Pnina Weiss

Imitators of exercise-induced bronchoconstriction

Exercise-induced bronchoconstriction (EIB) is described by transient narrowing of the airways after exercise. It occurs in approximately 10% of the general population, while athletes may show a higher prevalence, especially in cold weather and ice rink athletes. Diagnosis of EIB is often made on the basis of self-reported symptoms without objective lung function tests, however, the presence of EIB can not be accurately determined on the basis of symptoms and may be under-, over-, or misdiagnosed. The goal of this review is to describe other clinical entities that mimic asthma or EIB symptoms and can be confused with EIB.

Effect of vitamin D–binding protein genotype on the development of asthma in children

BACKGROUND Potential vitamin D-related influences on inflammatory diseases such as asthma are controversial, including the suggestion that vitamin D insufficiency is associated with increased asthma morbidity. Vitamin D-binding protein transports vitamin D metabolites in the circulation. Single nucleotide polymorphisms in the GC gene encoding vitamin D-binding protein are associated with circulating vitamin D metabolite levels in healthy infants and toddlers. OBJECTIVE To test the hypothesis that GC single nucleotide polymorphisms encoding the D432E and T436K variants predict subsequent development of asthma in healthy children. METHODS A retrospective medical record review was performed to determine the development of asthma in 776 children in whom GC genotype, vitamin D-binding protein concentration, and circulating 25-hydroxyvitamin D had been determined at 6 to 36 months of age. Demographic and detailed current clinical data were collected and criteria for asthma were recorded. RESULTS GC genotype was available for 463 subjects. After an initial analysis of all subject data, the analysis was limited to the predominant Hispanic population (72.1%) to minimize potential confounding effects of ethnicity. Asthma was diagnosed in 87 children (26%). Subjects with the GC genotype encoding the ET/ET (Gc1s/Gc1s) variant had lower odds of developing asthma, representing a protective effect compared with subjects with the DT/DT (Gc1f/Gc1f) variant. CONCLUSION In the Hispanic population of inner-city New Haven, Connecticut, the ET/ET (Gc1s/Gc1s) genotype of vitamin D-binding protein might confer protection against the development of asthma compared with the wild-type genotype DT/DT (Gc1f/Gc1f).

Exercise-induced bronchoconstriction and vocal cord dysfunction: two sides of the same coin?

Patients are referred often because of self-reported symptoms of dyspnea and wheeze during exercise. The two common causes of exercise-induced dyspnea are exercise-induced bronchoconstriction (EIB) and vocal cord dysfunction (VCD). It can be extraordinarily difficult to differentiate between the two, especially because they may coexist in the same patient. EIB is caused by bronchial smooth muscle constriction in the lower airways due to the inhalation of dry air or allergens during exercise; it is associated with the release of bronchoconstricting mediators from airway cells. EIB can occur in patients with or without persistent asthma. In contrast, VCD is associated with the paradoxical adduction of the vocal cords, especially during inhalation, which may produce inspiratory stridor. VCD can be solitary or comorbid with asthma and/or EIB. EIB classically is most severe after the cessation of exercise, while VCD typically occurs during exercise and resolves quickly upon exercise cessation. However, history is not adequate to differentiate between EIB and VCD, and appropriate challenge tests and flexible laryngoscopy during exercise are often necessary for diagnosis. This article examines our current understanding of these entities and discusses the mechanism, prevalence, diagnosis, and treatment.

Exercise induced bronchoconstriction in adults: evidence based diagnosis and management.

#### What you need to know EIB is defined as “the transient narrowing of the lower airway following exercise in the presence or absence of clinically recognized asthma.”1 Bronchoconstriction typically develops within 15 minutes after exercise and spontaneously resolves within 60 minutes. After an episode of EIB, there is often a refractory period of about 1-3 hours in which, if exercise is repeated, the bronchoconstriction is less emphasised in 40-50% of patients.2 3 EIB can also occur during exercise.4 5 The term “exercise induced bronchoconstriction” is preferred to that of “exercise induced asthma” since asthma is a chronic condition which is not induced by a single bout of exercise. EIB is more likely in people with asthma, but it also occurs in individuals without asthma.1 6 EIB is characterised by falls in forced expiratory volume in one second (FEV1) after exercise, while in people with asthma there is persistent airway inflammation and recurrent symptoms outside of exercise (that is, …

Positive Airway Pressure Therapy for Obstructive Sleep Apnea

Positive airway pressure (PAP) is considered first-line therapy for moderate to severe obstructive sleep apnea and may also be considered for mild obstructive sleep apnea, particularly if it is symptomatic or there are concomitant cardiovascular disorders. Continuous PAP is most commonly used. Other modes, such as bilevel airway pressure, autotitrating positive airway pressure, average volume assured pressure support, and adaptive support ventilation, play important roles in the management of sleep-related breathing disorders. This article outlines the indications, description, and comfort features of each mode. Despite the proven efficacy of PAP in treating obstructive sleep apnea syndrome and its sequelae, adherence to therapy is low. Close follow-up of patients for evaluation of adherence to and effectiveness of treatment is important.

Exercise-Induced Bronchoconstriction in Children and Adolescents

Exercise-induced bronchoconstriction (EIB) is common in children. This article reviews the epidemiology, clinical presentation, pathophysiology, diagnosis, and treatment of EIB. EIB is caused by transient narrowing of the airways during or most often after exercise and indicates airway hyperresponsiveness. EIB is an important cause of exercise limitation in children. However, the diagnosis of EIB can be challenging because symptoms poorly predict the presence of EIB. Bronchial challenges, such as cardiopulmonary exercise testing, are required to document EIB. The severity of EIB is worsened by exposure to inhalational toxicants such as chlorine in pools and air pollution. In most children, EIB can be effectively prevented by both nonpharmacological means and medications. Educating the child, his/her family, and supervising adults about asthma triggers and management is important. Prompt recognition and treatment of an asthma attack associated with exercise is critical; bronchodilators should be on the sid...

Lack of Identification of Asthmatic Players in a Youth Soccer League

Exercise-induced bronchoconstriction occurs in 10% to 15% of the general population and in up to 40% of youth soccer players. Sports-induced asthma exacerbations are a well-recognized cause of death in children. The aim of this descriptive study was to determine whether coaches and managers of a youth soccer league were aware of which players on their team carried the diagnosis of asthma or used bronchodilators and whether they had an emergency asthma action plan for these players. Secondary outcomes were the coaches’ and managers’ knowledge of asthma. Data collection consisted of a multiple-choice survey that was sent to 58 volunteer parent coaches and managers of a Connecticut town soccer organization. Twenty-nine (50%) coaches and managers responded to the survey; they supervised a total of 376 children. Most coaches and managers were not sure which players on their team had asthma (16, 55%) or used inhalers (17, 59%). Five (17%) coaches and managers identified 6 children who used an inhaler; 5 of the ...

Association between right ventricular dysfunction and restrictive lung disease in childhood cancer survivors as measured by quantitative echocardiography

Restrictive lung disease is a complication in childhood cancer survivors who received lung‐toxic chemotherapy and/or thoracic radiation. Left ventricular dysfunction is documented in these survivors, but less is known about right ventricular (RV) function. Quantitative echocardiography may help detect subclinical RV dysfunction. The aim of this study was to assess RV function quantitatively in childhood cancer survivors after lung‐toxic therapy.

Impact of extended duty hours on medical trainees

Many studies on resident physicians have demonstrated that extended work hours are associated with a negative impact on well-being, education, and patient care. However, the relationship between the work schedule and the degree of impairment remains unclear. In recent years, because of concerns for patient safety, national minimum standards for duty hours have been instituted (2003) and revised (2011). These changes were based on studies of the effects of sleep deprivation on human performance and specifically on the effect of extended shifts on resident performance. These requirements necessitated significant restructuring of resident schedules. Concerns were raised that these changes have impaired continuity of care, resident education and supervision, and patient safety. We review the studies on the effect of extended work hours on resident well-being, education, and patient care as well as those assessing the effect of work hour restrictions. Although many studies support the adverse effects of extended shifts, there are some conflicting results due to factors such as heterogeneity of protocols, schedules, subjects, and environments. Assessment of the effect of work hour restrictions has been even more difficult. Recent data demonstrating that work hour limitations have not been associated with improvement in patient outcomes or resident education and well-being have been interpreted as support for lifting restrictions in some specialties. However, these studies have significant limitations and should be interpreted with caution. Until future research clarifies duty hours that optimize patient outcomes, resident education, and well-being, it is recommended that current regulations be followed.

Recommended Protected Time for Pediatric Fellowship Program Directors: A Needs Assessment Survey

V IEW F ROM THE A SSOCIATION OF P EDIATRIC P ROGRAM D IRECTORS Recommended Protected Time for Pediatric Fellowship Program Directors: A Needs Assessment Survey Geoffrey M. Fleming, MD; Michael M. Brook, MD; Bruce E. Herman, MD; Chris Kennedy, MD, PhD; Kathleen A. McGann, MD; Katherine E. Mason, MD; Pnina Weiss, MD; Angela L. Myers, MD, MPH From the Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tenn (Dr Fleming); University of California San Francisco, San Francisco, Calif (Dr Brook); Department of Pediatrics, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah (Dr Herman); Children’s Mercy Kansas City, University of Missouri–Kansas City School of Medicine, Kansas City, Mo (Drs Kennedy and Myers); Department of Pediatrics, Duke University Medical Center, Durham, NC (Dr McGann); Department of Pediatrics, Case Western Reserve School of Medicine, Cleveland, Ohio (Dr Mason); and Department of Pediatrics, Yale University, New Haven, Conn (Dr Weiss) The authors declare that they have no conflict of interest. Address correspondence to Geoffrey M. Fleming, MD, Department of Pediatrics, Division of Critical Care Medicine, Vanderbilt University School of Medicine, 5112 DOT, 2200 Children’s Way, Nashville, TN 37232 (e-mail: geoffrey.fleming@vanderbilt.edu). A CADEMIC P EDIATRICS 2016;16:415–418 core program requirements: “The program director must devote a minimum of 0.5 FTE regardless of the size of the program.” 14 Core pediatric residency programs have recommendations for additional effort support in a graded increase on the basis of the size of the program and includes PDs, associate PDs, residency coordinators, and liaisons. Currently the “ACGME Program Requirements for Graduate Medical Education in the Subspecialties of Pediatrics” do not delineate any specific required time allotment for fellowship PDs but requires “sufficient pro- tected time.” 2 The goal of this study was to describe current time allotted for PDs in pediatric subspecialty fellowship training programs and to delineate the minimum time required for program administration to meet the regula- tions outlined by the ACGME. P EDIATRIC FELLOWSHIP TRAINING programs are the primary source of subspecialty practitioners who care for our nation’s children. There are 16 Accreditation Council for Graduate Medical Education (ACGME)-accredited pe- diatric subspecialties made up of 837 individual training programs that graduated over 8500 trainees from 2004 to 2013 in addition to those who graduated from combined board specialty programs that include a pediatric training component. 1 Explicit in the requirements for graduate medical education (GME) accreditation is the key role of the program director (PD), who is responsible for over- seeing all educational activities, assessing all trainee and faculty performance, maintaining and distributing all pro- gram policies and procedures, directing programmatic evaluation and process improvement, and monitoring compliance with all ACGME regulations. 2 Prior study has identified inadequate PD time as a barrier to complying with ACGME requirements in the nonpediatric subspe- cialties. 3 Dedicated administrative time has been identified as necessary for innovation and curricular design, and has been linked to ongoing accreditation by the ACGME. 4–12 The ACGME program requirements for core residency programs and many nonpediatric subspecialties now delin- eate program administration time requirements for PDs, associate PDs, and other support staff. The time allotted differs by specialty and varies in specification from hours per week to a percentage of total effort. 13 Current require- ments set forth by the ACGME range from 10% to 50% full-time equivalent (FTE) staff for the core medical and surgical specialties and for many of the subspecialty fel- lowships accredited by the American Board of Medical Specialties. For core pediatric residency programs, support of administrative efforts are specifically delineated in the A CADEMIC P EDIATRICS Copyright a 2016 by Academic Pediatric Association M ETHODS The study was conducted in 2 phases through the use of an anonymous national survey of fellowship PDs. An initial survey was created by the author group using a modified Delphi technique through 5 iterations and con- sisted of 23 items, including demographic data, definition of an FTE in the respondent’s institution, time allotted to administer the program, and the time needed by the respondent to administer their program. The survey was created in REDCap hosted by Vanderbilt University Med- ical Center. 15 This survey was distributed from August 20, 2013, to October 16, 2013, using the Association of Pediatric Program Directors (APPD) Fellowship Program Director (FPD) e-mail list. As a result of an initial low response rate, these data were considered pilot data. Volume 16, Number 5 July 2016