[The Global Initiative for Asthma and familial medicine-resident physicians. Impact of an educational strategy]

[Article in Spanish]

Cortes Hernandez R.

Servicio de alergia e inmunologia clinica, Hospital de Especialidades, Centro Medico Nacional Siglo XXI, Mexico, DF. norasegura yahoo.com.mx

BACKGROUND: The Global Initiative for Asthma (GINA) provides effective medical care to asthmatic patients. Knowledge and appropriate handling of GINAS' management guidelines for medicine residents significantly reduce asthma morbidity and mortality. OBJECTIVE: To evaluate the level of knowledge about asthma on Global initiative for Asthma program before and after an educational strategy in residents. MATERIAL AND METHODS: Forty-four residents of first, second, and third grade of UMF No. 21 and No. 28 took part in this project A magisterial lecture and a workshop about clinical cases on asthma were carried out. The lecture lasted three hours and asthma surveys, before and after the educational strategy; were applied. Descriptive statistics as well as t test in SPSS were used for statistical analysis. RESULTS: Average grade of the 44 residents before the workshop was of 4.24 +/- 1.6, and after the workshop of 6.00 +/- 1.71. Therewere no significant differences among groups peryear of medical residency onthe initial assessment; however, residents of first year showed an increment on asthma knowledge (p < 0.05) in the subsequent test. There were no differences among groups. CONCLUSIONS: Asthma educational workshops increase residents' awareness of asthma, mainly first-year medical students.

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A teenager with severe asthma exacerbation following ibuprofen.

Palmer GM.

Department of Anaesthesia and Pain Management, Royal Children's Hospital, Parkville, Victoria.

Aspirin-sensitive asthma, aspirin-intolerant asthma, aspirin- (or non-steroidal anti-inflammatory drug [NSAID]) exacerbated respiratory disease are terms for a disorder commonly described as affecting adults aged > 30y. With this perception, ibuprofen was administered for postoperative pain management to a 17-year-old boy with allergic rhinitis and previous severe asthma (at a time when well controlled), who then had a severe asthma exacerbation. Analysis of the literature in response to this case highlights four points: 1) NSAID-exacerbated asthma is not only a disorder of adults; it occurs in up to of 2% in asthmatic children, approaching probably 30% in older children with severe asthma and nasal disease. 2) The asthmatic reaction is dose-dependent and can occur with sub-therapeutic doses. Oral NSAID/aspirin challenge should be conducted in an environment where a severe asthma exacerbation can be appropriately managed. 3) The therapeutic use of non-selective [COX-1 preferential] NSAIDs should be avoided when sensitivity is known or suspected in adults and teenagers with severe asthma and chronic rhinosinusitis or nasal polyps. Use of these agents in younger children with mild episodic wheeze is probably safe. 4) Paracetamol use is probably safe, but aspirin-exacerbated respiratory disease may occur with clinical doses in a subgroup of aspirin-exacerbated respiratory disease patients. COX-2 selective inhibitors are probably safe, although this is controversial. Opioids and tramadol are suitable analgesic alternatives for patients with known or suspected susceptibility.

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Diminished Lipoxin Biosynthesis in Severe Asthma.

Israel E.

Pulmonary and Critical Care Medicine and Partners Asthma Center, Department of Internal Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, United States.

Rationale and Objectives: Severe asthma is characterized by increased airway inflammation that persists despite therapy with corticosteroids. Not merely an exaggeration of the eosinophilic inflammation that characterizes mild to moderate asthma, unique features are present in severe disease. Although arachidonic acid metabolism is well appreciated to regulate airway inflammation and reactivity, alterations in the biosynthetic capacity for both pro- and anti-inflammatory eicosanoids in severe asthma have not been determined. Methods: Patients with severe asthma were identified according to the NHLBI Severe Asthma Research Program criteria. Samples of whole blood from individuals with severe or moderate asthma were assayed for biosynthesis of lipoxygenase-derived eicosanoids. Measurements and Main Results: The counter-regulatory mediator lipoxin A4 was detectable in low picogram amounts using a novel fluorescence-based detection system. In activated whole blood, mean lipoxin A4 levels were decreased in severe compared to moderate asthma (0.4 [SD 0.4] ng/ml vs. 1.8 [SD 0.8] ng/ml, P=0.001). In sharp contrast, mean levels of pro-phlogistic cysteinyl leukotrienes were increased in samples from severe compared to moderate asthma (112.5 [SD 53.7] pg/ml vs. 64.4 [SD 24.8] pg/ml, P=0.03). Basal circulating levels of LXA4 were also decreased in severe relative to moderate asthma. The marked imbalance in lipoxygenase-derived eicosanoid biosynthesis correlated with the degree of airflow obstruction. Conclusions: Mechanisms underlying airway responses in severe asthma include underproduction of lipoxins. This is the first report of a defect in lipoxin biosynthesis in severe asthma, and suggests an alternate therapeutic strategy that emphasizes natural counter-regulatory pathways in the airway.

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Asthma Severity and Exposure to Occupational Asthmagens.

Kennedy SM.

U472-IFR69, INSERM, Villejuif, France.

Rationale: Severe asthma is a public health problem with limited information regarding preventable causes. Although occupational exposures have been implicated as important risk factors for asthma and asthma exacerbations, associations between occupational exposures and asthma severity have not been reported. Objective: To examine associations between occupational exposures and asthma severity. Methods: The Epidemiological study on the Genetics and Environment of Asthma combines a case control study with a family study of relatives of asthmatic cases. Adult cases (n=148) were recruited in chest clinics and non-asthmatic controls (n=228) were population-based. Occupational exposures to non-asthmagenic irritants and asthmagens (classified as 'any asthmagen' and 3 broad groups (high molecular weight agents, low molecular weight agents, mixed environments)) were assessed by an asthma-specific job exposure matrix. Asthma severity was defined from a 7-grade clinical score (frequency of attacks, persistent symptoms and hospitalisation). Severe (score >/=2) and mild asthmatics were compared to controls using nominal logistic regression. Main Results: Significant associations were observed between severe adult onset asthma and exposure to any occupational asthmagen (odds ratio 4.0 [95% CI 2.0-8.1]); high molecular weight agents (3.7 [1.3-11.1]); low molecular weight agents (4.4 [1.9-10.1]), including industrial cleaning agents (7.2 [1.3-39.9]); and mixed environments (7.5 [2.4-23.5]). No significant associations were found between non-asthmagenic irritants and asthma severity, nor between asthmagens and childhood onset asthma or mild adult onset asthma. Conclusions: Our results suggested a strong deleterious role of occupational asthmagens in severe asthma. Clinicians should consider occupational exposures in patients with moderate to severe asthma.

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Asthma: versatile treatment for a variable disease.

Murphy KR.

Midwest Children's Chest Physicians, 16945 Frances St., Omaha, NE 68130, USA. murphknsc aol.com

OBJECTIVE: This review describes factors contributing to the variable nature of asthma and the versatile treatment strategies required for the clinical management of the disease. DATA SOURCES: A comprehensive review of the literature using MEDLINE was conducted. STUDY SELECTION: Included articles were selected for their relevance to variability or severity of asthma. Bibliographies of selected articles served as additional sources of considered publications. RESULTS: Asthma severity can vary substantially among patients and within individual patients because of physiologic, environmental, or behavioral factors. Inhaled corticosteroids are an effective and versatile treatment option for special populations with asthma and for patients with varying degrees of asthma severity. Inhaled corticosteroids are now the preferred treatment for all three severity levels of persistent asthma, especially in young children and pregnant women. Treatment regimens may be adjusted up or adjusted down when appropriate to maintain optimal symptom control and limit potential adverse systemic effects. CONCLUSIONS: The clinical management of asthma is challenging given the day-to-day variability of the disease. Variability in pulmonary function and asthma symptoms may be minimized through increased awareness of the factors contributing to asthma variability as well as the effective use of inhaled corticosteroid therapy. Flexible treatment strategies that consider the different severities of asthma and account for variability within individual patients may be particularly useful in improving adherence and patient outcomes.

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Management of asthma among community-based primary care physicians.

Alberta Strategy to Help Manage Asthma (ASTHMA) Investigators.

University of Alberta, Edmonton.

BACKGROUND: Despite significant improvements in asthma treatment and the dissemination of national and international guidelines for asthma management, there are ongoing concerns that suboptimal care is being provided for patients with asthma. OBJECTIVE: To determine the current practice patterns of asthma care among primary care physicians. DESIGN: A cross-sectional study. SETTING: Province of Alberta, Canada (population: 3 million people). PARTICIPANTS: Patients, 5 years of age or older, who had a physician's diagnosis of asthma, and had at least two visits for asthma between 1996 and 2001. MEASUREMENT AND RESULTS: Charts of 3072 distinct patients (from 45 unique primary care physicians) were reviewed. Previous emergency department visits or hospitalizations were experienced by 20% of the sample. A total of 25% of patients had documented evidence that they had performed spirometry. More than half of the patients had no documented evidence that they had received any form of asthma education; only 2% of the charts indicated that patients received a written action plan. Two thirds of the patients were prescribed an inhaled steroid within 6 months of the last clinic visit. CONCLUSIONS: Our study indicates a gap in the provision of asthma education, written action plans, and spirometric testing for patients diagnosed with asthma among primary care physicians.

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Health care use and quality of life among patients with asthma and panic disorder.

Siddique MI.

Ferkauf Graduate School of Psychology and Albert Einstein College of Medicine, Yeshiva University, Rousso Building, 1300 Morris Park Ave., Bronx, NY 10461, USA. JFeldman aecom.yu.edu

The purpose of this study was to assess the associations between panic disorder (PD) and health services use, health-related quality of life, and use of short-acting beta2-agonists among individuals with asthma. We studied 21 adults with comorbid asthma and panic disorder (asthma-PD) and 27 asthma patients without PD (asthma-only). Participants attended a single session at a laboratory to complete the study. A retrospective chart review was conducted to assess use of health care resources for asthma treatment during the past 12 months. Patients completed the Asthma Quality of Life Questionnaire and lung function testing. Asthma-only and asthma-PD patients displayed no differences on asthma severity, as measured by spirometry and asthma medication class. Asthma-PD patients had more visits to their primary care physicians for asthma (p < 0.01) and reported a lower quality of life related to asthma (p < 0.01) and greater use of short-acting beta2-agonists (p < 0.05) than asthma-only patients. These findings were independent of pulmonary function, asthma medication class, and sociodemographic status. These data show that coexistence of PD in asthma is associated with increased use of primary care health resources and greater perceived impairment from asthma, independent of asthma severity. These findings indicate a need to develop interventions to improve quality of life and self-management of asthma among PD patients.

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Electronic asthma action plan database: asthma action plan development using Microsoft Access.

Salzman GA.

Pulmonary Division, Truman Medical Center, 2301 Holmes St., Kansas City, MO 64108, USA. Rita.Mangold tmcmed.org

We created a user-friendly database for use with asthma management consistent with the national guidelines for asthma. A database was designed by using Microsoft Access for the creation of asthma action plans that can be shared between providers caring for patients with asthma. This database and the use of "form entry" improved documentation of asthma action plans, which are increasingly being used to assess appropriateness of care. We currently have 400 asthma action plans in the database. These action plans can be queried to document compliance with accepted best practices. Asthma action plans can be created and stored in an Access database that is both user-friendly and that can be networked to provide more consistent asthma care.

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