Prevalence of asthma-like symptoms in young children

OBJECTIVE: To determine the prevalence, impact, and treatment of asthma-like symptoms in preschool children in USA and Europe. STUDY DESIGN: 7251 households in USA and Europe with at least one child aged 1-5 years were interviewed by telephone for recurrent days troubled by cough, wheeze or breathlessness during the recent 6 winter months. RESULTS: 9490 young children were identified, 32% of whom were reported to suffer from recurrent days with troublesome cough, wheeze or breathlessness. Detailed interview with the 2700 mothers of the symptomatic children showed that 24% of this interview population suffered weekly symptoms despite current treatment with considerable impact on lifestyle and healthcare resource use. Antibiotics, cough- and herbal-medications were the most commonly used treatments. Anti-asthmatic and anti-allergy agents were prescribed in the order: inhaled beta2-agonists > inhaled corticosteroid > oral anti-histamines > oral corticosteroids. The reported symptom burden was higher in Southern Europe and there were pronounced regional differences in treatment and diagnostic terms. CONCLUSIONS: Recurrent days with cough, wheeze or breathlessness in preschool children represents a major cause of morbidity in preschool children despite current treatment. There is a striking lack of international consensus on diagnosis and treatment. This uncontrolled morbidity highlights a significant unmet clinical need in preschool children.     

The prevalence of asthma and asthma-like symptoms among adults in rural Beijing, China.

No data have been reported on the prevalence of asthma in rural areas of China. The objective of the present study was to determine the prevalence of asthma-like symptoms, reported asthma and reported asthma attacks in rural Beijing, China, and to compare the prevalence in 20-44-yr-old participants with those reported for Canada and the European Community Respiratory Health Survey (ECRHS). For a cross-sectional survey, 30 villages were randomly selected in the counties of Shunyi and Tongxian, 50 km north and east respectively of the city of Beijing and within the municipality of Beijing. The International Union Against Tuberculosis and Lung Disease questionnaire on bronchial symptoms translated into Chinese was completed by village doctors for each individual of >15 yrs. The survey was completed by 22,561 individuals, representing 98% of the eligible population. The prevalence of asthma-like symptoms and reported asthma attacks was higher in females than in males and increased with age. Smoking significantly increased the prevalence of symptoms; the effect in females was greater than in males. Among the 20-44-yr-olds, the prevalence of reported asthma attacks in the previous 12 months was 0.67% in rural Beijing, very much lower than that reported in ECRHS centres (3.1%), urban Canada (6.9%) and semirural Canada (5.1%), after adjusting for age and sex. The prevalence of asthma-like symptoms was also very low in rural Beijing compared with ECRHS centres and Canada. It is concluded that the prevalence of asthma-like symptoms and reported asthma was low in rural China compared with other countries, consistent with reports of the relative scarcity of asthma in farms and the "hygiene hypothesis".     

Prevalence of asthma and asthma-like symptoms in inner-city elementary schoolchildren

American inner-city children are disproportionately affected by asthma. During the 1999-2000 school year, we conducted a survey of 6 Bronx, New York City elementary schools to assess the prevalence of asthma and asthma-like symptoms as reported by parents. Children with probable asthma had symptoms within the last 12 months and parents who indicated that their child had asthma. Children with possible asthma had symptoms within the last 12 months but lacked a diagnosis.Overall, 74% (4,775/6,433) of parents returned completed surveys, identifying 20% (949/4,775) of children as probable asthmatics, and 12% (589/4,775) as possible asthmatics. In multivariate analyses, probable asthma was associated with: Puerto Rican, Black, and white race/ethnicity, male gender, having health insurance, and registration at the poorest school. Possible asthma was associated with lack of health insurance and female gender, but was not associated with any specific race/ethnicity.Our findings support the effectiveness of school-based surveys to identify children at high risk for asthma. The challenge remains to engage children and families in appropriate follow-up care and to manage their illness, either through the use of school-based health centers or stronger links to community services.     

Prevalence of asthma and asthma-like symptoms in three French cities

Background. This study is part of the European Community Respiratory Health Survey (ECRHS), which uses a common methodology in different areas throughout the world. This paper describes the prevalences of reported asthma, asthma-like symptoms and nasal allergies, their relationships to age group and sex, and the relationships of asthma-like symptoms to current asthma, in the general population aged 20–44 years of three French urban areas.Methods. The study population of 2804 subjects in Grenoble, 3774 in Montpellier and 3152 in Paris (18th district), randomly selected from electoral rolls, answered a postal questionnaire (stage I of ECRHS). The response rates were 77.8%, 68.6% and 74.4%, respectively.Results. The prevalences were approximately 14% for wheezing, 16% for chest tightness and 4.5% for nocturnal shortness of breath in the three areas. Asthma attacks in the last 12 months were reported by 2.7% of subjects in Grenoble, 3.5% of subjects in Montpellier and 4.0% of subjects in Paris (P=0.02). For nasal allergies, the prevalences were 28.0%, 34.3% and 30.8%, respectively (P<0.001). Asthma was inversely correlated to age (higher prevalence in the youngest) but was not related to sex. Neither age distribution nor sex ratio explained the differences between areas. Among the asthma-like symptoms, wheezing and nocturnal shortness of breath correlated strongly with asthma, chest tightness correlated moderately and nocturnal coughing correlated poorly.Conclusion. The prevalences observed were higher than expected from previous comparable French studies in young adults. These results are consistent with the hypothesis of a recent increase of asthma and allergies.     

Work-related physical activity among cardiovascular specialists

Background:

Strong evidence supports positive correlation of physical activity with health benefits. Current recommendations by the American Heart Association are a minimum 30 minutes of moderate physical activity 5 days per week. This goal has been equilibrated with 10,000 steps per day.

Hypothesis:

Work‐related physical activity of cardiovascular (CV) specialists does not meet the currently recommended daily physical activity.

Methods:

Eight cardiothoracic (CT) surgeons, 7 general cardiologists, 5 procedural cardiologists, and 8 cardiac anesthesiologists (N = 28) participated in the study. Demographic information on each participant was recorded including age, resting heart rate, body mass index, and medical and social history. Subjects were asked to wear a spring‐levered pedometer on their hip for 2 weeks while at work and to record the total number of steps as well as number of hours worked each day.

Results:

The average daily steps walked during work were 6540, 6039, 5910, and 5553 for general cardiologists, CT surgeons, procedural cardiologists, and cardiac anesthesiologists, respectively. There were no statistically significant differences in the average number of steps taken per day among the groups. CT surgeons worked 12.4 hours per day compared to 9.3 hours by the cardiac anesthesiologists (P = 0.03).

Conclusions:

In this small, single‐center study, work‐related physical activity of CV specialists did not meet the recommended guidelines. Obtaining the recommended activity level might be a challenge, given their busy work schedule. Therefore, CV specialists must engage in additional, out‐of‐hours exercise to achieve the recommended daily exercise. © 2012 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

IL-8 and airway neutrophilia in children with gastroesophageal reflux and asthma-like symptoms

Gastroesophageal reflux (GER) may induce respiratory symptoms (RS) through inhalation of acid gastric contents. To characterize the airway inflammation associated with this condition, 20 children [7.4 (0.9) yr old] with "difficult to treat" RS and a positive 24-h oesophageal pH monitoring (pHm) were studied and bronchoalveolar lavage (BAL) performed. The control group included 10 children [7.3 (1.3) yr], non-atopics, with a respiratory clinical history similar to the cases but no reflux, as demonstrated by a negative 24-h oesophageal pHm. On BAL samples, in addition to inflammatory indexes, the lipid-laden macrophage (LLM) index was determined as index of gastric content inhalation. As compared to controls, GER children had higher neutrophil proportion (P=0.002), higher LLM index (P=0.004) and higher concentrations of interleukin (IL)-8 (P=0.005), myeloperoxidase (MPO) (P=0.001) and elastase (P=0.045) in BAL fluid. In GER children, but not in controls, neutrophil proportion significantly correlated with LLM index (r=0.65, P=0.002), with IL-8 (r=0.62, P=0.003) and MPO levels (r=0.54, P=0.014) but not with elastase concentrations. These results suggest an active pathogenetic role of IL-8 in the recruitment and activation of neutrophils in the airways of children with GER, respiratory symptoms and BAL findings suggestive of gastric content aspiration.     

Effects of active tobacco smoking on the prevalence of asthma-like symptoms in adolescents

The prevalence of asthma in adolescents markedly varies between different localities as found by the International Study of Asthma and Allergies in Childhood (ISAAC) and this may be due to environmental factors. Although tobacco smoke exposure is related to an increase in the prevalence of asthma, there is lack of information on that respect in children from developing countries, where active tobacco smoking usually starts early in adolescence. This study was undertaken to assess the effect of tobacco smoking on the prevalence of asthma symptoms in a random sample of 4738 adolescents aged 13.4 ± 1.05 years who responded the ISAAC video questionnaires plus questions on tobacco smoking. The prevalence of tobacco smoking in the last 12 months was 16.2%, with significant female predominance. The persistent smokers had a significantly higher prevalence of asthma-like symptoms ever and in the last 12 months (wheezing, wheezing with exercise, nocturnal wheezing, severe wheezing, and dry nocturnal cough) than ex-smokers and nonsmokers. More than 27% of asthma symptoms in our adolescents are attributable to active tobacco consumption (population attributable risk). This study strongly suggests that potent and more effective campaigns against tobacco smoking should be implemented in developing countries, where active tobacco smoking is dramatically increasing in children.     

Extrathoracic airway responsiveness in children with asthma-like symptoms,including chronic persistent cough

Asthma-like symptoms, including chronic persistent cough, are not always specific for classical asthma. In order to investigate whether assessment of extrathoracic airway hyperresponsiveness (EAHR) during methacholine bronchial challenge helped in the evaluation of pediatric patients with asthma-like symptoms such as chronic cough, we examined 133 consecutive, unselected patients (mean age, 10.06 +/- 2.16 years) who had neither established asthma nor bronchial obstruction previously. We recorded the forced mid-inspiratory flow (FIF(50)) as an index of extrathoracic airway narrowing. In addition, a 25% decrease in FIF(50) (PD(25)FIF(50)) below the cutoff concentration of < or = 8 mg/mL methacholine was assumed to indicate EAHR. According to the methacholine response, 81 patients had EAHR, and 41 of them had combined EAHR and bronchial hyperresponsiveness (BHR); 39 patients had only BHR. Airway hyperresponsiveness was not demonstrated in 13 patients and not in any of the control children. When patients with cough as the sole presenting symptom (60.9%) were compared with those with cough and wheeze (20.3%), those with cough alone had a significantly greater probability of having EAHR (OR, 4.16; 95% CI, 1.32-13.13) and a lower probability of having BHR (OR, 0.70; CI, 0.25-1.95) than those with cough and wheeze. Patients with cough, wheeze, and dyspnea (18.8%) had a significantly greater chance of having BHR than those with cough alone (OR, 5.08; CI, 1.55-16.64). Patients with cough and wheeze as compared with those with cough, wheeze, and dyspnea had significantly greater probability of having both EAHR and BHR (OR, 4.71; CI, 1.94-11.47).In order to ascertain the clinical relevance of EAHR, we assessed in the second part of the study whether the effects of treatment of the underlying disease would result in relief of airway hyperresponsiveness. Rhinosinusitis and perennial allergic rhinitis accounted for EAHR in 71 patients, and 34 of them also demonstrated BHR. They received specific therapy for their upper airway diseases for 4 weeks. Compared with values before treatment, FIF(50) and forced expiratory volume in 1 sec (FEV(1)) did not change significantly. The dose of methacholine causing a 20% fall in FEV(1) (PD(20)FEV(1)) and PD(25)FIF(50) values were significantly increased from 2.40 +/- 1.39 to 4.22 +/- 1.13 mg /mL (P < 0.001) and from 1.03 +/- 1.75 to 8.71 +/- 1.21 mg /mL (P < 0.0001), respectively.We conclude that measurements of EAHR and BHR are the most important ways to evaluate children with asthma-like symptoms, including chronic persistent cough when chest X-rays and pulmonary function tests remain within normal limits. Therefore, empirical treatment is not necessary when these investigations are available. Our results suggest that specific treatment of inflammation in the upper airways reversed persistant cough, and may play an important role in modulating lower airways responsiveness in patients with concomitant BHR.     

Work-related musculoskeletal disorders among physical therapists in Taiwan

Work-related musculoskeletal disorders (WMSD) refer to musculoskeletal injuries caused by the occupation. Physical therapists (PTs) suffer from a high risk of WMSD despite their extensive knowledge in ergometrics and injury prevention. This study aims to discover the incidence and prevalence of WMSD among PTs using Taiwan''s nationwide claims database. The trend of annual patients seeking rehabilitation and the prevalence of WMSD among PTs were presented. The age- and gender-specific incidence of WMSD were also calculated. The prevalence of WMSD in PTs varied from 6.1% to 75.2%, and the incidence ranged from 6.1 to 29.1 per 100 person-years during 1997 and 2012. For those aged ≤30 years, the incidence was higher in females than males (incidence rate ratio  = 1.08, 95% confidence interval [CI]: 1.02–1.14, P = .011), whereas for those aged from 31 to40 years, females had lower incidence of WMSD than males (incidence rate ratio  = 0.88, 95% CI: 0.80–0.96, P = .007). The patients/PTs ratio was higher (270.56–337.74) in 1998 and 2004 to 2007 and became stable (245.93–252.82) in 2008 to 2012, correlating with a rise in the WMSD prevalence in 1999 to 2007 and a steady prevalence after 2008 (63.5%–66.3%) in PTs. In conclusion, the risk of WMSD among PTs was positively correlated to the frequency of patients seeking rehabilitation service. In addition, age and gender were important risk factors for developing WMSD among PTs.     

Fluticasone or montelukast for preschool children with asthma-like symptoms: Randomized controlled trial

RATIONALE: Beneficial effects of anti-inflammatory therapy such as fluticasone propionate (FP) and montelukast (Mk) have been demonstrated in preschool children with asthma. However, comparative studies are lacking in this age group. Therefore, we conducted a study to evaluate and compare the effect of FP and Mk in preschool children with asthma-like symptoms. METHODS: In this multicenter, randomized, placebo-controlled, double-blind, double-dummy trial, children aged 2-6 years with asthma-like symptoms were included. In total, 63 children were randomly allocated to receive FP (25), Mk (18) or placebo (20) for 3 months. The primary outcome was the daily symptom score (wheeze, cough, shortness of breath) as recorded by caregivers in a symptom diary card. Secondary endpoints were rescue medication free days, blood eosinophils and lung function (interrupter technique and forced oscillation technique (FOT)). RESULTS: During the 3 months study period, symptoms improved in all 3 groups, with a statistically significant difference between FP and placebo in favor of the FP group (p=0.021). A significant reduction in circulating eosinophils after 3 months of treatment was found in the Mk group only (p=0.008), which was significantly different from the change found in the placebo group (p=0.045). With the exception of frequency dependence (measured by FOT), which showed a difference between FP and Mk after 3 months of treatment in favor of the FP group (p=0.048), no differences in lung function within or between groups were found. CONCLUSIONS: In spite of a lack of power, our results suggest that FP has a beneficial effect on symptoms and Mk on blood eosinophil level as compared to placebo. Except for a difference in one lung function parameter after 3 months between FP and Mk in favor of the FP group, this study revealed no differences between FP and Mk.     

Asthma and asthma-like disorders

Bronchial asthma is defined as a chronic inflammatory disease resulting in a reversible and variable bronchial obstruction. For the clinical diagnosis of the disease there are some key indicators but as there is no 'gold standard' a correct diagnosis will sometimes not be obtained. Examples are patients in a symptom-free stage, current medication interfering with the methods used, patients with asthma-like symptoms reporting lack of effect of bronchodilators and patients who are unable to perform a forced expiration in an airway function test. The prevalence of asthma is reported to be 5-10%. The prevalence of asthma-like symptoms may be double this. The term 'asthma-like' has been used to an increasing extent during the last few years, which may indicate an increasing awareness of the fact that asthma-like symptoms are not always classical asthma. In this overview some disorders with asthma-like symptoms, especially in adults, are presented. The spectrum of differential diagnoses in a clinic may depend on which doctor/specialist the patient is consulting. In an asthma and allergy clinic it has been found that the most common differential diagnoses are chronic obstructive pulmonary disease (COPD), nonasthmatic cough and sensory hyper-reactivity (SHR), a disorder which is sometimes mixed up with asthma due to similar symptoms (heavy breathing, cough, increased secretion, difficulty in getting air etc.) and similar trigger factors (smoke, strong scents, exercise, cold air etc.). Recently it has been suggested that a capsaicin inhalation test may be an objective test for identifying patients with SHR. In asthma effective treatment is available today but in asthma-like disorders, such as SHR, no effective therapy is available, underlining the need of further research for understanding the pathophysiological mechanisms.     

Bronchial hyperresponsiveness to 4.5% hypertonic saline indicates a past history of asthma-like symptoms in children

SUMMARY. To evaluate the importance of a past history of asthma-like symptoms over a period of 2 years and current bronchial hyperreactivity (BHR), 538 randomly selected schoolchildren, initially aged 7-8 years, were examined. At yearly intervals, three standardized questionnaires, including items from the ISAAC panel, were answered by parents. Following the last questionnaire, BHR to 4.5% hypertonic saline (HS) was recorded. In survey 1, lifetime prevalence of asthma was 4.9%. During the 12-month period, prevalence of wheeze and dyspnea ranged between 9.3 and 5.2% (Survey 1) and 5.9% and 4.4% (Survey 2). Among children with wheeze or dyspnea in Survey 3, BHR (defined as a fall of baseline FEV(1) > or = 15%) was significantly more frequent (50.0% and 60.7%, respectively) than among children without these symptoms (12.8%, P < 0.001, and 12.8%, P < 0.001, respectively). The negative predictive value of BHR to have neither wheeze nor dyspnea was about 88% and did not vary throughout the study (Survey 1, 87%; Survey 2, 88%; Survey 3, 88%). The relative risk of showing BHR was significantly increased in children with wheeze (survey 2, odds ratio (OR) 3.0 (95% confidence interval (CI) 1.0-8.7)) or dyspnea (Survey 1: OR 5.9 (95% CI 1.9-18.5), Survey 3: 5.2 (1.7-16.2), but not in children with dry cough or nocturnal cough (data not shown). Wheeze and dyspnea occurred repeatedly in the same individuals with BHR in a high percentage of children (83.3% and 76.5%, respectively). In conclusion, there is a strong association between recent and previous dyspnea and current BHR, and it indicates intraindividual persistence of symptom history.     

Differences in trigger factors and symptoms between patients with asthma-like symptoms and patients with asthma: development of a basis for a questionnaire

Patients with asthma-like symptoms but with negative asthmatests are often misdiagnosed as having asthma and treated as asthmatics.They describe their trigger factors and symptoms very similar to those of patients with asthma. The aim of the study was to analyze differences in symptoms and trigger factors between asthma-like patients and asthmatics in order to elaborate a basis for a questionnaire for epidemiological and clinical use. A questionnaire with 54 questions about trigger factors and 137 questions about symptoms was sent to 40 patients with asthma-like symptoms and 40 with asthma, all consecutively selected from patients referred to an out-patient clinic for asthma and allergy for investigation of suspected asthma. Data were analyzed statistically in two steps using multiple logistic regression analysis. Significant differences were seen in several trigger factors and symptoms after the first analysis. After the second analysis, seven out of the 54 trigger factors and 22 out of the 137 symptoms emerged as those that most significantly discriminated between the two patient groups. These trigger factors and symptoms can be the basis of a new questionnaire with high discriminating power. Before using it, it is important to evaluate the best combination of variables, add some demographic variables and totestthe reliability and validity ofthis new questionnaire.     

A case of eosinophilic lung disease presenting asthma-like symptoms and centrilobular shadows in both lung fields]

This case, in a 23-year-old man presenting with cough, sputum, dyspnea on effort and wheezing, had been diagnosed as bronchial asthma at another hospital. Because inhaled steroid and theophylline were far from effective, he was admitted to our hospital for further evaluation. A blood test revealed marked eosinophilia. Chest radiography showed diffuse, small nodular shadows in both lung fields, and a chest CT scan demonstrated diffuse centrilobular nodules and thickening of the bronchi and bronchioles. A spirometric test showed obstructive and restrictive ventilatory impairment, but the depressed forced vital capacity failed to show improvement in response to bronchodilator inhalation, discouraging a diagnosis of asthma. Eosinophilic lung disease with prominent eosinophilic bronchiolitis was diagnosed on the basis of BAL eosinophilia and thoracoscopic lung biopsy findings. The symptoms and blood eosinophilia were responsive to administration of oral prednisolone (30 mg daily); radiographic and CT findings also showed improvement. This case showed a marked similarity to the recently reported "eosinophilic bronchiolitis", and was probably not a type of bronchial asthma.     

Work-related musculoskeletal disorders

Work-related musculoskeletal disorders continue to be extremely common and to present an important challenge to clinicians. Debate regarding terminology and case definitions has discouraged practitioners from aggressively approaching the diagnosis and management of these conditions. Considerable progress has, however, been made recently. Previously more commonly referred to as repetitive strain injuries or cumulative trauma disorders, the new term work-related musculoskeletal disorders has fewer etiological implications. These disorders, affecting the back, lower limbs, and especially upper limbs and neck, can be extremely costly if not addressed appropriately. Generally resulting from a combination of physical factors (including repetition, force, and awkward postures) as well as other workplace environmental or organizational factors (including excessive work rates or durations, inadequate breaks, and a variety of psychosocial workplace characteristics), work-related musculoskeletal disorders can often be remediated when these factors are appropriately assessed and addressed. Clinicians must play a positive role in ensuring that this approach prevails.