Ashok M. Patel

Prevalence, pathophysiology, and treatment of patients with asthma and gastroesophageal reflux disease

About one third of the US adult population experiences symptoms of gastroesophageal reflux on a monthly basis. Asthma is present in about 5% of the same population. This article reviews and summarizes the literature in the following areas: (1) prevalence of gastroesophageal reflux disease (GERD) in asthmatic patients based on clinical symptoms, endoscopic esophagitis, and 24-hour ambulatory esophageal pH recordings; (2) proposed pathophysiologic mechanisms linking the 2 diseases; and (3) medical and surgical treatment trial results of antireflux therapy for asthmatic patients. Asthmatic patients appear to have an increased prevalence of GERD symptoms and 24-hour esophageal acid exposure. The clinical management of these patients remains controversial. Common management approaches to GERD in asthmatic patients include medical therapy with a proton pump inhibitor and/or antireflux surgery, which improve asthma symptoms in many patients but minimally affect pulmonary function.

Long-term fracture risk among children with asthma: A population-based study

Fracture risk among patients diagnosed with asthma in childhood is greater in males and oral corticosteroid users, but most fractures are of the appendicular skeleton and may relate to impaired skeletal development.

How Well Does Patient Self-Report Predict Asthma Medication Possession? Implications for Medication Reconciliation and Adherence Assessment

Background. Self-report is the most commonly used method for collecting information regarding asthma medication possession and adherence in clinical practice. Objective. To determine the agreement between self-report and pharmacy claims data for asthma medication possession. Methods. This is a retrospective study that examined pharmacy claims data 12 months before and after participants completed a structured asthma survey. This study was performed in a sample of health care workers and dependents >17 years old in a large, self-insured Midwestern United States health care center. The main outcome measure was agreement (kappa calculation) between self-report and pharmacy claims data of asthma medication possession. Results. Self-report of asthma medication use agreed moderately with pharmacy claims data for short-acting albuterol (κ = 0.47 ± 0.03), salmeterol (κ = 0.79 ± 0.04), and montelukast (κ = 0.69 ± 0.03) but only slightly for inhaled corticosteroids (κ = 0.18 ± 0.03) and prednisone (κ = 0.10 ± 0.03) (n = 1050 respondents). Both under self-reporting and over self-reporting were common with inhaled corticosteroids (14.4% and 23.1%, respectively) and varied significantly by specific drug type. Conclusions. Self-report moderately agrees with asthma medication possession for most adult asthma patients, though the agreement differs considerably between and within asthma medication classes.

Neuropeptide levels in nasal secretions from patients with and without chronic cough

BACKGROUND The pathophysiology of upper airway cough syndrome is not well understood. OBJECTIVE To investigate the levels of neuropeptides found in nasal mucus of subjects with and without the complaint of chronic cough. METHODS Preformed nasal mucus from 26 subjects complaining of postnasal drip with chronic cough and 17 without self-reported chronic cough was collected at the time of presentation. The nasal secretions were assayed for 3 neuropeptides-substance P (SP), calcitonin gene-related peptide (CGRP), and Neurokinin A (NKA)-that have been previously linked to chronic cough. RESULTS Coughing subjects with postnasal drip have significantly higher levels of CGRP and SP than noncoughing subjects with postnasal drip (69.0 ng vs 4.6 ng, P < .001 and 4.5 ng vs 3.4 ng, P = .004). The differences in NKA levels in nasal secretions between coughing and noncoughing subjects did not reach statistical significance (16.3 ng vs 3.4 ng, P = .067). CONCLUSIONS Both CGRP and SP levels are elevated in preformed nasal secretions of coughing subjects when compared with noncoughing subjects. Additional studies are needed to clarify whether CGRP and SP levels in preformed nasal secretions may assist in diagnosis or predicting treatment response in patients presenting with chronic cough.

Practical Considerations for Managing Asthma in Adults

Asthma is a common, chronic inflammatory disorder of the airways associated with pronounced health and economic consequences. Consistent and effective education that promotes an active partnership with patients remains the cornerstone for managing asthma. Identification and control of asthma triggers, regular monitoring of lung function, and adequate pharmacologic therapy are three other critical components. In this article, we describe several practical considerations for developing a collaborative, multidisciplinary approach to asthma care that emphasizes patient education and strengthens the partnership between patients and health-care professionals.

Effectiveness of trivalent inactivated influenza vaccine in influenza-related hospitalization in children: a case-control study.

Influenza is known to be associated with asthma exacerbation but the effectiveness of the trivalent inactivated flu vaccine (TIV) in children, especially children with asthma, in preventing hospitalization is unknown. We assessed the effectiveness of the TIV in all children and especially children with asthma to prevent hospitalization with influenza. We conducted a nested case control study of all pediatric subjects (6 months to 18 years old) who were evaluated at the Mayo Clinic, Rochester, MN, who had laboratory-confirmed influenza during each flu season from 1999 to 2006 to evaluate the efficacy of TIV in preventing hospitalization. A case-control analysis was performed with the cases and the controls being the subjects who did and did not required hospitalization with the influenza illness, respectively. There were 261 subjects with laboratory-confirmed influenza from 1996 to 2006. There was an overall trend toward higher rates of hospitalization in subjects who got the TIV when compared with the ones who did not get the TIV (odds ratio [OR], 3.67; CI, 1.6, 8.4). Using the Cochran-Mantel-Haenszel test for asthma status stratification, there was a significant association between hospitalization in asthmatic subjects and TIV (p = 0.001). TIV did not provide any protection against hospitalization in pediatric subjects, especially children with asthma. On the contrary, we found a threefold increased risk of hospitalization in subjects who did get the TIV vaccine. This may be a reflection not only of vaccine effectiveness but also the population of children who are more likely to get the vaccine.

Using the internet in asthma management: Current concepts and challenges

An essential component of quality asthma care is ongoing communication between patients and their caregivers. To make healthy, lifelong changes in their behavior, patients need to receive simple, consistent, and reinforcing messages. Interactive, electronic communication has the capacity to facilitate the timely exchange of data, including asthma-related information, among patients, their healthcare team, and other relevant decision-makers. Internet-based solutions are rapidly evolving and may be helpful, but use of the Internet for comprehensive asthma management still presents many practical challenges. Specifically, the following challenges require further investigation: (i) variable access to the Internet by patients and providers in practice settings; (ii) accelerative and unpredictable changes in asthma-specific knowledge, hardware, software, and infrastructure support; (iii) variations in website designs, navigation, and functionality; and (iv) the lack of systematic evaluation of the cost effectiveness of digital health interventions with regard to asthma-specific patient outcomes.Organizations and patients are also confronted with balancing and integrating asthma care received from face-to-face encounters and self-care assessment with advice available through virtual, Internet-based encounters. Human, institutional, and technical challenges are associated with the development phase of Internet-based solutions (such as technical infrastructure, expert knowledge, and legal issues) and with the implementation phase (such as data privacy and data exchange standards, algorithm quality, and cost). Effective responses are also needed for: (i) handling unanticipated electronic problems (such as electrical grid failures or computer viruses); (ii) accessing poor-quality, outdated, or unreliable asthma information; and (iii) coping with issues related to information overload. Many of these difficulties can be resolved on the local, institutional scale, but large-scale implementation will not occur until all involved parties collaborate to seek creative solutions. This review extends prior concepts articulated about the integrated delivery of quality asthma care and Internet development, identifies key questions to address with regard to website design and functionality, and highlights current model solutions emerging from institutional, regional, national, and international agencies.

The effect of theophylline and enprofylline on the late cutaneous response to antigen and compound 48 80

Theophylline and enprofylline have been demonstrated to reduce mast cell-mediator release, inhibit polymorphonuclear leukocyte activation, and have been reported to reduce the late bronchial response to antigen. The effects of theophylline and enprofylline on the late cutaneous response (LCR) to compound 48/80 and antigen were studied in 29 patients enrolled in a placebo-controlled, double-blind study of the effect of the xanthines in mild asthma. Skin testing to a common environment allergen and compound 48/80 was performed during a baseline period and in the second phase of the study after stable drug levels were achieved, at least 6 weeks later. During baseline, the mean immediate wheal diameter (IWD) with antigen was 15.7 mm +/- 0.5, resulting in 27/29 LCRs with a mean wheal diameter of 37.1 mm +/- 5.2. The mean IWD with compound 48/80 was 16.1 mm +/- 0.7, resulting in 26/29 LCRs with a mean wheal diameter of 19.6 mm +/- 2.8. Repeat skin testing during treatment revealed no statistically significant changes in the LCR elicited by antigen or 48/80 in any of the treatment groups. There was little correlation between the size of the immediate wheal produced by antigen or 48/80 and the resulting size of the late response (r = 0.174 to 0.519). However, for the same IWD, the resulting late response was smaller with 48/80 than with antigen (p = 0.003). We conclude that (1) theophylline and enprofylline have no effect on the LCR to 48/80 and antigen and (2) for equivalent immediate wheal sizes, the resulting late response is smaller with 48/80 than with antigen.