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[Bronchial asthma: allergy and inflammation. Principles of rational asthma therapy].

Improved concepts concerning the pathogenesis of chronic bronchial asthma, the role of air pollutants, infections, and allergic reactions are the basis of established therapeutic principles and the development of new drugs: Allergens initiate long lasting inflammatory processes ("late phase reactions") in the bronchial system. This inflammation causes bronchial hyperreactivity and altered lung function. A large number of inflammatory cells and mediators are involved. Air pollutants and infections can act in the same way. Asthma treatment should focus in the inflammatory process, start early and prevent and treat both chronic inflammation and acute bronchospasm.

Asthma↗

Clinical study of asthma in adolescents and in young adults. Correlation between laboratory findings and severity of asthma.

Fifty-eight mite-allergic asthmatic patients ages 15 to 22 years were examined. Low respiratory threshold to acetyl-choline (RT-Ach), high maximal histamine release (HR) by mite and anti-IgE, high serum IgE levels and high eosinophil counts were highly associated with the severity of asthma. RT-Ach correlated inversely with HR to mite and anti-IgE. The maximal histamine release from leukocyte caused by anti-IgE also correlated highly with the severity of asthma.

Adolescent↗

Asthma and nifedipine. Comparison of nifedipine, ketotifen and placebo in the prophylaxis of childhood extrinsic asthma.

These results were obtained on a double blinded study which compared the Nifedipine effects, a dihydropyrine calcium blocker of extensive cardiovascular function, the Ketotifen and a placebo orally administered, during 4 months, every 12 hours, on children with allergic asthma, older than 5 years old, who had a minimum of 2 years of evolution in their sickness. These people consulted the Allergic Service of the University Hospital of San Vicente de Paul in Medellín, Colombia, between July of 1984 and December 1986. Nifedipine diminished its intensity, frequency and the time the crisis lasted; it was seen at the end of the treatment. It also diminished bronchodilator consumption in more than 80% of the cases it 90% of the patients reported beneficial effects with Nifedipine and the improvement evaluated by the doctor showed 75%. These results were statistically similar to those obtained with Ketotifen but significantly superior to those obtained with the placebo. There wasn't any variation on the pulmonary function test, neither on the cardiovascular parameters evaluated. Side effects were mild and very few. We can assure that Nifedipine can be an alternative drug for the treatment of low or moderate child Extrinsic Asthma, given its similar behavior to Ketotifen, a drug of known effectiveness in this topic. The Calcium Blockers can become an elective treatment in the future for the asthmatic patient, if some molecules with higher affinity for respiratory tracts and better blocking effect, can be synthetized.

Asthma↗

[Thickening of the bronchial wall in asthma and asthma-like bronchitis].

Small ring-shaped images, related to 2nd or 3rd bronchial walls are seen in prahilar lung region in 80% of chest Xray films, when a bronchus in seen "end on". This bronchial wall thickening (greater than 0.3 mm) is present in numerous lung diseases such as silicosis, bronchiectasis and pulmonary edema. In order to evaluate the significance of such bronchial wall thickening in chronic obstructive bronchitis and bronchial asthma, 78 patients suffering from these diseases have been studied correlating bronchial wall-thickening with the major clinical and bio-humoral indices of broncho obstruction a significant correlation was found between bronchial wall thickening and Tiffeneau index (p less than 0.05), the PaO2 (p less than 0.01), and the E.S.R., expressed as Katz index (p less than 0.001). No correlation was observed between bronchial wall thickening and positivity to allergological tests. It follows that the bronchial wall thickening is an expression of mucous membrane edema and/or endobronchial mucous or purulent hypersecretion. This aspect, though not usefull in the differential diagnosis between chronic obstructive bronchitis and paroxysmal bronchial asthma due to topical inhalants, is indicative of an acute phase in the inflammation process in such patients.

Adolescent↗

[Psychological profiles of patients with bronchial asthma. First report: analysis according to the difference in severity of asthma].

Although it is well known that asthma is influenced by psycho-social factors, the present medical system does not take any measures to deal with these underlying factors. Many physicians are unable to assist patients with psycho-social problems due to the lack of time they are allowed for each patient. We have employed a variety of psychological test scales to assist in screening patients. As a result, we found that many severe asthmatics lack enthusiasm for therapy, possess pessimistic feelings toward their prognosis. They also have personality traits of extroversion in combination with psychological instability, which may given them problems of compliance, while some manifest a tendency to flight to illness. These factors may lead to further difficulty in treatment, including steroid dependency and death from asthma. Early intervention must be contemplated to prevent such outcomes.

Asthma↗

[Methotrexate in the treatment of asthma. Open trial in 10 corticoid-dependent patients with severe asthma].

Methotrexate was suggested as a treatment in 1976 by Mullarkey for severe steroid-dependent asthma, in order to reduce the use of systemic steroids responsible for numerous undesired side-effects. The aim of this open trial was to study the efficacy and tolerance of Methotrexate in the short, medium and long term and after its cessation, in ten patients aged 49.2 (+/- 3.0) who were suffering from severe steroid-dependent asthma (18.5 +/- 4.8 mg of prednisone daily for at least one year). Methotrexate was given in a dose of 15-30 mg for 14.3 months (+/- 1.8) with a post-treatment follow-up for eight patients lasting 7.9 months (+/- 1.7). The efficacy was assessed on the daily dosage of prednisone and was also evaluated using the FEV1 (VEMS) (the variations expressed were a percentage of the variation from the predicted value). In the short term (six weeks) there was no significant change in the FEV1 nor in the dose of prednisone. In the medium term (12 weeks) there was evidence of a reduction in the average daily dosage of prednisone of 39.5% with an increase in the FEV1 of 14.1%. In the long term MTX was not found as effective in reducing the dose of prednisone (15.2 mg) as on the FEV1 (an increase of 5.1% on the theoretical values). There was a favourable outcome for two patients who maintained the benefit after stopping the MTX. Seven out of ten patients presented with side effects of MTX, in three of whom the drug has to be stopped.(ABSTRACT TRUNCATED AT 250 WORDS)

Adrenal Cortex Hormones↗

Oxidant and acid aerosol exposure in healthy subjects and subjects with asthma. Part I: Effects of oxidants, combined with sulfuric or nitric acid, on the pulmonary function of adolescents with asthma.

Both peak flow decrements in children at summer camps and increased hospital admissions for asthma have been associated with summer "acid haze," which is composed of ozone and various acidic species. The objective of this study was to investigate the pulmonary effects of acid summer haze in a controlled laboratory setting. Twenty-eight adolescent subjects with allergic asthma, exercise-induced bronchospasm, and a positive response to a standardized methacholine challenge enrolled in the study; 22 completed the study. Each subject inhaled one of four test atmospheres by mouthpiece on two consecutive days. The order of exposure to the four test atmospheres was assigned via a random protocol: air, oxidants (0.12 parts per million [ppm]* ozone plus 0.30 ppm nitrogen dioxide), oxidants plus sulfuric acid at 70 micrograms/m3 of air, or oxidants plus 0.05 ppm nitric acid. Exposure to each of the different atmospheres was separated by at least one week. The exposures were carried out during alternating 15-minute periods of rest and moderate exercise for a total exposure period of 90 minutes per day. Pulmonary function was measured before and after exposure on both test days and again on the third day as a follow-up measurement. A postexposure methacholine challenge was performed on Day 3. Low methacholine concentrations were chosen for the postexposure challenge to avoid provoking a response. The protocol was designed to detect subtle changes in airway reactivity. The statistical significance of the pulmonary function values was tested using paired t tests. First, we compared the difference between baseline and postexposure measurements after air exposure on Day 1 with the differences between baseline and postexposure measurements after Day 1 exposure to each of the other three atmospheres. Second, we compared the difference between baseline and postexposure measurements after the Day 2 air exposure with the differences between baseline and postexposure measurements after the Day 2 exposure to each of the pollutant atmospheres. Third, we compared the difference between baseline measurements on Day 1 of each exposure atmosphere with measurements after exposure to the same atmosphere on Day 2 to detect delayed effects. No changes in any of the pulmonary function parameters were statistically significant when compared with changes after clean air exposure. Six subjects left the study because of uncomfortable symptoms associated with the exposures. These all occurred after exposure to pollutant atmospheres and not after exposure to clean air.(ABSTRACT TRUNCATED AT 400 WORDS)

Acid Rain↗

Asthma and atopy as diseases of unknown cause. A viral hypothesis possibly explaining the epidemiologic association of the atopic diseases and various forms of asthma.

The basic etiology of asthma and atopy is unknown. Family grouping of cases is evident and has led to the assumption that genetic predisposition to making excessive IgE responses and in some cases a genetically determined tendency to have irritable bronchi are the fundamental causes of these conditions. Interplay between these hereditary predispositions and environmental factors such as allergen exposure are thought to explain all of the characteristic findings. Many cases, however, develop without a positive family history, and there are a variety of findings not easily explained by current theory. The increasing incidence of these conditions makes it necessary to question long held assumptions and explore other hypotheses. A review of difficult to explain characteristics and epidemiology of asthma and atopy makes a hypothesis involving a transmissible agent or agents plausible enough to warrant serious consideration.

Asthma↗

[Asthma symptoms and anti-asthma drugs in 4 Scandinavian countries].

A study of the occurrence of asthma in six areas in four Nordic countries showed 18-25 percent of the populations investigated to have had wheezing or whistling in the airways during the previous 12-month period, and 2-3 percent to have had asthma attacks. The use of anti-asthmatics was found to have differed from one to another of the areas included in the study, and the result suggest the difference to depend upon corresponding differences in the extent to which an active approach to treatment was adopted for the care of patients with asthmatic problems.

Adult↗

[Eosinophil count in asthma. A marker of disease activity in intrinsic and extrinsic asthma].

The relationship between eosinophil count and pulmonary function (FEV1), respiratory symptoms, bronchial responsiveness to histamine and diurnal variation in peak expiratory flow rate (PEF) was studied in a group of asthmatics (n = 70) examined in childhood (mean age 10 yrs) and early adulthood (mean age 21 yrs), of whom 24 had intrinsic and 46 extrinsic asthma. Self-reported symptoms of asthma were graded on a scale from zero to five; histamine responsiveness was analysed by means of the dose-response slope (DRS). In both childhood and adulthood, a direct correlation was found between blood eosinophil count and symptom score (r = 0.69, p < 0.001 and r = 0.58, p < 0.001, respectively), whereas inverse correlations were observed between number of eosinophils and FEV1 expressed as percentage of predicted values (r = -0.75, p < 0.001 and r = -0.80, p < 0.001, respectively). Furthermore, in adulthood, eosinophil count was found to be significantly correlated to histamine responsiveness (logDRS) (r = 0.65, p < 0.001) and diurnal PEF variation (r = 0.81, p < 0.001); these correlations were also noted after dividing the subjects into intrinsic and extrinsic asthmatics. The findings in the present study suggest that the peripheral eosinophil count reflects asthmatic activity, and possibly the degree of inflammation in the airways, in both children and young adults.

Adolescent↗

[Guidelines for the diagnosis and management of bronchial asthma--a comparison of the Japanese guidelines for the adult asthma with GINA and ICR].

Although the concept of asthma management of the Japanese Guidelines is basically similar in the other guidelines including GINA, ICR, of British Thoracic Society, and of the other countries, assuming that asthma is a chronic inflammatory disorder of the airway, the program of stepwise pharmacologic therapy is not the same in various points. Therapy suggested in the Japanese Guidelines is different in 1) oral antiallergic drugs are widely used, 2) patients prefer oral bronchodilators to inhaled bronchodilators, 3) sustained released theophylline in the long term management and intravenous infusion of aminophylline for the treatment of acute exacerbation are accepted and frequently used by the physicians. Also the differences in the choice of medication between GINA, which is characterized by concept of cost, and other guidelines are discussed.

Asthma↗

[Asthma or asthma-like condition?].

Asthma is currently seen as an inflammatory disease of the airways. The clinical characteristics are any of a variety of airway symptoms occurring in conjunction with bronchial obstruction (which is reversible on treatment with beta 2-agonists or steroids) and bronchial hyper-responsiveness. The symptoms can be triggered by a variety of factors and the clinical picture is not uniform. The most common differential diagnoses are chronic obstructive lung disease (COLD) and asthma-like conditions unaccompanied by bronchial obstruction.

Adult↗

[Ambulatory sports in asthma improves physical fitness and reduces asthma-induced hospital stay].

Physical training is a well established method in the rehabilitation of patients with chronic obstructive pulmonary disease. In adult asthmatics its efficacy has been shown by intensive training programmes lasting for 2-12 weeks. No data exist on the effect of long-term physical training once a week. 31 patients (f = 24, m = 7; mean age 55 +/- 2 years; mean FEV1.0 82 +/- 4% pred.) participated in a physical training programme for at least 2 years. (8 patients had mild, 12 moderate and 11 severe asthma according to the International Consensus Report of 1993 [13]). Training time was 1 hour per week. The physical training programme consisted of breathing techniques like pursed-lip breathing and diaphragmatic exercise, progressive muscle relaxation, circuits and endurance training. According to the health insurance records 9 patients had been hospitalised for their disease two years prior to the study for a total number of 218 in-hospital days. During the 2 years of the study 2 patients had been hospitalised for a total number of 29 days (p < 0.001). A comparison group of 10 patients who did not participate in the rehabilitation programme had been hospitalised for their disease two years prior to and during the study period for a total number of 236 and 201 in-hospital days (p > 0.2). In a subgroup of 9 patients bicycle exercise testing was performed once a month and work load at a submaximal heart-rate (200-age) was recorded. During the two years mean work rate improved from 48 watts to 83 watts for 15 minutes (p < 0.01). We conclude from our findings that long-term physical training of adult patients with asthma in an outpatient setting once a week is effective in reducing hospitalisation days as well as in increasing cardiorespiratory fitness.

Adult↗

[Measuring the quality of life of children and adolescents with asthma--The Pediatric Asthma Quality of Life Questionnaire].

Quality of life becomes more and more important in evaluating the effects of treatments. At the moment, different questionnaires to measure quality of life in children and adolescents with asthma are available. The Paediatric Asthma Quality of Life Questionnaire (PAQL) was developed by Juniper and co-workers in Canada and has already been translated into German. It is a self- or interviewer-administered instrument for children and adolescents between age 7 and 17. The PAQL contains 23 items in three domains: activity limitation, symptoms, and emotional function. The empirical results suggest that the PAQL is reliable and sensitive to clinical change. Problems associated with the administration are discussed.

Adolescent↗

[Compliance and asthma--a delphi survey on therapy compliance by by asthma patients in ambulatory care].

Compliance of asthma patients to a prescribed course of treatment is of both medical and economic importance, as the progression of the illness can be halted or at least slowed down by a consistent treatment with anti-inflammatory drugs. The use of fixed combination products which contain both an anti-inflammatory active ingredient (e.g. sodium cromoglycate) and a short-acting beta-2-agonist can lead to improve a compliance and thus slow down the progression. This was established with the help of a survey by experts carried out according to the Delphi Method, separating adult asthmatics from children with asthma.

Adult↗

All that wheezes is not asthma. Paradoxical vocal cord movement presenting as severe acute asthma requiring ventilatory support.

A 23-year-old female presented with an acute exacerbation of her asthma, for which she required ventilatory support. Her wheeze disappeared immediately following tracheal intubation and ventilatory support was achieved with low airway pressures. We believe that the diagnosis of status asthmaticus was incorrect and that the patient was suffering from vocal cord dysfunction. We review reports of this condition and suggest that, in asthma, the expiratory flow limitation due to paradoxical vocal cord movement may be an appropriate physiological response to improve overall airflow. However, this glottic narrowing may cause respiratory distress of its own accord. Our observations suggest a simple approach to the diagnosis and management of patients whose respiratory distress may be caused by paradoxical vocal cord movement. Immediate relief of 'bronchospasm' in an asthmatic following tracheal intubation may establish the correct diagnosis. This has important implications for the management of these patients in the intensive care unit.

Adult↗

Asthma and allergy medication use and costs among pediatric primary care patients on asthma controller therapy.

As observational studies in children initiating GINA-Step 3 therapies are scarce, we evaluated outcomes and costs in a primary care cohort. Two-yr retrospective cohort study included French children (age: 6-14) continuously followed in BKL-Thalès database who received > or =2 consecutive prescriptions for GINA-Step 3 therapy (=addition of montelukast or other controllers ('other'), such as increasing inhaled-corticosteroid dose (hICS), adding long-acting beta agonist (LABA), or ICS + LABA). After matching on gender and propensity score, medication use [rescue (short-acting beta agonists), acute (antibiotics (AB), oral corticosteroids (OCS)), allergy (antihistamines, nasal steroids) and other respiratory] was estimated via mean number of prescriptions and mean cost (per child/per month), and cost trends. During 12-month follow-up, children adding montelukast (n = 71) vs. 'other' (n = 213) had similar asthma rescue/acute and allergy medication use. Subgroup with asthma and allergic rhinitis (A + AR) adding montelukast used less OCS and AB (p = 0.014). Two-yr cost trends suggest stable asthma/allergy medication use in montelukast group (0.83 euro) compared with increase in 'other' (5.39 euro), which was driven by nasal steroid use [0.32 euro ('other') vs. -0.04 euro (montelukast), p = 0.0013]. In subgroup with A + AR decline in asthma/allergy medication use in montelukast group (-0.47 euro) vs. increase in 'other' (11.05 euro), p = 0.015, was driven by differences in AB and OCS (p = 0.04) and nasal steroid use (p = 0.001). Concomitant asthma/allergy medication use was similar in children adding montelukast or 'other' controllers (hICS, LABA, ICS + LABA), while children with allergic rhinitis on montelukast used less AB. Concomitant medication costs after addition of montelukast remained stable, while 'other' group experienced increase, especially in children with concomitant allergic rhinitis.

Acetates↗

Diet and asthma, allergic rhinoconjunctivitis and atopic eczema symptom prevalence: an ecological analysis of the International Study of Asthma and Allergies in Childhood (ISAAC) data. ISAAC Phase One Study Group.

Several studies have suggested that the increasing prevalence of symptoms of asthma, rhinitis and eczema, could be associated with dietary factors. In the present paper, a global analysis of prevalence rates of wheeze, allergic rhinoconjunctivitis and atopic eczema was performed in relation to diet, as defined by national food intake data. Analyses were based on the International Study of Asthma and Allergies in Childhood (ISAAC) data for 6-7 and 13-14 yr old children. Symptoms of wheeze, allergic rhinoconjunctivitis and atopic eczema symptom prevalence were regressed against per capita food intake, and adjusted for gross national product to account for economic development. Dietary data were based on 1995 Food and Agriculture Organisation of the United Nations data for 53 of the 56 countries that took part in ISAAC phase I (1994/1995). The 13-14 year age group showed a consistent pattern of decreases in symptoms of wheeze (current and severe), allergic rhinoconjunctivitis and atopic eczema, associated with increased per capita consumption of calories from cereal and rice, protein from cereals and nuts, starch, as well as vegetables and vegetable nutrients. The video questionnaire data for 13-14 yr olds and the ISAAC data for 6-7 yr olds showed similar patterns for these foods. A consistent inverse relationship was seen between prevalence rates of the three conditions and the intake of starch, cereals, and vegetables. If these findings could be generalised, and if the average daily consumption of these foods increased, it is speculated that an important decrease in symptom prevalence may be achieved.

Adolescent↗