Respiratory viruses and exacerbations of asthma in adults.

OBJECTIVE--To study the role of respiratory viruses in exacerbations of asthma in adults. DESIGN--Longitudinal study of 138 adults with asthma. SETTING--Leicestershire Health Authority. SUBJECTS--48 men and 90 women 19-46 years of age with a mean duration of wheeze of 19.6 years. 75% received regular treatment with bronchodilators; 89% gave a history of eczema, hay fever, allergic rhinitis, nasal polyps, or allergies; 38% had been admitted to hospital with asthma. MAIN OUTCOME MEASURES--Symptomatic colds and asthma exacerbations; objective exacerbations of asthma with > or = 50 l/min reduction in mean peak expiratory flow rate when morning and night time readings on days 1-7 after onset of symptoms were compared with rates during an asymptomatic control period; laboratory confirmed respiratory tract infections. RESULTS--Colds were reported in 80% (223/280) of episodes with symptoms of wheeze, chest tightness, or breathlessness, and 89% (223/250) of colds were associated with asthma symptoms. 24% of 115 laboratory confirmed non-bacterial infections were associated with reductions in mean peak expiratory flow rate > or = 50 l/min through days 1-7 and 48% had mean decreases > or = 25 l/min. 44% of episodes with mean decreases in flow rate > or = 50 l/min were associated with laboratory confirmed infections. Infections with rhinoviruses, coronaviruses OC43 and 229E, influenza B, respiratory syncytial virus, parainfluenza virus, and chlamydia were all associated with objective evidence of an exacerbation of asthma. CONCLUSIONS--These findings show that asthma symptoms and reductions in peak flow are often associated with colds and respiratory viruses; respiratory virus infections commonly cause or are associated with exacerbations of asthma in adults.     

General practitioner response to elderly patients discharged from hospital.

OBJECTIVE--To determine the effect of discharge information given to general practitioners on their management of newly discharged elderly patients. DESIGN--A random sample of 133 elderly patients who had unplanned readmission to a district general hospital within 28 days of discharge was compared with a matched control sample of patients who were not readmitted. Information was gathered from the hospital, the patients, the carers, and the general practitioners about the information that the hospital had sent the general practitioner and the general practitioners'' response to this information. SETTING--All specialties in a district general hospital. PATIENTS--266 Patients aged over 65 representative in the main demographic indices of the population of elderly patients admitted to hospital. RESULTS--Ten weeks after discharge the doctors had received notice of discharge about 169 of the patients, but fewer than half the discharge notices were received within the first week. General practitioners were dissatisfied with the information in 60 cases. A general practitioner visited 174 of the patients after their discharge from hospital and three quarters of the visits took place within two weeks of the discharge. These visits were more likely to have been initiated by patients or families than by the doctor, and this was not influenced by the doctor receiving notice of the patient''s discharge. Older patients and those who had carers were the most likely to be visited. Nearly half of the carers were dissatisfied with some aspect of general practitioner care, problems with home visiting being the commonest source of complaint. CONCLUSIONS--Hospital communications to general practitioners about the discharge of elderly patients still cause concern, particularly in the time they take to arrive. Written instruction to vulnerable elderly patients asking them to inform their general practitioner of the discharge might be helpful. Carers complained of lack of support, and it is clearly important for someone (either the general practitioner or another health worker) to visit elderly people shortly after their discharge.     

The value of pulmonary function tests in the management of acute asthma.

We examined the influence of the forced expiratory volume in 1 second (FEV1) on the decision to admit or discharge patients who present with acute bronchospasm due to asthma and the ability of the FEV1 to predict the need for admission or the likelihood of relapse after discharge. The FEV1 was recorded at presentation before treatment and immediately after a decision to admit or discharge had been made. Of the 96 patients 10.4% were admitted, 10.4% were discharged but suffered a relapse, and 79.2% were discharged and did not suffer a relapse. The FEV1 had a low positive predictive value (47%) for admission or relapse when it was 0.7 L/min or less at presentation and 2.1 L/min or less before discharge or admission. The FEV1 did not alter the decision to admit or discharge in 97% of the cases. We believe that the FEV1 fails to identify patients who should be admitted or those who will likely suffer a relapse; however, patients with a final FEV1 greater than 2.4 L/min may be discharged with confidence.     

Prevalence and spectrum of asthma in childhood.

All the 7 year old schoolchildren in North Tyneside were screened for wheeze with a questionnaire followed by selective clinical assessment: 9.3% of the children had had episodic wheeze within the past year and all those followed up subsequently responded to one or more of the drugs used for asthma. A further 1.8% had had similar symptoms since starting school, though they had not wheezed in the past year. Frequently of symptoms in the 11% of children with features of asthma varied widely and correlated with bronchial reactivity on histamine challenge, but it was not possible to separate children with frequent wheeze from asymptomatic controls by their response to histamine. It was concluded that all these wheezy children had symptoms of a common basic disorder and that they should all be treated as asthmatic.     

The natural history of childhood asthma to adult life.

A randomly selected group of 331 children who had started to wheeze in childhood and a control group of 77 children were prospectively studied clinically and physiologically from 7 to 21 years of age. Most subjects improved during adolescence and about 55% of those whose wheezing had started before 7 years and stopped before adolescence remained wheeze free. Forty-five per cent of subjects who had apparently ceased to wheeze at 14 years had minor recurrences of wheezing between 14 and 21 years of age. Fewer than 20% of those with persistent symptoms in childhood had become totally wheeze free during adolescence, although there was amelioration in symptoms. Girls did less well during adolescence than boys, so that there was no longer an increased preponderance of boys with increasing severity of asthma. Normal growth was achieved in all grades despite the persistence of symptoms in many cases. At 21 years of age features of airways obstruction were often found during an interval phase, especially in those who had more persistent symptoms.     

Long-term Follow-up of Therapeutic Starvation

A total of 75 grossly obese patients were admitted to hospital for 80 episodes of prolonged starvation. Five took their own discharge within two weeks of admission and 12 defaulted from follow-up within 12 months of discharge. The others were all followed up for periods of 12 to 64 months. Altogether 39 episodes in 34 patients were classified as failures, eight as modified successes, and 16 as successes, though five of the latter patients subsequently defaulted. Success was associated with regular follow-up attendance but could not be otherwise predicted. A number of patients obtained tangible benefit from starvation despite a subsequent gain in weight.     

Social effects of wheeze in childhood: a 25 year follow up.

OBJECTIVES--To determine the outcome of childhood wheeze in terms of education, employment, housing, and social class. DESIGN--25 year follow up study. SETTING--Community study based at the department of thoracic medicine, Aberdeen Royal Infirmary. PARTICIPANTS--Three groups of subjects who had been identified in a random community survey in 1964: those who had had asthma in childhood (n = 97), those who had wheezed only in the presence of upper respiratory tract infections (n = 132), and a comparison group who had had no respiratory symptoms as children (n = 131). Subjects were aged 34 to 40 years at the time of the current study. MAIN OUTCOME MEASURES--Interview and questionnaire data on education, employment, housing and social class, ventilatory function, and peak flow rate. RESULTS--Pulmonary function testing showed that only the "asthmatic" group had airways obstruction; this group showed greater peak flow variation than the "wheezy" group, which did not differ from the comparison group. The asthmatic subjects were more likely to have experienced respiratory problems during their school years and associated with their work. Despite these problems, educational attainment, employment, housing, and eventual social class were similar for all three groups. CONCLUSION--Childhood wheeze did not adversely affect education, employment, housing, or social class in this population.     

Course of patients discharged early after myocardial infarction.

Two hundred and seventy-one (76%) out of 358 survivors of infarction were discharged by the eighth hospital day, and 251 (93%) of them survived to six weeks after discharge. Six of the 20 patients who died between discharge and six weeks did so after readmission and 14 died as outpatients. All these patients who died at home had transmural infarction and four had diabetes. In inpatients successful resuscitation occurred mainly within the first 48 hours, with only three successful long-term results from all the patients who suffered arrest later. This suggests that more prolonged inpatient care would not have reduced the late mortality. These figures justify continuing with an early discharge policy for most patients, but coronary care should probably be more prolonged for patients with diabetes.     

A Review of Patients Discharged from a Tuberculosis Hospital

A review of 665 discharges in 1965 from the Tuberculosis Unit of the Toronto Hospital at Weston revealed that 10% did not have tuberculosis; 8% had inactive tuberculosis at the time of last admission; and 82% had active tuberculous disease when admitted (66% were admitted for the first time and 16% were readmissions). Ninety-one per cent of those who did not have tuberculosis were discharged (alive) after a median stay in hospital of 68 days; the remaining 9% died from non-tuberculous diseases after a median stay of five days. Ninety-three per cent of those who were admitted with inactive tuberculosis were discharged (alive) after a median stay of 65 days; the remaining 7% died from non-tuberculous diseases after a median stay of three days. Of the 38 deaths among the 665 discharges, only 13 were due to tuberculosis; 19 had tuberculosis but died from various non-tuberculous diseases; and six had no evidence of tuberculosis.Suggestions are made for improving diagnostic accuracy before admission, and for facilitating the earlier discharge of certain patients following investigation in a tuberculosis hospital.     

Underdiagnosis and undertreatment of asthma in childhood.

A total of 179 Tyneside children who had suffered at least one episode of wheeze since school entry were seen at the age of 7. All but 14 had visited a doctor for chest symptoms, but a diagnosis of asthma had been offered to the parents of only 21 children, including three of the 56 children experiencing four to 12 wheezy episodes a year and 11 of the 31 children experiencing more than 12 episodes a year. Bronchodilator treatment was rarely offered in the absence of such a diagnosis, and two thirds of the children had never received a bronchodilator. Of the children experiencing four or more episodes a year, only a third had received bronchodilator drugs regularly, though half had lost more than 50 days from school because of wheeze. School absenteeism fell 10-fold in the 31 children finally offered continuous prophylactic treatment. Although many doctors had feared that use of the word "asthma" would cause anxiety, parents were uniformly relieved when given an explanation of their child''s recurrent wheeze. This study uncovered a disturbing amount of ill health in children that was easily rectified. Probably this same problem exists in other areas.     

Influences on hospital admission for asthma in south Asian and white adults: qualitative interview study

ObjectiveTo explore reasons for increased risk of hospital admission among south Asian patients with asthma.DesignQualitative interview study using modified critical incident technique and framework analysis.SettingNewham, east London, a deprived area with a large mixed south Asian population.Participants58 south Asian and white adults with asthma (49 admitted to hospital with asthma, 9 not admitted); 17 general practitioners; 5 accident and emergency doctors; 2 out of hours general practitioners; 1 asthma specialist nurse.ResultsSouth Asian and white patients admitted to hospital coped differently with asthma. South Asians described less confidence in controlling their asthma, were unfamiliar with the concept of preventive medication, and often expressed less confidence in their general practitioner. South Asians managed asthma exacerbations with family advocacy, without systematic changes in prophylaxis, and without systemic corticosteroids. Patients describing difficulty accessing primary care during asthma exacerbations were registered with practices with weak strategies for asthma care and were often south Asian. Patients with easy access described care suggesting partnerships with their general practitioner, had better confidence to control asthma, and were registered with practices with well developed asthma strategies that included policies for avoiding hospital admission.ConclusionsThe different ways of coping with asthma exacerbations and accessing care may partly explain the increased risk of hospital admission in south Asian patients. Interventions that increase confidence to control asthma, confidence in the general practitioner, understanding of preventive treatment, and use of systemic corticosteroids in exacerbations may reduce hospital admissions. Development of more sophisticated asthma strategies by practices with better access and partnerships with patients may also achieve this.

What is already known on this topic

South Asian patients with asthma are at increased risk of hospital admission with asthma compared with white patientsNo consistent differences in severity or prevalence of asthma, prescribed drugs, or asthma education have been described, and interventions to reduce admission rates in Asian patients have met with variable success

What this study adds

Compared with white patients, south Asian patients admitted to hospital with asthma had less confidence to control asthma, were unfamiliar with the concept of preventive medication, and had less confidence in their general practitionersSouth Asian patients managed asthma attacks through family advocacy and without systematic changes in prophylaxis and without systemic corticosteroidsPatients reporting difficulty in accessing primary care during attacks were often south Asian     

National survey of hospital patients.

OBJECTIVE--To survey patients'' opinions of their experiences in hospital in order to produce data that can help managers and doctors to identify and solve problems. DESIGN--Random sample of 36 NHS hospitals, stratified by size of hospital (number of beds), area (north, midlands, south east, south west), and type of hospital (teaching or non-teaching, trust or directly managed). From each hospital a random sample of, on average, 143 patients was interviewed at home or the place of discharge two to four weeks after discharge by means of a structured questionnaire about their treatment in hospital. SUBJECTS--5150 randomly chosen NHS patients recently discharged from acute hospitals in England. Subjects had been patients on medical and surgical wards apart from paediatric, maternity, psychiatric, and geriatric wards. MAIN OUTCOME MEASURES--Patients'' responses to direct questions about preadmission procedures, admission, communication with staff, physical care, tests and operations, help from staff, pain management, and discharge planning. Patients'' responses to general questions about their degree of satisfaction in hospitals. RESULTS--Problems were reported by patients, particularly with regard to communication with staff (56% (2824/5020) had not been given written or printed information); pain management (33% (1042/3162) of those suffering pain were in pain all or most of the time); and discharge planning (70% (3599/5124) had not been told about warning signs and 62% (3177/5119) had not been told when to resume normal activities). Hospitals failed to reach the standards of the Patient''s Charter--for example, in explaining the treatment proposed and giving patients the option of not taking part in student training. Answers to questions about patient satisfaction were, however, highly positive but of little use to managers. CONCLUSIONS--This survey has highlighted several problems with treatment in NHS hospitals. Asking patients direct questions about what happened rather than how satisfied they were with treatment can elucidate the problems that exist and so enable them to be solved.     

Respiratory symptoms and atopy in Aberdeen schoolchildren: evidence from two surveys 25 years apart.

OBJECTIVE--To estimate changes in the prevalence of respiratory symptoms and the reported diagnoses of asthma, eczema, and hay fever in primary school children in Aberdeen between 1964 and 1989. DESIGN--Determination of incidence prevalence and prevalence from survey data. SETTING--Aberdeen, Scotland. PARTICIPANTS--2743 primary school children (aged 8-13) from 1964 and 4003 [corrected] from 1989. MAIN OUTCOME MEASURES--Survey data on whether, according to the parent or guardian, the child wheezed or was troubled with shortness of breath; the number of episodes of breathlessness in the past year; and whether asthma, eczema, or hay fever had ever been diagnosed. RESULTS--Questionnaires were completed by the parents of 2510 children in 1964 and 3403 children in 1989. The prevalence of wheeze rose from 10.4% in 1964 to 19.8% in 1989, and the prevalence of episodes of shortness of breath increased from 5.4% to 10.0%. In both surveys wheeze and shortness of breath were more prevalent in boys than in girls. The reported diagnosis of asthma rose from 4.1% to 10.2%, hay fever from 3.2% to 11.9%, and eczema from 5.3% to 12%. The proportion of boys suffering from eczema rose from 47.7% to 60.0%. Hay fever showed a similar increase, from 49.4% to 60.1%, in boys over the 25 year period. Though the parents of a higher proportion of children with wheeze were aware of the diagnosis of asthma in 1989, because of the increased prevalence of wheeze the absolute number of parents of wheezy children who were not aware of a diagnosis of asthma increased from 7.4% to 9.6% of the population studied. CONCLUSION--The higher diagnosis rate for asthma is due not simply to changes in diagnostic fashion but reflects an increase over the past 25 years in the prevalence of respiratory symptoms, which in turn may reflect a more general change in the prevalence of atopy, the increase in which was particularly noticeable in boys. This increase explains some of the increase in hospital admission rates for children with asthma.     

Edinburgh emergency asthma admission service.

In December 1968 an emergency service was set up in Edinburgh to enable patients with severe asthma to be admitted to hospital without delay. Up to 31 August 1975, 82 such patients had been admitted on 162 occasions, on 116 without the intervention of a general practitioner. The service is extended to patients particularly at risk of developing fatal asthma, and since it began no patient has died from asthma outside hospital. One patient, however, died from tension pneumothorax that developed after admission. We believe that similar services should be available throughout Britain.     

The Rehabilitation Unit in the Treatment of Rheumatoid Arthritis

The Devonshire Royal Hospital, Buxton, England, was developed from a spa hospital into the Manchester Regional Centre for Rheumatism and Rehabilitation. Patients with active rheumatoid disease are admitted to the hospital''s Rheumatism Service, not to the Rehabilitation Unit. Fifty per cent of patients admitted to the Rehabilitation Unit have rheumatoid arthritis, with reablement or resettlement as their main problem. Nine hundred and eighty-eight rheumatoid patients admitted in a period of five years had chronic disease but recent disability (633 off work under one year). Their average hospital stay was 10 weeks. Five hundred and forty-four were admitted severely disabled; 247 were discharged so graded. One hundred and thirty-eight were fit for some work on admission and 498 on discharge. Sixty-five per cent of housewives could run their homes. In a sample of 100 male rheumatoid patients, 39 men were fit for their own jobs and were easily placed; 43 needed lighter work and over 20 of these were adequately resettled when checked at three and 36 months. The earnings of these men exceeded the cost of rehabilitation for the whole group.     

Attitudes and Long-term Adjustment of Patients Surviving Cardiac Arrest

Twenty patients surviving cardiac resuscitation following myocardial infarction were seen at least six months after the cardiac arrest. The patient and spouse were interviewed separately. Though they had not usually been informed by the medical staff, 16 of the 20 patients were aware that a cardiac arrest had occurred and had a good understanding of what this meant. Six patients remembered the start or end of the cardiac arrest and five specifically remembered external cardiac massage. Their feelings and their attitudes to the cardiac arrest are described.Initial anxiety was experienced by all the patients and their spouses, particularly after hospital discharge, but in the long term only five patients failed to make a reasonably satisfactory adjustment. Poor rehabilitation seemed to be mainly associated with persisting physical disability and personality factors and not with features associated with the cardiac arrest, such as the duration of external cardiac massage. The spouses often found it difficult to know exactly how to treat the patients after hospital discharge and most patients and spouses felt that more explanation and discussion with the medical staff would have helped to alleviate anxiety.     

Rehabilitation in Disseminated Sclerosis: An Evaluation of 28 Patients

The results of rehabilitation have been described and evaluated in a group of 28 patients moderately severely disabled with disseminated sclerosis between the ages of 19 and 71 years and in a controlled hospital setting. Twenty-three suffered chronic progressive disease and five were in remission from an acute exacerbation. They had had the disease an average of 12.7 years and were hospitalized an average of 5.4 months. On admission, 24 required much assistance with their activities of daily living, six had poor control of elimination, and four were depressed. On discharge, 13 cared for themselves with little or no help, four had overcome their problems of elimination, and three had improved emotionally. A major symptom in 13, fatigue, did not preclude successful performance, but a progression of disease or failure to react steadfastly did. None were gainfully employed. Six years after discharge, 18 of 20 were alive and happy at home.     

How informed is signed consent?

The assurance that patients fully understand the information given to them before they sign the consent form for operation has never been validated in this country. One hundred patients were interviewed by an independent medical observer in one surgical unit in a teaching hospital between two and five days after their operation. Although all the patients interviewed were fully aware that they had had an operation, 27 did not know which organ was operated on and 44 were unaware of the exact nature of the surgical procedure. A significantly higher age group was observed in the group of patients who were unaware of the basic facts relating to their operation, and the problem was encountered most commonly in patients over the age of 60. Because of the medical and legal importance the findings of this pilot study warrant further large scale investigations.     

The use of sedative-hypnotic drugs in a university teaching hospital.

We reviewed the charts of 476 patients admitted to a university teaching hospital to determine whether sedative-hypnotic drugs (SHDs) were being used excessively and to examine the use of SHDs as hypnotics. The frequency of medical and surgical indications for barbiturates and benzodiazepines or other minor tranquillizers as well as the use of such drugs were compared among different groups of patients and specialty wards. Of the patients 29% had a regular order and 40% had a PRN order; only 77% of the PRN orders were administered. A total of 215 patients (45%) received an SHD during their hospital stay, and 160 (34%) received the drug as a hypnotic. Medical indications accounted for 49% of the regular orders but only 2% of the PRN orders; moreover, 89% of all the PRN orders were for insomnia. On average, patients receiving SHDs as hypnotics were older (p less than 0.05) and stayed longer in hospital (p less than 0.01) than those who did not; however, no patient on the geriatric or pediatric ward received an SHD as a hypnotic during the hospital stay. The differences in use between patient groups may have been influenced by orientation of ward staff. Physicians should review their rationale for prescribing hypnotics and avoid routine orders on admission.     

ACUTE AND CHRONIC ASTHMA—Treatment with Theophylline in Hydro-Alcoholic Solution: Clinical Evaluation and Pulmonary Function Studies

A flavored solution containing 80 mg. of theophylline and 3 cc. of ethyl alcohol per 15 cc. was given orally to 31 patients with acute asthma to terminate the attack. Thirty patients with moderate to severe chronic asthma were alternated for three or four weeks on daily multiple doses of either the theophylline solution or a placebo.In the acute cases three-second Vital Capacity increased by 33.8 per cent and Maximal Breathing Capacity by 30.2 per cent in one hour after taking 60 cc. to 75 cc. of the theophylline solution. When placebos were given, both measures of lung function declined during the first half hour.Seventy-one and a half per cent of patients with acute cases felt moderate to complete relief of symptoms. In persons with chronic asthma the regular use of the theophylline solution did not change the frequency of asthma in most cases, but it decreased the severity in 59 per cent of cases. The values for three-second Vital Capacity and Maximal Breathing Capacity rose only a little.Gastric irritation was noted in one-third of the chronic cases and one-fourth of the acute cases. This could be reduced by appropriate measures.