Erik Lehman

Nasal congestion secondary to allergic rhinitis as a cause of sleep disturbance and daytime fatigue and the response to topical nasal corticosteroids

BACKGROUND Allergic rhinitis (AR) is a frequent disease affecting up to 20% of the population. AR causes a hypersensitivity reaction, which results in inflamed nasal mucosa and nasal congestion. Negative pressure generated during inspiration in the nasal airway secondary to nasal congestion may lead to nasal collapse, airway obstruction, and an increased number of sleep microarousals. Sleep disturbances and microarousals can detrimentally affect daytime energy levels, mood, and daytime function. It is unknown whether treatment directed to reduce congestion may reduce these microarousals, sleep problems, and, consequently, associated daytime fatigue. OBJECTIVE We sought to determine whether reducing nasal congestion with nasal steroids will reduce sleep complaints and daytime sleepiness. METHOD We enrolled 20 subjects in a double-blind, placebo-controlled study using Balaams Design. Patients were treated with topical nasal corticosteroids or placebo. Subjective data were collected by use of a daily diary, which focused on nasal symptoms, sleep, and daytime sleepiness. RESULTS The results demonstrated that nasal congestion and subjective sleep improved significantly in the topical corticosteroid-treated subjects but not in the placebo group. Sleepiness improved, but not significantly (p = 0.08). CONCLUSION Often, people with perennial allergies may attribute their daytime fatigue to causes such as the side effects of medications, when in fact, the fatigue may be a result of nasal congestion and associated sleep fragmentation. Decreasing nasal congestion with nasal steroids may improve sleep, daytime fatigue, and the quality of life of patients with AR.

Long-term weight loss maintenance in the United States

Context:Although the rise in overweight and obesity in the United States is well documented, long-term weight loss maintenance (LTWLM) has been minimally explored.Objective:The aim of this study is to estimate the prevalence and correlates of LTWLM among US adults.Design, setting and participants:We examined weight data from 14 306 participants (age 20–84 years) in the 1999–2006 National Health and Nutrition Examination Survey (NHANES). We defined LTWLM as weight loss maintained for at least 1 year. We excluded individuals who were not overweight or obese at their maximum weight.Results:Among US adults who had ever been overweight or obese, 36.6, 17.3, 8.5 and 4.4% reported LTWLM of at least 5, 10, 15 and 20%, respectively. Among the 17.3% of individuals who reported an LTWLM of at least 10%, the average and median weight loss maintained was 19.1 kg (42.1 pounds) and 15.5 kg (34.1 pounds), respectively. LTWLM of at least 10% was higher among adults of ages 75–84 years (vs ages 20–34, adjusted odds ratio (OR): 1.5; 95% confidence interval (CI): 1.2, 1.8), among those who were non-Hispanic white (vs Hispanic, adjusted OR: 1.6; 95% CI: 1.3, 2.0) and among those who were female (vs male, adjusted OR: 1.2; 95% CI: 1.1, 1.3).Conclusions:More than one out of every six US adults who has ever been overweight or obese has accomplished LTWLM of at least 10%. This rate is significantly higher than those reported in clinical trials and many other observational studies, suggesting that US adults may be more successful at sustaining weight loss than previously thought.

Preventable Newborn Readmissions Since Passage of the Newborns’ and Mothers’ Health Protection Act

BACKGROUND. Congress passed the Newborns’ and Mothers’ Health Protection Act in 1996, reversing the trend of shorter newborn nursery lengths of stay. Hope existed that morbidities would lessen for this vulnerable population, but some reports indicate that the timeliness and quality of postdischarge care may have worsened in recent years. OBJECTIVE. Our goal was to determine risk factors for the potentially preventable readmissions because of jaundice, dehydration, or feeding difficulties in the first 10 days of life in Pennsylvania since passage of the Newborns’ and Mothers’ Health Protection Act. PATIENTS AND METHODS. Birth records from 407826 newborns ≥35 weeks’ gestation from 1998 to 2002 were merged with clinical discharge records. A total of 2540 newborns rehospitalized for jaundice, dehydration, or feeding difficulties in the first 10 days of life were then compared with 5080 control infants. Predictors of readmission were identified by using multiple logistic regression analysis. RESULTS. An unadjusted comparison of baseline characteristics revealed numerous predictors of readmission. Subsequent adjusted analysis revealed that Asian mothers, those 30 years of age or older, nonsmokers, and first-time mothers were more likely to have a readmitted newborn, as were those with diabetes and pregnancy-induced hypertension. For neonates, female gender and delivery via cesarean section were protective for readmission, whereas vacuum-assisted delivery, gestational age <37 weeks, and nursery length of stay <72 hours were predictors of readmission in the first 10 days of life. CONCLUSIONS. Although readmissions for jaundice, dehydration, and feeding difficulties may be less common for some minority groups and Medicaid recipients in the era of the Newborns’ and Mothers’ Health Protection Act compared with nonminorities or privately insured patients, several predictors of newborn readmission have established associations with inexperienced parenting and/or breastfeeding difficulty. This is one indication that this well-intentioned legislation and current practice may not be sufficiently protecting the health of newborns and suggests that additional support for mothers and newborns during the vulnerable postdelivery period may be indicated.

Cluster Analysis of Obesity and Asthma Phenotypes

Background Asthma is a heterogeneous disease with variability among patients in characteristics such as lung function, symptoms and control, body weight, markers of inflammation, and responsiveness to glucocorticoids (GC). Cluster analysis of well-characterized cohorts can advance understanding of disease subgroups in asthma and point to unsuspected disease mechanisms. We utilized an hypothesis-free cluster analytical approach to define the contribution of obesity and related variables to asthma phenotype. Methodology and Principal Findings In a cohort of clinical trial participants (n = 250), minimum-variance hierarchical clustering was used to identify clinical and inflammatory biomarkers important in determining disease cluster membership in mild and moderate persistent asthmatics. In a subset of participants, GC sensitivity was assessed via expression of GC receptor alpha (GCRα) and induction of MAP kinase phosphatase-1 (MKP-1) expression by dexamethasone. Four asthma clusters were identified, with body mass index (BMI, kg/m2) and severity of asthma symptoms (AEQ score) the most significant determinants of cluster membership (F = 57.1, p<0.0001 and F = 44.8, p<0.0001, respectively). Two clusters were composed of predominantly obese individuals; these two obese asthma clusters differed from one another with regard to age of asthma onset, measures of asthma symptoms (AEQ) and control (ACQ), exhaled nitric oxide concentration (FENO) and airway hyperresponsiveness (methacholine PC20) but were similar with regard to measures of lung function (FEV1 (%) and FEV1/FVC), airway eosinophilia, IgE, leptin, adiponectin and C-reactive protein (hsCRP). Members of obese clusters demonstrated evidence of reduced expression of GCRα, a finding which was correlated with a reduced induction of MKP-1 expression by dexamethasone Conclusions and Significance Obesity is an important determinant of asthma phenotype in adults. There is heterogeneity in expression of clinical and inflammatory biomarkers of asthma across obese individuals. Reduced expression of the dominant functional isoform of the GCR may mediate GC insensitivity in obese asthmatics.

A Silent Response to the Obesity Epidemic Decline in US Physician Weight Counseling

Background:Guidelines recommend that physicians screen all adults for obesity and offer an intensive counseling and behavioral interventions for weight loss for obese adults. Current trends of weight-related counseling are unknown in the setting of the US obesity epidemic. Objectives:To describe primary care physician (PCP) weight-related counseling, comparing counseling rates in 1995–1996 and 2007–2008. Research Design:Data analysis of outpatient PCP visits in 1995–1996 and 2007–2008, as reported in the National Ambulatory Medical Care Survey. Subjects:A total of 32,519 adult primary care visits with PCPs. Measures:Rates of counseling for weight, diet, exercise, and a composite variable, weight-related counseling (defined as counseling for weight, diet, or exercise) between survey years. Adjusted analyses controlled for patient and visit characteristics. Results:Weight counseling declined from 7.8% of visits in 1995–1996 to 6.2% of visits in 2007–2008 [adjusted odds ratios, 0.64; 95% confidence intervals, 0.53, 0.79]. Rates of receipt of diet, exercise, and weight-related counseling similarly declined. Greater declines in odds of weight-counseling receipt were observed among those with hypertension (47%), diabetes (59%), and obesity (41%), patients who stand the most to gain from losing weight. Conclusions:Rates of weight counseling in primary care have significantly declined despite increased rates of overweight and obesity in the United States. Further, these declines are even more marked in patients with obesity and weight-related comorbidities, despite expectations to provide such care by both patients and policymakers. These findings have implications for determining deliverable, novel ways to engage PCPs in addressing the obesity epidemic.

Body mass index and phenotype in subjects with mild- to-moderate persistent asthma

BACKGROUND Although obesity has been hypothesized to worsen asthma, data from studies of subjects with well-characterized asthma are lacking. OBJECTIVE We sought to evaluate the relationship between body mass index (BMI), asthma impairment, and response to therapy. METHODS BMI (in kilograms per meter squared) and asthma phenotypic and treatment response data were extracted from Asthma Clinical Research Network studies. The cross-sectional relationship between BMI and asthma impairment was analyzed, as was the longitudinal relationship between BMI and response to asthma controller therapies. RESULTS One thousand two hundred sixty-five subjects with mild-to-moderate persistent asthma were evaluated. Analyses of lean versus overweight/obese asthmatic subjects demonstrated small differences in FEV1 (3.05 vs 2.91 L, P = .001), FEV1/forced vital capacity ratio (mean, 83.5% vs 82.4%; P = .01), rescue albuterol use (1.1 vs 1.2 puffs per day, P = .03), and asthma-related quality of life (5.77 vs 5.59, P = .0004). Overweight/obese asthmatic subjects demonstrated a smaller improvement in exhaled nitric oxide levels with inhaled corticosteroid (ICS) treatment than did lean asthmatic subjects (3.6 vs 6.5 ppb, P = .04). With ICS/long-acting beta-agonist treatment, overweight/obese asthmatic subjects demonstrated smaller improvements in lung function than lean asthmatic subjects, with an 80 mL (P = .04) and 1.7% (P = .02) lesser improvement in FEV1 and FEV1/forced vital capacity ratio, respectively. Significant differences in therapeutic response to leukotriene modifiers between BMI categories were not observed. CONCLUSIONS Increased BMI is not associated with clinically significant worsening of impairment in subjects with mild-to-moderate persistent asthma. There is a modest association between increased BMI and reduced therapeutic effect of ICS-containing regimens in this patient population. Prospective studies evaluating the effect of being overweight or obese on treatment response in asthma are warranted.

Efficacy of the topical nasal steroid budesonide on improving sleep and daytime somnolence in patients with perennial allergic rhinitis

Background:  Improving quality of life is considered to be a major endpoint and motivation for clinical intervention in patients with perennial allergic rhinitis (PAR). In addition to classical symptoms of congestion, pruritus, and rhinorrhea, patients will often complain of not being able to sleep well at night and of feeling fatigued during the day. Like sleep apnea, PAR has also been shown to cause sleep disturbance and consequently worsen daytime fatigue and somnolence.

Practices Associated with Weight Loss Versus Weight-Loss Maintenance Results of a National Survey

BACKGROUND Few studies have examined the weight-control practices that promote weight loss and weight-loss maintenance in the same sample. PURPOSE To examine whether the weight control practices associated with weight loss differ from those associated with weight-loss maintenance. METHODS Cross-sectional survey of a random sample of 1165 U.S. adults. The adjusted associations of the use of 36 weight-control practices in the past week with success in weight loss (≥10% lost in the past year) and success in weight-loss maintenance (≥10% lost and maintained for ≥1 year) were examined. RESULTS Of the 36 practices, only 8 (22%) were associated with both weight loss and weight-loss maintenance. Overall, there was poor agreement (kappa=0.22) between the practices associated with weight loss and/or weight-loss maintenance. For example, those who reported more often following a consistent exercise routine or eating plenty of low-fat sources of protein were 1.97 (95% CI=1.33, 2.94) and 1.76 (95% CI=1.25, 2.50) times more likely, respectively, to report weight-loss maintenance but not weight loss. Alternatively, those who reported more often doing different kinds of exercises or planning meals ahead of time were 2.56 (95% CI=1.44, 4.55) and 1.68 (95% CI=1.03, 2.74) times more likely, respectively, to report weight loss but not weight-loss maintenance. CONCLUSIONS Successful weight loss and weight-loss maintenance may require two different sets of practices. Designing interventions with this premise may inform the design of more effective weight-loss maintenance interventions.

High School Soccer Players With Concussion Education Are More Likely to Notify Their Coach of a Suspected Concussion

Previously published studies have found that concussion symptoms are underreported in youth athletics. This study evaluated the likelihood high school soccer players would identify themselves as having concussion related symptoms during game situations. A questionnaire inquiring about past concussion education and the likelihood of notifying their coach of concussion symptoms was administered to 183 high school soccer players. Of the 60 (33%) who completed the survey, 18 (72%) athletes who had acknowledged receiving concussion training responded that they would always notify their coach of concussion symptoms, as compared with 12 (36%) of the players who reported having no such training (P = .01). The results of this study suggest that athletes with past concussion training are more likely to notify their coach of concussion symptoms, potentially reducing their risk for further injury. Concussion education should be considered for all high school soccer players.

The Mark Coventry Award: Prevention of readmission for venous thromboembolism after total knee arthroplasty.

Venous thromboembolism is the most common reason for readmission after total knee arthroplasty. Prospective contrast venography was conducted from 1984 to 2003 in 1321 patients undergoing total knee arthroplasty. Patients with deep venous thrombosis or pulmonary embolism were treated with warfarin; those with negative venograms received no further anticoagulation. From 1984 to 1992, patients not completing venography were discharged without warfarin; since 1993 patients without venography received warfarin for 6 weeks. Readmission for deep venous thrombosis, pulmonary embolism, or bleeding was tracked for 6 months. Venography was completed in 810 patients; 343 (42.3%) had deep venous thrombosis. Readmission for venous thromboembolism occurred in 0.6% of patients after total knee compared with 1.62% after total hip arthroplasty. Following total knee arthroplasty, patients discharged on warfarin (target INR 2.0) had a 0.21% readmission rate compared with 1.05% for patients with negative venograms discharged without further anticoagulation. One patient suffered a fatal pulmonary embolism after negative venography and no outpatient prophylaxis. Secondary prophylaxis with extended warfarin therapy reduced venous thromboembolism-related readmission. Surveillance venograms were a poor predictor of ultimate thromboembolism risk and need for extended anticoagulation therapy. We therefore recommend extended warfarin prophylaxis for all patients after hospital discharge following total knee arthroplasty. Level of Evidence: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.