Asthma education.

Powell H.

Department of Respiratory and Sleep Medicine, Hunter Medical Research Institute, John Hunter Hospital, University of Newcastle, Locked Bag 1, Hunter Region Mail Centre, NSW 2310, Australia. mdpgg mail.newcastle.edu.au

Education about asthma and self-management of asthma are now key recommendations of asthma management guidelines. A Cochrane systematic review of 12 RCTs found that limited education programmes that offer information about asthma but not self-management skills did not reduce hospitalisation rates or visits to the doctor for asthma. The positive outcomes from limited asthma education were a reduction in symptoms. Asthma self-management education which consists of information, self-monitoring, regular medical review, and a written action plan is effective and leads to a reduction in hospitalisation and ER visits for asthma, unscheduled doctors visits, days lost from work, episodes of nocturnal asthma, indirect costs and an improvement in quality of life. The effects were large enough to be of both clinical and statistical significance. While a structured asthma self-management programme is effective in a hospital setting, attempts to deliver these programmes in primary care have met with varying success.

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Underdiagnosed asthma in South Australia.

Ruffin RE.

The Health Observatory, The Queen Elizabeth Hospital, University of Adelaide, Woodville, South Australia. Robert.adams nwahs.sa.gov.au

BACKGROUND: The prevalence of undiagnosed asthma in the general population and the clinical and demographic characteristics of these patients compared with those with diagnosed asthma are unclear. METHODS: The North West Adelaide Health Survey (NWAHS) is a population household interview survey of adults (age>18 years) in the north western suburbs of Adelaide, South Australia (regional population 0.6 million). Data obtained were weighted to the closest census data to provide population representative estimates. Positive answers to: "Have you ever had asthma?"; "Has it been confirmed by a doctor?"; "Do you still have asthma?" determined current physician diagnosed asthma. A positive bronchodilator response on spirometric testing according to ATS criteria without a physician's diagnosis determined undiagnosed asthma. Other measures included the SF-12 health survey questionnaire, the Selim index of severity of chronic lung disease, skin allergy tests, and demographic data. RESULTS: Of the 3422 individuals interviewed, 2523 (74%) agreed to participate in the clinical assessment. Of these, 292 (11.6%) had asthma, 236 (9.3%) with a doctor's diagnosis of asthma and 56 (2.3%) with undiagnosed asthma defined on spirometric criteria; thus, 19.2% of the total asthma group were undiagnosed. Those undiagnosed were more likely (p<0.05) to be >40 years old, on government benefits, with an income <AUD$40,000. Symptom frequency was similar in the two asthma groups, but mean spirometric values were lower in the undiagnosed group (p<0.05) while positive skin allergy tests were more common in the diagnosed group (p<0.05). SF-12 component summary scores were significantly lower in both asthma groups than in the non-asthma population. Undiagnosed asthma was frequent in men and in those aged >65 years. Health service use over the previous year was similar for both asthma groups. CONCLUSION: Undiagnosed asthma is common among the Australian population, with a similar clinical spectrum to those with diagnosed asthma.

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Systematic assessment of difficult-to-treat asthma.

Asthma and Allergy Research Group of the National Heart and Lung Institute.

Dept of Allergy, Upper Respiratory Medicine, National Heart and Lung Institute, Faculty of Medicine, Imperial College, London, UK. d.s.robinson imperial.ac.uk

Five per cent of asthmatics remain symptomatic despite high-dose treatment. The aim of the study was to investigate how often such difficult-to-treat asthma is due to intractable asthma, misdiagnosis, non-adherence with therapy, or psychiatric problems. Difficult asthma was defined as persistence of symptoms despite treatment at step 4 of British guidelines or requirement for long-term oral glucocorticoids (step 5). One-hundred patients with a respiratory physician diagnosis of asthma were investigated in a single tertiary respiratory unit in an open and descriptive study. Twelve of the patients studied did not have asthma and a further seven had additional diagnoses. Of the remainder, 55 had an asthma diagnosis confirmed by demonstration of reversible airflow narrowing or peak flow variability, whilst 20 did not. Non-compliance with prednisolone therapy was more frequent in the 55 with confirmed asthma (nine of 18 prescribed oral prednisolone at a dose of > or = 15 mg x day(-1)) and was not detected in the "unconfirmed asthma" group. There were no other significant differences between these groups. A major psychiatric component was detected in 10 patients. Systematic evaluation of difficult asthma is useful as it can identify alternative or additional diagnoses, psychiatric illness or nonconcordance with therapy in a substantial proportion of cases (32% in the present series).

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Reduced eosinophil apoptosis in induced sputum correlates with asthma severity.

Walsh GM.

Allergic and Asthmatic Inflammation Research Group, Dept of Medicine and Therapeutics, Institute of Medical Sciences, University of Aberdeen Medical School, Aberdeen, UK.

This study was carried out to investigate the relationship between induced sputum eosinophil apoptosis and clinical severity score, airway obstruction and symptom scores in patients with chronic stable asthma. Altogether, 41 chronic stable asthmatic subjects of varying severity defined by Aas score and 17 control subjects underwent spirometry, symptom questionnaire and successful sputum induction. Sputum was processed and cytospins prepared for light microscopy to determine normal and apoptotic eosinophils. Mild asthmatic subjects had a significantly lower percentage sputum eosinophils and a significantly higher eosinophil apoptotic ratio (AR) than moderate or chronic severe asthmatics. Severe asthmatic subjects had a significantly greater age, duration of asthma and sputum eosinophil count x mL(-1) than mild asthmatic subjects. Asthmatic subjects' symptom scores, severity scores and age inversely correlated with AR and the percentage of sputum eosinophils. Baseline forced expiratory volume in one second inversely correlated with percentage sputum eosinophils and positively correlated with AR. The study demonstrates a relationship between reduced sputum eosinophil apoptosis and increased clinical severity of chronic stable asthma, providing additional evidence that eosinophil apoptosis may be important in the resolution of eosinophilic airway inflammation in asthma.

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Trends of asthma in Mexico: an 11-year analysis in a nationwide institution.

Lugo A.

Unidad de Investigacion Medica en Epidemiologia Clinica, Hospital de Pediatria, Centro Medico Nacional Siglo XXI, Mexico DF, Mexico. mhvargasb yahoo.com.mx

STUDY OBJECTIVES: Asthma prevalence is increasing in many countries. Some recent articles, however, claim that this tendency is ending. Our aim was to investigate asthma trends in Mexico. DESIGN: Annual data on health services provided to asthmatic patients were retrospectively analyzed from 1991 to 2001. SETTING: The Instituto Mexicano del Seguro Social, the largest nationwide medical institution in Mexico (approximately 24 to 32 million insured subjects). PARTICIPANTS: Health services provided to subjects of any age. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Asthma-associated health services, either expressed as absolute number or as rate per insured subjects, progressively increased until 1997 in family physician office visits (FPOVs) [newly diagnosed cases only], emergency department visits (ERVs), and hospital discharges (HDs). From that year onward, the number and rates of asthma-associated health services decreased. The same trends were observed for age groups 0 to 4 years, 5 to 14 years, 15 to 44 years, and 45 to 64 years. Using a different approach, asthma was diagnosed each year in approximately 0.4% of all FPOVs, but a decrease in this percentage was observed from 1997 onward. Likewise, asthma caused increasing percentages of all ERVs and HDs until 1997, followed by a sharp decline thereafter. CONCLUSIONS: A decline in absolute and relative numbers of asthma-associated health services occurred over recent years in all medical settings, suggesting that the epidemic of new asthma cases is ending and/or that better control of the disease has been achieved.

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Sputum eosinophilia in cough-variant asthma as a predictor of the subsequent development of classic asthma.

Koh YY.

Department of Pediatrics, Inje University Sanggye Paik Hospital, Seoul, Korea.

BACKGROUND: A significant proportion of patients diagnosed with cough-variant asthma eventually manifest classic asthma signs, such as wheezing and dyspnoea. The aim of this study was to investigate whether the percentage of eosinophils and/or concentration of eosinophilic cationic protein (ECP) in sputum induced from patients with cough-variant asthma can predict the development of classic asthma. METHODS: Sixty-two children with cough-variant asthma were prospectively studied for 4 years. At the initiation of the study, sputum was induced with hypertonic saline, and the sputum samples were analysed for total and differential cell counts, and for ECP. Each subject was checked clinically at least every 3 months, and details of classic asthma signs experienced during the intervening periods were taken. RESULTS: Twenty-four (47.1%) of the 51 subjects available for follow-up developed signs of classic asthma, while 27 did not. The only significant difference in the sputum parameters between these two groups was a higher percentage of sputum eosinophils in subjects who developed classic asthma. A significant association was found between sputum eosinophil percentage and classic asthma development, but not between the concentration of sputum ECP and classic asthma development. CONCLUSION: Sputum eosinophilia in cough-variant asthma may be a correlate of the later development of classic asthma. This suggests that sputum differential cell counts may be useful in the clinical management of patients with cough-variant asthma, as they may enable the prediction of the subsequent classic asthma development.

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[Relationships between the diameters of Bacille Calmette-Guerin scars and asthma, atopy in urban and rural Beijing children]

[Article in Chinese]

Chen YZ.

Asthma Clinic and Education Center, Capital Institute of Pediatrics, Beijing 100020, China.

OBJECTIVE: To compare the diameters of Bacille Calmette-Guerin (BCG) scars between asthmatic (allergic) students and normal students, and to compare the diameters of BCG scars in children in rural Beijing area with those in urban Beijing area, and to compare the prevalence of asthmatic (allergic) symptoms and atopy between rural and urban Beijing students. METHODS: Sampled by cluster-random Method, 819 urban school children and 1 044 rural school children aged 13 - 14 years were recruited for the Beijing arm of the phase III international study of asthma and allergies in childhood. The children answered the core questionnaires, and underwent skin prick test for 13 allergens, and were checked for BCG scars on their arms. RESULTS: (1) In both rural and urban Beijing students, the mean diameters of BCG scars in those with asthma (allergy) (asthma ever, wheeze ever, current wheeze within 12 months, hay fever ever, repeated rash ever, eczema ever, allergic rhinitis, atopy, high-sensitivity or were diagnosed asthma) were (7.0 +/- 2.1) mm-(8.8 +/- 2.8) mm, which were not significantly different from those of (7.2 +/- 2.7) mm-(8.2 +/- 2.2) mm in normal students (P > 0.05). (2) Compared to the urban students, the mean diameter of BCG scars in the rural students was (8.2 +/- 2.3) mm, significantly larger than that of (7.3 +/- 2.9) mm in the urban students (P < 0.01). The prevalence of asthma (allergy) (asthma ever, wheeze ever, current wheeze within 12 months, hay fever ever, repeated rash ever, eczema ever, allergic rhinitis, atopy, high-sensitivity or diagnosed asthma) were 0.6% - 11.4% in the rural Beijing students, significantly lower than that of 3.1% - 35.7% in urban Beijing schoolchildren (P < 0.01). CONCLUSIONS: The diameters of BCG scars were not significantly different between asthmatic (allergic) students and normal students. The diameters of BCG scars in the rural students were significantly larger than those in the urban students. The prevalence of asthma and allergy in the rural children were significantly lower than that in the urban students. The results suggest that there is difference in immunity between rural and urban children from early life, which may be caused by the different living environments.

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Prevalence and correlates of asthma in the Puerto Rican population: Behavioral Risk Factor Surveillance System, 2000.

Cintron Y.

Department of Biostatistics and Epidemiology, Graduate School of Public Health, University of Puerto Rico, San Juan, Puerto Rico 00936-5067, USA.

The 2000 Behavioral Risk Factor Surveillance System (BRFSS) showed that Puerto Rico had the highest self-reported prevalence of asthma. Our objective was to estimate the self-reported prevalence of asthma among different population subgroups and determine its correlates in Puerto Rican adults as reported by the BRFSS. The BRFSS data gathered during 2000 were analyzed. To determine factors associated with self-reported prevalence of asthma, a simple unconditional logistic regression model was employed; then, to estimate adjusted weighted prevalence odds ratios, a multiple unconditional logistic regression model was used. The self-reported weighted prevalence of ever having asthma among Puerto Rican adults was 15.9% (14.8%-16.9%). Asthma prevalence was significantly higher in the following population subgroups: females (18.8%), educational attainment > 12 years (18.4%), having health coverage (16.3%), and obesity (21.0%). Asthma prevalence did not differ among age groups, region of residence, annual income, smoking at least 100 cigarettes in entire life, and physical activity. Almost half (45.6%) of asthmatics reported having children affected with the condition. The prevalence of asthma in any children of the interviewed was 33.2%, 51.3% were receiving treatment, and 30.6% and 24.3% reported having one to three visits to emergency departments and hospital admissions, respectively, resulting from asthma last year. Based on the logistic regression model, the following factors were significantly associated with asthma: sex, high educational attainment, health coverage and obesity. Consistent with previous studies in Puerto Ricans living in the mainland, a higher than expected prevalence of asthma was observed. The possibility of a genetic-environment interaction deserves further investigation.

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