defined as forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio < 0.7 at baseline and FAO was defined as FEV1/FVC ratio < 0.7 over the 2-year follow-up.

RESULTS

At baseline, the prevalence of airflow obstruction was 29.1%. Patients with airflow obstruction were significantly more likely to be male, and have a positive smoking history, comorbid CRS, and higher levels of SE-sIgE than those without airflow obstruction. Multivariate logistic regression analysis showed that airflow obstruction was significantly associated with current smoking and SE-sIgE sensitization at baseline. After the 2-year follow-up, baseline SE-sIgE sensitization was consistently related to FAO. Meanwhile, the number of exacerbations per year was significantly correlated with SE-sIgE levels.

CONCLUSIONS

Baseline SE-sIgE sensitization was significantly associated with the number of asthma exacerbations and FAO after the 2-year follow-up in elderly asthmatics. These findings warrant further investigation of the direct and mediating roles of SE-sIgE sensitization on airway remodeling.

Relationship between asthma and sarcopenia in the elderly: a nationwide study from the KNHANES

OBJECTIVE

Few studies have investigated the relationship between asthma and sarcopenia. We aimed to examine the relationship between asthma and sarcopenia in a community-dwelling geriatric population, especially regarding lung function and asthma control.

METHODS

A cross-sectional dataset from the Korean National Health and Nutrition Examination Survey 2008-2011 was utilized. Data regarding asthma history, age at asthma onset, recent asthma exacerbations, and hospitalization for asthma exacerbations were obtained using structured questionnaires. Appendicular skeletal muscle was calculated as the sum of the skeletal muscle mass, and physical activity was assessed using the International Physical Activity Questionnaire.

RESULTS

Asthma presented an estimated incidence of 6.17 ± 0.37% in the elderly. Groups were divided and analyzed according to asthma, muscle mass, and physical activity. Sarcopenia was associated with aging, male sex, smoking history, low body mass index (BMI), and reduced lung function with or without asthma. Sarcopenic asthma had a younger onset and reduced physical activity than non-sarcopenic asthma. Obstructive patterns were more frequent in asthmatics exhibiting low or moderate physical activity levels than in those with high activity, but asthma control was not associated with sarcopenia and physical activity. Multivariate logistic regression analyses showed that compared with control, sarcopenic asthma was associated with FEV1 < 60%, and airway obstruction, and with aging, male, and lower BMI, compared with non-sarcopenic asthma.

CONCLUSIONS

Our findings suggest that decreased muscle mass and physical activity levels contribute to reduced lung function in elderly asthmatics. Furthermore, sarcopenic asthma was associated with aging, low BMI, and reduced lung function in the elderly.

Clusters of Severe Eosinophilic Asthma in a Korean Asthma Cohort

BACKGROUND

Targeted therapies have broadened the available treatment options for patients with severe eosinophilic asthma (SEA). However, differences in the magnitude of treatment responses among patients indicate the presence of various underlying pathophysiological processes and patient subgroups.

OBJECTIVES

We aimed to describe the characteristics of SEA and identify its patient subgroups.

METHODS

Clinical data from the Cohort for Reality and Evolution of Adult Asthma in Korea were analyzed. Cluster analysis was performed among those with SEA using 5 variables, namely, prebronchodilator forced expiratory volume in 1 s, body mass index, age at symptom onset, smoking amount, and blood eosinophil counts.

RESULTS

Patients with SEA showed prevalent sensitization to aeroallergens, decreased lung function, and poor asthma control status. Cluster analysis revealed 3 distinctive subgroups among patients with SEA. Cluster 1 (n = 177) consisted of patients reporting the lowest blood eosinophils (median, 346.8 cells/μL) and modest severe asthma with preserved lung function during the 12-month treatment period. Cluster 2 (n = 42) predominantly included smoking males with severe persistent airway obstruction and moderate eosinophilia (median, 451.8 cells/μL). Lastly, cluster 3 (n = 95) included patients with the most severe asthma, the highest eosinophil levels (median, 817.5 cells/μL), and good treatment response in terms of improved lung function and control status.

CONCLUSIONS

Three subgroups were identified in SEA through the cluster analysis. The distinctive features of each cluster may help physicians predict patients who will respond to biologics with greater magnitude of clinical improvement. Further research regarding the underlying pathophysiology and clinical importance of each subgroup is warranted.

Prevalence and diagnostic values of laboratory animal allergy among research personnel

BACKGROUND

Laboratory animal allergy (LAA) has not been sufficiently investigated, although LAA is a relatively common work-related condition and important occupational hazard.

OBJECTIVE

This study aimed to evaluate the prevalence of LAA and analyze the diagnostic value of serum specific IgE (sIgE) using the skin prick test (SPT) as a comparative standard.

METHODS

Korean laboratory animal researchers who attended an annual symposium were requested to answer questionnaires regarding demographic characteristics, laboratory animal exposure, and symptoms related to laboratory animal exposure. A total of 213 participants underwent a SPT with mouse and rat epithelial allergen extract. We measured sIgE against rodent urine, epithelium, and serum allergens from 63 participants. SPT outcome served as the comparison method.

RESULTS

Among 223 participants, 213 had direct/indirect exposure to mice or rats, and 30% and 14% of them complained of allergic symptoms after exposure to mouse and rat, respectively. Sensitization rates were 28% for mouse epithelium and 23% for rat epithelium. Compared to a positive SPT with wheal ≥ 3 mm, presence of sIgE against rodent allergens showed a higher positive predictive value of 87-91% at a cut-off level of 0.35 KUA/L. Agreement between SPT and sIgE test was determined to be fair to moderate.

CONCLUSIONS

Sensitization and allergy to mouse and rat were prevalent among laboratory personnel in Korea. When evaluating cases of potential LAA, the sIgE test can provide added diagnostic value if the skin test is positive. Careful interpretation of two tests is required to accurately diagnose LAA.

Oleoylethanolamide induces eosinophilic airway inflammation in bronchial asthma

Asthma is a chronic eosinophilic inflammatory disease with an increasing prevalence worldwide. Endocannabinoids are known to have immunomodulatory biological effects. However, the contribution of oleoylethanolamide (OEA) to airway inflammation remains to be elucidated. To investigate the effect of OEA, the expression of proinflammatory cytokines was measured by RT-qPCR and ELISA in airway epithelial (A549) cells. The numbers of airway inflammatory cells and cytokine levels in bronchoalveolar lavage fluid, airway hyperresponsiveness, and type 2 innate lymphoid cells (ILC2s) were examined in BALB/c mice after 4 days of OEA treatment. Furthermore, eosinophil activation after OEA treatment was evaluated by measuring cellular CD69 levels in eosinophils from human peripheral eosinophils using flow cytometry. OEA induced type 2 inflammatory responses in vitro and in vivo. OEA increased the levels of proinflammatory cytokines, such as IL-6, IL-8, and IL-33, in A549 cells. In addition, it also induced eosinophilic inflammation, the production of IL-4, IL-5, IL-13, and IL-33 in bronchoalveolar lavage fluid, and airway hyperresponsiveness. OEA increased the numbers of IL-5- or IL-13-producing ILC2s in a mouse model. Finally, we confirmed that OEA increased CD69 expression (an eosinophil activation marker) on purified eosinophils from patients with asthma compared to those from healthy controls. OEA may play a role in the pathogenesis of asthma by activating ILC2s and eosinophils.

Impact and disease burden of chronic cough

Cough is an important physiological mechanism to protect the lower airways, but it is also one of the most common symptoms that lead patients to seek medical consultations. Chronic cough, usually defined by cough duration longer than 8 weeks in adults, is prevalent in the community and impairs quality of life in individual patients. There are several characteristics that may differentiate pathologic coughs from protective cough responses, including cough duration, frequency, hypersensitivity, impaired cough suppressibility, or treatment refractoriness. However, the impact of cough, or its perceived severity, is a sum of the patient's experience of coughing and is a factor that may finally define cough as a disease. Social isolation is a major impact of chronic cough, which is now worse due to the coronavirus disease 2019 pandemic and a widespread fear of cough as a source of contagion. Emotional impact and economic impact (medical cost, reduced work productivity, and job loss) are also important complications of chronic cough, and they interact in a vicious cycle, aggravated by social isolation and treatment failures. This paper is a narrative review that aims to address the impact and disease burden of chronic cough in adult patients. We review the literature, but also introduce the findings from recent qualitative interviews and the patients' experiences of the impact and burden of chronic cough and discuss unmet needs in these patients.

Patients' experiences of asthma exacerbation and management: a qualitative study of severe asthma

Exacerbation is a defining feature of severe asthma, and oral corticosteroids (OCSs) are frequently prescribed to manage exacerbations. This qualitative study was conducted to examine the experience of patients with severe asthma, with a focus on asthma exacerbation and OCS treatment.

Adults with severe asthma were recruited from three tertiary hospitals in South Korea. Data were collected through in-depth qualitative interviews. Verbatim transcripts were analysed using Colaizzi's phenomenological method to uncover the meaning of the participants’ experience. Recruitment of participants continued until thematic saturation.

14 patients with severe asthma were recruited. Four theme clusters emerged: 1) experience of asthma exacerbation; 2) impact on life; 3) OCS treatments; and 4) disease perception. The patients experienced severe physical and psychosocial distress from asthma exacerbations, felt helpless due to failed efforts to prevent exacerbation and were living a restricted life due to fear of exacerbation. They feared OCS side-effects but had no other choice than to rely on OCSs because other interventions were ineffective. Most had poor knowledge and understanding of severe asthma and the long-term health consequences.

Asthma exacerbation affects wide aspects of life in patients with severe asthma. Several components may underlie reliance on OCSs, including experience of distress during exacerbation, fear of future exacerbation and lack of proper knowledge about the long-term health consequences of severe asthma and OCS treatments. A multi-disciplinary approach is warranted to support the patients and to provide systematic education about the long-term health implications of severe asthma.

Exacerbation widely affects the lives of people with severe asthma. Distress during exacerbation and fear of future exacerbations may underlie oral steroid reliance. Systematic patient education is warranted about the long-term health implications.https://bit.ly/3lhsBiN

The role of allergen-specific IgE in predicting allergic symptoms on dog and cat exposure among Korean pet exhibition participants

BACKGROUND

The values of the skin prick test (SPT) and allergen-specific IgE (sIgE) measurement in predicting dog and cat allergies remain unclear. We aimed to evaluate the usefulness of SPT and sIgE measurement in predicting self-reported allergic symptoms during exposure to dogs and cats in Korean adults.

METHODS

A total of 552 participants in a pet exhibition in Korea completed questionnaires regarding exposure to dog or cat and the development of allergic symptoms during exposure. Study participants also underwent SPT using 3 different commercially available reagents, and had their blood drawn for measurement of serum total IgE and dog/cat-dander-IgE using ImmunoCAP®.

RESULTS

Measurement of sIgE for dog and cat dander allergens provided the highest positive and negative predictive values and sensitivity, but not specificity (58%, 87.2%, 67.9%, and 93.1% for allergic symptoms on dog exposure; 64.7%, 83.2%, 74.8%, and 88.9% for those on cat exposure, respectively), in predicting self-reported allergic symptoms on dog and cat exposure. The sIgE level consistently exhibited the highest area under the receiver operating characteristic curve (0.749 and 0.719 for allergic symptoms on dog and cat exposure, respectively). Careful interpretation of SPT and sIgE measurements maximized the positive and negative predictive values, sensitivity, and specificity for predicting allergic symptoms on dog exposure (71.4%, 87.3%, 75.3%, and 99.3%) and those on cat exposure (71.4%, 85.3%, 79.3%, and 98.9%).

CONCLUSIONS

The measurement of dog and cat dander sIgE levels may be useful for the exclusion of allergic symptoms related to pet exposure. Collective interpretation of SPT and sIgE tests facilitates identification of allergic symptoms on dog or cat exposure, giving a better rule-in test result.

Cough persistence in adults with chronic cough: A 4-year retrospective cohort study

BACKGROUND

There is very limited evidence regarding long-term prognosis of chronic cough. We examined longitudinal outcomes among patients with chronic cough, and explored predictors of cough persistence.

METHODS

A retrospective cohort was constructed of adults who had newly visited a specialist cough clinic in 2012-2013. All had undergone systematic investigation for chronic cough. The Hull Airway Reflux Questionnaire (HARQ) was administered to assess reflux cough symptoms. A follow-up survey was conducted in 2016-2017 to assess cough persistence.

RESULTS

From 418 candidates, 323 participated in the follow-up study; main analyses focused on patients with chronic persistent cough (n = 64; 19.8%) and remitted cough (n = 193; 59.8%). Compared with remitted cough group, chronic persistent cough group had more family history of chronic cough (17.2% vs. 4.7%, p = 0.001) and cold air-sensitive cough (62.5% vs. 44.6%, p = 0.013). The total HARQ score did not differ; however, two items (cough with eating and cough with certain foods) scored significantly higher in chronic persistent cough. In multivariate analyses, a family history of chronic cough (adjusted odds ratio 4.27 [95% confidence interval 1.35-9.89]), cold air-sensitive cough (2.01 [1.09-3.73]), and cough with eating (1.22 [1.02-1.45]) were associated with chronic persistent cough at 4 years.

CONCLUSIONS

Cough persists in about 20% of patients after 4 years following systematic assessment and treatments. Several cough characteristics, such as family history, cold air-sensitivity, or reflux cough, may be associated with cough persistence. Larger cohort studies are warranted to further understand long-term prognosis and confirm predictors of persistence in patients with chronic cough.

Comparing Inhaler Use Technique Based on Inhaler Type in Elderly Patients with Respiratory Disease

Background

The aim of this study was to investigate inhaler device handling in elderly patients. Inhaler devices with respect to misuse and error correction were also compared.

Methods

Inhaler use technique was assessed using standardized checklists at the first visit and 3-month follow-up visit after retraining. The primary outcome was difference in the acceptable use ratio among inhaler devices. Secondary outcomes included differences in error correction, the most common step of misuse, and factors affecting the accuracy of inhaler use.

Results

A total of 251 patients (mean age, 76.4 years) were included. The handling of 320 devices was assessed in the study. All patients had been trained before. However, only 24.7% of them used inhalers correctly. Proportions of acceptable use for Evohaler, Respimat, Turbuhaler, Ellipta, and Breezhaler/Handihaler were 38.7%, 50.0%, 61.4%, 60.8%, and 43.2%, respectively (p=0.026). At the second visit, the acceptable use ratio had increased. There were no significant differences among inhaler types (Evohaler, 63.9%; Respimat, 86.1%; Turbuhaler, 74.3%; Ellipta, 64.6%; and Breezhaler/Handihaler, 65.3% [p=0.129]). In multivariate analysis, body mass index, Turbuhaler, and Ellipta showed positive correlations with acceptable use of inhalers, whereas Chronic Obstructive Pulmonary Disease Assessment Test score showed a negative correlation.

Conclusion

Although new inhalers have been developed, the accuracy of inhaler use remains low. Elderly patients showed more errors when using pressurized metered-dose inhalers than using dry powder inhalers and soft-mist inhalers. However, there were no significant differences in misuse among inhaler devices after individual training. Results of this study suggests that repeat training is more important than inhaler type.

Metagenome analysis using serum extracellular vesicles identified distinct microbiota in asthmatics

Different patterns of bacterial communities have been reported in the airways and gastrointestinal tract of asthmatics when compared to healthy controls. However, the blood microbiome of asthmatics is yet to be investigated. Therefore, we aimed to determine whether a distinct serum microbiome is observed in asthmatics by metagenomic analysis of serum extracellular vesicles (EVs). We obtained serum from 190 adults with asthma and 260 healthy controls, from which EVs were isolated and analyzed. The bacterial composition of asthmatics was significantly different from that of healthy controls. Chao 1 index was significantly higher in the asthma group, while Shannon and Simpson indices were higher in the control group. At the phylum level, Bacteroidetes was more abundant in asthmatics, while Actinobacter, Verrucomicrobia, and Cyanobacteria were more abundant in healthy controls. At the genus level, 24 bacterial genera showed differences in relative abundance between asthmatics and controls, with linear discriminant analysis scores greater than 3. Further, in a diagnostic model based on these differences, a high predictive value with a sensitivity of 0.92 and a specificity of 0.93 was observed. In conclusion, we demonstrated distinct blood microbiome in asthma indicating the role of microbiome as a potential diagnostic marker of asthma.

Relationship between age and bronchodilator response at diagnosis in adult-onset asthma

BACKGROUND

Possible variation in bronchodilator response (BDR) according to age at the diagnosis of adult-onset asthma is unknown. Our aim was to assess if BDR in FEV1 is related to age at diagnosis of adult-onset asthma and how many subjects fulfill the 400 mL criterion of BDR, the suggested cut-off for asthma-like reversibility in asthma-COPD overlap (ACO).

METHODS

A total of 1030 patients with adult-onset asthma were included; 245 from SAAS (Seinäjoki Adult Asthma Study, Finland) and 785 from COREA (Cohort for Reality and Evolution of Adult Asthma in Korea) cohorts. BDR in FEV1 at the diagnosis of asthma was assessed. Patients were divided into groups based on age at asthma diagnosis: < 40, 40-59.9, and ≥ 60 years. The cohorts were analyzed separately.

RESULTS

BDR % in FEV1 did not differ between the groups of different age at asthma diagnosis and no correlation between BDR and age was found. Of patients aged ≥40 years, only 18% (SAAS-cohort) and 5% (COREA-cohort) reached the 400 mL BDR in FEV1. After exclusion of possible ACO patients, the results remained similar.

CONCLUSION

By using two large cohorts of steroid-naive patients with asthma, we have shown that BDR at diagnosis of asthma is constant over large age span range, and the limit of 400 mL in BDR in FEV1 is rarely reached.

TRIAL REGISTRATION

Seinäjoki Adult Asthma Study is registered at ClinicalTrials.gov with identifier number NCT02733016 .

Prevalence and impact of comorbid laryngeal dysfunction in asthma: A systematic review and meta-analysis

BACKGROUND

Laryngeal or vocal cord dysfunction has long been regarded as a mimic of asthma; however, recent evidence indicates that it may be a significant comorbid condition in patients with asthma.

OBJECTIVE

We aimed to systematically estimate the prevalence of comorbid laryngeal dysfunction (LD) in adults with asthma and characterize its clinical impact on asthma.

METHODS

Electronic databases were searched for relevant studies published until June 2019. Studies were included if LD was objectively defined by direct visualization of laryngeal movement. Outcomes included the prevalence of LD and its association with clinical asthma indicators, such as severity, control, and quality of life. Random effects meta-analyses were performed to calculate the estimates.

RESULTS

A total of 21 studies involving 1637 patients were identified. Overall, the pooled prevalence of LD in adults with asthma was 25% (95% CI = 15%-37%; I² = 96%). Prevalence estimates differed according to the diagnostic test utilized, with the lowest overall prevalence (4% [95% CI = 0%-10%; I² = 90%]) seen when LD was diagnosed by resting laryngoscopy without external stimuli; however, it was much higher when diagnosed by laryngoscopy studies utilizing an external trigger, such as exercise (38% [95% CI = 24%-53%; I² = 90%]) or in studies using a computed tomography-based diagnostic protocol (36% [95% CI = 24%-49%; I² = 78%]). Only 7 studies reported the associations between LD and clinical asthma indicators; inconsistencies between studies limited meaningful conclusions.

CONCLUSION

LD may be a common comorbidity in asthma, affecting about 25% of adult patients. Further prospective studies are needed to better characterize its clinical impact and the benefits of detecting and managing LD in patients with asthma.

Chronic Rhinosinusitis with Nasal Polyps in Older Adults: Clinical Presentation, Pathophysiology, and Comorbidity

PURPOSE OF REVIEW

Chronic rhinosinusitis and nasal polyps (CRSwNP) is a common condition that significantly affects patients' life. This work aims to provide an up-to-date overview of CRSwNP in older adults, focusing on its aging-related clinical presentations, pathophysiology, and comorbidity associations including asthma.

RECENT FINDINGS

Recent large population-based studies using nasal endoscopy have shown that CRSwNP is a mostly late-onset disease. Age-related changes in physiologic functions, including nasal epithelial barrier dysfunction, may underlie the incidence and different clinical presentations of CRSwNP in older adults. However, there is still a paucity of evidence on the effect of aging on phenotypes and endotypes of CRSwNP. Meanwhile, late-onset asthma is a major comorbid condition in patients with CRSwNP; they frequently present with type 2 inflammatory signatures that are refractory to conventional treatments when they are comorbid. However, as they are more commonly non-atopic, causative factors other than classical atopic sensitization, such as Staphylococcus aureus specific IgE sensitization, are suggested to drive the type 2 inflammation. There are additional comorbidity associations in older patients with CRSwNP, including those with chronic otitis media and head and neck malignancy. Age is a major determinant for the incidence and clinical presentations of CRSwNP. Given the heterogeneity in phenotypes and endotypes, longitudinal investigations are warranted to elucidate the effects of aging on CRSwNP.

Impact of Cough and Unmet Needs in Chronic Cough: A Survey of Patients in Korea

PURPOSE

Chronic cough is a common problem in various populations. The present study assessed the impact of cough and unmet needs in Korean patients with chronic cough.

METHODS

This cross-sectional multi-center study enrolled adult patients newly referred to clinic for assessment of chronic cough. A second group of patients with unexplained chronic cough following detailed assessment were recruited for comparison. Patients completed self-reported questionnaires, including cough characteristics, impact of cough on daily life, and unmet needs.

RESULTS

A total of 447 subjects were recruited from six referral clinics, including 408 with chronic cough and 39 with unexplained chronic cough. Almost all patients reported that cough impacted their daily lives. Psychosocial impacts were more evident in unexplained cough patients compared to newly referred patients. Approximately 75% of newly referred patients had previously sought medical care for cough on multiple occasions, but the effectiveness of treatment was limited (70.3%) or absent (17.3%). The most frequent unmet need was the ineffectiveness of treatment (49.3%), followed by unclear diagnosis (30.1%). The majority of participants ( > 80%) expressed the need for further information on accessing cough specialists and disease management. The main problem faced by unexplained cough patients was poor cough control despite treatment (64%).

CONCLUSIONS

Chronic cough has a substantial impact on daily life and is worst in those whose cough remains unexplained following assessment. Ineffectiveness of treatment and unclear diagnosis were major unmet needs. Medical information about chronic cough was also lacking. Improvements in the management of chronic cough patients in Korea are necessary.

Validation of the Prescreening Intradermal Skin Test for Predicting Hypersensitivity to Iodinated Contrast Media: A Prospective Study with ICM Challenge

BACKGROUND

The number of hypersensitivity reactions associated with iodinated contrast media (ICM) is increasing with widespread use of radiographic contrast agents. These hypersensitivity reactions are unpredictable and sometimes lead to severe reactions such as anaphylaxis.

OBJECTIVE

To investigate the value of intradermal skin test (IDT) as a clinical screening tool for prediction of a hypersensitivity reaction to ICM.

METHODS

We performed IDT in the patients scheduled to receive an iodinated contrast agent between September 2015 and April 2017. After IDT, the contrast agent tested was administered intravenously, regardless of the results of skin testing, and the patients were carefully monitored.

RESULTS

We recruited 2,918 patients in 2 hospitals, and 2,843 were included in the final analysis. Fifteen (0.5%) of the 2843 patients had a positive IDT result before scheduled computed tomography scan; however, none of these patients experienced a hypersensitivity reaction after the administration of a full dose of ICM. Meanwhile, 19 patients who experienced hypersensitivity reactions after ICM challenge had showed a negative IDT result. The sensitivity and the positive predictive value of IDT for ICM were both 0%.

CONCLUSIONS

Routine IDT before the administration of an iodinated contrast agent does not predict hypersensitivity considering its extremely low sensitivity and a low positive predictive value.

Breakthrough reactions during rapid drug desensitization: Clinical outcome and risk factors

BACKGROUND

Severe hypersensitivity reactions (HSRs) interfere with the administration of necessary drugs for patients; drug desensitization can be a good alternative strategy. Although rapid drug desensitization (RDD) has been shown to be safe and effective, some patients still experience breakthrough reactions (BTRs) during desensitization.

OBJECTIVE

We aimed to estimate clinical outcomes of RDD and to identify risk factors for BTR.

METHODS

From January 2015 to December 2017, retrospective analysis was done in cancer patients with HSRs to chemotherapy and monoclonal antibody who underwent 3-bag, 12-step RDD in Asan Medical Center.

RESULTS

A total of 58 patients (42 females; mean age, 54.7 ± 11.0) underwent 234 desensitization procedures. The most common underlying malignancy was gynecologic cancer (n = 26, 44.8%), and platinum-based drugs were common target drugs (135 cases of 36 patients). Twenty-six of 58 patients (44.8%) experienced 56 BTRs, whereas 178 cases (76.1%) of total desensitization did not show any reactions. Among them, 12 patients (20.7%) had moderate BTRs requiring systemic steroids, and 3 (5.1%) experienced severe BTRs requiring epinephrine administration. Logistic regression analysis revealed more severe initial HSRs (OR = 17.94, 95% CI = 1.78-181.68, P = .015), drug allergy history (OR = 7.83, 95% CI = 1.48-41.44, P = .035), and frequency of exposure to the chemotherapeutic agents (OR = 1.14, 95% CI = 1.01-1.28, P = .016) increased the risk of moderate to severe BTR.

CONCLUSION

The standardized 12-step protocol for RDD was effective and safe for most patients. Severity of initial HSR, history of drug allergy, and previous high exposure to the chemotherapeutic agent showed a positive correlation with BTR above moderate grade. Studies are needed to propose an individualized protocol according to patient-specific risk assessment.

Clinical characteristics of eperisone-induced immediate-type hypersensitivity

BACKGROUND

Eperisone is a commonly prescribed oral muscle relaxant, but few studies have been conducted of eperisone-induced hypersensitivity reactions.

OBJECTIVE

The purpose of this study was to investigate the clinical manifestations of eperisone-induced immediate-type hypersensitivity, and to evaluate the role of an intradermal test (IDT) in eperisone-induced anaphylaxis.

METHODS

This study was based on a retrospective review of medical records from 23 patients diagnosed as eperisone-induced immediate-type hypersensitivity with certain or probable causality. Intradermal tests were performed with a sterile 10 mg/mL eperisone solution.

RESULTS

Immediate-type hypersensitivity reactions to eperisone occurred within 15 minutes in 8.7%, within 30 minutes in 52.2%, and within 60 minutes in 82.6% of the patients, cumulatively. All patients showed cutaneous symptoms. Gastrointestinal symptoms were the second-most frequent (65.2%), respiratory symptoms (56.5%) followed, and cardiovascular symptoms were the least (39.1%). Nine (39.1%) patients were categorized as severe anaphylaxis. The mean onset time of severe anaphylaxis was 28.89 minutes, which was significantly shorter than non-severe anaphylaxis (p = 0.011). Five patients among the severe anaphylaxis group were evaluated with IDT, and all showed positive results. In contrast, all of the four patients who have done IDT among the moderate anaphylaxis group showed negative results. There was a significant relationship between severe anaphylaxis and positive IDT results (p = 0.008).

CONCLUSIONS

Eperisone-induced immediate-type hypersensitivity is not uncommon in Korea, and the IDT could be a useful and safe diagnostic tool, especially in severe anaphylaxis.

Chronic cough in the elderly

Chronic cough is a multi-factorial syndrome commonly presenting as cough hypersensitivity in adult patients. It is a common medical condition in the communities but is more prevalent in older adults. Elderly patients (≥65 years) frequently suffer from multiple comorbidities, which may lead to more clinical heterogeneity in chronic cough and pose diagnostic and therapeutic challenges. Hyposensitivity in cough reflex, probably resulting from central nervous system illnesses, is another potential concern. Despite these complexities and challenges, elderly-specific issues have rarely been addressed in current clinical practice guidelines for chronic cough. Considering recent trends in global population aging, the burden of elderly chronic cough is expected to increase into the near future. This review aimed to respond to following clinical questions: (1) is chronic cough a more heterogeneous condition in the elderly compared to younger adults; and (2) are there additional considerations when choosing the diagnostic and therapeutic approaches to this condition in the elderly?

Staphylococcus aureus Nasal Colonization and Asthma in Adults: Systematic Review and Meta-Analysis

BACKGROUND

Staphylococcus aureus (SA) is a frequent colonizer in humans, and it is known to be associated with chronic allergic diseases including asthma. Recent individual studies suggested that nasal SA colonization may be positively associated with asthma.

OBJECTIVE

To examine relationships between nasal SA colonization and asthma prevalence and activity in adults.

METHODS

Electronic databases were searched for studies published until June 2018. Studies that reported nasal SA colonization prevalence and asthma outcome (prevalence and disease activity) in general adult populations or patients with chronic rhinosinusitis (CRS) were included. Random effects meta-analyses were performed to calculate pooled odds ratio (OR) of the relationships. Subgroup analysis was conducted for the presence of nasal polyps within CRS populations.

RESULTS

A total of 21 cross-sectional studies were identified, and the data from 16 studies using culture methods for SA detection were meta-analyzed (5 general population-based studies and 11 studies of patients with CRS). In studies of general populations, nasal SA colonization had significant relationships with asthma prevalence (OR 1.19; 95% confidence interval [CI] 1.06-1.34; I² = 1%). In studies of patients with CRS, positive associations were also found but had a considerable heterogeneity (OR 1.87; 95% CI 1.18-2.97; I² = 72%). However, the results were comparable between CRS with and without nasal polyps.

CONCLUSIONS

This study demonstrated modest but significant relationships between nasal SA colonization and asthma, supporting potential roles of SA in adult patients with asthma. Further longitudinal cohort and intervention studies are warranted to identify host determinants and to clarify causality of the relationships.

Age-related prevalence of chronic rhinosinusitis and nasal polyps and their relationships with asthma onset

BACKGROUND

Chronic rhinosinusitis (CRS) is a major disease condition with high morbidity and can influence lower airway disease status in adults. However, its associations with adult asthma onset and activity have not been examined in detail in a general adult population.

OBJECTIVE

To investigate relationships between CRS with nasal polyps (CRSwNP) and asthma characteristics.

METHODS

A cross-sectional data set of 17,506 adult participants (≥18 years old) in the Korean National Health and Nutrition Examination Survey from 2010 through 2012 was analyzed. CRS was defined using structured questionnaires according to the international guideline, and presence of nasal polyps was objectively assessed using nasal endoscopy. Presence of asthma and its onset and current activity were assessed using structured questionnaires.

RESULTS

CRS was significantly related to asthma, but the relationships were distinct by CRS and asthma status. CRSwNP was significantly associated with adult-onset asthma (onset after 18 years of age) or late-onset asthma (onset after 40 years of age), whereas CRS without nasal polyps was related to childhood-onset asthma (onset before 18 years) or early-onset asthma (onset before 40 years) in adults. The 2 CRS subgroups showed significant associations with current asthma but not with past asthma. However, the comorbid asthma rate was lower than 10% among subjects with CRS.

CONCLUSION

This study found distinct age-related patterns of CRSwNP and asthma and demonstrated their significant associations in a general population. However, the low prevalence of asthma in CRSwNP is in sharp contrast to findings in Western populations, which warrants further investigation for ethnic or regional differences in relationships between CRSwNP and asthma.

The double-sidedness of cough in the elderly

Cough is a physiological reflex to protect airways against aspiration, but also it is one of the most frequent problems that lead patients to seek medical care. Chronic cough is more prevalent in the elderly than younger subjects, and more challenging to manage due to frequent comorbidities and possible side effects from drug treatment. Meanwhile, cough reflex does not decrease with natural aging but is often impaired by pathologic conditions like stroke. The impairment in cough reflex may lead to fatal complication like aspiration pneumonia. In this paper, we reviewed epidemiology and clinical considerations for chronic cough in the elderly, and summarized aging-related changes in cough reflex and also possible ways to normalize cough reflex and prevent aspiration pneumonia.

Correction: Impact of self-reported symptoms of allergic rhinitis and asthma on sleep disordered breathing and sleep disturbances in the elderly with polysomnography study

[This corrects the article DOI: 10.1371/journal.pone.0173075.].

Point prevalence and epidemiological characteristics of chronic cough in the general adult population: The Korean National Health and Nutrition Examination Survey 2010-2012

Cough is frequently self-limiting, but may persist longer in certain individuals. Most of previous studies on the epidemiology of chronic cough have only measured period prevalence, and thus have afforded limited information on the burden and natural course. We aimed to investigate the epidemiology of chronic cough by using a point prevalence measure in a large-scale general population.We analyzed cross-sectional data collected from 18,071 adults who participated in the Korean National Health and Nutrition Examination Survey 2010-2012. Presence and duration of current cough was ascertained by structured questionnaires, and cough was classified into acute (<3 weeks), subacute (3-8 weeks), or chronic cough (≥8 weeks). Demographic and clinical parameters were examined in relation to chronic cough.The point prevalences of acute, subacute, and chronic cough were 2.5 ± 0.2%, 0.8 ± 0.1% and 2.6 ± 0.2%, respectively. The proportion of current cough showed a steep decrease after 1 week of duration. However, 2 peaks in the prevalence of current cough were revealed; cough durations of less than 1 week and longer than 1 year were most common (31.1% and 27.7% of current cough, respectively). Subacute and chronic cough were more prevalent in the elderly (≥65 years); the positive associations with older age were independent of other confounders, including current smoking and comorbidities.This is the first report on the epidemiology of cough using a point prevalence measure in a nationally representative population sample. Our findings indicate a high burden of chronic cough among adults with current cough in the community. The dual-peak of cough duration suggested that the pathophysiology of acute and chronic cough may differ. The preponderance of elderly people in the prevalence of chronic cough warrants further investigation. In addition, more sophistication and validation of tools to define chronic cough will help our understanding of the epidemiology.

Impact of self-reported symptoms of allergic rhinitis and asthma on sleep disordered breathing and sleep disturbances in the elderly with polysomnography study

BACKGROUND

Sleep disordered breathing (SDB) and sleep disturbances have been reported to be associated with allergic rhinitis and asthma. However, population-based studies of this issue in the elderly are rare.

OBJECTIVE

To investigate the impact of self-reported rhinitis and asthma on sleep apnea and sleep quality using polysomnography in an elderly Korean population.

METHODS

A total of 348 elderly subjects who underwent one-night polysomnography study among a randomly selected sample were enrolled. Study subjects underwent anthropometric and clinical evaluations. Simultaneously, the prevalence and co-morbid status of asthma and allergic rhinitis, and subjective sleep quality were evaluated using a self-reported questionnaire.

RESULTS

Ever-diagnosis of allergic rhinitis was significantly more prevalent in subjects with SDB compared with those without SDB. Subjects with an ever-diagnosis of allergic rhinitis showed a higher O2 desaturation index and mean apnea duration. Indices regarding sleep efficiency were affected in subjects with a recent treatment of allergic rhinitis or asthma. Waking after sleep onset was longer and sleep efficiency was lower in subjects who had received allergic rhinitis treatment within the past 12 months. Subjects who had received asthma treatment within the past 12 months showed significantly lower sleep efficiency than others.

CONCLUSION

Our study indicates that a history of allergic rhinitis is associated with increased risk of SDB in the elderly. Sleep disturbance and impaired sleep efficiency were found in the subjects who had received recent treatment of allergic rhinitis or asthma. Physicians should be aware of the high risk of sleep disorders in older patients with respiratory allergic diseases.

Diagnostic accuracy of fractional exhaled nitric oxide measurement in predicting cough-variant asthma and eosinophilic bronchitis in adults with chronic cough: A systematic review and meta-analysis

BACKGROUND

Individual studies have suggested the utility of fractional exhaled nitric oxide (Feno) measurement in detecting cough-variant asthma (CVA) and eosinophilic bronchitis (EB) in patients with chronic cough.

OBJECTIVE

We sought to obtain summary estimates of diagnostic test accuracy of Feno measurement in predicting CVA, EB, or both in adults with chronic cough.

METHODS

Electronic databases were searched for studies published until January 2016, without language restriction. Cross-sectional studies that reported the diagnostic accuracy of Feno measurement for detecting CVA or EB were included. Risk of bias was assessed with Quality Assessment of Diagnostic Accuracy Studies 2. Random effects meta-analyses were performed to obtain summary estimates of the diagnostic accuracy of Feno measurement.

RESULTS

A total of 15 studies involving 2187 adults with chronic cough were identified. Feno measurement had a moderate diagnostic accuracy in predicting CVA in patients with chronic cough, showing the summary area under the curve to be 0.87 (95% CI, 0.83-0.89). Specificity was higher and more consistent than sensitivity (0.85 [95% CI, 0.81-0.88] and 0.72 [95% CI, 0.61-0.81], respectively). However, in the nonasthmatic population with chronic cough, the diagnostic accuracy to predict EB was found to be relatively lower (summary area under the curve, 0.81 [95% CI, 0.77-0.84]), and specificity was inconsistent.

CONCLUSIONS

The present meta-analyses indicated the diagnostic potential of Feno measurement as a rule-in test for detecting CVA in adult patients with chronic cough. However, Feno measurement may not be useful to predict EB in nonasthmatic subjects with chronic cough. These findings warrant further studies to validate the roles of Feno measurement in clinical practice of patients with chronic cough.

Lamotrigine-induced toxic epidermal necrolysis confirmed by in vitro granulysin and cytokine assays

Lamotrigine is a recent medication which is prescribed for various neuropsychiatric conditions. It is generally well-tolerated, but recent pharmacoepidemiological evidence suggests that lamotrigine is associated with risks of developing severe cutaneous drug reactions like toxic epidermal necrolysis (TEN). However, there still remains the diagnostic challenge regarding how to confirm the drug causality in suspected cases. In most cases so far, lamotrigine causality has not been objectively demonstrated, which was possibly due to high risk of oral challenge tests or the lack of useful in vitro drug assays. Here we report a case of lamotrigine-induced TEN, of which the drug causality was confirmed by in vitro granulysin and cytokine assays.

Reduction in glycated albumin can predict change in HbA1c: comparison of oral hypoglycaemic agent and insulin treatments

AIM

To investigate whether the change in glycated albumin 3 weeks after initiating anti-diabetes treatment (oral hypoglycaemic agent or insulin) could predict the corresponding change in HbA(1c) 3 months later in Korean patients with Type 2 diabetes.

METHODS

A total of 140 patients were enrolled into two groups: group I (insulin-based; n = 100) and group II (oral hypoglycaemic agent-based; n = 40). Both glycated albumin and HbA(1c) levels were measured as 'glucose control markers' during hospitalization. Glycated albumin was measured again at 3 weeks (first visit) after the initial measurement, and HbA(1c) was measured at 3 months (second visit) after the initial measurement.. The change in glucose control marker was defined as 100 × (follow-up glucose control marker--hospital glucose control marker)/hospital glucose control marker.

RESULTS

In both groups, the change in glycated albumin at the first visit and in HbA(1c) at the second visit showed a moderate linear relationship (r = 0.735; P < 0.01). In group II (r = 0.778; P < 0.01), a slightly stronger linear relationship was demonstrated than in group I (r = 0.738; P < 0.001); however, there was no statistically significant difference between the two groups. A correlation coefficient between the change in glycated albumin and HbA(1c) was not affected by sex, age, BMI, haemoglobin, serum creatinine or albumin.

CONCLUSION

The reduction in glycated albumin 3 weeks after the initiation of treatment corresponded with the reduction in HbA(1c) 3 months after starting treatment in both the group treated with a oral hypoglycaemic agent and the insulin-treated group of Korean patients with Type 2 diabetes.

A long-term-care setting pilot study evaluating predictors of success in medication self-administration

OBJECTIVE

To determine whether any specific patient variables or a short battery of neuropsychological tests of cognition and memory predict success in medication self-administration.

DESIGN

A prospective, single-blinded design.

SETTING

An extended care center of a university-affiliated VA Medical Center.

PATIENTS

Thirty predominately male, older veteran patients, mean age 70 +/- 4 years with a range of 63 to 79 years.

INTERVENTIONS

Neuropsychological testing [Mini-Mental Status Examination (MMSE), Delayed Word Recall Test (DWRT), Shipley Institute of Living Scale (SILS), Neurobehavioral Cognitive Status Examination (NCSE), Hopkins Verbal Learning Test (HVLT)], twice a week unannounced bedside medication counts and medication administration record inspections, and educational instruction, if needed, by nurses and pharmacists.

MAIN OUTCOME MEASURES

Patient characteristics such as age, number of medications, presence of a disorder that can alter cognitive or memory function, years of education, and results from the above listed neuropsychological tests. The dependent variable was successful or not successful as defined by whether the patient required a re-education intervention.

RESULTS

Fifteen patients required one or more re-education intervention(s) as a result of meeting the criteria for not being successful. The absence of major depression, stroke, or anxiety disorder did tend to predict success (P = 0.0716) in medication self-administration. The other patient specific characteristics did not predict success. Among the neuropsychological tests administered, only the Judgment Subtest of the NCSE tended to predict success (P = 0.098). The MMSE, DWRT, SILS,HVLT tests did not predict successful performance in the self-medication program.

CONCLUSIONS

Although the presence of a diagnosis that could potentially alter cognitive and memory function tended to predict success, no patient characteristics were found that predicted success independently. Among the neuropsychological tests, only the Judgment subtest of the NCSE tended to predict success in medication self-administration. We conclude that the NCSE and characterization of patient-specific factors, including diseases that may affect cognitive and memory function, seem to be the best predictors of success in medication self-administration in a long-term-care setting.