Knowledge of pediatricians in Rio de Janeiro, Brazil, about inhalation therapy in asthmatic children.

Ibiapina AA.

Primary Health Units. Rio de Janeiro. Brazil. marilenecs terra.com.br

BACKGROUND: Despite the numerous guidelines on the diagnosis and treatment of asthma, there are data that indicate that general pediatrician's knowledge of the disease and its preferred treatment is limited, which may influence the quality of care given to asthmatic children. The purpose of this study was to describe pediatrician's knowledge of spacers and of concepts of chilhood asthma, as well as their prescribing habits concerning inhalation therapy, in the public health system of the city of Rio de Janeiro. METHODS AND RESULTS: A descriptive cross-sectional study was performed in a sample of 72 pediatricians from the public health system of Rio de Janeiro. A questionnaire was used to assess prescriptions for spacers, the reasons whay spacers were not used, the models employed, classification of asthma according to clinical severity and symptom frequency, recommendation for the correct spacer volume according to age group, and the concept of asthma as an inflammatory disease. Seventy percent (51/72) of the physicians did not routinely prescribe the spacer. The reasons given were as follows: a) lack of spacer availability in the public health system in 55 % (28/51); b) high cost in 57 % (29/51); c) the complexity of their use in 35 % (18/51); d) unwillingness to use aerosol type medication in 15 % (8/51), and e)lack of knowledge of their function and utilization in 59 % (30/51). Of the 30 % (21/72) who reported they regularly and routinely prescribed the spacer in daily practice, 48 % (10/21) stated that this routine prescription, even when indicated, was below 25 % of what was expected and makeshift models were preferred by 24 % (5/21) of the pediatricians. Six percent of the pediatricians chose the appropriate spacer volume according to age group, 62.5 % (45/72) reported that they classified asthma according to severity, 16 % (7/45) gave the correct answers when classifying asthma according to national consensus, and 22 % (16/72) considered asthma to be an inflammatory disease. CONCLUSIONS: The results of this study suggest that pediatrician's knowledge of inhalation therapy with dosed aerosol spacers and of asthma-related concepts in the public health system in Rio de Janeiro is limited. This may restrict the quality of care given to the asthmatic children in the city and suggests the need for training programs for the management of asthmatic children.

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Allergen-induced bronchial inflammation in house dust mite-allergic patients with or without asthma.

van der Zee JS.

Department of Pulmonology, Academic Medical Center, Amsterdam, The Netherlands.

BACKGROUND: It is presently unknown which factors determine the occurrence and persistence of asthma in house dust mite-allergic individuals. The level of allergen-specific IgE antibodies does not seem to be decisive for asthmatic symptoms. Moreover, levels of exposure to mite allergens do not seem to differ significantly between asthmatic and non-asthmatics individuals. AIM: It was hypothesized that the presence or absence of asthmatic symptoms in house dust mite-allergic patients is associated with quantitative or qualitative differences in the cellular bronchial inflammatory response during the late phase of the allergic reaction. This hypothesis was tested in the bronchial allergen challenge model. MATERIAL AND METHODS: Whole lung challenges with house dust mite extract were performed in 52 house dust mite-allergic subjects, of whom 26 had asthma and 26 had perennial rhinitis without asthmatic symptoms. Primary outcomes were parameters for bronchial inflammation in serial samples of induced sputum (cell differentials, eosinophil cationic protein (ECP), interleukin-8 (IL-8), myeloperoxydase (MPO)). In addition, lung function, non-specific bronchial hyper-responsiveness and serial blood samples (eosinophils and IL-5) were analysed. RESULTS: At baseline sputum eosinophils and ECP were similar in both groups but neutrophils and IL-8 were higher in asthmatics. The early bronchoconstriction after allergen challenge was similar in asthma and non-asthmatic rhinitis (median decrease in FEV1: asthma -31.7% vs. non-asthmatics -29.1%, P > 0.1). The late phase bronchoconstriction was significantly greater in asthma (median decrease in FEV1: asthma -27.6% vs. non-asthmatics -18.9%, P = 0.02). Induction of bronchial hyper-responsiveness was similar in both groups. Bronchial allergen challenge elicited significant increases in sputum eosinophils and ECP, which were indistinguishable for both groups (P > 0.1 and P = 0.07, respectively). In contrast, higher numbers of neutrophils persisted in asthma 24h after challenge and were accompanied by significant increases in IL-8 and MPO, which were absent in non-asthmatics (difference between groups P = 0.007 and P = 0.05, respectively). CONCLUSION: Allergen challenge inducedvery similar increases in eosinophils and ECP in induced sputum in allergic asthmatics and in allergic non-asthmatic patients. The difference in bronchial inflammation between asthma and non-asthmatic rhinitis appeared to be more closely related to indices for neutrophilic inflammation.

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Bronchial hyperresponsiveness and airway inflammation in adolescents with asymptomatic childhood asthma.

Kohno S.

Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan.

BACKGROUND: About 70% of childhood asthmatics become free of asthma-related symptoms during adolescence. Little is known about bronchial hyperresponsiveness (BHR) and airway inflammation in young adults with "outgrown" childhood asthma. METHODS: We studied 61 nonsmoking medical students (18 intermittent mild asthmatics, 23 students with outgrown childhood asthma but free of asthma-related symptoms for 10 years (asymptomatic asthmatics) and 20 healthy students). BHR and lung function were measured, and induced sputum samples analyzed for eosinophil count, eosinophilic cationic protein (ECP), granulocyte-macrophage colony stimulating factor (GM-CSF), and tumor necrosis factor-alpha (TNF-alpha). RESULTS: BHR was still present in most asymptomatic asthmatics, but it was milder compared with healthy students. Only three subjects with previous asthma had no BHR and no signs of airway inflammation. Percentages of eosinophil, and ECP, TNF-alpha and GM-CSF concentrations in induced sputum of mild asthmatics and asymptomatic asthma groups were higher than in the healthy group. In asymptomatic asthmatics group, the duration of asthma, sputum eosinophil percentage, and the level of TNF-alpha in sputum correlated significantly with BHR. CONCLUSIONS: Only a few subjects with longstanding asymptomatic asthma could be considered as cured; most asymptomatic asthmatics continued to exhibit BHR and signs of airway inflammation. The outcome of childhood asthma and BHR was associated with the degree of airway inflammation and the duration of childhood asthma.

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Altered intracellular expression of the chemokines MIP-1alpha, MIP-1beta and IL-8 by peripheral blood CD4+ and CD8+ T cells in mild allergic asthma.

Bisset LR.

Clinical Immunology, Department of Internal Medicine, University Hospital, Zurich, Switzerland.

BACKGROUND: The ability of chemokines to regulate Th1 and Th2 responses suggests a role in the pathogenesis of atopic disorders such as allergic asthma where Th2 response dominance has been observed. Although the impact of allergic asthma on local chemokine production in the lung has been the subject of investigation, little is know about the influence of disease progression on peripheral chemokine production. We now report use of whole blood culture and flow cytometry to assess the influence of mild allergic asthma on peripheral T-cell chemokine expression. METHODS: Study participants included patients with mild allergic asthma (n = 7) and nonasthmatic controls (n = 7). Following in vitro stimulation of peripheral venous blood with phorbol 12-myristate acetate (PMA) and ionomycin, flow cytometry was used to estimate the percentage of CD4+ and CD8+ T cells producing a number of chemokines, including macrophage inflammatory proteins MIP-1alpha and MIP-1beta, RANTES (regulated on activation, T-cell expressed and secreted), monocytic chemotactic protein-1 (MCP)-1, and interleukin (IL)-8, or the cytokines interferon (IFN)-gamma and IL-4. Serum levels of MIP-1alpha, MIP-1beta, RANTES, MCP-1, IL-8, IFN-gamma and IL-4 were also assessed by quantitative ELISA. RESULTS: Intracellular expression of MIP-1beta by CD4+ and CD8+ T cells from allergic asthmatics was significantly reduced in comparison to that observed for nonasthmatics (median = 2.29% (1.75-3.50) vs 4.57% (3.38-6.64), P = 0.05; 14.20% (13.18-17.88) vs 44.10% (30.38-48.70), P = 0.01). Similarly, intracellular expression of MIP-1alpha by CD8+ T cells from allergic asthmatics was also significantly lower (3.67% (1.17-5.42) vs 17.10% (4.97-20.43), P = 0.05). Conversely, IL-8 expression by both CD4+ and CD8+ T cells from allergic asthmatics demonstrated significant enhancement (9.93% (7.77-11.28) vs 4.14% (3.61-7.11), P = 0.05; 8.40% (6.97-10.04) vs 4.98% (3.37-6.08), P = 0.05). Examination of intracellular IFN-gamma and IL-4 revealed no significant difference in the expression of either cytokine by CD4+ T-cells from allergic asthmatics and nonasthmatics. In contrast, expression of IFN-gamma was significantly reduced in CD8+ T-cells from allergic asthmatics (24.60% (21.08-32.50) vs 48.40% (41.50-55.28), P = 0.01). CONCLUSIONS: The occurrence in mild allergic asthma of peripheral T-cell chemokine expression suggestive of a diminished Th1 response, coinciding with marginal change in cytokine profiles indicative of a Th2 response bias, confirms the importance of chemokine involvement in the etiology of allergic asthma. The ability to use whole blood culture to estimate chemokine expression in T cell subsets may ultimately provide a practical means to evaluate disease status and to monitor early intervention therapies which target chemokines.

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Lack of agreement in classification of the severity of acute asthma between emergency physician assessment and classification using the National Asthma Council Australia guidelines (1998).

Kerr D.

Department of Emergency Medicine and Pediatrics, Royal Children's Hospital, Melbourne, Australia.

AIMS: To determine the level of agreement in classification of the severity of acute asthma at presentation to the emergency department, between emergency physician global assessment and severity classification according to the National Asthma Council Guidelines, Australia 1998 (NACG). METHODS: Prospective observational study in emergency departments throughout Australia, participating in the Asthma Snapshot 2000 project. Patients between the ages of one and 60 years presenting to participating emergency departments with acute asthma between 21 August and 3 September 2000 were included. Data collected were emergency physician global assessment of asthma severity and severity classification according to the National Asthma Council Guidelines and disposition. RESULTS: Five hundred and five subjects had completed data for emergency physician assessment of severity and for calculation of severity classification according to the National Asthma Council Guidelines. Weighted kappa for agreement in classification was 0.48 (95% confidence interval: 0.40, 0.56). Emergency physicians assess asthma as less severe compared to the National Asthma Council Guidelines assessment. CONCLUSIONS: Agreement between physician assessment of severity of acute asthma and severity classification according to National Asthma Council Guidelines is only moderate. This may have implications in treatment and disposition. This also suggests that emergency physicians may be using other methods to classify acute asthma than the National Asthma Council Guidelines classification.

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Bronchial dilatation in asthma: relation to clinical and sputum indices.

Mishima M.

Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Japan.

BACKGROUND: Investigations using high-resolution CT (HRCT) show that bronchial dilatation (BD) is found in many patients with asthma. However, the pathogenesis and pathophysiologic relevance of BD in asthma are poorly understood. A balance between matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) may control the remodeling of extracellular matrix, and excess MMPs have been associated with destruction or dilatation of airways in patients with bronchiectasis. OBJECTIVES: To study the prevalence of BD as assessed by HRCT according to standard subjective criteria in 37 patients with stable asthma and 10 healthy control subjects, and to examine the relation of BD in asthmatic patients to clinical characteristics and sputum indices, including MMP-9 and TIMP-1 levels. DESIGN: A prospective cohort study. RESULTS: At least one dilated bronchus was present in 23 asthmatic subjects (62%) and 2 control subjects (20%) [p = 0.030]. The ratio of dilated bronchi to all eligible bronchi in each subject (individual BD%) was higher in the asthmatic patients than in the control subjects (11.4 +/- 16.1% vs 1.3 +/- 3.0%, p = 0.011) [mean +/- SD]. Asthmatic patients with (n = 23) and those without BD (n = 14) were similar with regard to age, duration and severity of asthma, atopy, pulmonary function, sputum eosinophil or neutrophil count, and sputum levels of MMP-9 or TIMP-1 and their molar ratio. Individual BD% of asthmatic patients was also unrelated to these clinical and sputum variables. When analysis was confined to the 23 patients with BD, however, individual BD% correlated with the severity score of asthma (r = 0.49, p = 0.023). The results of follow-up HRCT obtained from 19 patients suggested that BD was a fixed rather than transient phenomenon. CONCLUSION: BD is more prevalent in asthmatic patients than in normal subjects and might be associated with the severity of asthma. Cellular inflammation or possible imbalance between MMP-9 and TIMP-1 was not demonstrated in this study to be related to BD in asthma.

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Prevalence and impact of asthma in children, Georgia, 2000.

Bason J.

Georgia Department of Human Resources, Division of Public Health, Atlanta, Georgia 30303, USA.

BACKGROUND: Asthma is a common chronic condition with significant impact on those who have it. Information about children with asthma was sought to guide state program planning. METHODS: A random-digit-dial telephone survey of 1503 households with 2700 children was conducted in Georgia. Primary caretakers were interviewed. Results for households, children, and caretakers were weighted by number of telephone lines; results for children were also weighted to the Georgia 1998 estimated population. Data were collected and analyzed in 2000. RESULTS: Asthma prevalence among children in Georgia aged 0 to 17 years was 10.5% (95% confidence interval [CI]=9.2%-11.9%). Among children with asthma, 64.8% (95% CI= 58.5-71.1) had an attack and 30.0% (95% CI=24.2-35.8) visited an emergency department in the last year. In the past year, 53.9% (95% CI=46.8-61.0) of school-aged children with asthma and 29.7% (95% CI=23.7-35.7) of adults in households of children with asthma missed school or work because of the child's asthma. Among children with asthma, 56.1% (95% CI=48.6-63.6) lived in a household where neither caretaker nor child has taken a course or been taught about managing asthma, and 28.6% (95% CI=22.1-35.1) lived in a household where adults smoked inside the house. CONCLUSIONS: Asthma has a substantial effect on the lives of children in Georgia, including medical events and missed school, and on adult caretakers in terms of missed work due to the child's asthma. To reduce the burden of asthma in Georgia, exposure of people with asthma to tobacco smoke in the home should be eliminated and training in asthma management should be more widely available.

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Nasal cytology and genotoxic damage in nasal epithelium and leukocytes: asthmatics versus nonasthmatics.

Rojas E.

Departamento de Biologia Celular y Tisular, Facultad de Medicina UNAM, Mexico City, Mexico. fortoul servidor.unam.mx

BACKGROUND: The best example of a chronic inflammatory respiratory disease is asthma, a disease which has an increasing prevalence worldwide. This chronic inflammation is also related to the generation of oxidative stress since the cells involved in the allergic reaction are capable of producing reactive oxygen species (ROS), and this might predispose asthmatics to increased genotoxic damage. METHODS: A respiratory symptomatology questionnaire was self-applied by asthmatic and nonasthmatic students. A single cell gel electrophoresis assay in two different cell types (nasal epithelial cells and leukocytes) was performed, and the cytology of the nasal smears stained with HE was evaluated. RESULTS: Both groups reported having a runny nose. Asthmatics had greater DNA damage in the nasal epithelial cells in contrast to nonasthmatics. In leukocytes no statistical significance in DNA damage was identified. Metaplasia was evident in asthmatics that also showed eosinophils and neutrophils as well as goblet cells and mucus at a higher frequency compared with nonasthmatics. CONCLUSIONS: Nasal symptoms did not correlate with genotoxic damage, since they were reported in both groups. Nasal epithelial cells of asthmatics are more sensitive to genotoxic damage, and chronic inflammatory response. Also the activity of eosinophils might mediate the DNA damage through the generation of ROS. Copyright 2003 S. Karger AG, Basel

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