Liisa Kuikka

Bronchial asthma after early childhood wheezing: a follow‐up until 4.5–6 years of age

Over a period of 12 months from 1981 to 1982, 83 patients aged less than 2 years were treated in hospital for acute bronchiolitis. The children were followed‐up prospectively; 68 (83%) completed the study until 4.5–6.0 years of age. At this age, 17 (25%) of the 68 children with bronchiolitis still suffered from wheezing attacks. These 17 asthmatics suffered from both atopic dermatitis (29 versus 6%) and allergic rhinitis (29 versus 8%) more frequently than non‐asthmatic children. In contrast, positive results in the skin prick tests were almost equally common (29 and 20%) in asthmatic and non‐asthmatic children. In these tests, allergies to birch pollen, timothy grass pollen and house dust mite were most common; asthma was particularly associated with house dust mite allergy. The presence of atopic dermatitis, elevated immunoglobulin E values and repeated wheezing episodes between I and 2 years of age were significant risk factors for later asthma. In conclusion, the risk for later asthma is increased after early childhood bronchiolitis; the frequency of asthma was 25% in the present study. Our results confirm that atopics are at a greater risk of developing asthma later in childhood than non‐atopics; the risk was significant from 1 year of age onwards.

Serum eosinophil cationic protein as a predictor of wheezing after bronchiolitis

We have evaluated the role of eosinophil cationic protein (ECP) concentrations in serum in predicting wheezing after bronchiolitis, during infancy and early childhood. A prospective study at a university hospital serving all pediatric patients in a defined area was designed. Serum ECP concentrations were measured in 92 infants under the age of 2 years on admission for acute bronchiolitis, and 6 and 16 weeks after hospitalization. Nebulized anti‐inflammatory therapy was initiated during hospitalization: 32 patients received cromolyn sodium and 32 patients received budesonide for 16 weeks; 30 control patients received no maintenance therapy. The numbers of subsequent physician‐diagnosed wheezing episodes and hospital admissions for obstructive airway disease were recorded during 16 weeks of follow‐up.

Inflammation markers and malnutrition as risk factors for infections and impaired health related quality of life among older nursing/home residents

OBJECTIVES To explore malnutrition and inflammation markers as risk factors for poor outcome such as infections and impaired health-related quality-of-life (HRQoL) among nursing home residents. DESIGN Prospective study lasting 8 months. SETTING Three nursing homes in Helsinki, Finland, in 2003. PARTICIPANTS Sample 1 included 199 residents whose Mini Nutritional Assessment (MNA) scores and complete follow-up records concerning infections and mortality were available, and Sample 2 included 55 patients (subsample) whose data concerning laboratory values, HRQoL, and infections during the 8 months follow-up period were available. MEASUREMENTS At baseline all residents were interviewed with a structured questionnaire consisting of demographic characteristics, activities of daily living (ADL), MNA, and 15D HRQoL instrument. Blood samples were drawn at baseline (hsCRP, IL-10, TNF-alfa,TGF-beta 1,WBC) and during follow-up if infections arose (CRP). Data concerning infections and mortality during the 8-month follow-up were collected. RESULTS In the whole study group (N=199), malnutrition according to the MNA (<17, n=79) was associated with poor outcome (a serious infection and/or death) during 8 months follow-up compared with those not malnourished according to the MNA (>17, n=120) (30.4% versus 14.2%, P=.006). However, MNA score below 17 did not predict infections in the subsample (n=55). The mean age of residents in subsample was 83 years, 44 (80%) were women. Those with MNA below 17 (n=18) did not differ from others (MNA>17, n=37) with respect to age, gender, ADL-functioning, cognition, or inflammatory markers. The group with MNA below 17 had significantly lower HRQoL according to the 15D both at baseline and at 8 months. During the 8-month follow-up, subsample residents in the highest quartile of hsCRP at baseline (>4.38 mg/L, n=13) had more infections than residents in lower quartiles (<4.38 mg/L, n=42). None of the other inflammation markers were associated with the number of infections or with HRQoL. CONCLUSION Malnutrition according to the MNA and hsCRP may be used as markers to flag nursing home residents at risk for poor outcome.

Nasopharyngeal eosinophil cationic protein in bronchiolitis

A prospective 4‐month follow‐up of children hospitalized with bronchiolitis revealed that high concentrations of eosinophil cationic protein (ECP) in nasopharyngeal aspirates (NPA) are predictive of wheezing after bronchiolitis. In the 29 patients who received no anti‐inflammatory therapy the median concentration of NPA ECP was 882 ng/g in those with physician‐diagnosed wheezing and 154 ng/g in those without subsequent physician‐diagnosed wheezing (P = 0.02). The NPA ECP concentrations of the whole study group of 88 children with and without subsequent hospital admissions for wheezing were 531 and 299 ng/g, respectively (P = 0.02). At entry the children with negative viral findings had significantly higher concentrations of respiratory tract ECP than those with positive viral findings (515 vs. 240 ng/g; P = 0.01). The concentration of ECP in respiratory secretions decreased significantly after bronchiolitis (P = 0.01) provided that no new viral or mycoplasmal infection occurred. NPA ECP values decreased in relation to time regardless of whether anti‐inflammatory therapy was used or not. Children with high concentrations of respiratory tract ECP seemed to benefit from anti‐inflammatory therapy with nebulized cromolyn sodium or budesonide; both drugs significantly decreased the number of subsequent physician‐diagnosed bronchial obstructions (P = 0.0006), and they tended to decrease the number of hospital admissions for wheezing (P = 0.08). Our results suggest that high concentrations of ECP in respiratory tract secretions in children with bronchiolitis reflect the presence of eosinophilic inflammation also seen in asthma. Pediatr. Pulmonol. 1997;24:35–41.

Medical errors and uncertainty in primary healthcare: a comparative study of coping strategies among young and experienced GPs.

Abstract Objective. To study coping differences between young and experienced GPs in primary care who experience medical errors and uncertainty. Design. Questionnaire-based survey (self-assessment) conducted in 2011. Setting. Finnish primary practice offices in Southern Finland. Subjects. Finnish GPs engaged in primary health care from two different respondent groups: young (working experience ≤ 5years, n = 85) and experienced (working experience > 5 years, n = 80). Main outcome measures. Outcome measures included experiences and attitudes expressed by the included participants towards medical errors and tolerance of uncertainty, their coping strategies, and factors that may influence (positively or negatively) sources of errors. Results. In total, 165/244 GPs responded (response rate: 68%). Young GPs expressed significantly more often fear of committing a medical error (70.2% vs. 48.1%, p = 0.004) and admitted more often than experienced GPs that they had committed a medical error during the past year (83.5% vs. 68.8%, p = 0.026). Young GPs were less prone to apologize to a patient for an error (44.7% vs. 65.0%, p = 0.009) and found, more often than their more experienced colleagues, on-site consultations and electronic databases useful for avoiding mistakes. Conclusion. Experienced GPs seem to better tolerate uncertainty and also seem to fear medical errors less than their young colleagues. Young and more experienced GPs use different coping strategies for dealing with medical errors. Implications. When GPs become more experienced, they seem to get better at coping with medical errors. Means to support these skills should be studied in future research.

The perceptions of a GP's work among fifth-year medical students in Helsinki, Finland.

Abstract Objective. To explore medical students’ potential interest in family medicine in the future and their perceptions of a GPs work. Design. A cross-sectional survey in 2008–2010. Setting and subjects. Fifth-year medical students prior to their main course in General Practice at the University of Helsinki. Main outcome measures. The students’ opinions regarding the GPs work and their perceptions of the main aims of a GPs work. Results. 309/359 medical students (mean age 25.7 years, 64% females) responded to the survey. Among the students, 76% considered the most attractive feature in the GPs work to be that it is versatile and challenging. The least attractive features included: too hasty, pressing work, too lonely work, and too many non-medical problems. The majority of the students considered the main aim of a GPs work as to identify serious diseases/disorders in order to refer those patients for specialized care (82%). Treatment of chronic diseases is an important responsibility of a GPs work according to 63% of the students. Only 38% considered health promotion to be an important aim. Conclusions. Medical students may have perceptions of the GPs work that influence their career choices to specialize in other fields.

Emotionally exhausting factors in general practitioners ' work

Background. Emotional exhaustion is central in burnout syndrome and signals its development. General practitioners’ (GP) work is emotionally challenging but research on these aspects is lacking. Objective. To study the prevalence of emotional exhaustion among GPs and to evaluate how their characteristics and work experiences are associated with emotional exhaustion. Design and methods. A questionnaire survey was carried out among GPs in Finland in 2011 in which questions were posed regarding their experience of emotional exhaustion and items related to their work experiences and professional identity. A statement “I feel burnt out from my job” (never, seldom, sometimes, quite often, or often) enquired about emotional exhaustion. Those responding quite often or often were categorized as emotionally exhausted. Results. Among the GPs, 68% responded (165/244). Of the respondents, 18% were emotionally exhausted. Emotional exhaustion was associated with older age, longer working history, experiences of having too much work, fear and reports of having committed a medical error, low tolerance of uncertainty in their work, and feeling alone at work. No differences in positive work experiences were found. In logistic regression analysis working experience > 5 years (OR 4.1, 95% CI 1.6–10.8; p = 0.0036) and feeling alone at work (OR 2.9, 95% CI 1.2–7.1; p = 0.020) predicted emotional exhaustion, having committed a medical error in the past three months predicted it marginally significantly (OR 2.4, 95% CI 1.0–5.9, p = 0.057), whereas tolerating uncertainty well protected against it (OR 0.2, 95% CI 0.09–0.7; p = 0.0098). Conclusions. Emotional exhaustion among GPs was common and associated with longer working history, having committed a medical error, and feelings of isolation at work. GPs should receive more support throughout their careers.

Asthma after bronchiolitis: what is the role of atopy?

I, et al. Characteristics of hospital-treated obstructive bronchitis in children aged less than two years. Acta Pediatr 1992;81:40-5 3. Kuikka L, Reijonen T, Remes K, Korppi M. Bronchial asthma after early childhood wheezing: a follow-up until 4.5-6 years of age. Acta Pediatr 1994;83:744-8 4. Furukawa S, Takeuchi T, Tsuda M, Baba M. Age-related serum IgE levels in healthy children. Saishin Igaku 1981;36:1217-9 (in Japanese) 5. Agata H, Kondo N, Fukutomi 0, Hayashi T, Shinoda S, Nishida T, et al. Comparison of allergic diseases and specific IgE antibodies in different parts of Japan. Ann Allergy 1994;72:447-51

Prevention of asthma in children at risk: avoiding cow's milk for 6 months and tobacco smoke forever - nothing special needed?

Editor, Maas et al. (1) published their interesting negative results of the PRESVAC study aimed to prevent asthma and allergy in children at high risk. In all, 476 children with allergic asthma in first-degree relatives were recruited before birth, 222 children were allocated into multifaceted environmental exposure-reducing intervention, and 221 children were controls. The program consisted of prenatal and postnatal avoidance of tobacco smoke exposure and avoidance of hairy pets, solid foods, and cow’s milk for 6 months (2). Exposure to house dust mite and to cat and dog dander decreased allergy but exposure to tobacco smoke did not. Although cow’s milk and solid foods were started later in the intervention group, there was no difference in the length of breast feeding (1). The authors stated that the negative result was caused by a poor adherence of the parents in the intervention program. However, a more probable explanation is that environmental exposure-reducing interventions, except cow’s milk and tobacco smoke avoidance, simply are ineffective. In Finland, a nationwide program aimed to prevent allergy and asthma was launched in 1979 and was applied to all newborns with asthma or allergy in their first-degree relatives. Counseling was given in maternity wards and well-baby centers. The measures included breast feeding for 6 months, postponing cow’s milk-based formulas and solid foods until age 4–6 months, avoidance of classic allergens in the diet for 9–12 months, and avoidance of exposure to tobacco smoke and hairy pets for at least 12 months (3). As the program was not monitored at the national level, we recruited 100 newborns at risk and 100 healthy controls in 1979 into a follow-up study. Ninety-one children at risk attended the follow-up visit and clinical examination at age 6 years; 47 had followed the program successfully and 44 had not (3). There were no differences between these two groups in the occurrence of asthma or allergy (4). Sixty-eight children were monitored until age 9 years, and the result remained negative (5). As expected, asthma and allergy were at both visits more common in children at risk than in controls. The nationwide program in Finland was discontinued in the 1990s, but the discontinuation was not easy. Many parents and even professionals believed in the program. Thereafter, all mothers, irrespective of allergy in the family, have been encouraged to breast-feed their babies for 4–6 months, and all smoking parents have been encouraged to stop smoking or to smoke only outdoors. As the authors concluded, there are two recent studies suggesting some benefits from corresponding programs, one from the Isle of Wight (6) and one from Canada (7). In the Canadian study, the randomized intervention consisted of reduction in exposure to house dust mite, avoidance of fairy pets, avoidance of tobacco smoke, exclusive breast feeding >4 months, and delayed introduction of solid foods, and the program was beneficial with a 56% reduction in doctor-diagnosed asthma at age 7 years (7). However, in their later analysis, the only individual component that decreased asthma risk was the avoidance of dog keeping (8). Surprisingly, avoidance of tobacco smoke and exclusive breast feeding >4 months even increased the asthma risk (8). The non-successful nationwide experience from Finland in 1980s and 1990s, in agreement with the findings of Maas et al. (1), suggests that there is no justification for any environmental avoidance interventions for children with asthma or allergy in first-degree relatives. The multifaceted programs cause additional work, additional cost, and even troubles in families and health care. All mothers should be encouraged to breast-feed their babies for 4–6 months, and all smoking parents should be encouraged to stop smoking.

FEAR OF FALLING: IS IT PERSISTENT?

To the Editor: Fear of falling (FOF) has been studied for more than 15 years. It has been suggested that it predicts functional decline in older people. Several measures and scales have been developed to measure FOF and selfefficacy related to it, but the original question ‘‘Are you afraid of falling?’’ has been used to chart FOF in several studies to investigate its predictive value for serious outcomes such as activity restriction, falls, and functional decline. One study found that FOF was fairly persistent in older women during a 3-year follow-up and that it occurs mainly as a consequence of mobility impairment. FOF was charted using three questions, one of which was ‘‘Are you afraid of falling?’’ If the participant responded ‘‘yes’’ to any of the questions, FOF was considered to be present. The reliability of the question ‘‘Are you afraid of falling?’’ and its association with self-efficacy (Falls Efficacy Scale) has been validated. Test–retest reliability was reported to be fairly good (Kappa 0.66) when this question was administered a second time 4 to 7 days later. A scale was developed to measure older patient’s selfcare activity and adherence to prescribed medications and healthy life style (including exercise, healthy eating, not smoking). One of the questions tested in the original scale was ‘‘Are you afraid of falling?’’ because it was assumed that FOF would affect an older person’s restriction of activities. To test the test–retest reliability, this question was administered twice to older persons 2 weeks apart in the Drugs and Evidence-Based Medicine in the Elderly Study, the details of which have been described previously. Altogether, 24 home-dwelling persons with stable cardiovascular disease participated in this substudy for reliability testing. The mean age of the participants was 83.8 (range 78–94), 70% were female, and 58% had an education less than 7 years. The mean Mini-Mental State Examination (MMSE) score of the participants was 26.6 points (range 22–29). Only one person had an MMSE score of 22, but she scored 0 on the Clinical Dementia Rating Scale (CDR). Only two persons had a CDR score of 0.5, and all the others had a score of 0. Thus, none of the participants were considered to have clinical dementia. The kappa value for test–retest reliability for the question ‘‘Are you afraid of falling?’’ was only 0.36, which is considered a poor value. This is much lower than the kappa reported in the original study with 18 persons. The reliability may be associated with the context and, for example, the time of the year when the question is asked. In Finland, in the winter, changing weather and slippery streets may affect older people’s FOF. In addition, their self-confidence may fluctuate over time. Why was FOF fairly persistent over 3 years in the previous study? It is likely that charting the fear with three questions may be a more-sensitive way of exposing the underlying fear, although according to the authors, the three questions yielded only 6% more cases than the basic question. A later study suggested that more than half of older people may deny their FOF and that it is only marginally associated with activity of daily living and instrumental activity of daily living functioning. The finding of the current study is consistent with that of the previous one and warrants caution when only this simple question is asked. In conclusion, many factors other than mobility impairment, such as the context, the time, and how the question is administered, probably determine FOF.