Indoor smoking bans in Bulgaria, Croatia, Northern Cyprus, Romania and Turkey.

BACKGROUND: The purpose of this study was to examine attitudes towards attempts to limit second-hand smoke (SHS) in five Eastern European nations. METHODS: The data consist of a Eurobarometer (64.3) survey distributed from November to December 2005. Logistic regression was employed to investigate support levels for indoor smoking bans across the five political units. RESULTS: Across nations, there is more support for smoking bans in offices and indoor work spaces and indoor public space as opposed to restaurants and bars and pubs. Personal smoking behaviours are linked strongly with the smoking bans. Most importantly, it is specific knowledge about the health dangers of smoking which fosters support for indoor smoking bans. CONCLUSION: Policy implications suggest that government and the media must disseminate accurate information about the harm of smoking to broader segments of the population to gain support for policies that affect the dangers of SHS in these nations.

Antibiograms of resistant Gram-negative bacteria from Scottish CF patients.

BACKGROUND: Over a 19-month pilot phase, 93 multiply resistant Gram-negative isolates from Scottish cystic fibrosis patients were sent to a referral laboratory for further investigation. METHODS: In common with the referring diagnostic laboratories, disc diffusion testing was carried out. Antibiotic susceptibility testing was also established by MIC methodology. NCCLS methods were used throughout. Twenty antibiotics were tested. RESULTS: Comparing disc diffusion results against MIC results, there were 167 (14%) major errors. By MIC, Pseudomonas aeruginosa (n = 59), Stenotrophomonas maltophilia (n = 16), Burkholderia cepacia (n = 10) and Alcaligenes xylosoxidans (n = 7) were susceptible to 18%, 11%, 4% and 35% of the antibiotics tested, respectively. Colistin and tobramycin were the most active agents against P. aeruginosa with 60% and 49%, respectively, testing susceptible. Minocycline and gentamicin were most active against S. maltophilia with 58% and 18%, respectively, testing susceptible. B. cepacia were most susceptible to co-trimoxazole (10%) and ciprofloxacin (10%). Five and six of the seven A. xylosoxidans isolates were susceptible to piperacillin and imipenem, respectively. CONCLUSIONS: Improved methods for susceptibility testing of such clinical isolates need to be employed in routine diagnostic laboratories. Levels of resistance in referred isolates were very high and similar to those described in the USA.

A randomised trial of self-management planning for adult patients admitted to hospital with acute asthma.

BACKGROUND: There is still debate over the benefit of self-management programmes for adults with asthma. A brief self-management programme given during a hospital admission for acute asthma was tested to determine whether it would reduce readmission. METHOD: A randomised controlled trial was performed in 280 adult patients with acute asthma admitted over 29 months. Patients on the self-management programme (SMP) received 40-60 minutes of education supporting a written self-management plan. Control patients received standard care (SC). RESULTS: One month after discharge SMP patients were more likely than SC patients to report no daytime wheeze (OR 2.6, 95% CI 1.5 to 5.3), no night disturbance (OR 2.0, 95% CI 1.2 to 3.5), and no activity limitation (OR 1.5, 95% CI 0.9 to 2.7). Over 12 months 17% of SMP patients were re-admitted compared with 27% of SC patients (OR 0.5, 95% CI 0.3 to 1.0). Among first admission patients, OR readmission (SMP v SC) was 0.2 (95% CI 0.1 to 0.7), p<0.01. For patients with a previous admission, OR readmission was 0.8 (95% CI 0.4 to 1.6), p=0.6. SMP patients were more likely than SC patients to be prescribed inhaled steroids at discharge (99% v 92%, p=0.03), oral steroids (98% v 90%, p=0.06), and to have hospital follow up (98% v 84%, p<0.01) but adjustment for these differences did not diminish the effect of the self-management programme. CONCLUSIONS: A brief self-management programme during hospital admission reduced post discharge morbidity and readmission for adult asthma patients. The benefit of the programme may have been greater for patients admitted for the first time. The programme also had a small but significant effect on medical management at discharge.

Patient weighting of importance of asthma symptoms.

BACKGROUND: Quality of life measures are increasingly important in evaluating outcomes in asthma. If some asthma symptoms are more troublesome to patients than others, this may affect their contribution to outcome measures. This study was designed to assess the relative importance of common symptoms in adults with asthma. METHODS: A postal survey using conjoint analysis was performed in 272 adults attending hospital outpatient clinics with moderately severe asthma. Patients were asked to chose between "symptom scenarios" offering different combinations of levels of five common asthma symptoms over one week. Two versions of the questionnaire were used with identical scenarios presenting symptoms in different orders. Different patients answered the two versions. Regression analysis was used to calculate symptom weights for daytime cough, breathlessness, wheeze and chest tightness, and sleep disturbance. RESULTS: Symptom order, percentage predicted peak expiratory flow (PEF), and symptoms in the week before the survey did not influence the choice of scenario. In both questionnaires patients were more likely to choose scenarios with low levels of cough and breathlessness than low sleep disturbance, wheeze or chest tightness. Regression weights for cough (-0.52) and breathlessness (-0.49) were twice those of wheeze (-0.25), chest tightness (-0.27), and sleep disturbance (-0.25). For 12% of patients cough dominated patient preferences, regardless of all other symptoms. Age was inversely related to weight given by patients to breathlessness. CONCLUSIONS: The prominence of cough among other asthma symptoms was unexpected. Daytime cough and breathlessness had greater impact for patients than wheeze or sleep disturbance. Age influenced symptom burden, with younger patients giving greater weight to breathlessness than older patients. Conjoint analysis appears to be a useful method for establishing the relative importance of common symptoms.

Fatal haemorrhage from aortic dissection following instillation of intrapleural streptokinase.

A patient is described who suffered fatal haemorrhage following intrapleural streptokinase for treatment of a presumed empyema. Autopsy revealed an unsuspected abdominal aortic dissection with extension of blood clot into the thoracic cavity. The importance of precise diagnosis of empyema and potential risks associated with intrapleural streptokinase are discussed.

Symptoms, quality of life, and health service contact among young adults with mild asthma.

This report assesses Quality of Life (QoL) and its relationship to current symptoms and prospective medical contact among 396 adult patients with asthma. Patients were 16 to 52 yr of age and in the care of family physicians in the northeast of Scotland. All patients had been prescribed asthma medication within the previous 3 mo. Mean %pred FEV(1) was 87.4, mean %pred PEF was 85.1; 41% reported respiratory symptoms every week in the month before interview. Patients completed the SF-36, SF-12, and St. George's Respiratory Questionnaire (SGRQ) scales. Although mean scores on the SF-36 and SF-12 were close to population norms for patients without chronic illness, the presence of any respiratory symptoms in the month before interview was related to significantly lower QoL scores on the SF-36 scales of Physical Functioning, Energy, Mental Health, Pain, and Health Perception: the SF-12 Physical Functioning scale, and the SGRQ Symptoms, Impact and Activities scales. Physician contact for asthma in the 12 mo after interview was significantly related to SF-36, SF-12, and SGRQ scores at time of interview; however, when adjusted for symptoms at time of interview, only the SGRQ scales remained significant predictors of prospective physician contact. We conclude that respiratory symptoms have significant impact on QoL among patients with mild asthma, measured by generic and respiratory QoL scales, but that a specific respiratory scale is better able to discriminate patients who will seek physician care for asthma.

Bronchial hyperresponsiveness and adult onset wheeze: the influence of atopy.

The commonly held belief that adult onset wheezing illness is primarily nonatopic in nature suggests that the role of atopy in the pathophysiology of bronchial hyperresponsiveness (BHR) in adult onset wheeze may be minimal. This study examined risk factors for BHR (BHR: provocative dose causing a 20% fall in forced expiratory volume in one second PD20 < or =16.38 micromol methacholine) among 82 subjects with adult onset wheeze and among 191 subjects who had never wheezed. Subjects were identified from a cohort of subjects aged 39-45 yrs who were known to have had no childhood wheeze and who were involved in a 30 yr follow-up survey. Risk factors for BHR were examined among all subjects with BHR and among subjects with BHR stratified according to whether or not they had ever wheezed. The prevalence of BHR was 40% (33/82) among the subjects with adult onset wheeze and 11% (21/191) among the subjects who had never wheezed. Lower baseline lung function (odds ratio (OR) = 0.94; 95% confidence interval (CI) = 0.92-0.97 per unit forced expiratory volume (FEV1)% predicted) and atopy (OR = 7.23; CI = 2.53-20.64 for all three measures of atopic compared to nonatopic) were associated with BHR, while smoking and family history showed no statistically significant relation to BHR. This pattern was also apparent in analyses stratified by symptom status. A family history of atopy increased the risk that BHR was accompanied by wheezing symptoms (OR = 4.75; CI = 1.53-14.72 for more than one affected relative compared to no affected relatives). These findings suggest that atopy is associated with bronchial hyperresponsiveness in adults known to have had no childhood wheeze. A familial factor reflecting genetic influences and/or shared environmental factors may influence whether bronchial hyperresponsiveness is associated with symptoms.

Requests for repeat medication prescriptions and frequency of acute episodes in asthma patients.

This study was conducted to determine if suboptimal use of inhaled steroid and over-reliance on bronchodilator medication to control asthma symptoms is associated with higher risk of acute asthma episodes. Details of repeat prescriptions for medication and use of health services over 12 months were collected for 754 adult outpatients with asthma; all were prescribed inhaled corticosteroid. Patients who requested less than five prescriptions per year were considered suboptimal users. Patients who requested seven or more bronchodilator prescriptions and less than five inhaled steroid prescriptions had significantly more family physician consultations for asthma episodes (p < 0.05), more hospital admissions (p < 0.05), and more disturbed nights in the week before hospital or family physician review (p < 0.05). Some patients with more severe asthma put themselves at risk by relying on bronchodilator medication rather than regular inhaled steroid for asthma control. Among patients who were low bronchodilator users, those who requested few inhaled steroid prescriptions were younger and more anxious but did not have an increased risk of acute asthma episodes.

Asthma, wheezy bronchitis, and atopy across two generations.

Although the prevalence of asthma has risen significantly during the last 30 yr, it is not clear whether this has occurred primarily in persons with a strong genetic predisposition to asthma and atopy or in other sections of the population. We have investigated outcomes in children of nuclear families selected through probands previously characterized by studies in 1964 and 1989 as having histories of persistent childhood onset atopic asthma, transient childhood wheezy bronchitis, and no respiratory symptoms or atopy. Children of wheezy bronchitic probands had a significantly better symptomatic outcome in adolescence, irrespective of the atopic status of the parent proband, than do children of either asthmatic or asymptomatic probands, suggesting that this may be a syndrome that shows familial aggregation and is distinct from asthma. Total serum IgE levels were significantly lower in children of nonatopic asymptomatic probands, including those with wheezing symptoms. In contrast children of nonatopic asymptomatic probands had an unexpectedly high prevalence of wheezing (33%), positive skin prick tests (56%), and positive specific serum IgE to common allergens (48%) that was similar to that found in children of atopic asthmatic probands. Our findings support the concept that wheezy bronchitis is a separate syndrome from atopic asthma. High total serum IgE levels within our population appear to be an important marker of genetic predisposition to atopy. Our data also suggest that much of the increase in asthma prevalence is associated with specific IgE sensitization and is occurring in persons previously considered to be at low risk of developing asthma or atopy.

Domiciliary nebuliser therapy--a valuable option in chronic asthma and chronic obstructive pulmonary disease?

Domiciliary nebulisers are in widespread use for patients who have severe chronic airways disease, both asthma and chronic obstructive pulmonary disease (COPD). We report a study of the use of domiciliary nebulisers designed to assess practical problems and the value of such therapy in preventing hospital admissions. A total of 405 patients underwent a structured interview at home and their case records were reviewed. Technical performance of the nebuliser compressors was assessed. The mean (SD) age of those interviewed was 64.5 (12) years. 185 patients had a physician diagnosis of asthma, and 208 had COPD. 87% patients used their nebuliser at least once daily. Side effects, reported by 54%, were related to frequency of use and commoner in younger patients. 29 subjects (7%) died within 2 years of receiving their nebuliser. Among the survivors, the 2 year periods before and after supply of the nebuliser were compared. The percentage of patients requiring hospital admission for exacerbations of lung disease fell from 56% to 46% (p < 0.01) but the number and duration of admissions was unchanged. Those whose admission duration increased had more severely impaired spirometry when the nebuliser was supplied and had lower activity scores and higher breathlessness scores at the time of interview indicating more severe disease. Approximately half of the compressors were malfunctioning and patients' understanding of the principles of nebuliser treatment was poor. The provision of domiciliary nebuliser can influence hospital admission in patients with obstructive airways disease. There is also a need for improved patient education and for technical support which may require the development of a nurse-run nebuliser service.

Risk factors for adult onset wheeze: a case control study.

Risk factors associated with adult onset wheeze were examined in a case control study of subjects aged 39-45 yr derived from a community cohort of 2,056 asymptomatic children originally studied in 1964. Participants included 102 cases with adult onset wheeze (since age 15) and 217 controls with no wheeze. Logistic regression analysis was used to determine independent risk factors for wheeze among all cases and three subgroups: doctor diagnosed asthma (n = 24), wheeze with chronic cough and phlegm (n = 31), and other wheeze (n = 47). The risk of adult onset wheeze among all cases increased with low socioeconomic status (relative risk [RR] 2.36), current smoking (RR 2.01), positive atopic status (RR 3.28), and positive family history of atopic disease (RR 5.49). Gender was not related to the risk of wheezing. The pattern of significant independent risk factors differed between the subgroups of cases. Socioeconomic status was associated with cough and phlegm and other wheeze. Smoking habit was only related to cough and phlegm. Atopy was associated with doctor diagnosed asthma and cough and phlegm. Family history of atopic disease was related to all subgroups, suggesting that despite apparent heterogeneity in diagnostic labeling, concurrent symptoms, and other risk factors, the different forms of adult onset wheeze may share a common allergic basis.

Quality of life and hospital re-admission in patients with chronic obstructive pulmonary disease.

BACKGROUND: There is some evidence that quality of life (QOL) in patients with chronic obstructive pulmonary disease (COPD) may predict clinical outcomes and use of resources. This study examined whether QOL scores could prospectively predict re-admission for COPD or death within 12 months of an original admission, and whether QOL scores predicted home nebuliser provision. METHODS: The study was carried out in all acute medical wards of Aberdeen Royal Infirmary, Woodend and City Hospitals, Aberdeen over 12 months. A total of 377 patients admitted with an exacerbation of COPD were identified in this time, 111 of whom were not included in the study because they refused the interview or died before discharge. The remaining 266 patients completed the St George's Respiratory Questionnaire (SGRQ). Information on spirometric parameters, nebuliser provision at discharge, provision of domiciliary oxygen, and re-admission within 12 months was collected from patient notes. RESULTS: The mean age of the patients was 68 years and 53% were men. The mean (SD) forced expiratory volume in one second (FEV1) was 38.8 (18.0)% predicted and forced vital capacity (FVC) was 58.9 (23.8)% predicted. Higher (worse) scores on the SGRQ were significantly related to re-admission for COPD in the next 12 months (difference = 4.8, 95% CI 1.6 to 8.0). Patients who were re-admitted and died from COPD did not differ in SGRQ scores from those who were re-admitted and survived for more than 12 months. Re-admission was not related to sex, age, or pulmonary function. One hundred and thirty eight patients did not have a home nebuliser before admission. Of these, 14 were provided with a home nebuliser at discharge. Patients provided with nebulisers had significantly worse SGRQ scores and worse FVC. The 41 patients given domiciliary oxygen did not differ in SGRQ or spirometric parameters. Logistic regression analysis of the three SGRQ subscales (Symptom, Impact and Activity), adjusting for lung function, age and sex, showed that all three subscales were significantly related to hospital readmission and that Impact scores were related to nebuliser provision. Women did not differ from men in Symptom scores on the SGRQ but differed markedly on the Activity and Impact scales. CONCLUSIONS: It is concluded that poor scores on the SGRQ, a QOL scale which measures patient distress and coping, are associated with re-admission for COPD and use of resources such as nebulisers, independent of physiological measures of disease severity.

Outcome of children of parents with atopic asthma and transient childhood wheezy bronchitis.

BACKGROUND: Childhood asthma and wheeze only in the presence of respiratory infection (wheezy bronchitis) appear to have different prognoses and may differ in their aetiology and heritability. In particular, slight reductions in lung function may be associated with episodes of wheezing associated with intercurrent viral infection. METHODS: Outcomes for wheezing symptoms and lung function were studied in 133 offspring of three distinct groups of 69 middle aged probands with childhood histories of (1) atopic asthma (n = 18), (2) wheeze associated with upper respiratory tract infection (wheezy bronchitis, n = 24), and (3) no symptoms (n = 27). Probands were selected from a previously studied cohort in which outcomes of wheezy bronchitis and asthma had been shown to differ. RESULTS: Children of probands with wheezy bronchitis had a lower prevalence of current wheezing symptoms. Forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) in boys of probands with a history of wheezy bronchitis were significantly reduced compared with either of the other two groups (p < 0.0001). In a multivariate analysis, grouping based on parent proband had a significant effect on lung function, independent of factors such as symptoms, atopy or smoking history. CONCLUSIONS: The different symptomatic and lung function outcome in children of probands with wheezy bronchitis and asthma provides further evidence that wheezy bronchitis and asthma differ in their natural history and heritability, and suggests that there may be familial factors specific to each wheezing syndrome.

Integrated care for asthma: matching care to the patient.

The purpose of the present study was to investigate whether criteria associated with assignment of asthma patients between general practice (GP) care alone, integrated care (shared between GP care and hospital clinic) or conventional specialist review could be identified, and whether outcomes for these patients differed over the next 12 months. Seven hundred and sixty four patients with a diagnosis of asthma and previously assigned to either integrated care or clinic care were reviewed after 1 year and reassigned. These patients were then followed for another 12 months and clinical data were collected over this time. After 12 months in clinic care or integrated care, assignment to integrated care was predicted by previous participation in integrated care (OR 2.94), patient preference for integrated care (OR 3.7), no admission (OR 1.56), fewer steroid courses during the previous year (OR 0.88) and nonattendance at review (OR 0.43) in the previous 12 months. Patient discharge to GP care was predicted by higher level of forced expiratory volume in one second (FEV1) (OR 1.49), lower number of GP consultations for troublesome asthma (OR 0.78), and nonattendance for review in the preceding year (OR 2.15). In the following 12 months, the three groups of patients differed significantly in hospital admissions (Discharged = 0.008; Integrated = 0.12; Clinic = 0.31), bronchodilators prescribed (Discharged = 8.5; Integrated = 10.2; Clinic = 13.9), GP consultations (Discharged = 1.3; Integrated = 3.0; Clinic = 4.1) and oral steroid courses (Discharged = 0.62; Integrated = 1.7; Clinic = 2.4). Patients assigned to integrated care, clinic care or discharged to general practice care form three distinct patient populations differing retrospectively and prospectively in morbidity and admission risk. In particular, patients assigned to integrated care fall midway in risk and morbidity between those discharged or those retained in clinic care. These results suggest that integrated care provides general practitioners with a system of management for asthma patients, for whom they do not wish frequent specialist review but who they do not believe can safely be discharged to general practice care only.

Outcome of wheeze in childhood: the influence of atopy.

We have previously demonstrated that the adult outcome of childhood asthma differs from that of wheeze occurring only in the presence of infection. This paper examines the role of atopy in relation to outcome. We investigated the atopic status, current symptoms and bronchial reactivity to methacholine of 235 subjects aged 34-40 yrs, originally classified at age 10-15 yrs as having asthma (asthma group), wheeze only in the presence of infection (wheezy group), or no respiratory symptoms (comparison group). Subjects from the original asthma group were more likely to be atopic as defined by skin test reactivity, total serum immunoglobulin E (IgE) measurement or specific IgE radio allergosorbent test (RAST) measurement than those from the wheezy group. The wheezy group differed significantly from the reference group only in RAST results, when other variables were taken into account. In a logistic regression model, the important independent predictors for adult wheezing symptoms were original group, atopy and current smoking. Methacholine responsiveness was independently associated with original group (the asthma group were more likely to respond positively), atopy and female gender. The results suggest that atopy is an important predictor for wheeze and bronchial hyperreactivity in middle age. However, the difference in outcome for children who had asthma compared to those who had wheeze only in the presence of infection cannot be explained by atopy alone.