The influence of active and passive smoking on habitual snoring

The impact of active smoking, passive smoking, and obesity on habitual snoring in the population is mainly unknown. We aimed to study the relationship of habitual snoring with active and passive tobacco smoking in a population-based sample. A total of 15,555 of 21,802 (71%) randomly selected men and women aged 25-54 years from Iceland, Estonia, Denmark, Norway, and Sweden answered a postal questionnaire. Habitual snoring, defined as loud and disturbing snoring at least 3 nights a week, was more prevalent among current smokers (24.0%, p < 0.0001) and ex-smokers (20.3%, p < 0.0001) than in never-smokers (13.7%). Snoring was also more prevalent in never-smokers exposed to passive smoking at home on a daily basis than in never-smokers without this exposure (19.8% vs. 13.3%, p < 0.0001). The frequency of habitual snoring increased with the amount of tobacco smoked. Active smoking and passive smoking were related to snoring, independent of obesity, sex, center, and age. Ever smoking accounted for 17.1% of the attributable risk of habitual snoring, obesity (body mass index > or = 30 kg/m(2)) for 4.3%, and passive smoking for 2.2%. Smoking, both current and ex-smoking, is a major contributor to habitual snoring in the general population. Passive smoking is a previously unrecognized risk factor for snoring among adults.

Extraesophageal manifestations of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) may manifest as laryngitis, asthma, cough, or noncardiac chest pain. Diagnosing these extraesophageal manifestations may be difficult for primary care physicians because most patients do not have heartburn or regurgitation. Diagnostic tests have low specificity, and a cause-and-effect association between GERD and extraesophageal symptoms is difficult to establish. Response to aggressive acid suppression is often the best indication of GERD etiology in a patient with extraesophageal symptoms.

[A case of Crohn's disease with broncho-bronchiolitis]

A 41-year old man was hospitalized for abdominal pain and melena. Two years before, he had contracted Crohn's disease, which was brought into remission by using mesalazine and oral corticosteroids. When Crohn's disease appeared to flare up again, the dose of corticosteroids was increased. Afterwards, when a gradual decrease in this dose was initiated, melena developed once again, along with a dry cough. Chest radiography revealed diffuse patchy shadows. A significant increase of lymphocytes was observed in the bronchoalveolar lavage fluid. Mesalazine was suspended and steroid pulse therapy was initiated in combination with azathioprine. Although the symptoms were alleviated and the patchy shadows disappeared, the bronchiectatic shadows remained. A broncho-bronchiolitis associated with Crohn's disease was finally diagnosed despite the need for a differential diagnosis of mesalazine-induced disease due to the long-term administration of mesalazine before the onset of the pulmonary lesion. Also, the pathological findings were inconsistent with many other reported cases, the onset of the pulmonary lesion coincided with the flare-up of an intestinal disease, and the pulmonary shadows remained long after the suspension of mesalazine.

Traffic-related air pollution near busy roads: the East Bay Children's Respiratory Health Study

Recent studies, primarily in Europe, have reported associations between respiratory symptoms and residential proximity to traffic; however, few have measured traffic pollutants or provided information about local air quality. We conducted a school-based, cross-sectional study in the San Francisco Bay Area in 2001. Information on current bronchitis symptoms and asthma, home environment, and demographics was obtained by parental questionnaire (n = 1,109). Concentrations of traffic pollutants (particulate matter, black carbon, total nitrogen oxides [NO(X)], and nitrogen dioxide [NO(2)]) were measured at 10 school sites during several seasons. Although pollutant concentrations were relatively low, we observed differences in concentrations between schools nearby versus those more distant (or upwind) from major roads. Using a two-stage multiple-logistic regression model, we found associations between respiratory symptoms and traffic-related pollutants. Among those living at their current residence for at least 1 year, the adjusted odds ratio for asthma in relationship to an interquartile difference in NO(X) was 1.07 (95% confidence interval, 1.00-1.14). Thus, we found spatial variability in traffic pollutants and associated differences in respiratory symptoms in a region with good air quality. Our findings support the hypothesis that traffic-related pollution is associated with respiratory symptoms in children.

Factor analysis of household factors: are they associated with respiratory conditions in Chinese children?

BACKGROUND

We explored methods to develop uncorrelated variables for epidemiological analysis models. They were used to examine associations between respiratory health outcomes and multiple household risk factors.

METHODS

We analysed data collected in the Four Chinese Cities Study (FCCS) to examine health effects on prevalence rates of respiratory symptoms and illnesses in 7058 school children living in the four Chinese cities: Lanzhou, Chongqing, Wuhan, and Guangzhou. We used factor analysis approaches to reduce the number of the children's lifestyle/household variables and to develop new uncorrelated 'factor' variables. We used unconditional logistic regression models to examine associations between the factor variables and the respiratory health outcomes, while controlling for other covariates.

RESULTS

Five factor variables were derived from 21 original variables: heating coal smoke, cooking coal smoke, socioeconomic status, ventilation, and environmental tobacco smoke (ETS) and parental asthma. We found that higher exposure to heating coal smoke was associated with higher reporting of cough with phlegm, wheeze, and asthma. Cooking coal smoke was not associated with any of the outcomes. Lower socioeconomic status was associated with lower reporting of persistent cough and bronchitis. Higher household ventilation was associated with lower reporting of persistent cough, persistent phlegm, cough with phlegm, bronchitis, and wheeze. Higher exposure to ETS and the presence of parental asthma were associated with higher reporting of persistent cough, persistent phlegm, cough with phlegm, bronchitis, wheeze, and asthma.

CONCLUSIONS

Our study suggests that independent respiratory effects of exposure to indoor air pollution, heating coal smoke, and ETS may exist for the studied children.

Mechanisms of chronic airway obstruction in smokers

Studies over the past few decades have showed a clear association between cigarette smoking and the development of chronic airway obstruction. Yet, only a minority of smokers is affected so that in many, even heavy, smokers, pulmonary function remains within normal limits. While carcinogens have been well characterized, there is only limited information about the constituents of cigarette smoke responsible for inducing chronic airway obstruction. In addition, the associated risks factors for airway obstruction in smokers have not been totally identified. The present paper is a review of the recently accumulated facts concerning the intimate action of cigarette smoke at the level of large and small airways and lung parenchyma. The role of classical inflammatory cells such as neutrophils and alveolar macrophages is reviewed, but emphasis is put on recent evidence indicating the involvement of CD8 + T-lymphocytes and possibly eosinophils in the genesis of the structural changes leading to airways obstruction. The mechanisms by which airway inflammation and remodelling cause airway narrowing and airflow limitation are discussed, along with the associated loss of lung elasticity secondary to destructive emphysema. Other biological, epidemiological, physiopathological, and clinical aspects are analyzed, stressing such fundamental aspects as the defence mechanisms, the morpho-functional correlations, the identification of susceptible smokers, and the early detection of airway obstruction, both in specialized laboratories and in primary care.

The effect of passive smoking on respiratory health in children and adults

Passive smoking, or environmental tobacco smoke (ETS), has been found to be causally associated with a large number of diseases in various organs although the evidence is sometimes conflicting. This review summarises the effects of passive smoking on respiratory symptoms, lung function and asthma in children and adults. In children, prenatal exposure to ETS is associated with impaired lung function and increased risk of developing asthma, while postnatal exposure mainly acts as a trigger factor for respiratory symptoms and asthma attacks. In adults, ETS exposure is associated with respiratory symptoms, asthma, a small but significant impairment of lung function and increased bronchial responsiveness. The consequence of workplace exposure seems to be more serious than domestic exposure. Legislative measures banning smoking at work have positive health effects in non-smokers and increase the quitting rate in smokers. Measures aimed at reducing childhood exposure to ETS should have high priority. Smoke cessation programmes for pregnant women attending antenatal clinics and for parents at the time of child hospitalisation for respiratory illness seem to have a fairly high success rate. Passive smoking is a widespread, important and avoidable risk factor for respiratory symptoms in both children and adults. Reducing passive smoking in the community will have a large positive effect on respiratory health.

Housing characteristics and children's respiratory health in the Russian Federation

OBJECTIVES

We studied housing characteristics, parental factors, and respiratory health conditions in Russian children.

METHODS

We studied a population of 5951 children from 9 Russian cities, whose parents answered a questionnaire on their children's respiratory health, home environment, and housing characteristics. The health outcomes were asthma conditions, current wheeze, dry cough, bronchitis, and respiratory allergy.

RESULTS

Respiratory allergy and dry cough increased in association with the home being adjacent to traffic. Consistent positive associations were observed between some health conditions and maternal smoking during pregnancy, many health conditions and lifetime exposure to environmental tobacco smoke (ETS), and nearly all health conditions and water damage and molds in the home.

CONCLUSIONS

Vicinity to traffic, dampness, mold, and ETS are important determinants of children's respiratory health in Russia.

Neonatal necrotizing tracheobronchitis: three case reports

Necrotizing tracheobronchitis is a serious affection observed in ventilated newborns, frequently infants with instable hemodynamic state. It is characterized by acute episodes of airway obstruction. The treatment consists of the desobstruction by rigid bronchoscopy. The vascular theory seems to be of utmost importance in the physiopathology. Three cases are reported.

Low frequency noise and stress: bronchitis and cortisol in children exposed chronically to traffic noise and exhaust fumes

A correlation of respiratory diseases to traffic related air pollution and noise was observed in an interview study. Since in that study the exposure was subjectively assessed, in the present field study nitrogen dioxide as indicator for vehicle exhausts and the mean night-time noise level were measured outside the children's windows in representative locations. Based on these measurements each child was placed in one of the following categories: low, medium or high traffic immission (ambient emissions). The physician contacts due to bronchitis of 68 children were assessed retrospectively from the files of the participating paediatricians. Saliva samples were collected from all children and the cortisol concentration was estimated. Children under high noise exposure (L(night, 8h) = 54-70dB(A)) had in comparison to all other children significantly increased morning saliva cortisol concentrations, indicating an activation of the hypothalamus-pituitary-adrenal (HPA) axis. Analysing a subgroup of children without high noise exposure showed, that children with frequent physician contacts due to bronchitis did not have increased morning saliva cortisol. However, multiple regression analysis with stepwise exclusion of variables showed that bronchitis was correlated more closely to morning salvia cortisol than to traffic immissions. On the other hand, the rate of physician contacts due to bronchitis increased in a dose dependent manner and significantly with increasing traffic immissions. From these results it can be concluded that high exposure to traffic noise, especially at nighttime, activates the HPA axis and this leads in the long term to an aggravation of bronchitis in children. This seems to be more important than the effect of exhaust fumes on bronchitis symptoms. The results of the present study should be subjected to further investigation using specially designed studies.

Role of microvascular permeability on physiologic differences in asthma and eosinophilic bronchitis

Asthma and eosinophilic bronchitis are characterized by a similar type of eosinophilic inflammation. However, eosinophilic bronchitis differs from asthma in that there is no variable airflow obstruction or airway hyperresponsiveness. We evaluated the roles of vascular endothelial growth factor (VEGF) and microvascular permeability in causing these differences between the two diseases. Inflammatory indexes in induced sputum, exhaled nitric oxide levels, and vascular permeability index were examined in 11 normal control subjects, 19 beclomethasone dipropionate (BDP)-treated subjects with asthma, 20 non-BDP-treated subjects with asthma, and 17 patients with eosinophilic bronchitis. The percentage of eosinophils in sputum and exhaled nitric oxide levels were significantly higher in non-BDP-treated subjects with asthma and patients with eosinophilic bronchitis than in other two groups; however, VEGF levels and vascular permeability index were significantly higher in non-BDP-treated (VEGF: mean; 4,710 [SD; 1,150] pg/ml, p < 0.0001; vascular permeability index: 0.028 [0.009], p < 0.0001) and BDP-treated (2,560 [1,070] pg/ml, p = 0.0002; 0.016 [0.006], p = 0.004) subjects with asthma than in patients with eosinophilic bronchitis (1,120 [800] pg/ml; 0.01 [0.005]) and normal control subjects (1,390 [1,280] pg/ml; 0.008 [0.003]). We found significant correlations between the VEGF level and the airway vascular permeability index in all patient groups. Thus, interaction between airway microcirculation and VEGF may be a key element in differences in airway function between asthma and eosinophilic bronchitis.

[Role of interview in diagnosis of gastroesophageal reflux in children]

THE AIM

Of the study was to establish the most frequent clinical symptoms of gastroesophageal reflux (GER) disease in children.

MATERIAL AND METHODS

214 children aged from 4 months to 15 years with symptoms suggested GER. The medical documentation of children was analyzed with regard to results of clinical symptoms and 24-hour pH-monitoring.

RESULTS

The most frequent symptom in newborn was spitting, in children aged 1-3 was vomiting, in children aged 4-15 was stomach pain. Amongst children to 3 years recurrent bronchitis was frequent co-existent disease, in older children duodenitis or/and gastritis. Based on positive result of 24-hour pH-monitoring gastroesophageal disease was diagnosed in 184 (86%) patients. Preliminary diagnosis of GER based on the medical interview with high percentage of positive results of 24-hour pH-monitoring. The introduced results prove the medical interview to be still significant part of GER diagnosis.

Exposure to the dental environment and prevalence of respiratory illness in dental student populations

OBJECTIVE

To determine if the prevalence of respiratory disease among dental students and dental residents varies with their exposure to the clinical dental environment.

METHODS

A detailed questionnaire was administered to 817 students at 3 dental schools. The questionnaire sought information concerning demographic characteristics, school year, exposure to the dental environment and dental procedures, and history of respiratory disease. The data obtained were subjected to bivariate and multiple logistic regression analysis.

RESULTS

Respondents reported experiencing the following respiratory conditions during the previous year: asthma (26 cases), bronchitis (11 cases), chronic lung disease (6 cases), pneumonia (5 cases) and streptococcal pharyngitis (50 cases). Bivariate statistical analyses indicated no significant associations between the prevalence of any of the respiratory conditions and year in dental school, except for asthma, for which there was a significantly higher prevalence at 1 school compared to the other 2 schools. When all cases of respiratory disease were combined as a composite variable and subjected to multivariate logistic regression analysis controlling for age, sex, race, dental school, smoking history and alcohol consumption, no statistically significant association was observed between respiratory condition and year in dental school or exposure to the dental environment as a dental patient.

CONCLUSION

No association was found between the prevalence of respiratory disease and a student's year in dental school or previous exposure to the dental environment as a patient. These results suggest that exposure to the dental environment does not increase the risk for respiratory infection in healthy dental health care workers.

Prevalence of asthmatic phenotypes and bronchial hyperresponsiveness in Turkish schoolchildren: an International Study of Asthma and Allergies in Childhood (ISAAC) phase 2 study

BACKGROUND

Numerous epidemiologic studies have revealed that bronchial asthma affects populations without regard to frontiers. However, standardized methodological approaches are necessary to compare these populations.

OBJECTIVE

To investigate objective markers of childhood asthma on an epidemiologic basis and to include Turkish children in international comparisons.

METHODS

Parental questionnaires were collected and skin prick tests performed on fourth grade primary schoolchildren, aged 8 to 11 years, residing in Ankara, Turkey. Pulmonary function tests and bronchial challenge with hypertonic saline (HS) were conducted in children selected from this cohort with a stratified random sampling according to the presence of current wheezing.

RESULTS

A total of 3,041 questionnaires were included in the evaluation. Skin prick tests were performed on 2,774 children (97.1%). A total of 347 children from this cohort underwent pulmonary function and bronchial challenge tests. In 18 (5.1%) of the 347 children, bronchial challenge tests could not be successfully completed. The prevalence values were 11.5% for current wheezing, 6.9% for physician-diagnosed asthma, and 7.7% for physician-diagnosed recurrent bronchitis. Population-based weighted prevalence of bronchial hyperresponsiveness (BHR) was 21.8%. Frequency of responses to HS was 38.6% among physician-diagnosed asthma cases and 30.5% among patients with current wheezing. Skin test positivity was present in 38.7% of the children with a diagnosis of asthma or asthmatic bronchitis, 35.0% of current asthmatic patients, and 19.2% of patients with current wheezing.

CONCLUSIONS

Objective markers, in addition to the questionnaire-based prevalence figures, need to be used in epidemiologic surveys for asthma, especially in countries with inadequate health care facilities or problems with interpretation of the wheeze concept.

Auswirkungen der Belastungen unter Tage im Steinkohlenbergbau auf die Lunge

The long-term exposure to dust in the hard coal mining industry can lead to various pathological lung changes, especially to chronic bronchitis without and with obstructive ventilation disorder, lung emphysema, pneumoconiosis (coal miner's pneumoconiosis, in Germany categorized as silicosis) and silicotuberculosis. These health disorders show a close pathogenetic and pathophysiological association and should not necessarily be regarded as individual entities. Most exposed subjects demonstrate more or less all of these pathological disorders. On account of individual (genetic?) susceptibility, their degree differs greatly. Some individuals are largely resistent, other subjects show severe effects like emphysema, progressive massive pneumoconiosis, or the Caplan syndrome. Several studies showed that the pathologically verified degree of lung fibrosis is associated with lung crystalline SiO(2) content whereas the emphysema score is inversely correlated with the coal content. With regard to diagnostics and medical expert opinion, it is important that conventional radiology has a low sensitivity. Further, health impairments of miners engaged for longtime which are insurance relevant (MdE) exist in cases without (BK 4111 if beginning after 12/31/1992) or with coalworkers' pneumoconiosis even for categories < 2/3.

Perception of airway narrowing during reduction of inhaled corticosteroids and asthma exacerbation

BACKGROUND

The perception of airway narrowing is reduced in subjects with severe asthma and may be related to the severity of airway inflammation. A study was undertaken to determine if the perception of airway narrowing changes during the reduction of inhaled corticosteroid (ICS) dose or during an asthma exacerbation.

METHODS

Forty two asthmatic subjects with well controlled asthma had their daily ICS dose halved every 2 months until they were weaned off ICS or they developed an exacerbation. Perception was measured at baseline and at monthly intervals during bronchial challenge with mannitol as the slope and intercept of the regression of the Borg score and percentage fall in forced expiratory volume in 1 second (FEV(1)), and as the Borg score at 20% fall in FEV(1) (PS(20)FEV(1)). Sputum was collected for measurement of inflammatory cell numbers.

RESULTS

In 33 subjects who successfully halved their ICS dose without exacerbation there were significant reductions in slope (p = 0.01), intercept (p = 0.01), and PS(20)FEV(1) (p = 0.003). Sputum eosinophils and airway hyperresponsiveness increased significantly but, in 14 subjects from whom sputum was obtained, changes in eosinophils were not correlated with changes in perception. Change in airway hyperresponsiveness correlated with change in PS(20)FEV(1) (r = -0.40, p = 0.025). In 27 subjects who developed an exacerbation, slope decreased (p = 0.02) and intercept increased (p = 0.01) compared with the visit before the exacerbation. Changes in intercept correlated with changes in resting FEV(1) (r = -0.57, p = 0.002).

CONCLUSIONS

Perception of airway narrowing decreases during ICS dose reduction and decreases further during a mild asthma exacerbation. These changes are related to concurrent changes in airway hyperresponsiveness and resting lung function. The effect of changes in airway inflammation on perception is unclear.

Airway inflammation in patients affected by obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome (OSAS) has been shown to be associated to upper airway inflammation. The object of the present study was to establish the presence of bronchial inflammation in OSAS subjects. In 16 subjects affected by OSAS, and in 14 healthy volunteers, airway inflammation was detected by the cellular analysis of the induced sputum. OSAS patients, as compared to control subjects, showed a higher percentage of neutrophils (66.7+/-18.9 vs. 25.8+/-15.6) (P<0.001) and a lower percentage of macrophages (29.4+/-18.4 vs. 70.8+/-15.3) (P<0.001). The percentage of eosinophils and lymphocytes were not significantly different in the two groups. OSAS subjects show bronchial inflammation characterized by a significant increase in neutrophils.

Acute bronchitis: state of the art diagnosis and therapy

In managing acute bronchitis, pneumonia or an exacerbation of underlying chronic bronchitis should be excluded. Simple bronchitis is best treated symptomatically while an exacerbation of chronic bronchitis can be treated with antibiotics. Broad spectrum antibiotics are appropriate in selected patients.

Resolution of plastic bronchitis with atrial pacing in a patient with fontan physiology

We describe a 5-year-old boy with Fontan physiology and a ventricular pacemaker who developed severe plastic bronchitis. Evaluation by cardiac catheterization revealed profoundly altered hemodynamics, which improved with atrial pacing. Following implantation of an atrial pacemaker, which restored atrioventricular (A-V) synchrony, the patient's hemodynamics greatly improved and his plastic bronchitis resolved.

[Diagnostic criteria and medical examination in occupational bronchitis]

The article deals with materials comprehensively tackling a problem of occupational bronchitis--independent nosologic entity in occupational respiratory pathology.

Otomastoiditis candidiásica y síndrome de hiper Ig E

PATIENT

A 5-year-old girl presented with chronic otorrhea, cervical adenopathies and cellulitis of the knee. In addition to these lesions, physical examination revealed eczema on the scalp, neck, perineal and umbilical regions and the persistence of deciduous teeth with adult teeth (double dental arch). Complementary investigations showed the following concentrations: IgE 23969 UI/l, IgD 440 U/L, IgG 23000 mg/L, and IgA 4220 mg/L. Intradermal skin testing to Candida was negative and the results of the remaining immunological studies were normal. Computerized axial tomography revealed bilateral otomastoiditis. Candida albicans was isolated from ear secretion cultures. The definitive diagnosis was hyper IgE syndrome. The patient responded favorably to antibiotic and antifungal therapy and is currently undergoing period outpatient monitoring.

[The new German general threshold limit value for dust--pro and contra the adoption in Austria]

Since it has been realised that inhalation of inert dust is one of the important confounding variables for the development of chronic bronchitis, the threshold values for occupational exposure to these dusts needs to be further decreased. The German Commission for the Investigation of Health Hazards of Chemical Compounds in the Work Area (MAK-Commission) has set a new threshold (MAK-Value) for inert dusts (4 mg/m3 for inhalable dust, 1.5 mg/m3 for respirable dust) in 1997. This value is much lower than the threshold values currently used world-wide. The aim of the present article is to assess the scientific plausibility of the methodology (databases and statistics) used to set these new German MAK-Values, regarding their adoption in Austria. Although we believe that it is substantial to lower the MAK-Value for inert dust in order to prevent the development of chronic bronchitis as a consequence of occupational exposure to inert dusts, the applied methodology used by the German MAK-Commission in 1997 to set the new MAK-Values does not justify the reduction of the threshold limit value. A carefully designed study to establish an appropriate scientific basis for setting a new threshold value for inert dusts in the workplace should be carried out. Meanwhile, at least the currently internationally applied threshold values should be adopted in Austria.

[Specific clinical course of occupational toxic dust bronchitis in workers exposed to wolfram and cobalt]

Chronic toxic dust bronchitis in workers exposed to wolfram and cobalt has been progressing in the course of many-year exposure to hazardous occupational factors. Its prevalence among the main-occupation workers is 2.2-fold higher versus workers of the control group who have never contacted the metal aerosols. The disease onset is slow and gradual in an overwhelming majority of cases and has the below clinical-and-functional peculiarities: 1) predominance of dyspnea over cough in the early bronchitis stage; 2) an early and often development of the concurrent asthmatic component; 3) subjective symptoms are far ahead of objective examination findings in the early disease stage; 4) obstructive changes in the distal sections of the air-conducting system (maximum-air-velocity volume75), if detected in latent bronchitis, can be a basis for an early disease diagnosis; 5) as well as lower key hemodynamic parameters and development of the hypokinetic blood circulation type, whereas, compensatory hyperfunctioning of the myocardium and the hyperkinetic blood circulation type are found in patients with occupational dust bronchitis working in other productions.

Relationship of exhaled nitric oxide to clinical and inflammatory markers of persistent asthma in children

BACKGROUND

Exhaled nitric oxide (eNO) is a noninvasive test that measures airway inflammation. Insufficient information is available concerning correlations between eNO and biologic, physiologic, and clinical characteristics of asthma in children currently not taking controller medications.

OBJECTIVE

The aim of this study was to find correlations between eNO and other characteristics of children with mild to moderate asthma currently not taking medications.

METHODS

Children aged 6 to 17 years with mild to moderate persistent asthma, taking only albuterol as needed, were characterized during 2 visits 1 week apart before being randomly assigned into a clinical trial. At the screening visit, online measurements of eNO, spirometry before and after bronchodilator, and biomarkers of peripheral blood eosinophils, serum eosinophil cationic protein, total serum IgE, and urinary leukotriene E4 were obtained. During a week characterization period before randomization, symptoms were recorded on a diary and peak expiratory flows were measured twice daily using an electronic device. At the randomization visit, eNO was repeated followed by a methacholine challenge and aeroallergen skin testing. Correlations and rank regression analyses between eNO and clinical characteristics, pulmonary function, and biomarkers were evaluated.

RESULTS

eNO was significantly correlated with peripheral blood eosinophils (r =.51, P <.0001), IgE (r =.48, P <.0001), and serum eosinophil cationic protein (r =.31, P =.0003) but not with urinary leukotriene E4 (r =.16, P =.08). A moderate correlation was found between eNO and the number of positive aeroallergen skin tests (r =.45, P <.0001). eNO did not correlate with FEV1% predicted but was weakly correlated with FEV1/forced vital capacity (r = -.19, P =.032), bronchodilator response (r =.20, P =.023), and FEV1 PC20 methacholine (r = -.31, P =.0005). No significant correlations were found between eNO and clinical characteristics or morning or evening peak expiratory flow measurements. The rank regression analysis demonstrated that 5 variables accounted for an R square of.52 (eosinophils [P <.0001], IgE [P =.0023], age [P <.0001], months of inhaled corticosteroid use in the year before study entry [P =.01], and FEV1 PC20 [P =.0061]).

CONCLUSIONS

These findings suggest that eNO provides information about the asthmatic state consistent with information from other markers of inflammation. It is a noninvasive technique that could be used in decisional management of children with asthma.

Sudden infant death syndrome: a critical review of approaches to research

This review explores the various research approaches taken attempting to solve the problem of SIDS. It would appear that major clues provided by pathological findings have been largely overlooked and as a consequence much effort, time, and money has been wasted on projects that satisfy only sub-specialty and political needs. Close examination of the pathological clues would provide better insights into the mechanisms underlying this enigmatic and heartbreaking problem.

Respiratory status in dairy farmers in France; cross sectional and longitudinal analyses

AIMS

To compare respiratory status in dairy farmers with that of non-farming controls.

METHODS

Longitudinal study in the Doubs (France). From a cohort constituted in 1994 (T1), 215 (81.1%) dairy farmers and 110 (73.8%) controls were reevaluated in 1999 (T2). The protocol comprised a medical and occupational questionnaire, spirometric tests at both evaluations, allergological tests at T1, and a non-invasive measure of blood oxygen saturation (SpO2) at T2.

RESULTS

In 1999 analyses, the prevalence of chronic bronchitis was higher (p = 0.013), and FEV1/VC (p < 0.025) and SpO2 (-0.7%, p < 0.01) lower in dairy farmers than in controls. In a multiple linear regression model, farming, age, and smoking were significantly and inversely correlated with SpO2. In the whole population, the mean annual decline in FEV1 and FEV1/VC was -13.4 ml and -0.30%, respectively. Farming was associated with an accelerated decline in FEV1/VC (p < 0.025) after adjustment for covariates. No relation between allergy and respiratory function changes was observed, except for FEF25-75.

CONCLUSIONS

This prospective study shows that dairy farming is associated with an excess of chronic bronchitis, with a moderate degree of bronchial obstruction and a mild decrease in SpO2.

Can respiratory syncytial virus etiology be diagnosed clinically? A hospital-based case-control study in children under two years of age

An unmatched, hospital-based case-control study was performed, to determine, whether respiratory syncytial virus (RSV) etiology in hospitalized young children can be predicted clinically. Children under 2 years of age admitted with a lower respiratory tract infection in three hospitals in northern Germany were included (one tertiary and two secondary centers). Cases were children tested positive for RSV by multiplex RT-PCR. One control group consisted of children tested negative for RSV in the multiplex-RT-PCR and a second control group consisted of patients in whom no PCR was done. A weighted backward stepwise logistic regression model was applied for multivariate analysis. RSV-etiology could be predicted with a sensitivity of 72.8% and a specificity of 73.2%. Young age, disease entity--pneumonia or bronchiolitis, center, intercostal retractions, absence of an underlying condition, low level of C-reactive protein, short duration of symptoms (all on admission), prematurity and epidemiologic year were predictive; anatomical infiltrates and wheezing were not. Pathogen specific diagnosis is necessary for individual therapy, allocation in observational studies or treatment trials and for surveillance of airway infections in children, since the positive predictive value is too low for an accurate diagnosis and decision making. Multivariate techniques are effective tools in complex clinical research for deconfounding.

Chronic bronchitis in an elderly population

BACKGROUND

in order to describe the prevalence and prognostic implications of chronic bronchitis in individuals 65 years or older we analysed data from The Copenhagen City Heart Study.

METHODS

the population was studied in 1976-1978 resurveyed in 1981-1983 and 1991-1994 and followed with regard to survival for up to 12 years. Approximately 3,700 elderly participants with a mean age of 76 years were available for analyses.

RESULTS

the prevalence of chronic bronchitis was 13.0% in women and 18.6% in men. Multiple logistic regression yielded the following predictors for chronic bronchitis: male gender (odds ratio with 95% confidence interval = 1.1 (0.9-1.3)), previous smoking odds ratio = 1.7 (1.2-2.2), present smoking odds ratio = 2.1 (2.1-3.8), previous exposure to dusts and fumes (odds ratio = 2.2 (1.7-2.7)), chest infections in childhood (odds ratio = 2.1 (1.6-2.9)), more than 6 chest infections in previous 10 years (odds ratio = 6.2 (4.1-9.2)) and alcohol consumption of more than 3 drinks a day (odds ratio = 1.8 (1.3-2.3)). Chronic bronchitis was a significant predictor of both subsequent respiratory infections and survival. After adjustment for age, smoking and lung function, a Cox regression showed that chronic bronchitis was significantly related to mortality from all causes with a hazard ratio with 95% confidence interval = 1.3 (1.1-1.4), all benign respiratory diseases (hazard ratio = 2.0 (1.6-2.7)), obstructive lung disease (hazard ratio = 2.5 (1.7-3.6)) and lung cancer (hazard ratio = 2.0 (1.4-2.9)).

CONCLUSIONS

in an elderly population, chronic bronchitis is a prevalent condition with important prognostic implications.

Estimating regression models with unknown break-points

This paper deals with fitting piecewise terms in regression models where one or more break-points are true parameters of the model. For estimation, a simple linearization technique is called for, taking advantage of the linear formulation of the problem. As a result, the method is suitable for any regression model with linear predictor and so current software can be used; threshold modelling as function of explanatory variables is also allowed. Differences between the other procedures available are shown and relative merits discussed. Simulations and two examples are presented to illustrate the method.

Adenoidectomy during early life and the risk of asthma

The objective of the study was to evaluate the risk of asthma in children who had undergone an adenoidectomy, an operation frequently performed on children with glue ear or recurrent otitis media. Two surveys were carried out, a nation-wide questionnaire returned by 483 individuals (survey A) and a survey of hospital discharge records involving 1616 children who had undergone an adenoidectomy and 161 control children who had undergone probing of the nasolacrimal duct due to congenital obstruction (survey B). The questionnaire (survey A) showed that an adenoidectomy before the age of 4 years was associated with asthma (OR 3.19, 95% CI 1.25; 8.13) and with allergy to animal dust (OR 2.50, 95% CI 1.27; 4.95). In survey B, asthma diagnosis was retrieved from the national asthma register. It showed also that adenoidectomy at an early age was associated with an increased risk of asthma (OR 6.74, 95% CI 2.99; 15.2). There was an association between asthma and adenoidectomy, even before adenoidectomy had actually been performed. The risk of asthma was highest among children who had had adenoidectomy because of recurrent otitis media. The observed association between an adenoidectomy and asthma may be explained by an underlying factor predisposing to both recurrent otitis media and asthma.

[The prevalence of skin and mucosal symptoms in gardeners handling Ficus benjamina (weeping fig) and Hedera helix (ivy). A cross-sectional study]

INTRODUCTION

Allergic and toxic initiative symptoms from skin, eyes and respiratory tract are well known among gardeners This study reports the prevalence of these symptoms among gardeners working with Ficus Benjamina (Fb) and Hedera helix (Hh).

MATERIAL AND METHODS

A questionnaire concerning allergic/toxic-irritative symptoms from skin, eyes and respiratory tract were forwarded to 57 gardeners. A total of 49 questionnaires were returned and matched on sex and age with a control group. A number of 46 women and 52 men participated, with a mean age of 39 (SD 9.7). Differences in frequencies of symptoms were expressed as odds ratio (OR) with a security level of 95% after conditioned logistic regression; other results were calculated from Mantel-Haenzel test.

RESULTS

There were more complaints among gardeners compared to the control group f as to symptoms of asthmatic bronchitis (OR 4.6 [0.98-21.2]), rhino conjunctivitis (OR 6.4 [2.1-20.2]) and skin symptoms (OR 4.3 [1.5-12.5]). The symptoms were especially profound among the caretakers of Fb and Hh and to a lesser degree among gardeners working in greenhouses growing Fb and Hh. The symptoms of the gardeners were to a higher degree independent of the season (OR 3.1 [1.1-9]), related to working environment (OR 16.1 [3.3-78.9]) and indoor work (OR 24 [4.8-118.7]).

DISCUSSION

This study seems to demonstrate high frequencies of apparently allergic and/or toxic irritative symptoms among gardeners and should be followed by a study including clinical examinations. With knowledge of the allergenic and toxic irritative properties of Fb and Hh it seems problematic that these plants are found in such high numbers in public and private places. Allergic testing including these plants should be performed to a higher degree than is actually the case.

Cigarette smoking-attributable morbidity---United States, 2000

Each year in the United States, approximately 440,000 persons die of a cigarette smoking-attributable illness, resulting in 5.6 million years of potential life lost, $75 billion in direct medical costs, and $82 billion in lost productivity. To assess smoking-attributable morbidity, the Roswell Park Cancer Institute, Research Triangle Institute, and CDC analyzed data from three sources: the Behavioral Risk Factor Surveillance System (BRFSS), the National Health and Nutrition Examination Survey III (NHANES III), and the U.S. Census. This report summarizes the results of that analysis, which indicate that an estimated 8.6 million persons in the United States have serious illnesses attributed to smoking; chronic bronchitis and emphysema account for 59% of all smoking-attributable diseases. These findings underscore the need to expand surveillance of the disease burden caused by smoking and to establish comprehensive tobacco-use prevention and cessation efforts to reduce the adverse health impact of smoking.

A nonparametric changepoint model for stratifying continuous variables under order restrictions and binary outcome

Modelling using monotonic regression can be a useful alternative to parametric approaches when optimal stratification for continuous predictors is of interest. This method is described here in the context of binary response. Within this framework we aim to address two points. First, we propose a method to enhance the parsimony of the model, by applying a reducing procedure based on a sequence of Fisher exact tests and a bootstrap method to select between full monotonic and reduced model. Secondly, we discuss the case of multiple predictors: an iterative algorithm (an extension of the Pool Adjacent Violators Algorithm) can be applied when more than one predictor variable is taken into account. The resulting model is a monotonic surface and can be applied alternatively to the additive monotonic models as described by Morton-Jones and colleagues when the explanatory variables are assumed to interact. The monotonic-surface model provides also a multivariate extension of the monotonic likelihood ratio test. This test is discussed here and an approach based on permutations to assess the p-value is proposed. Finally, we combine both ideas (reduced monotonic regression and monotonic-surface estimation) to a simple and easy to interpret model, which leads to a combination of the predictors in a few constant risk groups. Despite the fact that the proposed approach becomes somewhat cumbersome due to the lack of asymptotic methods to infer, it is attractive because of its simplicity and stability. An application will outline the benefit of using bivariate step functions in modelling.

Efficacy of local nasal immunotherapy for Dp2-induced airway inflammation in mice: Using Dp2 peptide and fungal immunomodulatory peptide

BACKGROUND

Local nasal immunotherapy (LNIT) is an effective immunotherapy. Peptides derived from the group 2 allergen of Dermatophagoides pteronyssinus, Dp2 28-40 and Dp2 28-40A, and fungal immunomodulatory peptide (FIP) have been shown to act as T(H)1 potential and response-inducing adjuvant. LNIT by the use of Dp2 peptides in conjunction with FIP were investigated.

OBJECTIVE

We sought to determine whether Dp2-induced airway inflammation in mice could be downregulated by Dp2 peptides or a mixture of Dp2 peptides with FIP.

METHOD

Mice were sensitized with rDp2 followed by LNIT with Dp2 peptides, FIP, or FIP and a mixture of Dp2 peptides. After intratracheal challenge with rDp2, the airway inflammation and hyperresponsiveness were determined by bronchoalveolar lavage fluid (BALF) analysis and methacholine challenge.

RESULTS

Both Dp2 peptides and FIP were able to inhibit rDp2-induced airway inflammation and airway hyperresponsiveness. An increase in IFN-gamma and a decrease in IL-5 in BALF and sera were found after LNIT with Dp2 peptides, FIP, and mixtures of both. Serum levels of TGF-beta were reduced after LNIT with FIP and Dp2 28-40. Penh values were significantly decreased after methacholine challenge in both the early and late phase.

CONCLUSIONS

LNIT with allergen-derived peptides and FIP can produce an anti-inflammatory effect on allergen-induced airway inflammation. LNIT with selected peptides and FIP might be a good alternative therapy for allergic airway disease.

The effects of an anti-CD11a mAb, efalizumab, on allergen-induced airway responses and airway inflammation in subjects with atopic asthma

BACKGROUND

Efalizumab is a humanized IgG(1) mAb against the lymphocyte function antigen-1 (LFA-1) alpha chain, CD11a. Blocking of LFA-1/intercellular adhesion molecule interactions could inhibit asthmatic inflammation by blocking adhesion and activation of LFA-1-positive leukocytes.

OBJECTIVE

A randomized, double-blinded, placebo-controlled, parallel group, multicenter study investigated the effects of efalizumab on allergen-induced airway responsiveness and airway inflammation.

METHODS

Thirty-five nonsmoking subjects with mild allergic asthma were randomized to receive efalizumab (n = 24) or placebo (n = 11) in 8 weekly subcutaneous doses (0.7 mg/kg conditioning dose followed by 7 weekly doses of 2.0 mg/kg). Allergen challenges were performed at screening and after 4 and 8 weeks of treatment. Samples of sputum (n = 18 subjects) and blood (n = 35 subjects) were collected the day before challenges, and sputum was collected again at 7 and 24 hours after each challenge. Nonparametric tests were used to compare allergen-induced differences between efalizumab and placebo groups.

RESULTS

Subjects receiving efalizumab developed headache (48%) and flu syndrome (28%) compared to subjects receiving placebo (0%). After 8 weeks of efalizumab, the maximum late percent fall in FEV(1) (late asthmatic response) was inhibited by 50%, but neither the late response nor the late area under the curve was statistically different than placebo (P =.098 and.062, respectively). Efalizumab had no effect on the maximum early percent fall in FEV(1) (early asthmatic response) or early area under the curve compared to placebo (P >.59). Efalizu-mab significantly reduced the postallergen increase in sputum EG2-positive cells and metachromatic cells (P <.05). No other comparisons were statistically different.

CONCLUSIONS

Blocking of LFA-1/intercellular adhesion module interactions by efalizumab inhibits the development of allergen-induced cellular inflammatory responses measured in induced sputum and might attenuate the late asthmatic response. Larger studies are needed to confirm this.

[Inflammation, bronchial hyperreactivity, and progression of asthma: a 5-year follow-up in grass sensitized farmers]

We studied in a group of 53 asthmatic farmers the influence of various treatment regimens on progression of disease, during five years follow-up. Specific immuno-therapy (SIT) and steroid treated patients showed significantly lower ECP levels and higher methacholine PD20 FEV1 than untreated patients, during all years of the study. During the first two years, spring ECP increase was higher in SIT treated patients than in steroid ones, however no significant differences were found during the following years. Bronchial hyperreactivity showed same course, except for a significant higher PD20 FEV1 in steroid and SIT treated asthmatics, in respect to the steroid or SIT alone. We may conclude that ECP and bronchial reactivity are useful for asthma monitoring and SIT and inhalant steroids have additional effects on asthma.

Treatment of plastic bronchitis in acute chest syndrome of sickle cell disease with intratracheal rhDNase

Plastic bronchitis, a condition associated with widespread mucous plugging of the tracheobronchial tree, is an increasingly recognised bronchoscopic finding in acute chest syndrome of sickle cell disease. Removal of casts by bronchoscopy is technically challenging. We describe a child with acute chest syndrome where bronchoscopic removal of extensive tracheobronchial plastic casts was facilitated by intratracheal rhDNase.

[Bronchoalveolar lavage in the diagnosis of occupational pulmonary diseases in miners]

One of objective methods of early and differential diagnosis of occupational pulmonary diseases in miners (pneumoconiosis, silicotuberculosis, dust bronchitis) is bronchoscopy with a cytologic examination of bronchoalveolar lavage fluid (BAF). BAF-examination was carried out in a total of 88 patients with incipient and advanced forms of dust bronchitis, pneumoconiosis and silicotuberculosis. A direct relationship has been revealed between a decline in local cell-bound immunity caused by a dust-inducted affection mononuclear phagocytes and advancing of stages of dust-related diseases.

Perioperative complications associated with brachial plexus repair in infants

This report details the complications experienced during 100 consecutive cases of brachial plexus surgery in infants. There were eight perioperative complications. There was no mortality or permanent sequelae from any complication.

Plastic bronchitis: an unusual bronchoscopic challenge associated with congenital heart disease repair

Plastic bronchitis is a rare disorder characterized by the formation of branching mucoid bronchial casts. Several pathophysiologic conditions are associated with development of these intrabronchial casts, including congenital heart defects. The management of plastic bronchitis presents an unusual and interesting bronchoscopic challenge. We describe a patient who underwent a Fontan procedure for correction of a congenital heart defect and subsequently developed respiratory distress secondary to plastic bronchitis on two occasions. In both cases, endoscopic intervention was required to remove these casts. A review of the literature, including the proposed etiologies, diagnosis, and current medical and surgical management, is also undertaken.

Respiratory and dermatological diseases in children with long-term exposure to road traffic immissions

The pathogenesis of allergies can be stimulated by adjuvant effects--i.e. air pollutants such as NO(2) and particles from diesel exhausts as well as noise--the latter especially during night-time. During sleep, noise signals which are associated with danger (i.e. lorry noise) have the potential to trigger stress reactions even if the noise level is low. Increases of cortisol in the first half of the night seem to play an important role. In a blind interview study, the combined effects of chronic exposure to traffic related air pollution and noise, upon the risk of skin and respiratory diseases in children were studied. All children between 5-12 years, who had consulted one of two participating paediatricians were included in the study. The paediatricians diagnoses of 400 children were analysed together with their parents answers regarding the density of road traffic on their street and several confounding factors. Multiple regression analyses resulted in relative risks of asthma, chronic bronchitis and neurodermitis, which increased significantly with increasing traffic load. A comparison with the literature on such effects caused by air pollution alone, showed that traffic noise during the night might have an adjuvant effect on the pathogenesis of the mentioned diseases.