"Severe-controlled" asthma 4 years later: is it still controlled?

BACKGROUND: Controlled severe asthma is based on needing regular medication and 4 markers of good asthma control. This study reevaluated a community sample defined 4 years earlier as "severe-controlled" based on electronic medical records of medications dispensed over 12 months. OBJECTIVES: Determine the current extent of clinically-controlled asthma and asthma-related quality-of-life among patients previously considered "severe-controlled". METHODS: 69 patients considered "severe-controlled" 4 years earlier answered a questionnaire that included the asthma control test (ACT), demographics, education, comorbidities, medications, asthma-related healthcare utilization, atopy history, environmental exposures, and follow-up. Patients underwent spirometry, eosinophil count, total IgE, and skin-prick testing for airborne allergens. RESULTS: Ninety-seven percent reported using combined inhalers (ICS + LABA) regularly. Only 4% visited the ER and none was hospitalized in the last year. Average predicted FEV1 was 80%. Average ACT score was 19; 51% reported recurrent heartburn, 46% night awakenings and 70% recurrent rhinitis. Skin-prick testing was positive in 72%, average IgE was 376 IU/ml. Eosinophil counts were ≥300/ml in 42% and ≥400/ml in 25%. ACT < 20 was strongly related to recurrent heartburn. Formal education was related to ACT ≥ 20 (p = 0.045) and perception of good asthma control the previous month (p < 0.001). Eosinophil count, recurrent heartburn, total IgE, and recurrent rhinitis were interrelated. CONCLUSIONS: Among severe asthmatics, good drug compliance, low use of relievers and low rates of exacerbations do not necessarily reflect asthma-related quality-of-life and optimal control. We urge physicians and HMOs to address asthma control in terms of quality-of-life based on validated questionnaires, and offer all patients asthma education; perhaps more to those with low formal education.

Severe and non-severe asthma in the community: A large electronic database analysis.

BACKGROUND: A large electronic database analysis was conducted in a community of 351,799 people, ages 20-70 years to determine the prevalence and clinical characteristics of severe asthma, according to 2014 international guidelines and healthcare utilization. METHODS: Severe asthmatics were grouped into controlled severe-asthma and uncontrolled severe-asthma and additional subgroups of uncontrolled severe asthma on the basis of medications dispensed. Non-asthmatic population at the same ages served as controls. RESULTS: A total of 19,991 (5.68%) were diagnosed as asthmatic, of which 4.65% had severe asthma. Of these, one-third was uncontrolled severe-asthma. Controlled severe-asthma group was similar to non-severe asthma and non-asthmatics in the rate of emergency room visits (21.5%, 22%, and 20%, respectively) and to all cause hospitalizations (7.4%, 7.4%, and 6.4%, respectively). Uncontrolled severe-asthmatics had significantly more hospitalizations (RR = 2.9) than controlled severe-asthmatics. Only 19.2% of uncontrolled-severe asthmatics had IgE testing and 3.6% were dispensed omalizumab. CONCLUSIONS: The prevalence of severe asthma is slightly less than 5% of all asthmatics. Controlling severe asthma is crucial to reducing healthcare utilization. A simple electronic database analysis, based on dispensed medications, can help healthcare providers identify subgroups of uncontrolled severe asthmatics that require focused efforts. CLINICAL TRIAL REGISTRATION: NCT01961258. Ethics Committee approval: 032/2013C.

[Perspectives in future asthma therapy].

Five to ten percent of all asthmatics, many dozens of millions of patients all over the world, do not respond to maximal medical therapy, including systemic steroids, and the toll of treating them constitutes about eighty percent of the total cost of managing all asthmatics. Other asthmatics who do respond to medical therapy either are not compliant with their medications or suffer from disabling adverse effects. The future therapy of asthma will concentrate on finding medical solutions to these sub-groups of patients but the entire asthmatic population will enjoy its achievements. The future trends in asthma therapy include immunomodulation, managing receptors and inflammatory mediators that are crucial in asthma pathogenesis, formulation of custom-made medications using individual pharmacogenetics, elaborated specific immunotherapy of atopic rhinitis, development of "smart inhalers" and sophisticated techniques in aerosol transportation to the airways, and bronchial thermoplasty which has only recently been approved. The daily clinical implications of these trends will probably unfold in the next five to fifteen years.

[Posture-dependent refractory hypoxemia].

Patent foramen ovate is a common finding in the general population. However, interatrial right to left shunt causing severe hypoxemia in the absence of pulmonary hypertension is a rare finding. The authors describe two such patients suffering from severe hypoxemia refractory to oxygen supplementation. The first, a 57-year-old mate, developed severe hypoxemia several months after right pneumonectomy. The second patient, an 83 year old lady was found with severe hypoxemia after an unrelated fall and the degree of hypoxemia was posture related. Regular transthoracic Doppler echocardiography did not explain the hypoxemia in either patient. One hundred percent oxygen breathing test suggested large right to Left anatomic shunt in both patients. Doppler echocardiography with intravenous agitated saline injection demonstrated the existence of interatrial right to left blood shunting in both patients in the absence of elevated systolic pulmonary artery pressure. Both patients underwent right heart catheterization. Pulmonary arterial hypertension was ruled out and the interatrial shunt was successfully occluded percutaneously by an Amplatzer device. In both patients, hypoxemia resolved immediately after the occlusion of the interatrial shunt and their quality of life improved remarkably. In cases of unexplained refractory hypoxemia, in the absence of acute lung disease, and especially if related to upright posture, one should consider platypnea-orthodeoxia syndrome and its most common cause, a right to left interatrial shunt. This can nowadays be successfully treated percutaneously.

[Reasons for the gap between asthma in reality and GINA guidelines].

Asthma is a common chronic disease worldwide, affecting 300 million people of all ages. In spite of the existence of scientifically proven clinical guidelines for the past 15 years and efficient controller medications, the gaps between asthma management in reality and the goals of the Global Initiative for Asthma (GINA) guidelines are huge. Asthma, being a chronic disease, might be a companion from early childhood to the end of life and, as such, may impose major obstacles in disease management. These obstacles may rise from patient coping skills and style, from reasons that depend on the general practitioner himself/herself and the medical establishment and, most probably, also from lack of agreement between patients and caregivers about what constitutes well-managed asthma. This review aims to reveal and clarify the known and possible reasons for the recently proven worldwide gaps that still exist between asthma in reality and the goals of asthma clinical guidelines. Presenting and discussing the reasons for these huge gaps will hopefully help general practitioners to close these gaps in order to improve their patients asthma related quality of life and preserve lung function throughout life and decrease morbidity.

[Acute eosinophilic pneumonia: a potentially fatal disease under a mask of acute community-acquired bacterial pneumonia].

Acute eosinophilic pneumonia (AEP) is a rare and sometimes fatal disease. Diagnosis of AEP may be especially difficult in its early stages, before development of peripheral eosinophilia. This is a case study of AEP in a 27 years old female, reviewing etiologic factors, clinical presentation, diagnostic procedures and current treatment strategies. An important feature is that an early presentation of AEP may mimic the onset of bacterial pneumonia. Misdiagnosis and delay of appropriate treatment may result in development of respiratory failure and even death. Therefore, it is important that the relevant information regarding AEP presented in this article is disseminated to a wide forum of physicians.

Genetic polymorphisms of the beta-2 adrenergic receptor in Israelis with severe asthma compared to non-asthmatic Israelis.

BACKGROUND: It has been argued that arginine replacement in locus 16 (Arg16) of beta 2 adrenergic receptor with glycin (Gly16) increases asthma severity, while glutamin replacement in locus 27 (Gln27) with glutamic acid (Glu27) decreases it. In addition, ethnic dependency of these polymorphisms has been described, but few studies investigated its relation to asthma severity in a non-anglosaxic population. OBJECTIVES: To investigate non-anglosaxic ethnic influences on beta 2AR polymorphisms and its correlations to asthma severity. METHODS: Sixty-six Israeli Jewish and Arab asthmatics who had near-fatal asthma and/or severe nocturnal asthma and/or steroid-dependency were investigated for genetic polymorphisms of beta 2AR and compared to matched controls. The Jewish patients included both Ashkenazi (of European origin) and non-Ashkenazi (originating from the Middle East or North Africa). The results were compared with those of ethnically matched 113 non-asthmatic Israelis and non-asthmatic Anglo-Saxons described in the literature. RESULTS: We found no significant genetic differences between the asthmatics and their controls or between the various ethnic groups of our population. However, the prevalence of Glu27 was significantly lower in non-asthmatic Israelis compared to non-asthmatic Anglo-Saxons. CONCLUSIONS: The genetic distribution of beta 2AR polymorphisms in severe Israeli asthmatics is not different from that of non-asthmatic Israelis and therefore its clinical impact on asthma is probably minimal.

[Water-pipe tobacco smoking among school children in Israel: frequencies, habits, and attitudes].

BACKGROUND: Tobacco smoking via a water-pipe (Nargile) is a new phenomena among school children in Israel in recent years. Water-pipe tobacco has the potential for nicotine addiction, for other smoking-related damages and for drug abuse. GOALS: Our primary goal was to characterize the frequencies of water-pipe smoking among school children in Israel, its distribution according to age, gender, habits and attitudes. The secondary goal was to compare its use to cigarette smoking among these school children. METHODS: A self-reported questionnaire was distributed among 388 school children (ages 12-18 years old) in grades A, and C, of middle schools and grade B of high schools in a central region of Israel. The questionnaires were answered unanimously and the process was conducted in classes by the school teacher and by nursing school students. RESULTS: Among all school children in this study, 41% smoke a water-pipe at various frequencies. Of all the children, 22% smoke at least every weekend. Water-pipe smoking was 3 times more frequent than cigarette smoking and was almost equally distributed among both genders, but girls were heavier smokers than boys, of either water pipe or cigarette smoking. Six percent of water-pipe smokers add psychoactive drugs or alcohol to the tobacco. The main reasons for water-pipe smoking were the pleasure achieved and the intimacy that it adds to the youngsters' meetings. Ninety percent of all the school children believe that water-pipe smoking is not healthy, but at least 50% believes it is less harmful than cigarettes. According to school children that smoke water-pipes at least every weekend, 40% of their parents are current or ex-smokers of water-pipes, in contrast with 10% of parents to non-smoking children and about a quarter of the children who smoke also do so together with their parents. CONCLUSIONS: Tobacco smoking via water-pipes is a very common phenomena among middle and high school children in Israel. Girls are heavier smokers and adding drugs or alcohol to water-pipe tobacco is a fact. School children and their parents perceive that tobacco smoking via water-pipe is much safer than cigarette smoking. These alarming findings call upon the need for aggressive intervention by the Ministries of Education and Health, as well as the Anti-Drug Authority. More rigorous efforts should be implemented in terms of education and dissemination of the data regarding known hazards among schoolteachers, parents and school children. Further research is also necessary in order to prevent other ominous and camouflaged modalities of nicotine addiction at an early age.

Bilateral and unilateral spontaneous massive hemothorax as a presenting manifestation of rare tumors.

Spontaneous true hemothorax is quite a rare manifestation of a presenting disease. This is a report of two patients, one with bilateral spontaneous massive hemothorax as a presenting manifestation of angiosarcoma involving the lungs and pleura, and the other with unilateral spontaneous hemothorax and hemorrhagic shock as a presenting manifestation of 'cystic' chondroblastoma. Differential diagnosis of spontaneous true hemothorax and its evaluation and management are discussed.

Bronchial asthma in Israel.

Asthma in Israel is a growing medical problem, affecting at least 7% of children and 3.7% of the total population. Mortality rates in the age group 5-34 years were on a rise between 1976 and 1990 but show a marked decrease in recent years, perhaps due to the sharp increase in sales of inhaled corticosteroids. There is also a recent indication that the relatively high crude mortality rate among women is declining (from 3.68 and 4.58 per 100,000 population in 1995 and 1996 respectively, to 3.58 per 100,000 in 1997). In spite of better asthma education and management there is still a gap between available medical knowledge and medical therapy and its utilization for the benefit of the asthmatic population in Israel.