A Comparison of Narrative and Table Formats for Presenting Hypothetical Health States to Patients with Gastrointestinal or Pulmonary Disease

Traditionally, quality-of-life researchers describe states of health for patients to rate either in narrative form or in table form, but evidence about which format patients prefer is limited. The authors performed 2 randomized studies to test whether patients prefer the table or narrative format and whether the format of presentation influences how patients rate health states. Approximately three-fourths of patients with gastrointestinal disease or chronic airflow limitation preferred the table format. There were no differences in patients’ ratings of 3 described health states or of their own health. Investigators should consider using the table presentation for describing health states to subjects who are not familiar with these states of health.

Development and validation of the Capacity of Daily Living during the Morning questionnaire and the Global Chest Symptoms Questionnaire in COPD

This report concerns the development and validation of two patient-reported outcomes questionnaires developed to assess chronic obstructive pulmonary disease (COPD) patients' ability to perform morning activities and to evaluate their morning symptoms. Based on interviews with COPD patients, the Capacity of Daily Living during the Morning (CDLM) questionnaire and the Global Chest Symptoms Questionnaire (GCSQ) were developed, linguistically validated and incorporated into two multicentre, randomised trials involving a total of 1,100 COPD patients; those trials were registered at ClinicalTrials.gov (NCT00496470 and NCT00542880). Data from these trials were used to determine the reliability, validity and responsiveness of the questionnaires and to derive estimates of minimal important differences (MIDs). Both questionnaires displayed good-to-high reliability (Cronbach's alpha 0.75-0.93). Analysis of convergent validity showed that CDLM and GCSQ scores correlated significantly (p<0.001) with symptoms, health-related quality of life (HRQoL) and use of rescue medication. In both trials, CDLM and GCSQ scores discriminated between patients with different levels of HRQoL, as assessed by the St George's Respiratory Questionnaire for COPD patients (SGRQ-C), but not with disease severity, as assessed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. A significant improvement in CDLM and GCSQ scores occurred in response to treatment. Estimations of MID scores, corresponding to an SGRQ-C MID of 4, were 0.20 for the CDLM questionnaire and 0.15 for the GCSQ. Both the CDLM questionnaire and the GCSQ are easy-to-use, reliable, responsive, self-administered questionnaires that report on patients' symptoms and ability to perform morning activities.

Diagnosis and management of acute aortic dissection, clinical and radiological follow-up

A clinical series of acute aortic dissections is presented. Twenty cases were of type A and 10 of type B. Acute severe chest pain was common, in type A also blood pressure difference between the arms and aortic regurgitation. The diagnosis was established by echocardiography, computerized tomography and/or aortography. Antihypertensive therapy was instituted immediately after diagnosis and was in type A cases followed by acute surgery unless definite contraindications existed. Of 14 surgically treated type A patients 13 survived the operation. On follow-up 1.5-3.5 years later, 12 patients were still alive and doing well, but the false channel remained open in all cases where it had not been resected totally. Only one of six conservatively treated type A patients survived. Type B dissections were operated on only if conservative therapy failed. Four of five conservatively and two of five surgically treated type B patients survived.

Estimating health utilities in patients with asthma and COPD: evidence on the performance of EQ-5D and SF-6D

OBJECTIVE

The objective of this study was to understand systematic differences in utility values derived from the EQ-5D and the SF-6D in two respiratory populations with heterogeneous disease severity.

METHODS

This study involved secondary analysis of data from two cross-sectional surveys of patients with asthma (N = 228; Hungary) and COPD (N = 176; Sweden). Disease severity was defined according to GINA and GOLD guidelines for asthma and COPD, respectively. EQ-5D and SF-6D scores and their distributional characteristics were compared across the two samples by disease severity level.

RESULTS

Within each patient population, mean EQ-5D and SF-6D scores were similar for the overall group and for those with moderate disease. Mean scores varied for patients with mild and severe disease. EQ-5D versus SF-6D scores in the asthma group by severity levels were 0.89 versus 0.80, 0.70 versus 0.73, 0.63 versus 0.64, and 0.51 versus 0.63, respectively. EQ-5D versus SF-6D scores in the COPD group by severity levels were 0.85 versus 0.80, 0.73 versus 0.73, 0.74 versus 0.73, and 0.53 versus 0.62, respectively.

CONCLUSIONS

Results suggest the EQ-5D and SF-6D do not yield consistent utility values in patients with asthma and COPD due to differences in underlying valuation techniques and the EQ-5D's limited response options relative to mild disease.

Clinical outcomes and adverse effect monitoring in allergic rhinitis

The subjective recording in diary cards of symptoms of itch, sneeze, nose running, and blockage, with the use of a rating scale to indicate the level of severity, is usual for clinical trials in allergic rhinitis. The primary outcome measure is usually a composite score that enables a single total symptoms score endpoint. It is appreciated, however, that rhinitis has a greater effect on the individual than is reflected purely by the recording of anterior nasal symptoms. Nasal obstruction is troublesome and may lead to sleep disturbance in addition to impaired daytime concentration and daytime sleepiness. These impairments affect school and work performance. Individuals with rhinitis find it socially embarrassing to be seen sneezing, sniffing, or blowing their nose. To capture these and other aspects of the disease-specific health-related quality of life, questionnaires such as the Rhinoconjunctivitis Quality of Life Questionnaire have been developed and validated for clinical trial use. The adoption of health-related quality of life questionnaires into clinical trials broadens the information obtained regarding the effect of the therapeutic intervention and helps focus on issues relevant to the individual patient. It must be appreciated that it is not only the disease that may adversely affect health-related quality of life; administered therapy, although intended to be beneficial, may also cause health impairment. Adverse-event monitoring is thus essential in clinical trials. The first-generation H 1 -histamines, because of their effect on central H 1 -receptors, are classically associated with central nervous system (CNS) effects such as sedation. Although this is not always perceived by the patient, it is clearly evident with objective performance testing, and positron emission tomography scanning has directly demonstrated the central H 1 -receptor occupancy. The second-generation H 1 -antihistamines have reduced central H 1 -receptor occupancy and considerably reduced or absent CNS sedative effects. Therefore, the CNS effects are entirely avoidable, and the first-generation H 1 -antihistamines should no longer be used in the management of allergic rhinitis. The considerably rarer but potentially very serious cardiac arrhythmogenic effects of H 1 -antihistamines are appreciated to be molecule-specific rather than class-specific. The in vitro screening of new compounds to eliminate the further development of those with cardiotoxicity ideally will lead to this adverse effect being historic. The incorporation of electrocardiogram recording in clinical trials provides direct information relating to prolongation of QT interval corrected for heart rate. Although administered at low doses, intranasal steroids still have the potential for systemic absorption and adverse consequences. However, it is appreciated that meaningful differences exist in the bioavailability of different steroid molecules, and although a small but statistically significant effect on growth in children has been identified with the long-term use of intranasal beclomethasone when administered twice daily for 1 year, this is not evident with all intranasal steroids. In addition, twice-daily intranasal steroid administration may have more effect--from the endocrinologic perspective--than once-daily administration in the morning, which coincides better with the natural diurnal variation in cortisol. Thus, once-daily intranasal steroid administration is preferable, and when used in studies in children, measurement of height change during the study period is an important outcome variable together with other indices of systemic steroid bioavailability (eg, tests of hypothalamic-pituitary-adrenal axis function). These considerations have even greater relevance if children are concurrently also receiving inhaled steroids for asthma, because the total steroid load will be greater.

Measuring functional performance in patients with COPD: a discussion of patient-reported outcome measures

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic condition and a major public health concern. Moreover, its prevalence is increasing. COPD commonly affects patient performance of daily activities that people perform in order to meet basic needs, fulfill usual roles, and maintain their health and well-being. What types of activities are affected and to what degree? How do these effects change over time? What impact, positive or negative, do various treatments have on the capacity of patients to perform activities? To address these questions, the concept of activity performance must be defined and appropriately measured.

METHODS

This paper presents a model of function that defines functional performance as distinct but related to physiological impairments and functional capacity. A systematic review of the literature was conducted to locate patient-reported outcome (PRO) instruments that have been used to capture functional performance in clinical studies of COPD and have been validated with patients with COPD. The content of each measure was reviewed to assess depth and breadth of coverage.

RESULTS

The systematic review yielded nine validated PROs used to capture functional performance in clinical studies of COPD: three are generic; six were designed specifically for use in patients with COPD. Variability in content coverage occurred across the PROs, with some sacrificing depth for breadth. Few of the PROs covered the full range of content as defined in the model. Limiting selected PROs to those that have been used with patients with COPD, while relevant to this population, may preclude other PRO instruments that can measure functional performance. The relevance of another instrument would, however, need to be confirmed with patients with COPD.

CONCLUSIONS

Selection of endpoints and instruments for clinical studies of COPD and its treatment must be driven by a clear definition of concepts of interest and the relevance of content areas to patients. Some existing instruments may provide adequate coverage of endpoints or content areas under investigation. Others clearly will not.

Application of generalizability theory confirmed lower reliability of the standard gamble than the feeling thermometer

OBJECTIVES

Recent studies suggest that rating clinical marker states (CMS) does not improve the measurement properties of the standard gamble (SG) and only slightly improves those of the feeling thermometer (FT). The poor intrarater (test-retest) reliability of CMS may explain their meager performance. Further, lack of interrater reliability may compromise the use of CMS in interpreting health state ratings. The aim of this study was to assess the reliability of CMS ratings for the SG and the FT.

STUDY DESIGN AND SETTING

Two similar studies in patients with chronic obstructive pulmonary disease (COPD, n=91) and in patients with gastroesophageal reflux disease (GERD, n=112) provided data for this analysis. Patients rated three different CMS (mild, moderate, and severe disease) twice several weeks apart. We used generalizability theory to calculate reliability coefficients.

RESULTS

Test-retest reliability for CMS ratings was higher for the FT compared to the SG (COPD: 0.86 vs. 0.67; GERD: 0.86 vs. 0.67). Interrater reliability was much higher for the FT compared to the SG (COPD: 0.78 vs. 0.46; GERD: 0.71 vs. 0.26).

CONCLUSIONS

These results suggest that the markedly poorer reliability of CMS for the SG than the FT is driven largely by poor interrater reliability.

Clinicians tend to overestimate improvements in asthma control: an unexpected observation

AIM

The original purpose of this study was to determine the Minimal Important Difference for the Asthma Control Questionnaire (ACQ) but an unexpected tendency of clinicians to overestimate improvements in asthma control thwarted the endeavour. We describe the observed clinician bias and discuss its implications for clinical practice and research.

METHODS

Ninety-four adults with inadequately controlled asthma received a full clinical consultation with one of nine asthma specialists. Medications were adjusted according to clinical needs. Four weeks later the same clinician estimated change in asthma control on a 15-point scale (-7 = a very great deal worse, 0 = no change, +7 a very great deal better). All patients completed the ACQ before each consultation but responses were not shown to the clinician.

RESULTS

Clinicians consistently recorded that patients improved more than their change in ACQ scores suggested (p = 0.018).

CONCLUSION

Clinicians should be aware of potential biases that may occur when estimating change in asthma control compared with measuring absolute status at each visit.

Patient understanding, detection, and experience of COPD exacerbations: an observational, interview-based study

STUDY OBJECTIVES

This study was conducted to gain insight into patients' comprehension, recognition, and experience of exacerbations of COPD, and to explore the patient burden associated with these events.

DESIGN

A qualitative, multinational, cross-sectional, interview-based study.

SETTING

Patients' homes.

PATIENTS

Patients (n = 125) with predominantly moderate-to-very severe COPD (age > or = 50 years; with two or more exacerbations during the previous year).

INTERVENTIONS

Patients underwent a 1-h face-to-face interview with a trained interviewer.

MEASUREMENTS AND RESULTS

During the preceding year, patients experienced a mean +/- SD of 4.6 +/- 5.4 exacerbations, after which 19.2% (n = 24) believed they had not fully recovered. Although commonly used by physicians, only 1.6% (n = 2) of patients understood the term exacerbation, preferring to use simpler terms, such as chest infection (16.0%; n = 20) or crisis (16.0%; n = 20) instead. Approximately two thirds of patients stated that they were aware of when an exacerbation was imminent and, in most cases, patients recounted that symptoms were consistent from one exacerbation to another. Some patients (32.8%; n = 41), however, reported no recognizable warning signs. At the onset of an exacerbation, 32.8% of patients (n = 41) stated that they reacted by self-administering their medication. Some patients spontaneously mentioned a fear of dying (12.0%; n = 15) or suffocating (9.6%; n = 12) during exacerbations, and effects on activities, mood, and personal/family relationships were frequently reported. Physicians tended to underestimate the psychological impact of exacerbations compared with patient reports.

CONCLUSIONS

This study shows that patients with frequent exacerbations have a poor understanding of the term exacerbation. Patient recollections suggest that exacerbation profiles vary enormously between patients but that symptoms/warning signs are fairly consistent within individuals, and are generally recognizable. Exacerbations appear to have a significant impact on patient well-being, including psychological well-being, and this may be underestimated by physicians.

Health status measurement in COPD: the minimal clinically important difference of the clinical COPD questionnaire

BACKGROUND

Patient-reported outcomes (PRO) questionnaires are being increasingly used in COPD clinical studies. The challenge facing investigators is to determine what change is significant, ie what is the minimal clinically important difference (MCID). This study aimed to identify the MCID for the clinical COPD questionnaire (CCQ) in terms of patient referencing, criterion referencing, and by the standard error of measurement (SEM).

METHODS

Patients were > or = 40 years of age, diagnosed with COPD, had a smoking history of >10 pack-years, and were participating in a randomized, controlled clinical trial comparing intravenous and oral prednisolone in patients admitted with an acute exacerbation of COPD. The CCQ was completed on Days 1-7 and 42. A Global Rating of Change (GRC) assessment was taken to establish the MCID by patient referencing. For criterion referencing, health events during a period of 1 year after Day 42 were included in this analysis.

RESULTS

210 patients were recruited, 168 completed the CCQ questionnaire on Day 42. The MCID of the CCQ total score, as indicated by patient referencing in terms of the GRC, was 0.44. The MCID of the CCQ in terms of criterion referencing for the major outcomes was 0.39, and calculation of the SEM resulted in a value of 0.21.

CONCLUSION

This investigation, which is the first to determine the MCID of a PRO questionnaire via more than one approach, indicates that the MCID of the CCQ total score is 0.4.

Exacerbations of COPD: quantifying the patient's perspective using discrete choice modelling

Patient-centred care is the current vogue in chronic obstructive pulmonary disease (COPD), but it is only recently that robust techniques have become available to determine patients' values and preferences. In this international cross-sectional study, patients' concerns and expectations regarding COPD exacerbations were explored using discrete choice modelling. A fractional factorial design was used to develop scenarios comprising a combination of levels for nine different attributes. In face-to-face interviews, patients were presented with paired scenarios and asked to choose the least preferable. Multinomial logit (with hierarchical Bayes) methods were used to estimate utilities. A total of 125 patients (82 males; mean age 66 yrs; 4.6 mean exacerbations.yr-1) were recruited. The attributes of exacerbations considered most important were impact on everyday life (20%), need for medical care (16%), number of future attacks (12%) and breathlessness (11%). The next most important attributes were speed of recovery, productive cough and social impact (all 9%), followed by sleep disturbance and impact on mood (both 7%). Importantly, analysis of utility shifts showed that patients most feared being hospitalised, housebound or bedridden. These issues were more important than symptom improvement. Strategies for the clinical management of chronic obstructive pulmonary disease should clearly address patients' concerns and focus on preventing and treating exacerbations to avoid these feared outcomes.

Relationship between respiratory symptoms and medical treatment in exacerbations of COPD

Exacerbations of chronic obstructive pulmonary disease (COPD) can be defined symptomatically or by healthcare contacts, yet the relationship between these events is unknown. Data were collected during a 1-yr study of the budesonide/formoterol combination in COPD patients, where exacerbations, defined by increases in treatment, were compared with daily records of respiratory symptoms, rescue medication use and peak expiratory flow (PEF). The relationship between changes in these variables and the medical event was examined using different modelling approaches. Data from the first exacerbation treated with oral corticosteroids and/or antibiotics and/or hospitalisation (event based) were available in 468 patients. Patients exacerbating were significantly more breathless and more likely to report cough than healthy patients, but did not differ in baseline spirometry. Exacerbations defined by changes in individual symptoms were only weakly related to event-based exacerbations; however, defined with 63% of such events being predicted from symptom changes. Changes in rescue medication use or PEF were poor predictors of event-based exacerbations. The mean peak change in symptoms was closely related to the onset of therapy. In conclusion, event-based exacerbations are a valid way of identifying acute symptom change in a chronic obstructive pulmonary disease population. However, daily symptom monitoring is too variable using the current diary cards to make individual management decisions.

Modification of the asthma quality of life questionnaire (standardised) for patients 12 years and older

Background

The age limit for some adult asthma clinical trials has recently been lowered to 12 years. In this study we have made minor modifications to the standardised version of the adult Asthma Quality of Life Questionnaire (AQLQ(S)) to make it valid for patients 12 years and older (AQLQ12+).

Methods

We have used two clinical trial databases, in which the AQLQ12+ was used, to compare the measurement properties of the questionnaire in patients 12–17 years and patients 18 years and older. A total of 2433 patients (12–75 years), with current asthma and with data that could be evaluated both at randomisation and end of treatment, were included.

Results

The analysis showed that internal consistency, responsiveness and correlations with other clinical indices were very similar in patients 12–17 years and patients 18 years and older.

Conclusion

The measurement properties of the AQLQ12+ are similar in adolescents and adults and therefore the instrument is valid for use in adult studies which include children 12 years and older.

Health-related quality of life is related to COPD disease severity

BACKGROUND

The aim of this study was to evaluate the association between health-related quality of life (HRQL) and disease severity using lung function measures.

METHODS

A survey was performed in subjects with COPD in Sweden. 168 subjects (70 women, mean age 64.3 years) completed the generic HRQL questionnaire, the Short Form 36 (SF-36), the disease-specific HRQL questionnaire; the St George's Respiratory Questionnaire (SGRQ), and the utility measure, the EQ-5D. The subjects were divided into four severity groups according to FEV1 per cent of predicted normal using two clinical guidelines: GOLD and BTS. Age, gender, smoking status and socio-economic group were regarded as confounders.

RESULTS

The COPD severity grades affected the SGRQ Total scores, varying from 25 to 53 (GOLD p = 0.0005) and from 25 to 45 (BTS p = 0.0023). The scores for SF-36 Physical were significantly associated with COPD severity (GOLD p = 0.0059, BTS p = 0.032). No significant association were noticed for the SF-36, Mental Component Summary scores and COPD severity. Scores for EQ-5D VAS varied from 73 to 37 (GOLD I-IV p = 0.0001) and from 73 to 50 (BTS 0-III p = 0.0007). The SGRQ Total score was significant between age groups (p = 0.0047). No significant differences in HRQL with regard to gender, smoking status or socio-economic group were noticed.

CONCLUSION

The results show that HRQL in COPD deteriorates with disease severity and with age. These data show a relationship between HRQL and disease severity obtained by lung function.

Measurement properties and interpretation of three shortened versions of the asthma control questionnaire

The Asthma Control Questionnaire (ACQ) measures the adequacy of asthma treatment as identified by international guidelines. It consists of seven items (5 x symptoms, rescue bronchodilator use and FEV1% of predicted normal). A validation study suggested that in clinical studies measurement of FEV1 and bronchodilator use may not be needed but this has never formally been tested in a clinical trial. The aims of this analysis were (1) to examine the measurement properties of three shortened versions of the ACQ (symptoms alone, symptoms plus FEV1 and symptoms plus short-acting beta2-agonist) and (2) to determine whether using the shortened versions would alter the results of a clinical trial. In the randomised trial, 552 adults completed the ACQ at baseline and after 13 and 26 weeks of treatment. The analysis showed that the measurement properties of all four versions of the ACQ are very similar. Agreement between the original ACQ and the reduced versions was high (intraclass correlation coefficients: 0.94-0.99). Mean differences between the ACQ and the shortened versions were less than 0.04 (on the 7-point scale). Clinical trial results using the four versions were almost identical with the mean treatment difference ranging from -0.09 (P=0.17), to -0.13 (P=0.07). For interpretability, the minimal important difference for all four versions was close to 0.5. In conclusion, these three shortened versions of the ACQ can be used in large clinical trials without loss of validity or change in interpretation.

Asthma treatment needs: a comparison of patients' and health care professionals' perceptions

BACKGROUND

Patients' perceptions of asthma tend to differ from those of clinicians, who primarily focus on asthma control. Patients' treatment needs and preferences may not be adequately addressed.

OBJECTIVE

The aims of this study were as follows: to provide data on unmet treatment needs and to investigate the main finding of a qualitative study using a questionnaire study.

METHODS

To assess treatment needs in patients with asthma, focus groups were conducted with patients/parents and clinicians. Based on these results, quantitative surveys of adult patients and parents were performed in the United Kingdom, Germany, and Spain.

RESULTS

The UK focus group comprised 11 patients and 8 parents; in Germany, there were 10 patients and 11 parents; in Spain, there were 5 patients and 8 parents. The focus groups showed some differences between clinicians' and patients'/parents' perceptions of treatment. For patients, side effects meant long-term effects (ie, 10-20 years); for clinicians, it meant occasional local problems. The quantitative study comprised 454 participants: 310 adult patients (mean [SD] age, 37.13 [13.12] years) and 142 parents (children's mean [SD] age, 13.98 [1.37] years), plus 2 nonspecified. Some patients reported good asthma control and simultaneously reported frequent exacerbations. Most patients and parents expressed a preference for a simpler regimen using fewer drugs, and most had concerns about their treatment. Although some patients concurred with treatment guidelines, 62.2% tended to rely on reliever medication (ie, bronchodilators). Additionally, 6.9% described their asthma as very well-controlled but reported experiencing asthma symptoms > or =3 days per week. Finally, 1.9% of patients and 2.1% of parents reporting very well-controlled asthma also reported visiting the emergency department or calling a physician for a home visit in the previous 3 months.

CONCLUSIONS

Asthma patients and parents of asthmatic children had unmet treatment needs and may interpret medical terminology differently than clinicians.

Measuring symptom response to pharmacological interventions in patients with COPD: a review of instruments used in clinical trials

OBJECTIVES

To identify and evaluate the instruments used to measure the effect of pharmacological intervention on symptoms of chronic obstructive pulmonary disease (COPD) in clinical trials.

DESIGN

An extensive literature search was conducted for articles published in English in a peer-reviewed journal from 1995 to March 2002 which described a randomised controlled clinical trial measuring symptoms of COPD in response to pharmacological interventions.

PATIENTS

Patients with any severity of COPD.

INTERVENTIONS

Any pharmacological intervention for treatment of COPD.

MEASUREMENTS AND RESULTS

A total of 43 eligible articles were identified. The individual symptoms most frequently measured were dyspnoea/breathlessness, chest tightness or discomfort and exacerbations. There was considerable variability in the methods, terminology and symptom measurement instruments used. The most widely used instruments for measuring dyspnoea were the Borg scale, the Baseline Dyspnoea Index and the Transitional Dyspnoea Index. None of the instruments used had published evidence of rigorous psychometric testing.

CONCLUSIONS

Numerous methods have been employed to assess the symptoms of COPD in clinical trials, making it difficult to compare the results of different trials. No single measurement instrument predominates, and none of the measures identified in the review have undergone rigorous psychometric testing in this patient population. There is a clear need for a fully developed and validated tool for measuring the effects of therapeutic interventions on symptoms in COPD in clinical trials.

Measuring health-related quality of life in adults during an acute asthma exacerbation

BACKGROUND

Acute severe asthma can be distressing for patients. It is important to be able to identify the causes of the distress so that these can receive attention in conjunction with the conventional treatment of the airways.

STUDY OBJECTIVE

To modify the Asthma Quality of Life Questionnaire (AQLQ) for evaluating patients with acute severe asthma and to test the measurement properties of the Acute Asthma Quality of Life Questionnaire (Acute AQLQ).

METHODS

The Acute AQLQ contains the symptom and emotional function items of the AQLQ (n = 11), which are capable of changing over short periods of time. The measurement properties were tested during a clinical trial to compare formoterol and salbutamol in the treatment of acute severe asthma in hospital emergency departments.

RESULTS

The 88 patients in the clinical trial provided evidence that the Acute AQLQ has high internal consistency (Cronbach alpha = 0.90) and is very responsive to change in status (p < 0.00001) with a responsiveness index of 2.5. Correlations between the Acute AQLQ and other measures of clinical status provided evidence of the validity of the instrument.

CONCLUSION

The Acute AQLQ has strong measurement properties and can be used with confidence to identify the problems that are distressing to patients during an acute asthma exacerbation and to evaluate the effectiveness of interventions.

Psychometric and utility-based measures of health status of asthmatic patients with different disease control level

OBJECTIVE

To explore the relationship between asthma control level and health-related QOL (HR-QOL), and to understand the role of various psychometric and utility-based methods in studying this relationship.

METHODS

Two hundred and twenty-eight consecutive adult outpatients and inpatients at four sites participated in the study. Physicians identified the level of disease control according to the Global Initiative for Asthma (GINA) classification system. Patients filled in three different HR-QOL questionnaires (EuroQol 5-D [EQ-5D], Short-Form 36-item health survey [SF-36], and St George's Respiratory Questionnaire [SGRQ]) and a direct time trade-off question. The Short Form-6D (SF-6D) was used to derive utility values from SF-36 data.

RESULTS

All patient-reported evaluation methods could discriminate between patients with different disease control levels, and both generic and disease-specific instruments strongly correlated to each other. The magnitude of differences in HR-QOL between groups with different disease control levels was clinically meaningful. All three HR-QOL measures reflected a relationship between disease control level and HR-QOL, but the actual pattern of the relationship depended on the instrument used. Utilities gained from the EQ-5D index, compared with the SF-6D index, had higher values in the patient group with the best disease control and lower values in the patient group with poor disease control.

CONCLUSION

When choosing an instrument to measure the health status of asthmatic patients in clinical studies, the severity range of the study population should be considered. Researchers might prefer to use the EQ-5D in asthma patients with severe disease or poor disease control and the SF-6D in patients with mild disease or good disease control.

The impact of exacerbations on the asthmatic patient's preference scores

The purpose of this study was to examine the effect of exacerbations on mild to moderate asthmatic patients' preference-based, health-related, quality of life scores and also to describe the effect of these exacerbations on daily life. In a survey, 100 mild to moderate asthmatic patients in the United Kingdom were asked to rate three different health marker states on a scale between 0 (death) and 100 (perfect health), defined as: your asthma of today, a mild exacerbation, and a severe exacerbation of asthma. They were also asked to describe their symptoms and what they did when experiencing an exacerbation. During exacerbations the vast majority of asthmatic patients have significant symptoms and consume a considerable amount of health care resources, which often overlap. The health marker state "your asthma of today" was given a mean score of 81.0, a mild exacerbation a score of 62.1, and a severe exacerbation a score of 25.6, indicating a large impact on patients' daily life and their health-related quality of life. In conclusion, asthmatic patients are severely affected in their health and daily living by mild and severe exacerbations. Considerable effort should be made to reduce the number and severity of exacerbations.

Formoterol used as needed improves health-related quality of life in asthmatic patients uncontrolled with inhaled corticosteroids

Clinical benefits have been shown to occur when using the long-acting beta2-agonist formoterol 4.5 microg for as-needed medication rather than terbutaline 500 microg in patients with unstable asthma taking an inhaled corticosteroid. This study compared their effects on health-related quality of life and the relation with conventional clinical indices in the same population. 362 asthmatics were randomized to use either formoterol 4.5 microg or terbutaline 500 microg as needed, both inhaled via Turbuhaler. The Asthma Quality of Life Questionnaire (AQLQ) was practised at enrolment and completed by 341 patients after randomization and at 4, 8, and 12 weeks. Clinical indices were measured at the same time points. Mean overall AQLQ scores were comparable at baseline, being 4.90 in the formoterol and 4.82 in the terbutaline group and improved during treatment by 0.41 and 0.17 units, respectively (mean difference 0.24, 95% CI 0.08, 0.39, P<0.005). Mean improvement in the symptom domain was 0.49 units when using formoterol. Correlations between changes in clinical indices and changes in AQLQ scores during the 12-week period were weak (maximum r value=0.37). When used for as-needed medication, formoterol 4.5 microg provided an improvement in asthma-specific quality of life and to a somewhat greater extent than the widely used terbutaline 500 microg. The symptom domain in AQLQ showed almost 0.5 units improvement after formoterol, a change that is considered to be clinically relevant.

Health-related quality of life in asthma studies. Can we combine data from different countries?

The aim was to compare health-related quality of life (HRQL) in patients with asthma from 4 countries, and to investigate the correlations between HRQL and clinical indices.341 patients; 140 (Sweden), 54 (Norway), 65 (the Netherlands) and 82 (Greece) were treated with formoterol fumarate 4.5 microg or with terbutaline sulphate 0.5mg for 12 weeks inhaled 'on demand' via Turbuhaler. The Asthma Quality of Life Questionnaire (AQLQ) and clinical indices were assessed. The mean baseline AQLQ overall scores in Sweden (4.97), in the Netherlands (5.04), in Norway (4.68) and in Greece (4.68) were in the same range, however, with a significant difference between the four countries (p=0.038). When comparing AQLQ, activity limitation and symptoms domains, the differences between the countries were not statistically significant. The cross-sectional correlations between AQLQ overall score and the clinical indices were similar in all four countries. The magnitude of change in AQLQ was consistent with the other clinical variables. The correlations between change in AQLQ overall score and change in clinical indices were low to medium in all countries. In conclusion, the consistency of cross-sectional correlations between the AQLQ overall and clinical indices across countries supports the validity of translations of the AQLQ used in this study. There were differences in baseline values between the countries. The treatment response in AQLQ differed to the same extent as other clinical indices. When combining HRQL data from different countries, there might be cultural, gender and socio-economic differences, explaining different responses to treatment.

Health-related quality of life, utility, and productivity outcomes instruments: ease of completion by subjects with COPD

An important outcome of any clinical intervention is the change in the subject's own perceived state of health. This can be categorized as health-related quality of life (HRQL), utility (preference-based health state), and daily life performance. 174 Swedish subjects with chronic obstructive pulmonary disease (COPD) (mean age 64.3 PlusMinus; 12 years) completed five self-administered questionnaires: Short Form 36 (SF-36), St George's Respiratory Questionnaire (SGRQ), EuroQol-5D (EQ-5D), Health States-COPD (HS-COPD), and Work Productivity and Activity Impairment Questionnaire for COPD (WPAI-COPD). The subjects scored these outcomes instruments for ease of completion using a 5-point scale. The time taken to complete them was noted and the administrators' opinion of the subjects' comprehension of the questionnaires recorded using a 4-point scale. A score of 1-3 ("very easy" to "acceptable") was recorded by 92% of subjects for the SF-36, 90% for SGRQ, 80% for EQ-5D, 83% for WPAI-COPD, and 53% for HS-COPD. The HS-COPD was graded "very difficult" to complete by 21% of subjects compared with 3-5% of subjects for the other questionnaires. The mean time taken to complete all questionnaires was 39 minutes, and the large majority of subjects scored "good" for understanding by the administrator. Age correlated significantly with the degree of the subject's opinion of the ease of completion of five outcomes instruments, while the influence of gender, socio-economic status and disease severity was not statistically significant.

One-year safety and efficacy of budesonide/formoterol in a single inhaler (Symbicort Turbuhaler) for the treatment of asthma

BACKGROUND

A budesonide/formoterol single inhaler has been developed for convenient treatment of patients whose asthma is inadequately controlled by inhaled glucocorticosteroids alone.

OBJECTIVES

To compare long-term safety and efficacy of budesonide/formoterol single inhaler with budesonide plus formoterol via separate inhalers in adults with asthma.

METHODS

In this open, randomized, parallel-group 6-month extension conducted in a subset of centres from a previous 6-month study, patients (n=321) received two inhalations bid of budesonide/formoterol (Symbicort Turbuhaler) 160/4.5 microg delivered dose or corresponding doses of budesonide (Pulmicort Turbuhaler) plus formoterol (Oxis Turbuhaler) via separate inhalers.

RESULTS

Significantly fewer patients receiving budesonide/formoterol single inhaler withdrew compared with budesonide plus formoterol (9 vs. 19%, P=0.008). Incidence and severity of AEs were low and similar in both groups. No clinically important differences between groups, or changes, were identified in laboratory measurements, vital signs or ECG. Treatments produced similar improvements in lung function, ACQ scores and Mini AQLQ domains that were maintained throughout 12 months.

CONCLUSIONS

Budesonide/formoterol in a single inhaler is as safe and effective in the long-term treatment of asthma as budesonide plus formoterol via separate inhalers. The lower number of withdrawals with budesonide/formoterol may reflect better adherence to treatment compared with budesonide plus formoterol.

A health-related quality-of-life comparison of formoterol (Oxis) Turbuhaler plus budesonide (Pulmicort) Turbuhaler with budesonide Turbuhaler alone and noncorticosteroid treatment in asthma: a randomized clinical study in Russia

BACKGROUND

In Russia, current therapy for the long-term management of asthma is mainly nonsteroidal. This situation provides the opportunity to evaluate new asthma treatments in a patient cohort with little previous exposure to inhaled corticosteroids.

OBJECTIVES

To compare the effect of formoterol (Oxis) Turbuhaler plus budesonide (Pulmicort) Turbuhaler with budesonide Turbuhaler alone, on the health-related quality of life (HRQL) of patients with mild to moderate asthma.

METHODS

A double-blind, parallel-group, randomized, 12-week study compared formoterol Turbuhaler plus budesonide Turbuhaler and budesonide Turbuhaler alone with an open control group of the investigator's choice of noncorticosteroid therapy. Patients completed the Short Form 36 (SF-36) and the Asthma Quality of Life Questionnaire (AQLQ).

RESULTS

The improvement in HRQL scores for patients treated with noncorticosteroids was significantly less (p < 0.05) than those treated with formoterol plus budesonide and budesonide alone in all domains of the SF-36 and AQLQ with one marginal exception (budesonide versus investigator's choice, SF-36, Mental Component Scale, p = 0.053). Improvements in HRQL scores of formoterol plus budesonide, compared with budesonide alone, although generally higher, were not significantly different. Formoterol plus budesonide was more effective in improving lung function and reducing both symptoms and the need for relief terbutaline inhalation.

CONCLUSION

Formoterol Turbuhaler plus budesonide Turbuhaler and budesonide Turbuhaler alone significantly improved the HRQL of patients with mild to moderate asthma compared with noncorticosteroid treatment.

Budesonide/formoterol (Symbicort) is well tolerated and effective in patients with moderate persistent asthma

The aim of this study was to compare the safety and efficacy of budesonide/formoterol 160/4.5 microg, two inhalations twice daily, with that of the mono-products administered at the same daily doses via separate inhalers. A total of 586 patients (mean age 45 years) was included in this six-month, open, randomised, multicentre study. Patients received either budesonide/formoterol (n=390) or budesonide plus formoterol (n=190). Safety was assessed by adverse events, vital signs and laboratory values. Efficacy was evaluated using spirometry tests, the Mini Asthma Quality of Life Questionnaire and the Asthma Control Questionnaire. Both treatments were well tolerated, with no differences in safety parameters between the groups. Mean FEV1 increased by 5-6% over baseline in both groups. There was no significant difference in the change from baseline between the groups using the disease-specific questionnaires. Asthma exacerbations occurred with low frequency in both groups. Withdrawal rates were also comparable between the groups (p=0.085). Budesonide/formoterol in a single inhaler was as effective and as well tolerated as budesonide plus formoterol via separate inhalers.

Topoisomerase II-alpha expression in different cell cycle phases in fresh human breast carcinomas

Topoisomerase II-alpha (topo II alpha) is the key target enzyme for the topoisomerase inhibitor class of anti-cancer drugs. In normal cells, topo II alpha is expressed predominantly in the S/G2/M phase of the cell cycle. In malignant cells, in vitro studies have indicated that the expression of topo II alpha is both higher and less dependent on proliferation state in the cell. We studied fresh specimens from 50 cases of primary breast cancer. The expression of topo II alpha in different cell cycle phases was analyzed with two-parameter flow cytometry using the monoclonal antibody SWT3D1 and propidium iodide staining. The expression of topo II alpha was significantly higher in the S/G2/M phase of the cell cycle than in the G0/G1 phase in both DNA diploid and DNA non-diploid tumors. In 18 of 21 diploid tumors, and in 25 of 29 non-diploid tumors, >50% of the topo II alpha-positive cells were in the G0/G1 phase. This significant expression of topo II alpha in the G0/G1 phase of the cell cycle may have clinically important implications for treatment efficacy of topoisomerase II inhibitors.

Expression of topoisomerase IIalpha in the G0/G1 cell cycle phase of fresh leukemic cells

Topoisomerase IIalpha (topo IIalpha) is the target enzyme for several antineoplastic drugs. Correlation between low expression of topo IIalpha and drug resistance has been shown in vitro, but there is limited evidence of a correlation to initial response to treatment or to overall prognosis. Normal cells express topo IIalpha in S/G2/M phase of the cell cycle but not in G0/G1 phase. However, some data suggest that topo IIalpha could be expressed in G0/G1 phase in malignant cells. We have investigated the expression of topo IIalpha in leukemic cells from 25 patients with acute leukemia by flow cytometry, separating cells of different cell cycle phases. We demonstrated that 9/25 samples showed >50% positive cells in G0/G1, and another five samples showed >20%. This finding could possibly provide an explanation to previous difficulties in correlating topo IIalpha expression with clinical outcome. Six of eight patients, where >20% of the cells in G0/G1 were positive for topo IIalpha, entered CR, compared to one of five patients with <20% topo IIalpha positive cells in G0/G1. We suggest that topo IIalpha expression in G0/G1 in leukemic cells may be of predictive value for clinical response to cytostatic drugs.

Correlation between objective measures of airway calibre and clinical symptoms in asthma: a systematic review of clinical studies

Clinical symptoms are often used as a measure in asthma management, but a variety of symptoms and scales are available. The objectives of this systematic review were as follows: (a) to present correlations between symptoms and measures of airway calibre; (b) to present the scoring systems/ scales used in the publications. In the review, more than 10 000 publications were found under the key words: asthma and symptom(s). Twenty-one remained when FEV1/PEF, scale/score and correlation were added as key words. In summary, no standardized method exists for measuring asthma symptoms with respect to severity. This is the case for both the symptoms and the scales. There are two recently-developed asthma-control scales available (one of which has not yet been published and is not included in the review).

Cost-effectiveness analysis of budesonide aqueous nasal spray and fluticasone propionate nasal spray in the treatment of perennial allergic rhinitis

BACKGROUND

An economic evaluation was performed analyzing direct medical costs in Canada for the treatment of perennial allergic rhinitis (PAR) with budesonide aqueous nasal spray and fluticasone propionate nasal spray. Three hundred fourteen patients with at least a 1-year history of PAR were randomized into a double-blind, parallel-group study of 6 weeks' duration. The treatments were daily doses of budesonide 256 microg, fluticasone propionate 200 microg, or placebo. Both active treatments produced significantly lower mean scores for overall nasal symptoms compared with placebo, and both were well tolerated. Budesonide was significantly more effective than fluticasone in reducing "blocked nose."

METHOD

A retrospective cost-effectiveness analysis utilizing the clinical trial data was performed on the total costs of (1) budesonide-based and (2) fluticasone-based treatment strategies, including the relative importance of the drug costs in both strategies.

RESULTS

The average treatment cost per patient in Canada over 12 months in the budesonide group was CAD 389.85 which was 23.3% lower than in the fluticasone group, which was CAD 508.06, due to lower drug acquisition costs (for the year 1998).

CONCLUSION

Budesonide aqueous nasal spray was shown to be more cost-effective than fluticasone propionate nasal spray in the treatment of perennial allergic rhinitis. This result is valid in the province of Ontario, Canada and in many other settings with the same structure of relative prices. The result is mainly driven by a difference in drug cost.

Neuron-specific enolase increases in plasma during and immediately after extracorporeal circulation

BACKGROUND

Minor cerebral complications are common after cardiac surgery. Several biochemical markers for brain injury are under research; one of these is neuron-specific enolase (NSE). The purpose of this study was to investigate the release of this enzyme into the blood during and immediately after extracorporeal circulation and to evaluate the effect of hemolysis on this release.

METHODS

Sixteen patients scheduled for elective heart surgery were included in the study. Blood samples for analysis of NSE and free hemoglobin in plasma were drawn before, during, and up to 48 hours after the end of extracorporeal circulation. The release of NSE from erythrocytes and its correlation to the release of free hemoglobin was studied by serial dilution and hemolysis in vitro.

RESULTS

The peri- and postoperative course was uneventful in all patients. Extracorporeal circulation initiated a release of NSE that reached a maximum 6 hours after the end of perfusion. Thereafter, the levels declined with an estimated t1/2 of 30 hours. The concentration of free hemoglobin increased during the perfusion, with maximum levels at the end of perfusion, after which they fell rapidly to normal values. The in vitro study showed a strong linearity between the release of NSE and free hemoglobin after induced hemolysis.

CONCLUSIONS

The increased levels of enolase at the end of cardiopulmonary bypass can, to a major part, be explained by the release from hemolysed erythrocytes. The value of NSE as a marker for brain injury in these situations is therefore doubtful.

High-dose inhaled budesonide may substitute for oral therapy after an acute asthma attack

Patients attending the emergency room with acute asthma, participating in a study comparing salbutamol (albuterol in the United States) via a dry powder inhaler (Turbuhaler) with pressurized metered-dose inhaler (pMDI), were included in this 1-week follow-up study with the aim of assessing whether inhaled budesonide via Turbuhaler may be an alternative to prednisolone tablets after an acute asthma attack. Eighty-one patients with a mean age of 38 years and forced expiratory volume in 1 sec (FEV1) of 64% predicted normal value after treatment with salbutamol were randomized in this double-blind, double-dummy, parallel-group study. The doses given were budesonide 1600 microg b.i.d. or prednisolone in daily doses from 40 mg (day 1) decreased to 5 mg (day 7). FEV1 was recorded before and after the 7-day treatments and peak expiratory flow (PEF) morning and evening, clinical symptoms (visual analogue scale 0-100), and doses of rescue medication (terbutaline Turbuhaler 0.25 mg/dose) were recorded daily. The mean increase in FEV1 from baseline to day 7 was 17.3% in the budesonide Turbuhaler group and 17.6% in the prednisolone group. Mean values of morning PEF increased from day 1 to day 7 by 67 L/min in the budesonide Turbuhaler group and by 57 L/min in the prednisolone group (not significant). There were no statistically significant differences between the groups in clinical symptoms and in the number of doses of rescue medication. Because of disease deterioration, five patients in the Turbuhaler group and three in the prednisolone group needed additional symptomatic as well as corticosteroid treatment. Inhaled budesonide in high doses may be a substitute for oral therapy as follow-up treatment after an acute asthma attack.

Beta 2-agonists administered by a dry powder inhaler can be used in acute asthma

Patients with acute asthma attending the emergency room were included in a double-blind, double-dummy and parallel group study to investigate whether a dry powder inhaler (Turbuhaler) can be used in acute asthma. If so, the aim was to establish the potency relationship between a beta 2-agonist (salbutamol) administered by the dry powder inhaler and the pressurized metered-dose inhaler (pMDI). Eighty-six patients with a mean age of 38 years and forced expiratory volume in 1 s (FEV1) of 37% of predicted normal value were randomized at Siriraj Hospital in Bangkok to either Turbuhaler (50 micrograms dose -1) or pMDI (100 micrograms dose -1) with spacer (Volumatic). Doses of 100 + 300 + 300 + 300 micrograms salbutamol were given at 0, 15, 30 and 45 min via Turbuhaler and repeated at 90, 105, 120 and 135 min (total dose 2000 micrograms). The same inhalation schedule with identical number of doses was used for the pMDI with spacer but in double doses (total 4000 micrograms), assuming a dose-potency ratio of salbutamol administered via Turbuhaler compared with the pMDI of 2:1. At 85 min after the first dose, 60 mg prednisolone was given orally. FEV1 was measured 10 min after each dosing. Peak inspiratory flow (PIF) through Turbuhaler was measured on each dosing occasion. Plasma (P)-salbutamol, serum (S)-potassium concentrations, pulse rate, blood pressure and adverse events were recorded. No statistically significant differences were observed in the increase in FEV1 between the groups: 55 min (165 min) after the first dose, the increase was 0.47 l and 47% (0.64 l and 63%) in the Turbuhaler group, and 0.46 l and 42% (0.68 l and 65%) in the pMDI group. Mean PIF though Turbuhaler was 49 l min -1 (range 26-68) at first inhalation and increased to 60 l min -1 (range 38-86). There was no correlation between the initial PIF through Turbuhaler and the initial FEV1 response. P-salbutamol and S-potassium values correlated well. A larger decrease in S-potassium was noticed after 75 min in the pMDI group (0.38 mmol l -1) compared with the Turbuhaler group (0.23 mmol l -1) (P = 0.02). In conclusion, the use of a dry powder inhaler, Turbuhaler, was investigated in the emergency room treatment of acute asthma, and was as effective as a pMDI with spacer. Half the dose of salbutamol administered via Turbuhaler was as effective as the full dose given via a pMDI with spacer.

The appearance of S-100 protein in serum during and immediately after cardiopulmonary bypass surgery: a possible marker for cerebral injury

OBJECTIVE

To investigate the appearance and elimination of brain-specific S-100 protein in serum during and immediately after cardiopulmonary bypass.

DESIGN

Prospective study.

PARTICIPANTS

Twenty-nine patients undergoing elective cardiac surgery.

INTERVENTIONS

Twenty-seven patients were operated on for coronary artery disease; two patients had valve replacement. Serial measurements of S-100 in arterial blood during and up to 48 hours after cardiopulmonary bypass were made.

MEASUREMENTS AND MAIN RESULTS

The perioperative and postoperative course was uneventful in 25 patients, with no clinical signs of neurologic complications. S-100 was not detected before extracorporeal circulation was started. Detectable concentrations (detection limit, 0.2 microgram/L) appeared in serum after 10 minutes of perfusion and reached maximum levels, 2.43 +/- 0.3 micrograms/L, at the end of bypass. The levels then declined with elimination t1/2 of 2.2 hours. Only two patients had detectable concentrations of S-100 48 hours after the end of bypass. In four patients who developed clinical signs of cerebral injury, levels of S-100 were significantly higher at the end of bypass and 24 hours after the end of bypass.

CONCLUSIONS

Cardiopulmonary bypass initiates a release of brain-specific S-100 to the systemic circulation. The release and elimination of S-100 seem to follow a reproducible pattern in patients with no signs of cerebral injury. In patients who developed cerebral injury, the concentrations of S-100 in blood were increased, thus suggesting that S-100 may be a usable marker for cerebral injury after extracorporeal circulation.

Dose response to inhaled terbutaline powder and peak inspiratory flow through Turbuhaler in children with mild to moderate asthma

The purpose of this study was to investigate the relative effectiveness of 0.25 mg, 0.5 mg, and 1.0 mg of terbutaline, administered via Turbuhaler, in children with mild to moderate asthma, and to register peak inspiratory flow rates through Turbuhaler (PIFTBH). Thirty-seven children in Portugal (one center) and 45 children in Sweden (one center) aged 3-10 years participated in two separate, double-blind, placebo-controlled, crossover, and randomized studies of the same design. Because of differences in other therapies for asthma and climate, combination of the two studies into one metanalysis did not appear appropriate. The children inhaled 0.25 mg, 0.5 mg, and 1.0 mg terbutaline sulfate and placebo t.i.d. for consecutive 2-week periods without washout periods. Peak expiratory flow rates (PEF) were measured at home before and 15 minutes after each inhalation in the morning, afternoon, and evening. PIFTBH was measured twice at each of four clinic visits. At the Portuguese center the increases in mean morning PEF from before to after inhalation were 32 L/min after 0.25 mg, 35 L/min after 0.5 mg, and 40 L/min after 1.0 mg. The corresponding figures in Sweden were 26 L/min, 31 L/min, and 29 L/min after 0.25 mg, 0.5 mg, and 1.0 mg, respectively. For children 3-6 years, mean values for PIFTBH were 60 L/min in Portugal (n = 15), and 58 L/min in Sweden (n = 23). In the 7-10 year group the mean PIFTBH was 72 L/min (n = 22) in Portugal, and 68 L/min (n = 22) in Sweden. We conclude that inhalation of terbutaline sulfate via Turbuhaler at a small dose of 0.25 mg resulted in good bronchodilation and was comparable to inhalations of 0.5 mg and 1.0 mg in children aged 3-10 years with mild to moderate asthma. PIFTBH were comparable to values previously recorded in healthy 6-year-old and older children and in adult asthmatic patients.

A 1-year comparison of turbuhaler vs pressurized metered-dose inhaler in asthmatic patients

An open, randomized, parallel-group study was conducted to investigate whether asthmatic patients, considered adequately treated with a corticosteroid and/or short-acting beta 2-agonist via pressurized metered-dose inhaler (pMDI), could be transferred to a corresponding nominal dose of budesonide and/or terbutaline via Turbuhaler, an inspiratory flow-driven multidose dry powder inhaler (Astra Draco; Lund, Sweden), without a decrease in the effect of treatment. One thousand four patients (555 women; mean age, 44 years; mean peak expiratory flow [PEF], 102% predicted normal value) were randomized and treated with either pMDI (current therapy) or Turbuhaler for 52 weeks. The variables studied were asthma-related events, morning PEF, and inhaler-induced clinical symptoms. Asthma-related events were defined in two ways: (1) sum of health-care contacts plus doublings or additions of steroids, and (2) number of 2 consecutive days with PEF less than 80% of baseline. Baseline was obtained from a 2-week run-in period while receiving previous therapy. No statistically significant difference was found in asthma-related events according to definition 1. According to definition 2, there was a statistically significant difference between the groups in favor of Turbuhaler (p = 0.008). The mean number of events was 1.7 with Turbuhaler and 2.2 with pMDI. The mean number of weeks per patient with a PEF less than 90% of baseline was 4.5 with Turbuhaler compared with 6.0 with pMDI (p = 0.002). The sum of inhaler-induced symptoms after 1 year of use was statistically significantly lower with Turbuhaler (0.40) than with pMDI (0.75) (p = 0.0001). In conclusion, budesonide and terbutaline in Turbuhaler offered a superior alternative to corticosteroids and bronchodilators delivered by pMDIs in the maintenance treatment of asthma.

The inhalation device influences lung deposition and bronchodilating effect of terbutaline

The development of new inhalation devices for asthma drugs raises the issue of the relationship between pulmonary deposition and therapeutic effect of inhaled drugs in patients with obstructive lung diseases. We thus conducted a randomized, double-blind and double-dummy, four-period crossover study in 13 patients with moderate asthma (mean age 36 yr; FEV1 59% of predicted), who inhaled 0.25 and 0.5 mg terbutaline sulphate on separate occasions either via a pressurized metered dose inhaler (pMDI) or Turbuhaler (TBH). Pulmonary deposition was 8.1 +/- 2.7% and 8.3 +/- 2.3%, respectively, of the nominal dose for pMDI and 19.0 +/- 7.3%, and 22.0 +/- 8.1% for TBH. The FEV1 increase after 0.25 mg terbutaline sulphate via TBH was significantly greater than after 0.25 mg via pMDI. No significant differences in FEV1 increase were observed between 0.25 mg via TBH, 0.5 mg via pMDI, or 0.5 mg via TBH. Other lung function variables showed similar dose- and device-related changes. We concluded that: (1) the dose of terbutaline sulphate deposited in the lungs is dependent on which inhalation system is used; (2) TBH delivers about twice the amount of drug to the lungs as the pMDI; and (3) the observed difference in deposition is reflected in the bronchodilating effect.

Serum S100 protein: a potential marker for cerebral events during cardiopulmonary bypass

BACKGROUND

There is no simple method to determine the incidence or severity of brain injury after a cardiac operation. A serum marker equivalent to cardiac enzymes is required. S100 protein leaks from the cerebrospinal fluid to blood after cerebral injury. We sought to determine the pattern of release after extracorporeal circulation (ECC).

METHODS

Thirty-four patients without neurologic problems underwent coronary bypass using ECC. Four had carotid stenoses. Nine others underwent coronary bypass without ECC. Serum S100 levels were measured before, during, and after the operation.

RESULTS

S100 was not detected before sternotomy. Postoperative levels of S100 were related to duration of perfusion (r = 0.89, p < 0.001). Patients who did not have ECC had undetectable or fractionally raised levels except in 1 who suffered a stroke. No patient in whom ECC was used suffered an event, but those with carotid stenosis had greater S100 levels.

CONCLUSIONS

S100 protein leaks into blood during ECC and may reflect both cerebral injury and increased permeability of the blood brain barrier. S100 is a promising marker for cerebral injury in cardiac surgery if elevated levels can be linked with clinical outcome.

Cerebral complications after cardiac surgery assessed by S-100 and NSE levels in blood

OBJECTIVE

Assessment of the value of blood analysis of the astroglia protein, S-100, and neuron-specific enolase for the detection of nervous system dysfunction after cardiac surgery.

DESIGN

Prospective study. Neurologists blinded from laboratory results.

SETTING

University hospital.

PARTICIPANTS

38 patients undergoing cardiac surgery.

INTERVENTIONS

21 patients were operated for coronary artery disease; seven patients with replacement of the aortic valve of whom 2 also had coronary bypass. Four patients had mitral valve replacement of whom 2 also had coronary bypass. One patient had both aortic and mitral valve replacement and coronary bypass. Two patients were operated on because of aortic arch aneurysm.

MEASUREMENTS AND MAIN RESULTS

Neurologic examinations were performed before and after surgery. General behavior of the patients was repeatedly assessed. Blood samples for analysis were collected before operation and on the second day after surgery. In 8/38 patients (21%), a neurologic complication, one of which was lethal, occurred. In 27 patients (71%), the neurologic outcome was uncomplicated, and in 3 (8%), it could not be classified. Elevated S-100 and neuron-specific enolase levels were found in 7/8 patients who endured a neurologic complication and in 4/27 free of complication. (Fisher's exact test p < 0.001). Positive and negative predictive values were 64% and 96%, respectively. S-100 (range 0.5 to 1.3 micrograms/L) and neuron-specific enolase levels (range 8.6 to 16.7 micrograms/L) were lower for the 7 patients with nonlethal complications than for the patient who died (9.5 micrograms/L and 31.3 micrograms/L, respectively).

CONCLUSIONS

S-100 and neuron-specific enolase levels after cardiac surgery are associated with neurologic complications. The results have implications on patient-related treatment and prognosis as well as for the development of safer perfusion techniques.

Dose potency relationship of terbutaline inhaled via Turbuhaler or via a pressurized metered dose inhaler

OBJECTIVE

The relative dose potency of cumulative doses of terbutaline sulfate inhaled via Turbuhaler and via a pressurized metered dose inhaler was estimated with respect to lung efficacy and systemic effect.

METHODS

The study was an open, crossover, randomized, multicenter study including 31 adult patients with asthma [forced expiratory volume in one second (FEV1), 65% of predicted]. The patients inhaled terbutaline doses of 0.125, 0.125, 0.25, 0.5, 1.0, and 2.0 mg (a total of 4 mg) at 30-minute intervals. Lung function [FEV1, forced vital capacity (FVC), forced expiratory flow at 75% of FVC (FEF75%), and peak expiratory flow (PEF)], and systemic effect variables (serum potassium, tremor, pulse, blood pressure) were monitored prior to the first inhalation and 15 to 25 minutes after each inhaled dose.

RESULTS

The mean relative dose potency of terbutaline inhaled via Turbuhaler compared with pressurized metered dose inhaler was 1.5 (95% confidence interval: 1.2 to 1.8) with respect to FEV1 and serum potassium, respectively. The corresponding relative dose potencies for PEF, FVC, and FEF75% were 1.0, 1.2, and 1.6, respectively, with no statistically significant difference between the two devices. No differences between the devices were evident with regard to blood pressure and pulse.

CONCLUSION

The results suggest that Turbuhaler is more efficient in the delivery of inhaled terbutaline to the lungs compared with the conventional pressurized metered dose inhaler.

Comparison of Bricanyl Turbuhaler and Ventolin Rotahaler in children with asthma

BACKGROUND

Pulmonary administration of beta 2-agonists by means of pressurized metered dose inhaler is widely used in the treatment of asthma. Young children have difficulties in using these inhalers unless a spacer device is used. To overcome this problem inspiratory flow driven dry powder inhalers have been developed.

OBJECTIVE

The aim of this study was to compare the efficacy and safety of the two powder inhalers Bricanyl Turbuhaler (terbutaline sulphate 0.5 mg t.i.d.) and Ventolin Rotahaler (salbutamol 0.4 mg t.i.d.) in 20 children 2 to 6 years old with mild to moderate asthma.

METHODS

The study had an open randomized crossover design with 1 week run-in without treatment and the two treatment periods of 2 weeks each. Efficacy was measured with peak expiratory flow determination, asthma symptom scores, and need for rescue medication. Adverse events were recorded.

RESULTS

Peak expiratory flow increased significantly (P < .001) after both treatments. There were no statistically significant differences in peak expiratory flow, asthma symptom scores, need for extra inhalations, or adverse events between the devices. Most children (parents) preferred the Turbuhaler.

CONCLUSION

Both Bricanyl Turbuhaler and Ventolin Rotahaler seem to be effective and well tolerated in the treatment of asthma in preschool children. Of special interest is that even the youngest children in the study group were able to use these powder inhalers.

Terbutaline via pressurised metered dose inhaled (P-MDI) and Turbuhaler in highly reactive asthmatic patients

There is some concern over the environmental consequences of chlorofluorocarbons (CFCs) used in pressurized metered-dose inhalers (p-MDIs). Turbuhaler was designed to deliver a drug as a dry powder without administering additives directly to the airways. The aim of this study was to evaluate the comparative irritant and bronchodilating effects of the same dose of terbutaline delivered by a p-MDI and via Turbuhaler. Ten symptomatic, asthmatic patients, with highly reactive airways (provocative concentration of methacholine producing a 20% fall in forced expiratory volume in one second (PC20) < 0.2 mg.ml-1), inhaled, on separate days, 0.25 mg terbutaline via p-MDI or Turbuhaler. Changes in airway calibre were followed as specific airways conductance (sGaw). On a third day, patients inhaled from a placebo p-MDI containing all constituents except terbutaline. The study was conducted in a single-blind fashion and in random order. There were no significant differences in baseline sGaw on any of the study days. Inhalation of terbutaline from the p-MDI produced a transient percentage fall in sGaw at 1 min, reaching a mean maximum +/- SD of 17 +/- 8% at 10 s and then returning to baseline value after 20 s, followed by a progressive increase in sGaw to a maximum of 39 +/- 45% above baseline at 45 min. In contrast, inhalation of terbutaline via Turbuhaler caused no significant bronchoconstriction (fall in sGaw, 3 +/- 16%) at 10 s and achieved a greater increase in sGaw, reaching 63 +/- 51% at 45 min, although just failing to reach statistical significance compared to terbutaline p-MDI inhalation.(ABSTRACT TRUNCATED AT 250 WORDS)

Terbutaline in COPD comparison between Turbuhaler and chlorofluorocarbon (CFC) inhaler

Patients with chronic obstructive pulmonary disease (COPD) often subjectively benefit from inhaled beta 2-agonists in spite of little or no demonstrable effect in forced expiratory volume in 1 second (FEV1.0). A comparison between the effects of terbutaline administered via a dry powder inhaler (Turbuhaler) and via a chlorofluorocarbon (CFC) inhaler in conjunction with a spacer device (Nebuhaler) was performed in patients with regard to FEV1.0, forced expiratory capacity (FVC), residual volume (RV), and specific conductance (s-Gaw). Fifteen hospitalised patients (11 male) with COPD were studied, each of whom had a diurnal variation in peak expiratory flow (PEF) not exceeding 15% and with a demonstrated volume response to inhaled beta 2-agonists in FVC and/or RV of at least 15%. Patients were administered each of the following five treatments on a single occasion in a randomized order (latin square) in intervals of at least 2 days: placebo, terbutaline via Turbuhaler (1.0 and 2.5 mg) and terbutaline via a CFC inhaler (1.0 mg without and 2.5 mg with Nebuhaler). Inhalation of terbutaline in different doses and from different devices induced a decrease in RV, an increase in FVC, and s-Gaw and a less pronounced increase in FEV1.0. No statistically significant differences between the four terbutaline treatments were seen, but all were significantly different from the placebo. These findings indicate that while patients with COPD may benefit from inhaled terbutaline through decreased hyperinflation, the choice of inhalation device seems to be of little importance for its efficacy.

Cardiac pheochromocytoma

Cardiac pheochromocytoma is a rare tumour and may be difficult to localize. We present a 32-year-old male with a cardiac pheochromocytoma that was successfully resected. An initial unenhanced CT did not reveal the tumour. MIBG-scintigraphy indicated the location, but to get full information, a dynamic contrast-enhanced CT of the chest during adequate alpha and beta blockade was essential. ECG-gated MRI gave further information about the anatomical details.

A comparison of terbutaline inhaled by Turbuhaler and by a chlorofluorocarbon (CFC) inhaler in children with exercise-induced asthma

The present study compared the bronchodilating effect of inhalation from the Turbuhaler (0.5 mg terbutaline x 2) with the effect of inhalation from the chlorofluorocarbon (CFC) inhaler (0.25 mg terbutaline x 4) in children aged 9-17 years with reproducible, exercise-induced asthma (EIA). The treatments were given on two occasions, 5 min apart (terbutaline 0.5 mg + 0.5 mg). The study was performed as a double-blind, double-dummy, and placebo-controlled trial in 12 asthmatic children. The study was conducted on three separate days. The bronchoconstriction was induced by steady running on a treadmill. Forced expiratory volume in 1 s (FEV1.0), vital capacity (VC), and volume of trapped gas (VTG) were measured before and after the exercise test and after treatment. The study showed that the same amount of terbutaline inhaled from the Turbuhaler or from a CFC inhaler is equally effective for reversing EIA, and that the Turbuhaler is possibly more effective for treating spasm in small airways.

Bronchodilating effect of terbutaline powder in acute severe bronchial obstruction

The bronchodilating effect of terbutaline dry powder inhaled via Turbuhaler was compared with terbutaline inhaled via a conventional, chlorofluorocarbon (CFC) inhaler and Nebuhaler (750 ml spacer) in 68 consecutive patients attending the emergency department with acute severe bronchial obstruction. The study was of an open, randomized, parallel group design with one study day. Patients were treated with 2.5 mg of terbutaline 15 min apart, either as dry powder via Turbuhaler or with a CFC inhaler in conjunction with Nebuhaler. Data from 62 patients were analyzed. The mean baseline FEV1 values were 0.81 L (SD, 0.64; range, 0.14 to 2.74 L) in the Turbuhaler group (n = 33), and 0.90 L (SD, 0.90; range, 0.27 to 2.60 L) in the Nebuhaler group (n = 29). The mean increases in FEV1 from baseline were 0.40 L (SD, 0.40; range, 0.06 to 2.36 L) and 0.21 L (SD, 0.25; range, -0.05 to 0.95 L) 10 min after the last inhalation via Turbuhaler and Nebuhaler, respectively. The difference between mean values of the increase in FEV1 after terbutaline treatment with Turbuhaler and the CFC inhaler and Nebuhaler was statistically significant (p = 0.0004, ANOVA). This study showed that inhalation of terbutaline via Turbuhaler produced a significantly greater increase in FEV1 compared with the same dose of terbutaline administered via the CFC inhaler and Nebuhaler in patients attending the emergency department with acute severe bronchial obstruction.