Cecilia Maria Patino

Central and Peripheral Visual Impairment and the Risk of Falls and Falls with Injury

OBJECTIVE To evaluate whether central (CVI) and peripheral visual impairment (PVI) are independent risk factors for falls and falls with injury 4 years later. DESIGN Population-based, prospective cohort study. PARTICIPANTS A population-based sample of 3203 adult Latinos. METHODS Baseline presenting binocular central distance acuity was measured and impairment was classified as mild (20/40-20/63) or moderate/severe (<or=20/80). Peripheral visual impairment was classified as mild (-6 dB < mean deviation < -2 dB in worse eye), moderate/severe (mean deviation <or=-6 dB in worse eye). MAIN OUTCOME MEASURES Falls and falls with injury in the past 12 months were assessed by self-report at the 4-year follow-up visit. RESULTS Out of 3203 individuals, 19% reported falls and 10% falls with injury 4 years after the baseline examination; participants with falls were more likely to be >or=60 years of age, be female, report lower income, have >2 comorbidities, report alcohol use, report wearing bifocal glasses, and report obesity. Among those who reported falls, 7% had CVI (visual acuity >20/40) compared with 4% who did not report falls; and 49% had PVI (mean deviation < -2 dB) compared with 39% of those who did not report falls (both P<0.0001). After adjusting for confounders, moderate to severe CVI and PVI were associated with increased risk for falls (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.02-5.45; P(trend) = 0.04; and OR, 1.42; 95% CI, 1.06-1.91l P(trend) = 0.01, respectively) and with falls with injury (OR, 2.76; 95% CI, 1.10-7.02; P(value) = 0.03; and OR, 1.40; 95% CI, 0.94-2.05 P(trend) = 0.04, respectively). CONCLUSIONS Both CVI and PVI were independently associated with increased risk for falls and falls with injury 4 years after the initial examination in a dose-response manner. Although vision-related interventions for preventing falls have mainly focused on correcting CVI, this study suggests that targeting both central and peripheral components may be necessary to effectively reduce rates of falls and falls with injury related to vision loss.

Interactions between genes and environment in the development of asthma

Allergic diseases in general and asthma in particular have become an increasing problem for public health, especially in developed countries. Epidemiologic evidence suggests that the prevalence of asthma has increased signi®cantly, especially among children (1, 2), and it is now the most frequent cause of chronic symptoms in the pediatric age (3). Some authorities questioned the validity of the ®rst reports that suggested that the prevalence of asthma was increasing considerably in the population as a whole. The main argument was that the reported increases were due to a greater awareness among physicians and caregivers and among the population in general of the importance of asthma as a cause of chronic respiratory symptoms, especially among children (4). This was a plausible argument, because it is still true today that many children with asthma receive other diagnoses (wheezy bronchitis, spastic bronchitis, etc.). However, recent surveys that have included objective measures of risk factors for asthma, such as allergic sensitization and bronchial hyperresponsiveness (5), con®rm that only a small proportion of the observed increases in the prevalence of asthma are due to a shift in diagnostic labeling. The same can be said for other diseases associated with IgEmediated immune responses such as allergic rhinitis (6). There is widespread consensus today among the experts that these increases are real. Identifying the factors that have caused these increases and developing new preventive strategies that will address this epidemic are signi®cant challenges for both the scienti®c community and public health authorities.

Does higher body mass index contribute to worse asthma control in an urban population

BACKGROUND Epidemiologic findings support a positive association between asthma and obesity. OBJECTIVE Determine whether obesity or increasing level of body mass index (BMI) are associated with worse asthma control in an ethnically diverse urban population. METHODS Cross-sectional assessment of asthma control was performed in patients with asthma recruited from primary care offices by using 4 different validated asthma control questionnaires: the Asthma Control and Communication Instrument (ACCI), the Asthma Control Test (ACT), the Asthma Control Questionnaire (ACQ), and the Asthma Therapy Assessment Questionnaire (ATAQ). Multiple linear regression analysis was performed to evaluate the association between obesity and increasing BMI level and asthma control. RESULTS Of 292 subjects with a mean age of 47 years, the majority were women (82%) and African American (67%). There was a high prevalence of obesity with 63%, with only 15% normal weight. The mean score from all 4 questionnaires showed an average suboptimal asthma control (mean score/maximum possible score): ACCI (8.3/19), ACT (15.4/25), ACQ (2.1/6), and ATAQ (1.3/4). Regression analysis showed no association between obesity or increasing BMI level and asthma control using all 4 questionnaires. This finding persisted even after adjusting for FEV(1), smoking status, race, sex, selected comorbid illnesses, and long-term asthma controller use. CONCLUSION Using 4 validated asthma control questionnaires, we failed to find an association between obesity and asthma control in an urban population with asthma. Weight loss may not be an appropriate strategy to improve asthma control in this population.

The effect of BCG vaccine at birth on the development of atopy or allergic disease in young children

BACKGROUND Exposure to infectious diseases may reduce the development of asthma or allergy. In particular, the role of the BCG vaccine in modulating asthma or allergy has been a source of speculation. OBJECTIVE To study newborns from 3 international sites to evaluate the prospective effect of BCG vaccine on allergic diseases or atopic development. METHODS Infants were enrolled from newborn and well-infant clinics in Thailand, Argentina, and Turkey. The standard BCG vaccine for each country was given at birth. Parents who consented to have their infant included in the protocol completed an allergy family questionnaire. Infants underwent a standard purified protein derivative (PPD) test at 9 to 12 months of age, and the reaction size was measured. At the age of 2 years, the children returned to be studied. Allergy skin tests to common allergens appropriate to location and age were performed, and the parents completed the International Study of Allergy and Asthma in Childhood questionnaire. The PPD reaction size was compared with the presence of atopy and allergy questionnaire responses. RESULTS A total of 1,704 infants were studied. Statistical significance was found between a negative PPD response vs any positive PPD response and the risk of having an allergic history at the age of 2 years in Turkey (relative risk, 2.11; 95% confidence interval, 1.25-3.55; P = .005) and Thailand (relative risk, 2.16; 95% confidence interval, 1.18-3.94; P = .02) but not Argentina (relative risk, 1.09; 95% confidence interval, 0.70-1.68; P = .70). CONCLUSIONS This study further supports the role of infectious agents in modulating asthma and allergy development.

The Asthma Control and Communication Instrument: A clinical tool developed for ethnically diverse populations

BACKGROUND Lower levels of quality asthma care among racially diverse populations might be due to inaccurate disease status assessments. The Asthma Control and Communication Instrument (ACCI) is a new tool that captures patient report of disease status during routine care. OBJECTIVE We sought to test the ACCIs psychometric properties in a racially diverse population. METHODS We performed a cross-sectional study. Subjects were recruited from specialist and generalist urban outpatient clinics. The ACCI and measures of asthma control, quality of life, lung function, and specialist rating of asthma status were collected. Four ACCI domains were separately validated: Acute Care, Bother, Control, and Direction. Principal component analysis, internal consistency, concurrent, discriminative, known-groups validity, and accuracy were evaluated. RESULTS Two hundred seventy asthmatic patients (77% female subjects, 55% black) participated. ACCI Control domain internal consistency was 0.80. ACCI Bother, Control, and Direction domains showed strong concurrent validity with asthma control and quality-of-life measures (all P < .001). ACCI Acute Care and Direction domains showed strong concurrent validity with individual validation items (all P < .001). The ACCI Control domain discriminated clinically important levels of disease status measured by asthma control, quality of life (both P < .001), and percent predicted peak expiratory flow rate (P = .005) and was associated with specialist rating of disease status (P < .001), confirming known-groups validity. The accuracy of the ACCI Control domain in classifying patients with uncontrolled asthma was very good (area under the curve, 0.851; 95% CI, 0.742-0.95870). Results were similar for both black and white subjects. CONCLUSION The ACCI is a promising clinical tool that measures asthma disease status during routine health care and is valid for use in both black and white populations.

Patient Factors Used by Pediatricians to Assign Asthma Treatment

OBJECTIVE. Although asthma is often inappropriately treated in children, little is known about what information pediatricians use to adjust asthma therapy. The purpose of this work was to assess the importance of various dimensions of patient asthma status as the basis of pediatrician treatment decisions. PATIENTS AND METHODS. We conducted a cross-sectional, random-sample survey, between November 2005 and May 2006, of 500 members of the American Academy of Pediatrics using standardized case vignettes. Vignettes varied in regard to (1) acute health care use (hospitalized 6 months ago), (2) bother (parent bothered by the childs asthma status), (3) control (frequency of symptoms and albuterol use), (4) direction (qualitative change in symptoms), and (5) wheezing during physical examination. Our primary outcome was the proportion of pediatricians who would adjust treatment in the presence or absence of these 5 factors. RESULTS. Physicians used multiple dimensions of asthma status other than symptoms to determine treatment. Pediatricians were significantly more likely to increase treatment for a recently hospitalized patient (45% vs 18%), a bothered parent (67% vs 18%), poorly controlled symptoms (4–5 times per week; 100% vs 18%), or if there was wheezing on examination (45% vs 18%) compared with patients who only had well-controlled symptoms. Pediatricians were significantly less likely to decrease treatment for a child with well-controlled symptoms and recent hospitalization (28%), parents who reported being bothered (43%), or a child whose symptoms had worsened since the last doctor visit (10%) compared with children with well-controlled symptoms alone. CONCLUSIONS. Pediatricians treat asthma on the basis of multiple dimensions of asthma status, including hospitalization, bother, symptom frequency, direction, and wheezing but use these factors differently to increase and decrease treatment. Tools that systematically assess multiple dimensions of asthma may be useful to help further improve pediatric asthma care.

The use of inhaled antibiotic therapy in the treatment of ventilator-associated pneumonia and tracheobronchitis: a systematic review

BackgroundVentilator-associated respiratory infections (tracheobronchitis, pneumonia) contribute significant morbidity and mortality to adults receiving care in intensive care units (ICU). Administration of broad-spectrum intravenous antibiotics, the current standard of care, may have systemic adverse effects. The efficacy of aerosolized antibiotics for treatment of ventilator-associated respiratory infections remains unclear. Our objective was to conduct a systematic review of the efficacy of aerosolized antibiotics in the treatment of ventilator-associated pneumonia (VAP) and tracheobronchitis (VAT), using the Cochrane Collaboration guidelines.MethodsWe conducted a search of three databases (PubMed, Web of Knowledge and the Cochrane Collaboration) for randomized, controlled trials studying the use of nebulized antibiotics in VAP and VAT that measured clinical cure (e.g., change in Clinical Pulmonary Infection Score) as an outcome measurement. We augmented the electronic searches with hand searches of the references for any narrative review articles as well as any article included in the systematic review. Included studies were examined for risk of bias using the Cochrane Handbook’s “Risk of Bias” assessment tool.ResultsSix studies met full inclusion criteria. For the systemic review’s primary outcome (clinical cure), two studies found clinically and statistically significant improvements in measures of VAP cure while four found no statistically significant difference in measurements of cure. No studies found inferiority of aerosolized antibiotics. The included studies had various degrees of biases, particularly in the performance and detection bias domains. Given that outcome measures of clinical cure were not uniform, we were unable to conduct a meta-analysis.ConclusionsThere is insufficient evidence for the use of inhaled antibiotic therapy as primary or adjuvant treatment of VAP or VAT. Additional, better-powered randomized-controlled trials are needed to assess the efficacy of inhaled antibiotic therapy for VAP and VAT.

The Impact of Change in Visual Field on Health-Related Quality of Life: The Los Angeles Latino Eye Study

PURPOSE To assess the impact of change in visual field (VF) on change in health-related quality of life (HRQoL) at the population level. DESIGN Prospective cohort study. PARTICIPANTS Three thousand one hundred seventy-five Los Angles Latino Eye Study participants. METHODS Objective measures of VF and visual acuity and self-reported HRQoL were collected at baseline and at the 4-year follow-up. Analysis of covariance was used to evaluate mean differences in change of HRQoL across severity levels of change in VF and to test for effect modification by covariates. MAIN OUTCOME MEASURES General and vision-specific HRQoL. RESULTS Of 3175 participants, 1430 (45%) showed a change in VF (≥1 decibel [dB]) and 1715 (54%) reported a clinically important change (≥5 points) in vision-specific HRQoL. Progressive worsening and improvement in the VF were associated with increasing losses and gains in vision-specific HRQoL for the composite score and 10 of its 11 subscales (all P(trend)<0.05). Losses in VF of more than 5 dB and gains of more than 3 dB were associated with clinically meaningful losses and gains in vision-specific HRQoL, respectively. Areas of vision-specific HRQoL most affected by greater losses in VF were driving, dependency, role-functioning, and mental health. The effect of change in VF (loss or gain) on mean change in vision-specific HRQoL varied by level of baseline vision loss (in VF, visual acuity, or both) and by change in visual acuity (all P(interaction)<0.05). Those with moderate or severe VF loss at baseline and with a more than 5 dB loss in VF during the study period had a mean loss of vision-specific HRQoL of 11.3 points, whereas those with no VF loss at baseline had a mean loss of 0.97 points. Similarly, with a more than 5 dB loss in VF and baseline visual acuity impairment (mild or severe), there was a loss in vision-specific HRQoL of 10.5 points, whereas with no visual acuity impairment at baseline, there was a loss of vision-specific HRQoL of 3.7 points. CONCLUSIONS Both losses and gains in VF produce clinically meaningful changes in vision-specific HRQoL. In the presence of pre-existing vision loss (VF and visual acuity), similar levels of VF change produce greater losses in QOL.

Asthma-related health status determinants of environmental control practices for inner-city preschool children.

BACKGROUND Asthma guidelines recommend environmental control practices (ECPs) to improve asthma health. In the inner city, where asthma morbidity is high, it is not known whether childrens health status affects the use of ECPs. OBJECTIVE To investigate health status determinants of ECPs in the homes of children with asthma. METHODS Caregivers of children aged 2 to 6 years with (n = 150) and without (n = 150) asthma completed a survey about ECPs. Atopic status was determined by means of skin prick testing. RESULTS Most ECPs were similarly practiced, regardless of whether the child had asthma. Only pet avoidance was more common in children with asthma (30% vs 19%). Asthma severity and recent acute health care visits for asthma were not associated with ECP use. Most ECPs were not linked to allergen sensitization (eg, mite and mouse), although cockroach-sensitized children were more likely to have cockroach control than nonsensitized individuals (65% vs 45%). Caregivers of asthmatic children with rhinitis were more likely than those without rhinitis to report ECPs, including pet avoidance (44% vs 15%), smoking avoidance (78% vs 53%), cockroach control (65% vs 42%), mouse control (78% vs 42%), air-conditioning (45% vs 24%), and allergyproof covers (7% vs 0%). CONCLUSIONS The presence of asthma, asthma severity, and allergen sensitization seem to have little relationship to ECP use in the homes of inner-city children. Rhinitis was consistently linked to ECPs, which suggests that caregivers may make changes in the home environment for upper airway but not lower airway symptoms.

Rhinitis symptoms and habitual snoring in Ecuadorian children

STUDY OBJECTIVES To determine the prevalence of habitual snoring (HS) and its association with symptoms of rhinitis in a Latin American country and, secondarily, to assess how commonly physicians address rhinitis in the community. PATIENTS OR PARTICIPANTS Six- to twelve-year-old school-aged children. POPULATION AND METHODS We designed a cross-sectional, community-based study of the pediatric population, centered in schools of Guayaquil, Ecuador. The study was evaluated and approved by the ethical committee of the Hospital Luis Vernaza as a local institution. MEASUREMENTS AND RESULTS A 15.1% prevalence of HS was reported among 806 responders out of 1193 surveys. The frequency of HS was associated with the number of rhinitis symptoms and a previous diagnosis of rhinitis, with those reporting 2 rhinitic symptoms being more likely to report HS (p=0.01). Only a small minority of caregivers reported being aware of either HS or rhinitis as health problems. CONCLUSIONS HS is a highly prevalent symptom among Ecuadorian children, and the prevalence is further increased if the diagnosis of rhinitis or even >1 rhinitis symptom is concomitantly present. Since few caregivers of HS children are informed about the causes and consequences of this condition, increased health education about this condition is needed.