Incidence of Churg-Strauss syndrome in asthma drug users: a population-based perspective

OBJECTIVE: To estimate the incidence of Churg-Strauss syndrome (CSS) among a large population of asthma drug users. METHODS: A retrospective study was conducted among patients who had been dispensed asthma drugs at 3 managed care organizations. Adults who received >or =3 dispensings of an asthma drug during any consecutive 12-month period between January 1, 1995 and June 30, 2000 were identified. Information on patient age, gender, enrollment status, asthma drugs dispensed, and inpatient and outpatient diagnoses and procedures was obtained from automated databases. Chart reviews were performed on persons identified by combinations of diagnostic and billing codes indicative of CSS. A rheumatologist reviewed abstracted information on all subjects; those who met >or =2 American College of Rheumatology criteria for CSS were reviewed by 2 clinical experts. Each clinical expert independently rated the cases; disagreements were resolved by consensus. Cases classified as having "probable/definite" CSS were included in these analyses. The incidence of CSS was estimated overall and according to patient gender, age, and calendar year. RESULTS: From a population of 184,667 asthma drug users contributing 606,184 person-years of exposure, 21 incident cases of CSS were identified (overall incidence of 34.6 per million person-years; 95% confidence interval 21.4 to 53.0). Incidence rates did not differ by gender and age group. The incidence rates for 1995, 1996, 1997, 1998, 1999, and the first 6 months of 2000 were 0, 22, 52, 75, 14, and 14 per million person-years respectively. CONCLUSIONS: Results from this population-based study suggest a somewhat lower incidence of CSS in asthma drug users than previously reported and provides important information as to the risk of developing CSS from a population-based perspective.     

Routine Cyclosporine concentration - C2 level Monitoring. Is it helpful during the early post Transplant Period?

Background

Pre dose or trough blood cyclosporine (CSA) concentration is routinely monitored and the result is used to alter patient''s drug dosing. Patients with identical pre dose blood CSA may have very different systemic exposure to the drug. Recently CSA 2 hour post dose level [C2] has been reported to correlate better with drug exposure. We undertook this study to evaluate the influence of trough and C2, CSA concentration monitoring on short-term renal allograft outcomes.

Methods

25 patients of renal transplant receiving a triple drug regimen of CSA micro emulsion (Panacea Biotec) 8mg/kg, azathioprine 1mg/kg and prednisolone 0.5mg/kg were analyzed prospectively for graft outcomes. CSA levels were monitored in whole blood by radioimmunoassay using monoclonal antibodies, at 72 hours after the transplant.

Results

The mean age of patients was 37.08 + 9.1 years. There were 20 males and 5 females. The mean age of donors was 40.2 + 8.2 years. There were 11 related donors with at least a haplomatch, 4 spousal and 10 unrelated donors with a nil antigen match. The mean pre dose CSA concentration was 289.22 + 171.9ng/ml; range (98.8 + 783.41ng/ml). The CSA concentration at 2 hours after the CSA administration was 838 + 310.87ng/ml (range, 169 + 1268ng/ml). 3 (12%) patients had acute rejection. In these patients the mean pre dose CSA concentration was 328.67ng/ml and the mean C2, CSA concentration was 1006.26ng/ml. CSA induced hemolytic uraemic syndrome was diagnosed in one patient. The trough and C2, CSA concentration levels were 174 and 870.83ng/ml respectively in this patient.

Conclusion

In our study CSA levels, trough and peak showed significant inter patient variability. The trough and C2 concentration levels did not correlate with the episodes of acute rejection. We conclude that in a triple drug regimen with fixed dosing schedules routine trough CSA level monitoring is not helpful in the acute post renal transplant period.Key Words: Cyclosporine levels, Cyclosporine trough levels, C2 levels     

Sonovue improves endocardial border detection and variability in assessing wall motion score and ejection fraction during stress echocardiography

Background Stress echocardiography is useful for assessing patients with coronary artery disease unable to undergo formal exercise testing. Considerable skill is required to avoid large intra- and inter-observer variability due to poor endocardial definition. Intravenous ultrasound contrast agents are now available which may improve this variability. Aim To study intravenous Sonovue in assessing wall motion score and ejection fraction (EF) during stress echocardiography. Methods Thirty-eight patients undergoing arbutamine stress echocardiography for known or suspected coronary artery disease were studied. Echocardiographic analysis of wall motion score index, endocardial border detection (EBD) and EF was performed at rest and at peak stress before and after intravenous injection of Sonovue, by experienced and inexperienced observers. Results All three observers noted an improvement in endocardial border definition following Sonovue (p=<0.001). At baseline, there was a significant difference in wall motion score index between experienced and inexperienced observers at rest (p=0.01) and at peak stress (p=0.001). Following Sonovue administration this was no longer significant (p=0.07, p=0.114). Intra-observer variability of end diastolic, end systolic volumes (ESV) and EF improved following contrast (p<0.05) at rest and during stress. Conclusion Sonovue significantly improved EBD and reduced intra-observer variability of EF at rest and during peak arbutamine infusion.     

Use of alternative therapies for menopause symptoms: results of a population-based survey

OBJECTIVE: To describe self-reported prevalence of the use of alternative therapies for menopause symptoms and subject characteristics associated with their use. METHODS: A telephone survey of 886 women aged 45-65 years (87.2% response rate) was conducted at Group Health Cooperative in Washington state. Women were asked about eight alternative therapies and their use for menopause symptoms. RESULTS: The proportion of women who used each therapy was 76.1% for any therapy, 43.1% for stress management, 37.0% for over-the-counter alternative remedies, 31.6% for chiropractic, 29.5% for massage therapy, 22.9% for dietary soy, 10.4% for acupuncture, 9.4% for naturopath or homeopath, and 4.6% for herbalists. The proportion of women who used it to manage menopause symptoms was 22.1% for any therapy, 9.1% for stress management, 13.1% for over-the-counter alternative remedies, 0.9% for chiropractic, 2.6% for massage therapy, 7.4% for dietary soy, 0.6% for acupuncture, 2.0% for naturopath or homeopath, and 1.2% for herbalists. Among women who used these therapies, 89-100% found them to be somewhat or very helpful. A history of breast cancer was associated with a six-fold increase in use of dietary soy for menopause symptoms (odds ratio 6.23, 95% confidence limits 2.54, 15.28). Current users of hormone replacement therapy were half as likely to use alternative remedies or providers (odds ratio 0.48, 95% confidence limits 0.29, 0.77) as were never users. Sleep disturbances were associated with a four-fold increase in the use of body work, a three-fold increase in the use of stress management, and more than doubled the use of dietary soy products to manage menopause symptoms. CONCLUSION: The use of alternative therapies for menopause symptoms is common, and women who use them generally find them to be beneficial. Physicians should routinely ascertain perimenopausal women's use of alternative therapies.     

Lung function and mortality in the United States: data from the First National Health and Nutrition Examination Survey follow up study

BACKGROUND: A study was undertaken to define the risk of death among a national cohort of US adults both with and without lung disease. METHODS: Participants in the first National Health and Nutrition Examination Survey (NHANES I) followed for up to 22 years were studied. Subjects were classified using a modification of the Global Initiative for Chronic Obstructive Lung Disease criteria for chronic obstructive pulmonary disease (COPD) into the following mutually exclusive categories using the forced expiratory volume in 1 second (FEV(1)), forced vital capacity (FVC), FEV(1)/FVC ratio, and the presence of respiratory symptoms: severe COPD, moderate COPD, mild COPD, respiratory symptoms only, restrictive lung disease, and no lung disease. Proportional hazard models were developed that controlled for age, race, sex, education, smoking status, pack years of smoking, years since quitting smoking, and body mass index. RESULTS: A total of 1301 deaths occurred in the 5542 adults in the cohort. In the adjusted proportional hazards model the presence of severe or moderate COPD was associated with a higher risk of death (hazard ratios (HR) 2.7 and 1.6, 95% confidence intervals (CI) 2.1 to 3.5 and 1.4 to 2.0), as was restrictive lung disease (HR 1.7, 95% CI 1.4 to 2.0). CONCLUSIONS: The presence of both obstructive and restrictive lung disease is a significant predictor of earlier death in long term follow up.     

Adaptation to social isolation. Acute and long-term stress responses of growing gilts with different coping characteristics

The present experiment studied the acute and long-term stress responses of reactive and proactive prepubertal gilts to social isolation. Gilts with either reactive or proactive features were identified according to behavioral resistance in a backtest at a young age (2-4 days), respectively being low (LR) and high resistant (HR) in this test. At 7 weeks of age, 12 gilts of each type were socially isolated. Initially, isolation was stressful for both types of gilts, as shown by increased cortisol concentrations and decreased body temperatures. Moreover, both types reacted with increases in exploration and vocalizations. Stress responses to isolation, however, differed in magnitude and/or duration between LR and HR gilts, which was in line with expected reaction patterns on the basis of preferred ways of coping. The cortisol response to isolation was higher in LR gilts, and they generally showed more explorative behavior. HR gilts seemed to be more engaged in walking/running behavior in the first hour after isolation, they generally vocalized more and their noradrenaline excretion in urine was higher at 3 weeks after the start of isolation. Several responses to isolation in the longer term pointed to a prolonged higher general state of stress of HR gilts. Body temperature in HR gilts, for instance, did not recover during 3 weeks of isolation, but values returned to "normal" within 1 day in LR gilts. At 1 week of isolation, relatively high parasympathetic responsivity to novelty was observed in HR gilts, probably due to stress-related high sympathetic reactivity. A shift in percentages of leucocyte subsets, typically occurring under conditions of stress, only developed in HR gilts during isolation. Finally, gastric ulceration was found in one HR gilt, but did not occur in LR gilts. To conclude, LR and HR gilts differed in their strategies to adapt to social isolation, and especially for HR gilts, this procedure seemed to become a chronic stressor.     

First-time parenthood: influences on pre- and postnatal adjustment in fathers and mothers

The objective of the study was to examine moods and adjustment through the transition to parenthood as an issue affecting the couple; to examine not only the postpartum but also the pregnancy experience and to explore how each partner's experiences interact with those of the other. A longitudinal repeated measures design was utilized with 327 healthy couples with a first-time pregnancy who were from Melbourne, Victoria in 1995-98. Each partner was interviewed on four occasions: mid- and late pregnancy, early postpartum and 4 months postnatally. Twenty per cent of mothers and 12% of fathers were significantly distressed at mid-pregnancy (Time 1) and this persisted until the early postpartum (Time 3) phase. Young age (particularly in women), negative mood, poor relationship functioning, gender role stress (particularly performance failure regarding work and sex in males) and low social support predicted distress in mid-pregnancy (Time 1). Negative mood in partner and self, and poor relationship functioning at mid-pregnancy predicted vulnerability to postnatal distress (Time 3 and/or Time 4). The incidence of distress in couples during mid- and late pregnancy is of concern and highlights the importance of considering the total transition to parenthood, not only the onset of postnatal distress. The analyses of predictors of postnatal distress from prenatal variables suggest that a 'contagion of distress' may operate in some couples. The standard management provided for couples experiencing pregnancy may be inadequate for many couples. These findings suggest that it is important to consider the mood and relationship quality of both partners and to offer intervention services as early as possible to offset possible progression into postnatal depression.     

Office spirometry for lung health assessment in adults: a consensus statement from the National Lung Health Education Program

Chronic obstructive pulmonary disease (COPD) is easily detected in its preclinical phase using spirometry, and successful smoking cessation (a cost-effective intervention) prevents further disease progression. This consensus statement recommends the widespread use of office spirometry by primary-care providers for patients > or = 45 years old who smoke cigarettes. Discussion of the spirometry results with current smokers should be accompanied by strong advice to quit smoking and referral to local smoking cessation resources. Spirometry also is recommended for patients with respiratory symptoms such as chronic cough, episodic wheezing, and exertional dyspnea in order to detect airways obstruction due to asthma or COPD. Although diagnostic-quality spirometry may be used to detect COPD, we recommend the development, validation, and implementation of a new type of spirometry-office spirometry--for this purpose in the primary-care setting. In order to encourage the widespread use of office spirometers, their specifications differ somewhat from those for diagnostic spirometers, allowing lower instrument cost, smaller size, less effort to perform the test, improved ease of calibration checks, and an improved quality-assurance program.