Hospital admissions and readmissions for asthma in the age group 0-4 years.

SUMMARY. Childhood rates for admission and readmission for asthma are highest under the age of 5 years. From a registration study in 0-4-year-olds, 100 patients (68 male) were admitted to hospital for asthma and followed for 1 year, yielding a total of 136 admissions. To examine factors that may play a role in admissions and readmissions, histories and laboratory tests for atopic status at initial presentation, and clinical data on admission were evaluated. Age groups 0-1 year (n = 54) and 2-4 years (n = 46) were analyzed separately, of whom 20 (37%) and 9 (20%) patients, respectively, had at least one readmission. In the age group 2-4 years, patients with antibodies against inhalant allergens, determined by radioallergosorbent test (RAST), had a significantly higher risk of readmission (RR = 1.54; 95% CI, 1.22-1.95). In the age group 0-1, year prevalence of sensitization to inhalant allergens was low (20% vs. 72% in age group 2-4 years) and constituted only a slight risk (P = 0.097) for readmission. A history of eczema showed a negative association in the age group 0-1 year. Treatment of the first admission did not differ between children only admitted once and those requiring readmission. In both age groups, clinical features at admission did not differ significantly between first and subsequent admissions, and neither did length of stay. Number of readmissions were higher in the age group 0-1 year than in the age group 2-4 years (27/81 (33%) vs. 9/55 (16%), P = 0.028), with no indication of a lower threshold for admission. In the age group 0-1 year, 60% of the readmissions occurred within 2 months of first hospitalization. Moreover, in the age group 0-1 year a trend was observed that inhaled steroids were prescribed less frequently on discharge following first admission in those children who were readmitted than in the children who had a first admission only (4/20 (20%) vs. 15/34 (44%), P = 0.073). More "aggressive" therapy with anti-inflammatory drugs and close medical follow-up after discharge seem to be indicated.

Risk factors for exacerbations and hospital admissions in asthma of early childhood.

Hospital admissions and readmissions for asthma in early childhood remain causes for concern. The purpose of this study was to identify predisposing risk factors related to asthma exacerbations and precursors of hospital admissions in young children. Subjects were patients with doctor-diagnosed asthma from a clinical registration study, aged 0-4 years, and followed up for 2 years. Data from histories and laboratory tests for atopic status at initial presentation, and the patient's condition at visits over the 2-year follow-up period were evaluated. Exacerbation was defined as increases in cough and/or wheeze and/or breathlessness, increase in beta(2)-agonist use, and a clinical need for a short course of oral corticosteroids. Age groups 0-1 year and 2-4 years, based on age at initial presentation, were analyzed separately. In the age group 0-1 year, 71/113 (63%) patients had at least one exacerbation, and 20 experienced recurrent exacerbations (>/=3). Predisposing risk factors for exacerbation were damp housing (odds ratio (OR) 7.6 (2. 0-28.6)) and colds (OR 3.6 (1.4-9.6)), and for recurrent exacerbations sensitization to inhalant allergens (Phadiatop(R)) (OR 8.1 (1.6-40.5)) and damp housing (OR 3.8 (1.1-12.8)). Hospital admissions were significantly associated with number of exacerbations. In the age group 2-4 years, 58/144 (40%) patients had at least one exacerbation, and 21 experienced recurrent exacerbations (>/=2). Predisposing risk factors for exacerbation were mean age at initial presentation (OR 0.92 (0.88-0.97)) and level of total IgE (OR 2.3 (1.4-3.9)), whereas for recurrent exacerbations no predictor variables were found. Hospital admissions were significantly associated with damp housing. Results from this study may facilitate recognition of young asthmatic patients at risk of (recurrent) exacerbations, and help to identify those in whom early intervention with anti-inflammatory therapy may be necessary. We also emphasize the importance of preventive measures in decreasing damp housing.

Prognostic characteristics of asthma diagnosis in early childhood in clinical practice.

A registration study from clinical practice was set up to assess the prognostic value of symptoms and laboratory data at first visit for doctor-diagnosed 'asthma' in early childhood. A total of 419 children aged 0-4 y, who were newly referred to the outpatient department of the Juliana Children's Hospital with possible asthma were enrolled over a 2-y period. Data from history taking, physical examination, laboratory tests for atopic status at first visit and data from follow-up visits were recorded. Two years after the first visit all medical records were reviewed for diagnostic label. The age groups 0-1 y and 2-4 y were analysed separately, because respiratory symptoms are often transient and sensitization to inhalant allergens is uncommon before the age of 2 y. The clinical diagnosis 'asthma' was made in 113 of 231 (49%) children aged 0-1 y and in 144 of 188 (77%) children aged 24 y. Characteristics from history taking indicated shortness of breath was the most prognostic symptom in both age groups. Eczema, wheeze and non-allergic provoking factors (weather conditions) were further predisposing factors in the 0-1 y group, as were allergic provoking factors (inhalant allergens) and absence of ear-nose-throat-history in the 2-4 y group. Adding laboratory data to history total serum IgE had prognostic value, but specific serum IgE against inhalant allergens (Phadiatop) was a strong predisposing factor, especially in the 2-4 y group. These prognostic characteristics may enhance early recognition of asthma in infants and improve asthma care in clinical practice.

Asthma statistics in The Netherlands 1980-94.

Concern about the rising asthma mortality and morbidity in several countries in the 1980s, and the consequent development of international guidelines for diagnosis and management of asthma, gave reason to evaluate national mortality and hospital admission data from the Netherlands for asthma [International Classification of Diseases (ICD) 493] over the period 1980-94, as well as for chronic obstructive pulmonary disease (COPD) (ICD 490-2, 496) and acute bronchi(oli)tis (ICD 466), according to age (0-4, 5-34, 35-64 and > or = 65 years). Rates per million population per year were calculated and time trend analyses were performed. Hospital admissions for asthma showed a decrease in all age groups except in age group 0-4 years. In this age group, an increase was found which continued in the 1990s. Hospital admissions also increased for COPD and acute bronchi(oli)tis in the age group 0-4 years. These increases, however, had no impact on the respiratory mortality, which remained stable and even fell for acute bronchi(oli)tis. Asthma mortality showed a large decline in the 1990s in age group > or = 65 years in both sexes, and also fell, to a lesser extent, in age group 35-64 years. In both age groups, rising COPD trends were found in hospital admissions and mortality, except in males aged 35-64 years, in whom trends fell in the last decade. In age group 5-34 years, asthma mortality declined over the whole study period, whilst the other respiratory trends were stable. It is concluded that asthma statistics in the Netherlands indicate favourable development, except for the age group 0-4 years. In this age group, morbidity from asthma and from other reactive airway disorders is still of great concern.

The use of serum eosinophil cationic protein (ECP) in the management of steroid therapy in chronic asthma.

BACKGROUND: Corticosteroid therapy has become the mainstay in the treatment of asthma. However, the risk-benefit balance in the patient calls for assessment of the state of inflammation in the airways. In this respect serum eosinophil cationic protein (ECP) might be a marker, which can easily be measured in a clinical setting. Studies have indicated a relation between level of serum ECP and activity and severity in asthma. OBJECTIVE: To investigate the feasibility to guide steroid therapy on the basis of the level of serum ECP in patients with chronic asthma. METHODS: Twenty adult patients on maintenance inhaled steroid therapy visited the chest clinic once every 2 months over a 12-month period. At each visit a short history, blood sample for ECP and number of eosinophils, baseline spirometry, and histamine inhalation provocation test (PC20) were obtained. On the basis of level of ECP, adjustments in daily dose of steroids were considered. Data were compared with those of a previous 6-month ECP evaluation study in these same patients. RESULTS: In 10 patients mean dose of inhaled steroids was decreased > or = 25%. ECP rose slightly (antilogged mean from 9.06 to 11.8 micrograms/L) and lung function decreased slightly (mean FEV1 %predicted from 85.5 to 81.6). In seven patients mean dose of inhaled or oral (n = 2) steroids was increased > or = 25%. In this group ECP decreased but remained elevated at > or = 20 micrograms/L (antilogged mean from 30.5 to 25.6 micrograms/L) and lung function improved (mean FEV1 %predicted from 67.2 to 74.5). In both groups patients' scores of asthmatic well-being increased significantly, and PC20 did not show a trend. Exacerbation rate remained the same in the decreased and the no change group (n = 3, in which no substantial change in steroid dose occurred), but was reduced by about 50% in the increased group. CONCLUSION: From this observational study it is concluded that adjusting steroid therapy guided by serum ECP-level may be helpful in tailoring asthma treatment.

Serum eosinophil cationic protein (ECP) in chronic asthma. Relationship to spirometry, flow-volume curves, PC20, and exacerbations.

Serum ECP was measured in a double-blind study in relation to spirometry, flow-volume curves, and histamine PC20 (30-s tidal breathing method, normal value > 32 mg ml-1) in 20 chronic asthmatic patients (five male), mean age 48.9 yr (SD 11.0), once a month and at additional visits due to acute exacerbations over a 6-month period. All patients were on maintenance inhaled corticosteroid therapy. Serum ECP was considered elevated at > or = 20 micrograms l-1. ECP showed significant negative correlations with lung function, especially when ECP was elevated (45/143 observations): r = -0.48, -0.48, and -0.49 for respectively FEV1, PEF, and MMEF (all at baseline and as % predicted, P = 0.001), the best correlation being with FEV1/FVC ratio (r = -0.61, P < 0.001). PC20 only had a weak overall correlation with ECP (r = -0.21, P = 0.015). Eosinophilia at > or = 0.400 x 10(9) cells l-1 (38/143 observations) did not show any significant correlations with the lung function variables. The patients were subdivided into three groups according to exacerbations. Group A consisted of seven patients with suspected infectious exacerbations (mean 1.4), group B of six patients with suspected inflammatory exacerbations (mean 3.2), and group C of seven patients who did not experience any symptomatic exacerbations. A significant difference in mean ECP was found between group B and A (33.1 vs. 10.2, P = 0.003). Group B also differed significantly from group A with respect to lung function and PC20, but not to atopy, lung function and PC20 being lower and variability higher in group B. The findings of this study suggest that serum ECP is a sensitive marker of inflammatory airflow obstruction in chronic asthma. Elevated ECP seems to denote patients at risk from inflammatory exacerbations, resulting in practical implications for the therapeutic management of chronic asthma.

[Trends in consultations and prescriptions for children with COPD]. / Trends in consulten en prescripties wegens CARA bij kinderen.

National data were provided on consultations (first, repeat) and prescriptions in patients having ambulatory care for asthma and COPD combined, by age group (0-4, 5-11, and 12-19 yr) and doctor's category (GP, specialist) over the period 1981-1990. Prescriptions were subdivided into (1) beta 2-agonists, anticholinergics, ketotifen, methylxanthines, cromoglycate, inhaled steroids, oral steroids, (2) antibiotics, (3) other drugs. Age specific rates/1000 persons/year were calculated. Rates for first consultations remained steady, pointing to a stable incidence. Rates for repeat consultations increased in the 0-4 yr age group (GP and specialist) and the 5-11 yr age group (specialist). Prescription rates for the pulmonary medication group also rose in particular in these two age groups. For the GP, however, they were counterbalanced by decreasing trends in prescriptions of the 'other drugs', pointing to a shift towards more rational treatment. The increased ratios of prescription rate to consultation rate, not only for the anti-inflammatory drugs but for the bronchodilators as well, especially in the specialist category, suggest an increased morbidity (severity) from obstructive airways disease in childhood.

[Frequency of hospitalization for respiratory disorders in 0-14-year-old children]. / Frequentie van ziekenhuisopname wegens respiratoire aandoeningen bij kinderen van 0-14 jaar.

National hospital admission frequencies were analysed for asthma (ICD-9 code 493), acute bronchi(oli)tis (ICD-code 466), pneumonia and influenza (ICD-code 480-487), and chronic obstructive pulmonary disease (ICD-code 490-492 and 496) for 1980-1989 by sex and according to age (0-4 years, 5-9 years, and 10-14 years). Rates per million of the childhood population per year were calculated and time trend analyses performed by least squares regression. In the age group 0-4 years the admission rates for the respiratory diseases were highest and a general tendency towards increasing rates was present, and significant trends were found for asthma and acute bronchi(oli)tis. In the age groups 5-9 years and 10-14 years the admissions rates were considerably lower and fluctuated with no trends to point to except for a significant increasing trend for acute bronchitis in girls aged 5-9 years and a significant decreasing trend for asthma in boys aged 10-14 years. From the presented data it can be concluded that in childhood the health issue with respect to the respiratory diseases concerns the very young in particular.

[Trends in the frequency of hospitalization for asthma and chronic obstructive lung disease in The Netherlands, 1980-1988]. / Trends in de frequentie van ziekenhuisopname wegens astma en chronisch obstructieve longziekte in Nederland, 1980-1988.

National hospital admission frequencies were analysed for asthma (ICD-9 code 493) and chronic obstructive pulmonary disease (COPD) (ICD-code 490 + 491 + 492 + 496) for 1980-1988 by sex and according to age (0-4, 5-34, 35-64, and greater than or equal to 65 years). Rates per million of the population per year were calculated and time trend analyses performed by least square regression. The admission rate for asthma showed a decrease in the total male and female population, as was the case in all age groups, except for the age group 0-4 years in which a significant increase was found. For COPD an increase was observed in total admissions in males and females, due to a substantial increase in the age group greater than or equal to 65 years, while in females the increase in the age group 35-64 years also contributed. The striking increase in hospitalisation for asthma in young children needs further attention, as does the increase in hospital admissions for COPD in older people, particularly with respect to women, for whom continuing rising trends can be expected.

Mortality and morbidity from respiratory diseases in childhood in The Netherlands, 1980-1987.

National mortality and hospitalization data from the Netherlands were analysed for asthma (International Classification of Diseases) (ICD 493), acute bronchi(oli)tis (ICD 466), pneumonia and influenza (ICD 480-487), and other chronic obstructive pulmonary diseases (ICD 490 + 491 + 492 + 496) in children aged 0-14 yrs for 1980-1987. No trends were seen in the mortality in age groups 0-4 yrs and 5-14 yrs, which actually concerned small numbers. In general a tendency towards increasing hospital admission rates for respiratory diseases was observed in both sexes in age groups 0-4 yrs and 5-9 yrs but not in age group 10-14 yrs, and significant increases were found for asthma in males and females aged 0-4 yrs and in males aged 5-9 yrs, and for acute bronchitis in females aged 5-9 yrs. Hospital admission rates in the Netherlands for asthma appeared to be low compared to other countries. The average length of stay, however, for both asthma and the other respiratory diseases was substantial though declining. Clinical information is required on possible causal factors of the apparent need for hospitalization for reactive airway disorders in young children, and on the management of asthma in particular.

Evaluation of the Phadiatop test in an epidemiological study.

Sera from 204 adult patients with chronic airways obstruction were analysed with the Phadiatop, a new allergosorbent test with a paper disc containing the most relevant inhalant allergens, the PRIST for total IgE determinations, and a panel of seven RAST tests with the common inhalant allergens in The Netherlands as reference. The aim was to evaluate the Phadiatop as screening test in the in vitro diagnostic procedures in an epidemiological setting. The Phadiatop was classified positive or negative according to percentage binding, total IgE was considered elevated at values greater than 100 kU/l and the RAST panel positive when at least one RAST result was class greater than 1. The prevalence of inhalant atopy came to 27.9%. The predictive value of the Phadiatop for a positive RAST panel was 96.4%, and for a negative RAST panel 97.3%. For the PRIST these values were 51.9% and 87.2% respectively. The correlation between the log percentages binding of the Phadiatop and the RAST panel was 0.93. It is concluded that the Phadiatop is a valuable test for the screening of inhalant atopy, and as the percentage binding of the Phadiatop may reflect the degree of sensitization it could also be applied as a quantitative measure especially for epidemiological purposes.

Time trends and survival in patients presented for surgery with non-small-cell lung cancer 1969-1985.

All evaluable patients (n = 920) with primary non-small-cell lung cancer (NSCLC) who were presented for surgery in our hospital between 1969 and 1985 were reviewed as to histological findings, postoperative stage, age group and surgical procedure. Time trend analyses showed a significant increase over time in the proportion of adenocarcinomas (p = 0.025) and in the proportion of the elderly (greater than or equal to 70 years; p = 0.014). The 5-year survival rates by year of operation showed no improvement at all over time; on the contrary they showed a decline, which however only reached significance for patients who underwent pneumonectomy (p = 0.034). It is noted that the overall survival curves up to 5 years showed no significant differences between patients with adenocarcinoma and patients with squamous cell carcinoma, or between patients aged 70 years or more and patients aged 60-69 years. Despite expanded preoperative diagnostic techniques and developments in surgical treatment, no improvement in the survival after surgery for NSCLC over the period 1969-1985 could be established.

[The Phadiatop test, a new in-vitro test for inhalation allergy]. / De 'Phadiatop-test', een nieuwe in vitro-test voor inhalatie-allergie.

The Phadiatop test, a new in-vitro test for inhalant allergy, was evaluated in relation to a RAST panel, and in comparison with total IgE. In 248 patients, aged 12-64 years, who had been prescribed pulmonary medication in general practice, the Phadiatop, total IgE (PRIST), and specific IgE (RAST) test were carried out with seven inhalant allergens common in the Netherlands. RAST was considered positive at class greater than or equal to 2 and total IgE elevated at values greater than or equal to 200, greater than or equal to 150, and greater than or equal to 100 kU/l in age groups 12-14, 15-16, and 17-64 years respectively. The result of the Phadiatop test is given as positive or negative. The predictive value of the Phadiatop test for one or more positive RAST results was 100% and its predictive value for all RAST results being negative was 97.1%, while these predictive values for total IgE were 84.7% and 71.2% respectively. It is concluded that the Phadiatop test is a valuable test to confirm or exclude sensitization to common inhalant allergens.

Clinical evaluation of five spirometers. Monaghan M403, Pneumoscreen, Spirotron, Vicatest and Vitalograph.

Five spirometers were compared with the Stead-Wells spirometer in 100 subjects, using the FVC and FEV1 as parameters. In addition, some physical characteristics were studied. The Stead-Wells is a water-sealed spirometer, recommended as a reference spirometer by the American Committees on Environmental Health and Respiratory Physiology. The Vicatest and Vitalograph are volume-displacement dry spirometers. They showed a very good linearity over their entire volume ranges; their FVC and FEV1 readings showed very good correlations with the readings of the Stead-Wells spirometer. The Monaghan, Pneumoscreen, and Spirotron are flow-integrating "electronic" spirometers. The volumes recorded were found to be dependent on the values of the flow; their FVC and FEV1 readings also showed good correlations with the readings of the Stead-Wells spirometer, but to a lesser extent than the two dry spirometers. Therefore, for routine assessment of ventilatory function we prefer, at present, the modern volume-displacement dry spirometers.