Death from asthma in two regions of England

The British Thoracic Association has conducted a confidential inquiry into death from asthma of adults aged 15 to 64 years resident in the West Midland and Mersey regions in 1979. Information concerning the patients, their asthma, and death was obtained by questionnaire, interview with the general medical practitioner and a relative, and from patient records. A panel of three physicians, helped by a pathologist, identified 90 patients as dying of asthma and assessed management and treatment in the last year, last month of life, and the fatal attack. They were generally chronic asthmatics, but unstable, most having suffered severe attacks previously. Corticosteroids and bronchodilator drugs were in general underprescribed or not given in sufficiently large doses. Inhaled corticosteroids and cromoglycate had frequently not been tried. The patient''s co-operation with the management of the asthma was satisfactory for only 42 of the 90 patients. For 71 of the patients the fatal attack lasted under 24 hours; of the 77 who died at home or at work, 50 did not receive any medical attention in the fatal attack. Failure to recognise the severity of the asthma by patients, relatives, and doctor often caused delay in starting appropriate treatment. The interaction of several of these adverse factors often contributed to the patient''s death. The panel considered that there were potentially preventable factors contributory to the death of 77 (86%) of the 90 patients. Within the limits of retrospective judgment the panel considered that the routine management of the asthma was often unsatisfactory as patients known to suffer severe acute attacks were often not adequately supervised or instructed in the management and treatment of their asthma. From this retrospective inquiry we concluded that closer overall supervision, including careful attention to patient education, earlier and more intensive treatment, and pre-arranged immediate admission to hospital for asthma emergencies is desirable.     

Asthma deaths in Cardiff 1963-74: 90 deaths outside hospital.

In a detailed study of factors associated with death from bronchial asthma outside hospital 90 patients were investigated. The fatal attack was typically short and was most likely to occur in patients with a long history. Deaths often occurred before effective medical help was obtainable, but occasionally the patient or the doctor underestimated the severity of the attack. Patients especially at risk were those recently discharged from hospital after a previous attack. These deaths might be prevented by better patient education, a self-admission service for selected asthmatics, and by doctors using objective measurements of severity of asthma for the control of treatment. The underuse of corticosteroids is an important factor associated with death.     

Nonfatal childhood injuries: a survey at the Children's Hospital of eastern Ontario.

OBJECTIVE: To examine the types and severity of injuries seen in the Emergency Department of the Children''s Hospital of Eastern Ontario and the circumstances surrounding the events. DESIGN: Chart review. SETTING: A tertiary care hospital that serves a child population of 600,000 in eastern Ontario and western Quebec. PARTICIPANTS: Every sixth day''s charts of children up to 17 years of age who visited the Emergency Department because of injuries between Sept. 1, 1984, and Aug. 31, 1985, were examined retrospectively. RESULTS: A total of 2886 charts were reviewed. There were more boys than girls. Most (1354 [46.9%]) of the accidents had occurred at home. Falls and sports-related accidents were the leading causes of injury (in 1088 [37.7%] and 560 [19.4%] of the cases respectively). Most of the visits were for minor injuries (bumps, swellings, cuts, bruises and scrapes), and only 114 (4.0%) of the children were admitted to the hospital. Injuries from motor vehicle accidents accounted for the highest admission rate (17.4%). Important information regarding the circumstances surrounding the events (e.g., whether a seat belt or car seat was used) was frequently missing from the charts. CONCLUSIONS: Nonfatal injuries are common, especially in or around the home, and remain a significant problem in our society in terms of radiographic and consulting fees, time off from school or work and pain. Given the difficulties in obtaining information on the circumstances surrounding the events prospective studies are needed. Factors related to the occurrence and severity of childhood injury and whether these factors can be altered remain a high priority for research.     

The Novel 10-Item Asthma Prediction Tool: External Validation in the German MAS Birth Cohort

Background

A novel non-invasive asthma prediction tool from the Leicester Cohort, UK, forecasts asthma at age 8 years based on 10 predictors assessed in early childhood, including current respiratory symptoms, eczema, and parental history of asthma.

Objective

We aimed to externally validate the proposed asthma prediction method in a German birth cohort.

Methods

The MAS-90 study (Multicentre Allergy Study) recorded details on allergic diseases prospectively in about yearly follow-up assessments up to age 20 years in a cohort of 1,314 children born 1990. We replicated the scoring method from the Leicester cohort and assessed prediction, performance and discrimination. The primary outcome was defined as the combination of parent-reported wheeze and asthma drugs (both in last 12 months) at age 8. Sensitivity analyses assessed model performance for outcomes related to asthma up to age 20 years.

Results

For 140 children parents reported current wheeze or cough at age 3 years. Score distribution and frequencies of later asthma resembled the Leicester cohort: 9% vs. 16% (MAS-90 vs. Leicester) of children at low risk at 3 years had asthma at 8 years, at medium risk 45% vs. 48%. Performance of the asthma prediction tool in the MAS-90 cohort was similar (Brier score 0.22 vs. 0.23) and discrimination slightly better than in the original cohort (area under the curve, AUC 0.83 vs. 0.78). Prediction and discrimination were robust against changes of inclusion criteria, scoring and outcome definitions. The secondary outcome ‘physicians’ diagnosed asthma at 20 years'' showed the highest discrimination (AUC 0.89).

Conclusion

The novel asthma prediction tool from the Leicester cohort, UK, performed well in another population, a German birth cohort, supporting its use and further development as a simple aid to predict asthma risk in clinical settings.     

Serious childhood injuries caused by air guns.

OBJECTIVE: To determine the severity of nonfatal injuries to children caused by air guns and pellet guns. DESIGN: Case series (hospital chart review). SETTING: Inpatient wards of the Children''s Hospital of Eastern Ontario. PATIENTS: All children under 18 years of age admitted to the hospital from Jan. 1, 1979, to Dec. 31, 1989, under ICD code E917, E922, E955, E965, E970 or E985 who had suffered air gun injuries. MAIN OUTCOME MEASURES: Personal data, circumstances of event and clinical data. RESULTS: The 43 children (37 boys) had a median age of 12 years. The circumstances of the accident were known in 20 cases: 17 children were playing and 3 were cleaning the gun when it went off. Four children thought the gun was unloaded. In five cases the bullet ricocheted into the eye. Nine injuries were self-inflicted. Injury was to the extremities in 21 (49%), the eyes in 15 (35%) and the head and neck in 7 (16%). The median length of hospital stay was 4 days. Six children had long-term disabilities, all the result of eye injuries; two had cataract surgery, and four required enucleation of the eye. CONCLUSIONS: Air guns can cause serious injury to children. Their sale needs to be banned or at least carefully regulated.     

Greater severity of new onset asthma in allergic subjects who smoke: a 10-year longitudinal study

Background

Little is known about the association between cigarette smoking and asthma severity. We assessed smoking as a determinant of disease severity and control in a cohort of clinic-referred allergic subjects who developed new onset asthma.

Methods

Allergic rhinitis subjects with no asthma (n = 371) were followed-up for 10 years and routinely examined for asthma diagnosis. In those who developed asthma (n = 152), clinical severity and levels of asthma control were determined. Among these subjects, 74 (48.7%) were current smokers, 17 (11.2%) former smokers, and 61 (40.1%) never smokers.

Results

When comparing current or past smokers to never smokers they had a higher risk of severe asthma in the univariate analysis, which became non-significant in the multivariate analysis. On the other hand, the categories of pack-years were significantly related to severe asthma in a dose response relationship in both the univariate and multivariate analysis: compared to 0 pack years, those who smoked 1-10 pack-years had an OR(95% CI) of 1.47(0.46-4.68), those who smoked 11-20 pack-years had an OR of 2.85(1.09-7.46) and those who smoked more than 20 pack-years had an OR of 5.59(1.44-21.67) to develop more severe asthma. Smokers with asthma were also more likely to have uncontrolled disease. A significant dose-response relationship was observed for pack-years and uncontrolled asthma. Compared to 0 pack years, those who smoked 1-10 pack-years had an OR of 5.51(1.73-17.54) and those who smoked more than 10 pack-years had an OR of 13.38(4.57-39.19) to have uncontrolled asthma.

Conclusions

The current findings support the hypothesis that cigarette smoking is an important predictor of asthma severity and poor asthma control.     

National asthma attack audit 1991-2. General Practitioners in Asthma Group.

OBJECTIVE--To describe the frequency and characteristics of asthma attacks in the United Kingdom and to compare actual management with recommended guidelines for the management of attacks. DESIGN--Correspondence survey. SETTING--218 general practices in the United Kingdom. SUBJECTS--1775 patients of all ages who had a total of 1805 asthma attacks over three months. MAIN OUTCOME MEASURES--Patient characteristics, place of management of attacks, comparison of actual management with recommended guidelines. RESULTS--Of the 1805 attacks, 300 occurred in boys aged 0-9, 144 in girls aged 0-9, and 118 in women aged 20-29. The estimated frequency of attacks in the community was 14.3 per 1000 patients per year. 1546 (86%) patients with attacks were managed within general practice, 225 (12%) were admitted to hospital, and 34 (2%) were discharged from an accident and emergency department. Two patients died. On initial presentation, 248 (14%) patients were "not breathless," 900 (50%) were "moderately breathless," 535 (30%) were "breathless and distressed," 68 (4%) were "too breathless to talk," and 2 were "moribund." Recording of clinical data was variable. Underuse of nebulised bronchodilators and systemic steroid was apparent in all grades of clinical severity. Contrary to current guidelines for asthma management, "step up" in maintenance therapy after an attack was often not practised. CONCLUSION--Reported management was at variance with recommended guidelines. This has major implications for the design and distribution of future guidelines.     

Asthma deaths in Cardiff 1963-74: 53 deaths in hospital.

In a study of factors associated with death from bronchial asthma in hospital 53 patients were investigated. Typically the fatal attack persisted for several days before admission to hospital and normally occurred in patients with a long history of asthma. The patient or doctor often underestimated the severity of the attack. On admission most patients were severely ill, and over a third died within 24 hours. Peak flow rate and blood gases were rarely measured. Corticosteroid treatment was often underused, and patients rarely received assisted ventilation before death. Infection played a part in 14 deaths, five of them associated with assisted ventilation. Admitting asthmatics to a special respiratory ward with facilities for standardised assessment and treatment and introducing a self-admission service may help to prevent some of these deaths.     

miR-1165-3p、miR-145水平在支气管哮喘患者中的表达及其临床意义

摘要 目的：探讨微小RNA（MicroRNA,miR）-1165-3p、miR-145水平在支气管哮喘患者中的表达及其临床意义。方法：收集2021年1月-2022年3月中国人民解放军总医院第六医学中心62例支气管哮喘患者作为研究组,其中轻度急性发作27例,中度急性发作22例,重度急性发作13例。另收集同时期、同年龄段30例健康体检者作为对照组。采用实时荧光定量PCR（RT-PCR）检测各组血清miR-1165-3p、miR-145表达水平。采用Spearman相关分析不同程度支气管哮喘患者与血清miR-1165-3p、miR-145之间的相关性。通过受试者工作特征（ROC）分析血清miR-1165-3p、miR-145表达水平对不同程度支气管哮喘的诊断效能。结果：与对照组相比,研究组中白细胞介素-6（IL-6）、嗜酸性粒细胞、总免疫球蛋白E（IgE）水平显著升高,第1秒用力呼气容积（FEV₁）占预测值百分比（FEV₁%）则显著降低,差异均有统计学意义（P＜0.05）。不同严重程度支气管哮喘患者（轻度、中度、重度）血清miR-1165-3p、miR-145表达水平均高于健康对照组,支气管哮喘越严重,其表达水平越高,且组间、组内比较差异均有统计学意义（P＜0.05）。Spearman相关分析显示,miR-1165-3p、miR-145、IL-6表达水平与哮喘严重程度呈正相关（P＜0.05）,FEV₁%与哮喘严重程度呈负相关（P＜0.05）,嗜酸性粒细胞、总IgE与哮喘严重程度无相关性（P＞0.05）。对轻度、中度、重度急性支气管哮喘发作的诊断效能显示：血清miR-1165-3p的曲线下面积（AUC）（0.95CI）分别为3.085（0.326～29.221）、0.712（0.611～0.829）、0.755（0.602～0.948）。血清miR-145的AUC（0.95CI）分别为0.833（0.708～0.979）、0.754（0.590～0.964）、0.816（0.671～0.993）。结论：血清miR-1165-3p、miR-145表达水平具有较高的诊断效能,支气管哮喘越严重,诊断的特异性越高,可作为支气管哮喘严重程度的无创诊断指标。     

Evolution of Asthma Severity in a Cohort of Young Adults: Is There Any Gender Difference?

Introduction

Little is known about the distribution of asthma severity in men and women in the general population. The objective of our study was to describe asthma severity and change in severity according to gender in a cohort of adult asthmatics

Methods

Subjects with asthma were identified from random samples of the 22 to 44 year-olds from the general population, screened for asthma from 1991 to 1993 in 48 centers from 22 countries and followed-up during 1998–2002, as part of the European Community Respiratory Health Survey (ECRHS). All participants to follow-up with current asthma at baseline were eligible for the analysis. To assess change over the follow-up, asthma severity at the two surveys was defined using standardized data on respiratory symptoms, lung function and medication according to the Global Initiative for Asthma (GINA) Guidelines. Another quantitative score (Ronchetti) further considering hospitalizations was also analysed.

Results

The study included 685 subjects with asthma followed-up over a mean period of 8.65 yr (min 4.3-max 11.7). At baseline, asthma severity according to GINA was distributed as intermittent: 40.7%, 31.7% as mild persistent, 14% as moderate persistent, and 13.5% as severe persistent. Using the Ronchetti score derived classification, the distribution of asthma severity was 58% mild, (intermittent and mild persistent), 25.8% moderate, and 15.4% severe. Whatever the classification, there was no significant difference in the severity distribution between men and women. There was also no gender difference in the severity distribution among incident cases which developed asthma between the two surveys. Men with moderate-to-severe asthma at baseline were more likely than women to have moderate-to-severe asthma at follow-up. Using GINA, 69.2% of men vs. 53.1% of women (p = 0.09) with moderate-to-severe asthma at baseline were still moderate-to-severe at follow-up. Using Ronchetti score, 53.3% of men vs. 36.2% of women (p = 0.03) with moderate-to-severe asthma at baseline were still moderate-to-severe at follow-up.

Conclusions

There was no gender difference in asthma severity at the two surveys. However, our findings suggest that asthma severity might be less stable in women than in men.     

Death from asthma.

The factors associated with the deaths of 31 asthma patients were examined. The subjects, whose deaths occurred in the period 1967 through 1979, had all received some care at the Hospital for Sick Children in Toronto, but only nine died there. The greatest single cause of death was the inappropriate use of beta-agonists, with or without the concurrent use of epinephrine. In seven patients an asthma attack that occurred outside hospital progressed so rapidly that there was insufficient time for them to obtain adequate therapy. In five cases the assessment of the patient''s condition or the therapy recommended by the attending physician appeared to have been inadequate. Two patients suffered an acute attack in hopital and did not respond to treatment that appeared to have been adequate. In six cases the available information was insufficient to indicate the cause of death. Over half (18) of the deaths occurred in teenagers. Various ways of preventing death from asthma are discussed, including better education of physicians and patients, adequate management of factors that provoke bronchospasm, sufficient follow-up -- especially in teenagers -- and the use of approaches with teenagers that encourage better compliance.     

Acrolein and Asthma Attack Prevalence in a Representative Sample of the United States Adult Population 2000 – 2009

Background

Acrolein is an air toxic and highly potent respiratory irritant. There is little epidemiology available, but US EPA estimates that outdoor acrolein is responsible for about 75 percent of non-cancer respiratory health effects attributable to air toxics in the United States, based on the Agency''s 2005 NATA (National-Scale Air Toxics Assessment) and acrolein''s comparatively potent inhalation reference concentration of 0.02 µg/m³.

Objectives

Assess the association between estimated outdoor acrolein exposure and asthma attack reported by a representative cross-sectional sample of the adult United States population.

Methods

NATA 2005 chronic outdoor acrolein exposure estimates at the census tract were linked with residences oif adults (≥18 years old) in the NHIS (National Health Interview Survey) 2000 – 2009 (n = 271,348 subjects). A sample-weighted logistic regression model characterized the association between the prevalence of reporting at least one asthma attack in the 12 months prior to survey interview and quintiles of exposure to outdoor acrolein, controlling for potential confounders.

Results

In the highest quintile of outdoor acrolein exposure (0.05 – 0.46 µg/m³), there was a marginally significant increase in the asthma attack pOR (prevalence-odds ratio [95% CI]  = 1.08 [0.98∶1.19]) relative to the lowest quintile. The highest quintile was also associated with a marginally significant increase in prevalence-odds (1.13 [0.98∶1.29]) in a model limited to never smokers (n = 153,820).

Conclusions

Chronic exposure to outdoor acrolein of 0.05 – 0.46 µg/m³ appears to increase the prevalence-odds of having at least one asthma attack in the previous year by 8 percent in a representative cross-sectional sample of the adult United States population.     

Seventy Years of Asthma in Italy: Age,Period and Cohort Effects on Incidence and Remission of Self-Reported Asthma from 1940 to 2010

Background

It is well known that asthma prevalence has been increasing all over the world in the last decades. However, few data are available on temporal trends of incidence and remission of asthma.

Objective

To evaluate the rates of asthma incidence and remission in Italy from 1940 to 2010.

Methods

The subjects were randomly sampled from the general Italian population between 1991 and 2010 in the three population-based multicentre studies: ECRHS, ISAYA, and GEIRD. Individual information on the history of asthma (age at onset, age at the last attack, use of drugs for asthma control, co-presence of hay-fever) was collected on 35,495 subjects aged 20–84 and born between 1925–1989. Temporal changes in rates of asthma incidence and remission in relation to age, birth cohort and calendar period (APC) were modelled using Poisson regression and APC models.

Results

The average yearly rate of asthma incidence was 2.6/1000 (3,297 new cases among 1,263,885 person-years). The incidence rates have been linearly increasing, with a percentage increase of +3.9% (95%CI: 3.1–4.5), from 1940 up to the year 1995, when the rates begun to level off. The stabilization of asthma incidence was mainly due to a decrease in the rates of atopic asthma after 1995, while non-atopic asthma has continued to increase. The overall rate of remission was 43.2/1000person-years, and it did not vary significantly across generations, but was associated with atopy, age at asthma onset and duration of the disease.

Conclusions

After 50 years of a continuous upward trend, the rates of asthma incidence underwent a substantial stabilization in the late 90s. Despite remarkable improvements in the treatment of asthma, the rate of remission did not change significantly in the last seventy years. Some caveats are required in interpreting our results, given that our estimates are based on self-reported events that could be affected by the recall bias.     

血清中IL-17和Eotaxin水平检测在支气管哮喘患儿中的应用价值

摘要 目的：研究血清中白介素-17（interleukin,IL-17）和嗜酸性粒细胞趋化因子（Eotaxin）水平检测在支气管哮喘患儿中的应用价值。方法：选择2018年1月～2019年12月陕西省中医医院和西安市第一医院的60例支气管哮喘患儿为观察组,其中的18例缓解期患儿为缓解期组,42例急性发作期患儿为急性发作期组,且选择在我院体检的60例健康儿童为对照组。比较缓解期组、急性发作期组患儿和对照组儿童的血清IL-17和Eotaxin水平;比较缓解期组、急性发作期组患儿的一秒钟用力呼气量（forced expiratory volumeat 1st,FEV₁）以及最大呼气流量（peak expiratory flow,PEF）和生活质量评分;分析缓解期组、急性发作期组患儿的血清IL-17与Eotaxin的相关性;并分析缓解期组、急性发作期组患儿的血清IL-17、Eotaxin水平与PEF、FEV₁和生活质量评分的相关性。结果：缓解期组、急性发作期组患儿的血清IL-17和Eotaxin水平明显高于对照组（P<0.05）,且急性发作期组患儿的血清IL-17和Eotaxin水平明显高于缓解期组（P<0.05）;急性发作期组患儿的PEF、FEV₁和生活质量评分明显低于缓解期组（P<0.05）;缓解期组、急性发作期组患儿的血清IL-17与Eotaxin之间均呈明显的正相关性（P<0.05）;缓解期组患儿的血清IL-17、Eotaxin水平与PEF、FEV₁和生活质量评分均呈明显的负相关性（P<0.05）;急性发作期组患儿的血清IL-17、Eotaxin水平与PEF、FEV₁和生活质量评分均呈明显的负相关性（P<0.05）。结论：血清IL-17和Eotaxin在支气管哮喘患儿的发病过程中可以相互影响,共同参与患儿生理病理改变过程,血清IL-17和Eotaxin可作为评估支气管哮喘患儿病情严重程度和生活质量的客观指标。     

Plasma CC16 levels are associated with development of ALI/ARDS in patients with ventilator-associated pneumonia: a retrospective observational study

Background

Asthma is a difficult diagnosis to establish in preschool children. A few years ago, our group presented a prediction rule for young children at risk for asthma in general practice. Before this prediction rule can safely be used in practice, cross-validation is required. In addition, general practitioners face many therapeutic management decisions in children at risk for asthma. The objectives of the study are: (1) identification of predictors for asthma in preschool children at risk for asthma with the aim of cross-validating an earlier derived prediction rule; (2) compare the effects of different treatment strategies in preschool children.

Design

In this prospective cohort study one to five year old children at risk of developing asthma were selected from general practices. At risk was defined as 'visited the general practitioner with recurrent coughing (≥ 2 visits), wheezing (≥ 1) or shortness of breath (≥ 1) in the previous 12 months'. All children in this prospective cohort study will be followed until the age of six. For our prediction rule, demographic data, data with respect to clinical history and additional tests (specific immunoglobulin E (IgE), fractional exhaled nitric oxide (FENO), peak expiratory flow (PEF)) are collected. History of airway specific medication use, symptom severity and health-related quality of life (QoL) are collected to estimate the effect of different treatment intensities (as expressed in GINA levels) using recently developed statistical techniques. In total, 1,938 children at risk of asthma were selected from general practice and 771 children (40%) were enrolled. At the time of writing, follow-up for all 5-year olds and the majority of the 4-year olds is complete. The total and specific IgE measurements at baseline were carried out by 87% of the children. Response rates to the repeated questionnaires varied from 93% at baseline to 73% after 18 months follow-up; 89% and 87% performed PEF and FENO measurements, respectively.

Discussion

In this study a prediction rule for asthma in young children, to be used in (general) practice, will be cross-validated. Our study will also provide more insight in the effect of treatment of asthma in preschool children.     

Terminal cancer care and patients' preference for place of death: a prospective study.

OBJECTIVE--To assess the preference of terminally ill patients with cancer for their place of final care. DESIGN--Prospective study of randomly selected patients with cancer from hospital and the community who were expected to die within a year. Patients expected to live less than two months were interviewed at two week intervals; otherwise patients were interviewed monthly. Their main carer was interviewed three months after the patient''s death. SETTING--District general hospital, hospices, and patients'' homes. MAIN OUTCOME MEASURE--Stated preferred place of final care; actual place of death; reason for final hospital admission for those in hospital; community care provision required for home care. RESULTS--Of 98 patients approached, 84 (86%) agreed to be interviewed, of whom 70 (83%) died during the study and 59 (84%) stated a preferred place of final care: 34 (58%) wished to die at home given existing circumstances, 12 (20%) in hospital, 12 (20%) in a hospice, and one (2%) elsewhere. Their own home was the preferred place of care for 17 (94%) of the patients who died there, whereas of the 32 patients who died in hospital 22 (69%) had stated a preference to die elsewhere. Had circumstances been more favourable 67% (41) of patients would have preferred to die at home, 16% (10) in hospital, and 15% (9) in hospice. CONCLUSION--With a limited increase in community care 50% more patients with cancer could be supported to die at home, as they and their carers would prefer.     

Heart Rate Variability During 24 Hours in Asthmatic Children

The autonomic circadian rhythm plays an important role in asthma. In recent years it has become possible to evaluate autonomic nervous function (ANF) using analysis of heart rate variability (HRV). We analyzed the HRV in the 24h period following the state without an asthma attack in order to study the relationship between asthma and ANF. The HRV was analyzed in 94 asthmatic children (ages 5–15 years). These subjects were divided into groups according to the severity of their asthma. After recording a 24h ambulatory electrocardiograph (AECG), the HRV was analyzed by a computer. Evaluation of the HRV was carried out using time-domain and frequency-domain analyses. The ANF of asthma subjects was decreased in comparison to the normal group. The severity of asthma had a significant effect on the %RR50 (the proportion of cycles during which the difference is > 50 ms), the SD (standard deviation; mean of standard deviation of all normal RR intervals for all 5-minute periods), the low-frequency (LF) band (0.04 to 0.15 Hz), and the high-frequency (HF) band (0.15 to 0.4 Hz) (%RR50: F = 4.31, p = 0.01; SD: F=3.48, p = 0.03; LF: F=3.67, p = 0.02; HF: F=3.41, p = 0.03). These values were lowest in the severe asthma group. With regard to the therapy grouping, the index that exhibited a significant difference was the NNA (mean of normal-to-normal RR intervals over 24h) (F = 4.43, p = 0.01) In conclusion, even in the normal condition in which the patient is free of an asthma attack, the ANF of asthma sufferers differs from that of normal children. It is possible that the different ANF of asthma sufferers is related to the severity of the asthma. (Chronobiology International, 14(6), 597–606, 1997)     

A major outbreak of asthma associated with a thunderstorm: experience of accident and emergency departments and patients' characteristics. Thames Regions Accident and Emergency Trainees Association.

OBJECTIVE--To investigate the time course of an epidemic of asthma after a thunderstorm, characteristics of patients affected, and the demand on emergency medical resources. DESIGN--Study of registers and records in accident and emergency departments and questionnaire to staff. SETTING--London area. SUBJECTS--All patients presenting at 12 accident and emergency departments with asthma or other airway disease. MAIN OUTCOME MEASURES--Numbers of patients, clinical features, information on shortage of resources--equipment, drugs and staff. RESULTS--The epidemic had a sudden onset on 24 June 1994; 640 patients with asthma or other airways disease attended during 30 hours from 1800 on 24 June, nearly 10 times the expected number. Over half (365) the patients were aged 21 to 40 years. A history of hay fever was recorded in 403 patients; for 283 patients this was the first known attack of asthma; a history of chronic obstructive airways disease was recorded in 12 patients. In all, 104 patients were admitted (including five to an intensive care unit). Several departments ran out of equipment or drugs, called in additional doctors, or both. CONCLUSIONS--This study supports the view that this epidemic was larger than previously reported epidemics and the hypothesis that "thunderstorm associated asthma'' is related to aeroallergens. Demands on resources were considerable; a larger proportion of patients needing intensive care would have caused greater problems.     

The relationship between asthma and depression in primary care patients: a historical cohort and nested case control study

Background and Objectives

Asthma and depression are common health problems in primary care. Evidence of a relationship between asthma and depression is conflicting. Objectives: to determine 1. The incidence rate and incidence rate ratio of depression in primary care patients with asthma compared to those without asthma, and 2. The standardized mortality ratio of depressed compared to non-depressed patients with asthma.

Methods

A historical cohort and nested case control study using data derived from the United Kingdom General Practice Research Database. Participants: 11,275 incident cases of asthma recorded between 1/1/95 and 31/12/96 age, sex and practice matched with non-cases from the database (ratio 1∶1) and followed up through the database for 10 years. 1,660 cases were matched by date of asthma diagnosis with 1,660 controls. Main outcome measures: number of cases diagnosed with depression, the number of deaths over the study period.

Results

The rate of depression in patients with asthma was 22.4/1,000 person years and without asthma 13.8 /1,000 person years. The incident rate ratio (adjusted for age, sex, practice, diabetes, cardiovascular disease, cerebrovascular disease, smoking) was 1.59 (95% CI 1.48–1.71). The increased rate of depression was not associated with asthma severity or oral corticosteroid use. It was associated with the number of consultations (odds ratio per visit 1.09; 95% CI 1.07–1.11). The age and sex adjusted standardized mortality ratio for depressed patients with asthma was 1.87 (95% CI: 1.54–2.27).

Conclusions

Asthma is associated with depression. This was not related to asthma severity or oral corticosteroid use but was related to service use. This suggests that a diagnosis of depression is related to health seeking behavior in patients with asthma. There is an increased mortality rate in depressed patients with asthma. The cause of this needs further exploration. Consideration should be given to case-finding for depression in this population.     

Risk factors and outcomes among children admitted to hospital with pandemic H1N1 influenza

Background

Limited data are available on disease characteristics and outcomes of children with 2009 pandemic influenza A(H1N1) virus infection (pandemic H1N1 influenza) who have required hospital admission.

Methods

We reviewed the charts of 58 children with pandemic H1N1 influenza admitted to a large pediatric hospital in Ontario, Canada, between May 8 and July 22, 2009. We compared risk factors, severity indicators and outcomes of these children with those of 200 children admitted with seasonal influenza A during the previous 5 years (2004/05 to 2008/09).

Results

Children with pandemic H1N1 influenza were significantly older than those with seasonal influenza (median age 6.4 years v. 3.3 years). Forty-six (79%) of the children with pandemic H1N1 influenza had underlying medical conditions; of the other 12 who were previously healthy, 42% were under 2 years of age. Children admitted with pandemic H1N1 influenza were significantly more likely to have asthma than those with seasonal influenza (22% v. 6%). Two children had poorly controlled asthma, and 6 used inhaled medications only intermittently. The median length of stay in hospital was 4 days in both groups of children. Similar proportions of children required admission to the intensive care unit (21% of those with pandemic H1N1 influenza and 14% of those with seasonal influenza) and mechanical ventilation (12% and 10% respectively). None of the children admitted with pandemic H1N1 influenza died, as compared with 1 (0.4%) of those admitted with seasonal influenza.

Interpretation

Pandemic H1N1 influenza did not appear to cause more severe disease than seasonal influenza A. Asthma appears to be a significant risk factor for severe disease, with no clear relation to severity of asthma. This finding should influence strategies for vaccination and pre-emptive antiviral therapy.Influenza causes significant morbidity and mortality in childhood.¹ Infants, young children and people 65 years of age and older account for the highest rates of influenza-related hospital admission.² Earlier case series of 2009 pandemic influenza A(H1N1) virus infection (pandemic H1N1 influenza) reported small numbers of children^3,4 or did not present data on children separately.⁵ A recently published series that included 122 children confirmed typical influenza-like presentation, reported a high prevalence of underlying medical conditions (60%, including asthma in 29%) and described the need for intensive care in 20% and mechanical ventilation in 10%.⁶ A previous comparison of children with pandemic H1N1 influenza and those in previous years with seasonal influenza included only children considered to have died of influenza.⁷In this article, we present our experience with children admitted to hospital with pandemic H1N1 influenza. Our primary goal was to describe the demographic characteristics, clinical features and markers of severity of illness of these children. Our secondary goal was to identify risk factors for severe disease or poor outcome by comparing these children with those who had been admitted in previous years with seasonal influenza.