An algorithmic approach to diagnosing asthma in older patients in general practice.

Adams RJ.

Department of Medicine, University of Adelaide, The Queen Elizabeth Hospital, Woodville Road, Woodville, SA 5011, Australia. richard.ruffin adelaide.edu.au.

What we need to know How effective would an algorithm be in helping general practitioners diagnose asthma? What proportion of older people with undiagnosed asthma fail to recognise symptoms? What proportion of the population believe asthma does not occur in the older population? What systems or supports do GPs need to diagnose asthma more effectively? What we need to do Work on developing a gold standard for asthma diagnosis. Develop prototype algorithms for general practice discussion. Conduct a general practice study to assess the effectiveness of an algorithm. In conjunction with GPs, develop a pilot program to increase awareness of the current asthma problem. Conduct focus-group research to identify why some people do not believe they can develop asthma for the first time in adult life. Conduct focus-group research to identify why some adults do not attribute asthma symptoms to asthma. Conduct focus groups with GPs to identify what support is needed to diagnose asthma more effectively. Consult with all stakeholders before an intervention is used. Evaluate any interventions used.

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A Randomized Trial of Citalopram versus Placebo in Outpatients with Asthma and Major Depressive Disorder: A Proof of Concept Study.

Rush AJ.

Departments of Psychiatry and Internal Medicine.

BACKGROUND: The prevalence of asthma has increased in recent years and depression is common in this population. Minimal data are available on the treatment of depressed asthma patients. METHODS: Ninety adults with asthma and current major depressive disorder were randomized to receive citalopram or placebo for 12 weeks. At each visit, the Hamilton Rating Scale for Depression (HRSD), Inventory of Depressive Symptomatology - Self-Report, Asthma Control Questionnaire, and Asthma Quality of Life Questionnaire were administered, and oral corticosteroid use assessed. RESULTS: In the evaluable sample (n = 82), the primary outcome, a random regression analysis of HRSD scores, revealed no significant between-group differences. Bonferroni corrected secondary outcomes revealed HRSD scores decreased significantly in both groups with a significantly greater decrease in the citalopram group at week 6. Changes in asthma symptoms were similar between groups. The groups had similar rates of oral corticosteroid use at baseline, but the citalopram group had less corticosteroid use during the study. Changes in asthma symptom severity correlated with changes in depressive symptom severity. CONCLUSIONS: A reduction in depressive symptoms was associated with improvement in asthma. Corticosteroid use, an important measure of severe asthma exacerbations, was lower in the citalopram group. Larger clinical trials in this population are warranted.

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Operational definitions of asthma in studies on its aetiology.

Burney P.

Unit of Environmental Epidemiology, National Public Health Institute, P.O. Box 95, 70701 Kuopio, Finland. Juha.Pekkanen ktl.fi.

The most popular way to define asthma based on questionnaires is to use definitions taken from cross-sectional international studies on asthma. These definitions may not, however, be optimal for future studies focusing on risk factors of asthma. The current authors, therefore, compared the performance of different operational definitions of asthma. The European Community Respiratory Health Study I was a cross-sectional study of 21,924 subjects aged between 25-44 yrs in 18 countries. Operational definitions of asthma compared included different combinations of symptoms of asthma and bronchial hyperresponsiveness. A continuous asthma score, ranging from 0-8, was defined as the sum of positive answers to eight main symptom questions. There was no threshold in the associations of asthma symptoms with severity or risk factors of asthma, which would have suggested a dichotomous definition of asthma. Using dichotomous definitions requiring the presence of several asthma symptoms strengthened associations with studied risk factors, and also increased the estimated specificity and positive predictive value. Using a continuous asthma score also improved the power of the analyses. In conclusion, dichotomous definitions of asthma yielding higher odds ratios are achieved by requiring positive responses to several questions on symptoms. However, symptoms of asthma are possibly best analysed as a continuous asthma score.

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Racial Differences in Asthma Morbidity During Pregnancy.

Hartert TV.

Vanderbilt University School of Medicine, Departments of Pediatrics, Medicine, and Preventive Medicine, and the Division of General Pediatrics, Division of General Internal Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Center for Education and Research on Therapeutics, Center for Health Services Research; Department of Biostatistics, Mid-South Geriatric Research Education and Clinical Center; Quality Scholars Program, VA TN Valley Health Care System; General Clinical Research Center; and Meharry/Vanderbilt Center for Reducing Asthma Disparities, Nashville, Tennessee.

Objective: Little is known about racial differences in asthma outcomes during pregnancy. We performed a cohort study to estimate racial differences in maternal asthma outcomes in a low-income population of pregnant women in which blacks and whites have similar medical care access and benefits. Methods: We conducted a population-based cohort study of asthma-related morbidity in black and white pregnant women enrolled in Tennessee's Medicaid Program, TennCare. Pregnant women were identified through TennCare enrollment files linked to birth certificates, 1995-2001. Prepregnancy, women with asthma were identified using International Classification of Diseases, 9th Revision, codes for health care visits and pharmacy files for asthma medication. Adjusted relative rates (RR) of rescue corticosteroid prescriptions, emergency department (ED) visits, and hospitalizations during pregnancy were compared by race using Poisson regression. Results: We identified 4,315 women with asthma (4%) from a population of 112,171 pregnant women of black or white race with at least 180 days of continuous enrollment in TennCare before pregnancy. Blacks were more likely to receive a course of rescue corticosteroids than whites (14.6% versus 11.9%, adjusted RR 1.35, 95% confidence interval [CI] 1.14-1.61), have an emergency department visit (16.7% versus 8.7%, adjusted RR 1.89, 95% CI 1.57-2.27), or be hospitalized for asthma (9.0% versus 5.2%, adjusted RR 1.73, 95% CI 1.34-2.24). Conclusion: Pregnant women with asthma had high asthma-related morbidity. Black women had clinically significantly more morbidity than whites. There is a need to improve the medical care of low-income women with asthma, particularly black women. Level of Evidence: II-2.

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Exhaled nitric oxide levels during acute asthma exacerbation.

Krauss B.

Department of Emergency Medicine, Loma Linda University School of Medicine, CA, USA. mgill ahs.llumc.edu <mgill ahs.llumc.edu>

OBJECTIVES: Fractional exhaled nitric oxide (FE(NO)) has been shown in laboratory settings and trials of patients with stable asthma to correlate with the degree of airway inflammation. The authors hypothesized that the technique of measuring FE(NO) would be reproducible in the setting of acute asthma in the emergency department (ED) and that the FE(NO) results during ED visits would potentially predict disposition, predict relapse following discharge, and correlate with the National Institutes of Health (NIH) asthma severity scale and peak expiratory flow measurements. METHODS: The authors prospectively measured FE(NO) in a convenience sample of ED patients with acute exacerbations of asthma, both at the earliest possible opportunity and then one hour later. Each assessment point included triplicate measurements to assess reproducibility. The authors also performed spirometry and classified asthma severity using the NIH asthma severity scale. Discharged patients were contacted in 72 hours to determine whether their asthma had relapsed. RESULTS: The authors discontinued the trial (n = 53) after a planned interim analysis demonstrated reproducibility (coefficient of variation, 15%) substantially worse than our a priori threshold for precision (4%). There was no association between FE(NO) response and corresponding changes in spirometry or clinical scores. Areas under the receiver operating characteristic curves for the prediction of hospitalization and relapse were poor (0.579 and 0.713, respectively). CONCLUSIONS: FE(NO) measurements in ED patients with acute asthma exacerbations were poorly reproducible and did not correlate with standard measures of asthma severity. These results suggest that using existing technology, FE(NO) is not a useful marker for assessing severity, response to treatment, or disposition of acute asthmatic patients in the ED.

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The impact of a large-scale population-based asthma management program on pediatric asthma patients and their caregivers.

Feigin J.

UnitedHealth Group, Minnetonka, Minnesota, USA.

BACKGROUND: The consequences of pediatric asthma include missed school attendance, limitations in physical activity, and increased health care utilization and costs. Caregivers of asthmatic children are affected through missed work days and decreased job productivity. In response to these issues, a disease management program encompassing asthmatic children and their caregivers was developed as part of the core services offered to members of a large, national health care plan. OBJECTIVE: To determine the impact of the asthma management program on pediatric asthma patients and their caregivers over a 12-month period. METHODS: In this longitudinal study, 401 randomly selected member households with asthmatic children from 17 regional markets completed surveys before and after 12 months of participation in the asthma management program. Program interventions, which were tailored according to risk and need status, included various staggered educational mailings, reminder aids, videos, a peak expiratory flow rate meter, and telephonic case management. The Asthma Quality Assessment System survey, a battery of self-reported quality indicators, was used to solicit information from parents or caregivers of asthmatic children on issues pertaining to quality of life, asthma management skills and knowledge, and lost work/school days related to asthma. RESULTS: Statistically significant postprogram outcomes were observed in various domains, including a reduction in adverse utilization, symptomatology, and restricted activity days for children and lost work days for adult caretakers. CONCLUSIONS: These findings demonstrate that a large-scale population-based intervention program can produce measurable clinical and economic benefits, thereby lessening the burden of asthma on the family unit.

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Asthma prevalence and drug prescription in asthmatic children.

Pedianet Family Pediatricians Asthma Study Group (F-PASG).

Dept of Pediatrics, University of Padova, Italy.

A cross-sectional study was conducted on among 28,856 children aged from birth to 14 years to determine the prevalence of asthma and assess its treatment in a sample of asthmatic children. Children diagnosed with asthma were identified by a sensitive algorithm applied to the information stored in the computerized medical records between 1997 and 1998. Pediatricians then reviewed and validated the diagnosis. Specific information was obtained, after age stratification under 5 yrs and over 6 ys, from the medical records and by interview regarding their personal details and treatment of asthmatic patients. In all, 1,263 cases of asthma were identified (64% males) with a prevalence of 6.3% among males and 4% among females in under 5 year-olds, and 3.9% for males and 2.1% for females in over 6 year-olds. The prevalence of asthma diagnosed directly by the pediatrician was consequently higher among under 5 year-olds, in both genders, than among the older children. Contrary to the international guidelines, pediatricians prescribed more oral corticosteroids and nebulized short-acting beta-2 agonists for children under 5 ys olds than for over 6 year-olds (13.3% Vs 4.8% and 25% Vs 10.9%, respectively, p < 0.001). For the > or = 6 year-olds, the most commonly prescribed treatments were oral antihistamines (13.9% Vs 12.6%), inhaled corticosteroids via metered-dose inhaler (30.8% Vs 28.7%) and sodium cromoglycate (12.1% Vs 4.8%, p < 0.001).

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Physical activity in urban school-aged children with asthma.

Serwint JR.

Warren Grant Magnuson Clinical Center, National Institutes of Health, Bethesda, Maryland, USA. dlang mail.cc.nih.gov

OBJECTIVES: To compare the physical activity levels of children with and without asthma and evaluate predictors of activity level in children with asthma. METHODS: Parents of 137 children with asthma and 106 controls 6 to 12 years old who attended an urban primary care pediatric clinic were interviewed by telephone. A structured survey evaluated 1 day's total activity and the number of days active in a typical week; asthma characteristics and treatment; physician advice; opportunities for physical activity; and caregiver beliefs about physical activity. The activity levels of children with and without asthma were compared. Predictors of activity level of children with asthma were evaluated. RESULTS: Children with asthma were less active than their peers. The mean amount of daily activity differed by group: 116 (asthma) vs 146 (nonasthma) minutes; 21% (asthma) vs 9% (nonasthma) were active <30 minutes/day; and 23% (asthma) vs 11% (nonasthma) were active <3 days/week. Among children with asthma, disease severity and parental beliefs regarding exercise and asthma predicted activity level. Children with moderate or severe persistent asthma were more likely to be active <30 minutes/day (odds ratio: 3.0; confidence interval: 1.2-7.5), and children whose parents believed exercise could improve asthma were more likely to be highly active > or = 120 minutes/day (odds ratio: 2.5; confidence interval: 1.2-5.4). CONCLUSIONS: Disease severity and parental health beliefs contribute to the lower activity level of children with asthma. Pediatricians should evaluate exercise level as an indicator of disease control and address exercise and its benefits with patients and caregivers to help achieve the goal of normal physical activity in children with asthma.

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