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Changes to inhaled corticosteroid dose when initiating combination inhaler therapy in long-acting β agonist-naive patients with asthma: a retrospective database analysis.

Retrospective prescribing data were obtained from 46 general practice surgeries in NHS Scotland. Patients with asthma who were naïve to previous long-acting β agonist therapy and initiated combination inhaler therapy in 2008-2009 were classified according to the inhaled corticosteroid (ICS) dose in their combination inhaler compared with the highest dose of ICS they received before initiation.

Among the 685 patients (541 (79.0%) who had been prescribed an ICS previously), those originally on low-, medium- or high-dose ICS were changed to high-dose combination therapy in 122/250 (48.8%), 94/151 (62.3%) or 85/113 (75.2%) cases in each ICS dose category, respectively. These results suggest that evaluation of appropriate high-dose ICS prescribing in general practice is needed.

Coping and social problem solving correlates of asthma control and quality of life.

In a sample of adults with asthma receiving care and medication in an outpatient pulmonary clinic, this study tested for statistical associations between social problem-solving styles, asthma control, and asthma-related quality of life. These variables were measured cross sectionally as a first step toward more systematic application of social problem-solving frameworks in asthma self-management training. Recruitment occurred during pulmonology clinic service hours.

Forty-four adults with physician-confirmed diagnosis of asthma provided data including age, gender, height, weight, race, income, and comorbid conditions. The Asthma Control Questionnaire, the Mini Asthma Quality of Life Questionnaire (Short Form), and peak expiratory force measures offered multiple views of asthma health at the time of the study. Maladaptive coping (impulsive and careless problem-solving styles) based on transactional stress models of health were assessed with the Social Problem-Solving Inventory-Revised: Short Form.

Controlling for variance associated with gender, age, and income, individuals reporting higher impulsive-careless scores exhibited significantly lower scores on asthma control (β = 0.70, p = 0.001, confidence interval (CI) [0.37-1.04]) and lower asthma-related quality of life (β = 0.79, p = 0.017, CI [0.15-1.42]). These findings suggest that specific maladaptive problem-solving styles may uniquely contribute to asthma health burdens.

Because problem-solving coping strategies are both measureable and teachable, behavioral interventions aimed at facilitating adaptive coping and problem solving could positively affect patient's asthma management and quality of life.

Management dilemmas in acute pulmonary embolism

Background

Physicians treating acute pulmonary embolism (PE) are faced with difficult management decisions while specific guidance from recent guidelines may be absent.

 Methods

Fourteen clinical dilemmas were identified by physicians and haematologists with specific interests in acute and chronic PE. Current evidence was reviewed and a practical approach suggested.

 Results

Management dilemmas discussed include: sub-massive PE, PE following recent stroke or surgery, thrombolysis dosing and use in cardiac arrest, surgical or catheter-based therapy, failure to respond to initial thrombolysis, PE in pregnancy, right atrial thrombus, role of caval filter insertion, incidental and sub-segmental PE, differentiating acute from chronic PE, early discharge and novel oral anticoagulants.

 Conclusion

The suggested approaches are based on a review of the available evidence and guidelines and on our clinical experience. Management in an individual patient requires clinical assessment of risks and benefits and also depends on local availability of therapeutic interventions.

Rhinovirus and risk of childhood asthma

Caliskan et al1 report a significant interaction between genotype variants at the 17q21 locus and human rhinovirus (HRV) wheezing illness in early life leading to the development of childhood onset asthma. The authors studied the Childhood Origins of Asthma (COAST) and the Copenhagen Prospective Study on Asthma in Childhood (COPSAC) birth cohorts, as well as 100 adults. Genotype-specific effects of HRV stimulation on peripheral blood mononuclear cells (PBMCs) were examined.

Five asthma-associated 17q21 single nucleotide polymorphisms (SNPs) were genotyped in the COAST and COPSAC cohorts. Each was tested for an association with asthma and phenotypes of viral wheezing illness using either a linear or binary regression model. PBMCs were analysed in vitro from each of the adult participants using PCR to assess the expression of 17q21 polymorphisms in HRV-stimulated and HRV-unstimulated cells. All SNPs examined in the COAST cohort showed significant associations with HRV wheezing illness and...

The effect of positive expiratory pressure (PEP) therapy on symptoms, quality of life and incidence of re-exacerbation in patients with acute exacerbations of chronic obstructive pulmonary disease: a multicentre, randomised controlled trial

Background

Positive expiratory pressure (PEP) is a technique used to enhance sputum clearance during acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The impact of PEP therapy during acute exacerbations on clinically important outcomes is not clear. This study sought to determine the effect of PEP therapy on symptoms, quality of life and future exacerbations in patients with AECOPD.

 Methods

90 inpatients (58 men; mean age 68.6 years, FEV1 40.8% predicted) with AECOPD and sputum expectoration were randomised to receive usual care (including physical exercise)±PEP therapy. The Breathlessness, Cough and Sputum Scale (BCSS), St George's Respiratory Questionnaire (SGRQ) and BODE index (Body mass index, airflow Obstruction, Dyspnoea, Exercise tolerance) were measured at discharge, 8 weeks and 6 months following discharge, and analysed via linear mixed models. Exacerbations and hospitalisations were recorded using home diaries.

 Results

There were no significant between-group differences over time for BCSS score [mean (SE) at discharge 5.2 (0.4) vs 5.0 (0.4) for PEP and control group, respectively; p=0.978] or SGRQ total score [41.6 (2.6) vs 40.8 (2.8) at 8 weeks, p=0.872]. Dyspnoea improved more rapidly in the PEP group over the first 8 weeks (p=0.006), however these benefits were not observed at 6 months. Exacerbations (p=0.986) and hospitalisations (p=0.359) did not differ between groups.

 Conclusions

We found no evidence that PEP therapy during AECOPD improves important short-term or long-term outcomes. There does not appear to be a routine role for PEP therapy in the management of such individuals.

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