Consumer attitudes on cough and cold: US (ACHOO) survey results

OBJECTIVE

The Attitudes of Consumers Toward Health, Cough, and Cold (ACHOO) survey was developed to better inform health care providers on the natural history and impact of common cold and cough, and related consumer experience and behaviors.

RESEARCH DESIGN AND METHODS

Randomly selected US Internet/mobile device users were invited to participate in an online survey (N = 3333) in October 2012. Response quotas modeled upon 2010 US Census data ensured a demographically representative sample. To reduce potential bias from the quota design, 75% of the completed surveys were randomly selected as the primary analysis pool.

MAIN OUTCOME MEASURES

Survey questions assessed participant demographics, frequency and duration of cough/cold symptoms, impact of symptoms on daily life, treatment preferences, and knowledge about cough/cold pathophysiology.

RESULTS

In the past year, 84.6% of respondents had experienced at least one cold. Colds typically started with sore/scratchy throat (39.2%), nasal congestion (9.8%), and runny nose (9.3%) and lasted 3-7 days. Cough, the most common cold symptom (73.1%), had a delayed onset (typically 1-5 days after cold onset) and a long duration (>6 days in 35.2%). Nasal congestion and cough were the most bothersome symptoms. Many respondents waited until symptoms were 'bad enough' (42.6%) or multiple symptoms were present (20.2%) before using nonprescription medications. Drivers of choice included effectiveness in relieving symptoms, safety, and past experience. Respondents rarely consulted clinicians regarding treatment, and more than three-quarters had never received instructions from a clinician on how to choose a nonprescription cough/cold medication. Misperceptions regarding etiology and treatment of the common cold were prevalent. The main limitation is potential recall bias, since respondents had to recall cough/cold episodes over the prior year.

CONCLUSIONS

The ACHOO survey confirms that cold is a common, bothersome experience and that there are gaps in consumers' knowledge of pathophysiology and appropriate management of cough/cold.

Allergic Rhinitis and its Impact on Asthma (ARIA): achievements in 10 years and future needs

Allergic rhinitis (AR) and asthma represent global health problems for all age groups. Asthma and rhinitis frequently coexist in the same subjects. Allergic Rhinitis and its Impact on Asthma (ARIA) was initiated during a World Health Organization workshop in 1999 (published in 2001). ARIA has reclassified AR as mild/moderate-severe and intermittent/persistent. This classification closely reflects patients' needs and underlines the close relationship between rhinitis and asthma. Patients, clinicians, and other health care professionals are confronted with various treatment choices for the management of AR. This contributes to considerable variation in clinical practice, and worldwide, patients, clinicians, and other health care professionals are faced with uncertainty about the relative merits and downsides of the various treatment options. In its 2010 Revision, ARIA developed clinical practice guidelines for the management of AR and asthma comorbidities based on the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system. ARIA is disseminated and implemented in more than 50 countries of the world. Ten years after the publication of the ARIA World Health Organization workshop report, it is important to make a summary of its achievements and identify the still unmet clinical, research, and implementation needs to strengthen the 2011 European Union Priority on allergy and asthma in children.

Development and implementation of guidelines in allergic rhinitis – an ARIA-GA2LEN paper

The links between asthma and rhinitis are well characterized. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines stress the importance of these links and provide guidance for their prevention and treatment. Despite effective treatments being available, too few patients receive appropriate medical care for both diseases. Most patients with rhinitis and asthma consult primary care physicians and therefore these physicians are encouraged to understand and use ARIA guidelines. Patients should also be informed about these guidelines to raise their awareness of optimal care and increase control of the two related diseases. To apply these guidelines, clinicians and patients need to understand how and why the recommendations were made. The goal of the ARIA guidelines is to provide recommendations about the best management options for most patients in most situations. These recommendations should be based on the best available evidence. Making recommendations requires the assessment of the quality of available evidence, deciding on the balance between benefits and downsides, consideration of patients’ values and preferences, and, if applicable, resource implications. Guidelines must be updated as new management options become available or important new evidence emerges. Transparent reporting of guidelines facilitates understanding and acceptance, but implementation strategies need to be improved.

Unmet needs in asthma: Global Asthma Physician and Patient (GAPP) Survey: global adult findings

BACKGROUND

The Global Asthma Physician and Patient (GAPP) Survey is the first global quantitative survey designed to uncover asthma attitudes and treatment practices among separate groups of physicians and patients, with the goal of identifying barriers to optimal management.

METHOD

A total of 5582 physician and patient interviews were conducted globally online, by telephone and face-to-face. This paper highlights key global findings from the adult arm (3559 interviews) conducted in 16 countries.

RESULTS

Physician and patient responses were found to differ when respondents were asked the same set of questions. Perceptions of time spent on asthma education, the quality of physician-patient communications, awareness and experience of side effects and understanding and knowledge of treatment noncompliance were found to differ between these two sets of respondents.

CONCLUSIONS

The GAPP Survey not only defines an unmet need in asthma treatment, but also reveals that there is a direct relationship between the quality of physician-patient communication, the level of treatment side effects and the extent of patient compliance. These survey findings highlight a clear need for improved patient-focused care in asthma.

Pharmacologic therapy for the treatment of asthma in children

Asthma in children results in a large negative global impact and its recent increase in prevalence demands an aggressive and comprehensive treatment program. Recently there has been increasing global cooperation for developing more standardized treatment plans to address this complex disease. Advances in our knowledge of the exact mechanisms of this disease continue to lead to better pharmacologic treatment options. A variety of medications are currently available for the treatment of both acute and chronic asthma symptoms. The importance of controller medications that affect the underlying inflammatory process has been emphasized in the most recent treatment recommendations. The initial choice of medications for asthma treatment is frequently based on the severity classification of the asthma symptoms. Severity classifications include mild intermittent, mild persistent, moderate persistent, and severe persistent. Guidelines for treatment options for each of these severity classifications are available which incorporate appropriate flexibility for such a dynamic disease. These guidelines are based on evidence of effectiveness, relative safety, and other factors. This article reviews many of these medications, their actions, side effects, relative efficacy, and their indications for pediatric asthma treatment.

Efficacy, safety, and patient preference of inhaled nasal corticosteroids: a review of pertinent published data

Most clinical studies of inhaled nasal corticosteroids have established comparable safety and efficacy; therefore, there remains little to distinguish the various products from each other in the treatment of allergic rhinitis. However, patient preference is recognized increasingly as an important factor in selecting appropriate treatment. This review discusses the different methodologies that have been used to measure patient preference for intranasal corticosteroids. Patient questionnaires and other instruments for assessment that are used to measure such preferences are discussed as well as several different study designs. Now, the challenge is to implement more studies that show the reliability and consistency of instruments used to assess patient preference.

Measuring outcomes in pediatric asthma

The incidence and severity of pediatric asthma continues to increase in developed countries throughout the world. In determining what works best in the management of the asthmatic child, outcome measurements specific for this population have been developed. There are three major categories of outcomes that should be addressed in pediatric asthma. First are the clinical and physiologic measurements, which include lung functions, clinical symptoms, and number of emergency department and hospital visits. Measurement of both generic and disease-specific health-related quality of life (HQL) is advocated because each provides complementary information about how the condition affects everyday functioning and well-being, and whether treatments have their intended effects. Finally, economic outcomes should be considered, which include direct costs, such as physician and medication costs, and indirect costs, such as missing school or the parents missing work due to their child's asthma.

A new tool for monitoring asthma outcomes: the ITG Asthma Short Form

BACKGROUND

Asthma treatment has broadened from managing clinical markers to incorporate factors that are most meaningful to patients, collectively called health-related quality of life (HQL).

OBJECTIVE

To develop an asthma-specific HQL tool, meeting demands for brevity, usefulness and measurement precision.

METHODS

The 20-item Sydney Asthma Quality of Life Questionnaire (AQLQ) and six additional items were studied using factor analysis, reliability and validity tests among asthma patients 14 and older.

RESULTS

The 15-item Integrated Therapeutics Group Asthma Short Form (ITG-ASF) retains the validity of the AQLQ with improved scaling properties and interpretability. The ITG-ASF yields 6 scores: Symptom-Free Index, Functioning with Asthma, Psychosocial Impact of Asthma, Asthma Energy and Asthma-Confidence in Health and a Total. All items correlated 0.40 or higher with their hypothesized scales and passed discriminant validity tests, with scaling success rates from 75 to 100%. Reliability exceeded the minimum of 0.70 for group comparisons. Ceiling and floor effects were acceptable. Scales were valid in relation to changes in asthma severity and lung function. The best predictor of asthma severity (National Asthma Education and Prevention Program (NAEPP) staging) was the Symptom-Free Index. A Spanish translation is available, Chinese-American is forthcoming. The reading grade level is 4.8.

CONCLUSIONS

Development of the ITG-ASF was a data-driven process maximizing measurement precision and breadth while minimizing burden. The ITG-ASF is a brief, comprehensive and empirically valid tool that complements traditional markers of the outcomes of asthma care.

Complementary/alternative medicine in the treatment of asthma

OBJECTIVE

This review will familiarize clinical allergists/immunologists with the common forms of complementary/alternative medicine (CAM) that are being used frequently by their patients. It reviews reasons that patients seek alternative health care therapies and the most common illnesses that are treated with this form of medicine. Cultural differences in CAM are also reviewed. The article focuses on specific therapies used to treat asthma and reviews the efficacy of these therapies based on the available scientific literature. The reader will also learn about views of other physicians on CAM and how this topic is being addressed in US medical schools.

DATA SOURCES

Computer-assisted MEDLINE searches for articles on "complementary/alternative medicine" or "herbal therapy" and "asthma" or "atopy."

STUDY SELECTION

Pertinent abstracts and articles in the above areas were selected. Articles selected for detailed review included review articles of the subjects along with randomized, double-blind placebo-controlled studies in animals and humans.

RESULTS

Complementary/alternative medicine is commonly used by patients with chronic conditions including asthma. One-third of the US population has tried CAM. The literature supporting the efficacy of these therapies is lacking. Some reports elucidate the mechanism of action of certain herbal therapies that could possibly be helpful in the treatment of allergic diseases. There are, however, few well-controlled studies that support the efficacy of CAM in the treatment and clinical improvement of human subjects with asthma or atopic disorders.

CONCLUSION

Available scientific evidence does not support a role for CAM in the treatment of asthma. The studies in the literature often have significant design flaws that weaken the conclusions such as insufficient numbers of patients, lack of proper controls, and inadequate blinding. Further studies are needed to prove or disprove the efficacy of CAM. Physicians often find CAM intimidating because they are unaware of the clinical evidence and feel uncomfortable advising their patients on its efficacy. There is definitely a need for more education among physicians in this area. It is also important that physicians inquire and discuss the use of CAM with their patients since the majority of patients are using some form of CAM.

Impact of changes in asthma severity on health-related quality of life in pediatric and adult asthma patients: results from the asthma outcomes monitoring system

The goals of asthma treatment have broadened beyond managing traditional clinical markers of disease severity, and now include a focus on benefits of treatment in terms that are most meaningful to patients. Measurement of both generic and disease-specific health-related quality of life (HQL) is advocated because each provides complementary information about how the condition affects everyday functioning and well-being and whether treatments have their intended effects. The purpose of this study was to determine the impact of changes in asthma severity (defined using NHLBI/NAEPP severity staging) on patient-assessed HQL. Two hundred and thirty-three pediatric asthma patients and 269 adult asthma patients were evaluated in a one-year observational study. Analyses were performed to compare the generic and asthma-specific scores for patients whose asthma severity improved, stayed the same, or worsened over one year. The asthma-specific scales are sensitive to changes in disease severity. Of the generic scales, those tapping areas of physical health are more affected than the mental/emotional scales. This confirms that HQL measures are responsive to changes in asthma severity. They complement traditional clinical markers used to evaluate changes in a patient's disease state and thus give the physician another useful tool in following the clinical progress of the child with asthma.

Cognitive, social, and economic costs of allergic rhinitis

Allergic rhinitis is a highly prevalent, chronic condition. In addition to physical discomfort, rhinitis symptoms have been associated with detrimental effects on the psychological and social aspects of patients' lives. In allergy-specific questionnaires, subjects with allergic rhinitis consistently report lower quality of life than nonallergic controls. Untreated patients are embarrassed and frustrated by their allergy symptoms. Atopic individuals consistently exhibit significant declines in cognitive processing, psychomotor speed, verbal learning, and memory during allergy season. The discomfort, cognitive impairment, and absenteeism associated with allergic rhinitis exact a significant economic toll on U.S. businesses through decreased productivity. When combined with direct medical expenditures, the economic burden of allergic rhinitis is considerable. The effect of treatment on the economics of allergic rhinitis is highly variable: relatively inexpensive medications (lower direct costs) have central nervous system side effects that can cause somnolence and impair learning, memory, and performance (higher indirect costs). Health outcomes data on the effects of allergic rhinitis and its treatments can help establish, monitor, and improve standards of care; as well as inform priority setting, direct resource allocation, and eliminate unnecessary practices.

Quality of life in allergic rhinitis

OBJECTIVE

This review will furnish the reader current information on the importance of quality of life evaluation in patients suffering from allergic rhinitis, the different types of quality of life instruments used, and how they can be used in judging different pharmaceutical therapies.

DATA SOURCES

Computer-assisted MEDLINE searches for articles assessing "quality of life" and "outcomes" in rhinitis. Also MEDLINE searches evaluating health-related quality of life in relationship to different pharmacologic treatments in allergic rhinitis.

STUDY SELECTIONS

Pertinent abstracts and articles in two broad areas were selected. The first groups were articles in the fields of outcomes, quality of life, allergic rhinitis, and its relationship to health-related quality of life. The second group of articles evaluated different pharmacologic agents' effect on the health-related quality of life of rhinitis patients. Both sets of articles were critically analyzed with important representative studies selected for this review.

RESULTS

Health-related quality of life of patients with allergic rhinitis is impaired as measured by both generic and specific health-related quality of life instruments. Use of second generation antihistamines, intranasal corticosteroids, and intranasal ipratropium bromide have been shown to improve the health-related quality of life of sufferers of allergic rhinitis.

CONCLUSIONS

The measuring of health-related quality of life is assuming a primary position in outcomes analysis in the patient with allergic rhinitis. Studies have documented the validity of using generic and specific health-related quality of life instruments in allergic rhinitis. Each type has its own weaknesses and strengths that the user needs to appreciate. Appraising the role of different pharmacologic agents in allergic rhinitis in improving the patient's quality of life is an important part of proving the medication's worth to the health care community.

Outcomes analysis in asthma

Physicians, patients, employers, managed care organizations, insurance companies, and government all want to know how different approaches to management of asthma are improving care. To this end, the field of outcomes analysis in asthma is playing a major role. Clinical, physiologic, humanistic, and economic outcomes are being assessed using different types of general and asthma-specific instruments. Historically, clinical and physiologic outcomes have been of most concern to clinicians. However, humanistic outcomes, such as health-related quality of life and patient satisfaction, shift the focus to the patient. Economic outcomes, especially cost-effectiveness, evaluate how to achieve the best outcomes at the lowest cost. These outcomes have been used to evaluate asthma intervention programs. Several large asthma outcomes research projects, which should define the future of outcomes analysis in asthma, are under way.

Airway fluoroscopic diagnosis of vocal cord dysfunction syndrome

BACKGROUND

Vocal cord dysfunction syndrome is often misdiagnosed as refractory asthma. Airway fluoroscopy has recently been proposed as an alternative to laryngoscopy in the initial evaluation of certain cases of suspected vocal cord dysfunction.

OBJECTIVE

To evaluate the use of airway radiographs and fluoroscopy in a patient with suspected vocal cord dysfunction.

METHODS

We used soft tissue technique airway radiographs and fluoroscopy to evaluate the glottic function during inspiration and expiration in a 9-year-old boy with refractory asthma and suspected vocal cord dysfunction.

RESULTS

The study confirmed paradoxical vocal cord motion.

CONCLUSIONS

Airway radiographs and fluoroscopy provide a rapid and noninvasive means of diagnosing vocal cord dysfunction. Patients should still have laryngoscopy performed at the earliest possible moment to rule out the possibility of other laryngeal abnormalities.

The role of outcome studies in allergy and clinical immunology

Outcomes research is becoming an integral part of the sweeping changes occurring in the U.S. health care system. By developing outcomes monitoring systems in allergic disorders, allergists will be able to collect information showing their commitment to excellent clinical care, which improves the patient's quality of life in a cost-effective way. Outcomes data is also important in determining the number of allergists that need to be trained, appropriate therapeutic regimens for allergic disorders, evaluating differences in practice styles of allergists throughout the country, and in revising practice parameters in allergic disorders. Through the Joint Council of Allergy, Asthma, and Immunology, a subcommittee on outcomes was formed. This subcommittee awarded a national asthma outcomes monitoring project to The Health Institute, New England Medical Center, Boston. This project, which will be in three phases, will generate information on outcomes of board-certified allergists in asthma care. Another goal of this project will be to produce standardized instruments and collection methods, which will be made available for use by all allergists to collect their own outcomes data.

Cell-mediated immune status of children with recurrent infection

OBJECTIVE

To evaluate the cell-mediated immune status of children with recurrent respiratory tract infections.

DESIGN

We evaluated the cell-mediated immune status of 76 patients referred because of recurrent infection. Patients were divided into those with serologic abnormalities and those without such findings. Twenty-three healthy children served as control subjects. Studies of lymphocyte phenotype included CD4+ CD29+ cells (an immunologically mature phenotype), lymphocyte proliferation studies, cytokine production including interleukin-2 (IL-2), IL-4, IL-6, and interferon gamma), and measurement of in vitro IgM and IgG synthesis.

RESULTS

Lymphocyte proliferation and T-cell phenotype were similar in both patient groups as well as in control subjects. The proportions of CD4+ CD29+ cells at different ages were similar in all groups. Patients with serologic abnormalities (e.g., partial IgA deficiency, partial IgG subclass deficiency) produced more IL-2 and IL-4 than did other patients. The control population had greater spontaneous IgM and IgG synthesis than the patient groups.

CONCLUSION

Routine studies of T-cell function of patients with recurrent infection provide little information useful in making clinical decisions.

A seven-year-old boy with sinusitis, otitis media, and asthma

A 7-year-old boy with recurrent otitis media, bronchitis, pneumonia, asthma, and sinusitis was found to have primary ciliary dyskinesia. It was important to rule out other systemic diseases such as immune deficiency and cystic fibrosis. Electron microscopy of a properly obtained and prepared biopsy of the mucosal surface of the nose, trachea, or bronchus is essential.

New pharmacologic agents in the treatment of asthma

This article will review four new medications for the treatment of asthma. Extensive studies have been undertaken with these medications to demonstrate their efficacy. All these agents, in use in other countries, are presently in different stages of review by the Food and Drug Administration. This review will give physicians an understanding of these medications, so when they are approved in the United States, the clinician will have an idea of their proper place in treatment of the asthmatic patient.

Role of immunoglobulin subclasses and specific antibody determinations in the evaluation of recurrent infection in children

We studied humoral immune function in 267 children with recurrent respiratory infections referred to our immunology clinic to determine the most appropriate immunologic studies for evaluating recurrent infections in children. Of this highly selected population, 58% had a partial deficiency in one or more of the major immunoglobulin isotypes or IgG subclasses (defined as at least 2 SD below the normal age-adjusted mean). In none of the patients was there a total absence of an immunoglobulin isotype. The most common abnormality was partial IgA deficiency, which was found in one third of the patients. Twenty-six patients had only partial IgG subclass deficiencies, of which 20 were deficiencies of a single subclass. IgG1 was an isolated partial defect in three patients, IgG3 in five patients, and IgG2 and IgG4 were selective partial defects in six patients each. Tetanus toxoid and pneumopolysaccharide type 3 were the most immunogenic of the immunogens tested; hyporesponsiveness to pneumococcal polysaccharide types 7, 9, and 14 was common. Nineteen percent of the patients with normal immunoglobulin concentrations who were tested had lower-than-expected antibody titers; 42% of those tested with partial isotype deficiencies had deficient antibody responses. Of 25 patients with selective partial IgG subclass deficiencies or combined IgG subclass deficiencies, eight had antibody deficiencies. Our findings indicate that a high proportion of children referred to immunology clinics for recurrent infection have a demonstrable immunologic abnormality. Selective IgG subclass deficiency or a combined IgG subclass deficiency without an associated deficiency in a major immunoglobulin isotype is unusual. Identification of such patients is not predictive of the capacity to form antibodies to the antigens tested in this study and, in our opinion, adds little to the initial evaluation of immune function in such children.

Prevalence of latex sensitivity in children evaluated for inhalant allergy

We prospectively examined 80 children referred to a university allergy/immunology clinic for evaluation for inhalant allergies to determine the prevalence of latex hypersensitivity in this group. All children were skin tested with a Multi-test device to 35 inhalant allergens and a latex glove extract. Only one child gave a questionable history of latex sensitivity, but her skin test was negative. Three of 44 (6.8%) atopic children had a positive latex skin test (wheal greater than 4 mm); none of the 36 nonatopic children had a positive latex skin test. Two of the three children had a history of two or more surgical procedures but denied any clinical hypersensitivity reactions during surgery. Previous reports have demonstrated a personal history of atopy and of surgical procedures as risk factors for the development of latex hypersensitivity. This study helps verify these risk factors and should increase the awareness of this possible health hazard in this select group of children.

Proving penicillin allergy

Allergic reactions to penicillin are usually short-lived and reversible, but they can be fatal. What causes these reactions? Can they be avoided? How is the risk of penicillin allergy evaluated? Drs Erffmeyer and Blaiss describe the full spectrum of allergic, immune, and nonimmune reactions to penicillin and discuss how to assess and treat patients with suspected penicillin allergy.

Drug allergy

Adverse reaction to drugs is a common problem in the pediatric population. This article discusses the different types of adverse drug reactions and their mechanisms. Also included are representative clinical syndromes of drug hypersensitivity reactions, as well as certain organ systems syndromes. Finally, diagnosis and management of allergic reactions to particular drugs such as penicillin, iodinated contrast dye, insulin, and others are discussed.

Anaphylaxis to cabbage: detection of allergens

Allergy to cabbage and other foods in the Brassica family has rarely been observed in man. We report a case of facial and throat swelling in an atopic female after she ingested coleslaw on two separate occasions. She had 4+ reactions to cabbage, mustard plant, cauliflower, and broccoli by skin testing. A RAST using cabbage extract was positive for specific IgE antibody. Analysis of cabbage extract by gel filtration showed five peaks of ultraviolet-absorbing material at 280 nm. Allergenic activity was demonstrated by RAST inhibition in two fractions of the cabbage extract. This report confirms IgE sensitivity can occur to foods in the Brassica family.

How helpful is the radioallergosorbent test in the diagnosis of allergic disease?

We compared the results of clinical history, skin testing, and radioallergosorbent test (RAST) scores on 274 patients seen in an allergy clinic, using nine different allergens, namely ragweed, oak, Bermuda grass, redtop, Timothy, Alternaria, cat hair, house dust, and dust mite. More than 90% of patients who reported clinical allergy to pollens had a positive skin test to the respective allergen. Only two thirds of these patients also had a positive RAST, while only one patient in this group had a positive RAST and a negative skin test. Of the patients reporting allergy to cat hair, 60% had a positive RAST but only 46% had a positive skin test. For the case of dust allergy, there was poor agreement between test results and history, since more than half of the patients who reported symptoms from dust exposure had a negative RAST and negative skin test results.

Beclomethasone dipropionate aerosol: hematologic and immunologic effects

Inhaled beclomethasone dipropionate aerosol is a topically active corticosteroid that has proved to be of great value in treating asthma. The authors have examined the effect of inhaled beclomethasone dipropionate aerosol on circulating leukocytes and on immunological measurements in normal adult subjects. Subjects inhaled either 400 micrograms or 1600 micrograms as a single dose. White blood cell counts, total neutrophil counts, total eosinophil counts and total lymphocyte counts were determined at 0, 2, 4 and 6 hours following an 8:00 a.m. inhalation. Among the 11 subjects who inhaled 400 micrograms, the total white blood cell count increased significantly at six hours (p less than 0.05). The total neutrophil count was increased significantly at 2, 4 and 6 hours (p less than 0.05). Total eosinophil counts and total lymphocyte counts were diminished but not significantly. Among the five subjects inhaling 1600 micrograms similar findings were observed. Seventeen volunteers inhaled 200 micrograms of beclomethasone dipropionate qid for 24 hours. In addition to the above studies, T and B cell numbers were determined and lymphocyte transformation studies were performed. Although trends similar to those observed with single larger dose inhalations were seen, the changes were not statistically significant. The results of these studies indicate that inhaled beclomethasone dipropionate does have the potential to affect circulating leukocytes.