Do parents who smoke underutilize health care services for their children? A cross sectional study within the longitudinal PIAMA study

Background

A higher prevalence of respiratory symptoms and an associated increase in health care utilization among children with parents who smoke is to be expected. From previous studies however, it appears that parents who smoke may underutilize health services for their children, especially with respect to respiratory care. This study explores the validity and generalizability of the previous assumption.

Methods

Data were obtained from a Dutch birth-cohort study; the Prevention and Incidence of Asthma and Mite Allergy (PIAMA) project. Information regarding parental smoking, the child's respiratory symptoms and health care use and potential confounders were obtained by postal questionnaires. Multivariate logistic models were used to relate parental smoking to the child's respiratory symptoms and health care use.

Results

The study comprised 3,564, 4-year old children. In the crude analysis, respiratory symptoms were more frequent among children with a parent who smoked, while health care utilization for respiratory symptoms was not significantly different between children with or without a parent who smoked. In the multivariate analyses, maternal smoking had a larger impact on the child's respiratory symptoms and health care use as compared to paternal smoking. Maternal smoking was positively associated with mild respiratory symptoms of the child, adjusted odds ratio [AOR] 1.50 (1.19–1.91), but not with severe respiratory symptoms AOR 1.03 (0.75–1.40). Among children with mild respiratory symptoms, children with a mother who smoked were less likely to be taken to the general practitioner (GP) for respiratory symptoms, than children with mothers who did not smoke, AOR 0.58 (0.33–1.01). This finding was less pronounced among children with severe respiratory symptoms AOR 0.86 (0.49–1.52). Neither GP visits for non-respiratory symptoms nor specialized care for respiratory disease were significantly associated with parental smoking.

Conclusion

Mothers who smoke appear to underutilize health care for their children with mild respiratory symptoms. Health care workers should be informed about this phenomenon. Inquiring after the respiratory health of the children during regular visits to healthy baby clinics may help to track potential underutilization of care.

'You think that I'm smoking and they're not': why mothers still smoke in the home

Past research into smoking and motherhood has explained how smoking enables mothers to care in conditions of hardship and poverty. However, much of this research was conducted before the risks to the health of non-smokers of inhaling tobacco smoke were widely known, and so mothers' attitudes towards passive smoking and caring remain under explored. Children living with smokers are at risk of developing serious acute and chronic conditions during childhood and later life. Despite increased awareness of health messages among parents, young children are still exposed to environmental tobacco smoke (ETS) in the home, with maternal smoking identified as the primary source of exposure. In this paper, we present the findings from a project set up to explore the changing social and environmental context of smoking and motherhood. Using focus groups, 54 mothers of children aged under five years from the Merseyside area of England, who smoked, discussed their beliefs about smoking, passive smoking and the health of their children. Although mothers were aware of the messages linking ETS exposure to childhood illnesses they appeared to rely more on their own explanations for any ill health experienced by their children, discounting smoking as a primary cause and preferring alternative explanations including 'genetics' and 'pollution'. These alternative explanations were common both within and between groups, suggesting that they form part of a wider resistant dialogue constructed within families and communities, where information about smoking and child health is received, challenged, and reconciled with existing knowledge, before being either accepted or rejected. Crucially, this alternative dialogue supports the mothers' continued smoking, and is inevitably linked to their personal need to smoke while caring. These findings have implications for the development of future strategies for promoting the health of children with mothers who are reluctant, or feel unable, to accept that smoking can affect the health of their children.

Analysis and evaluation of environmental tobacco smoke exposure as a risk factor for chronic cough

Exposure to environmental tobacco smoke (ETS) and active tobacco smoking has been shown to increase symptoms of bronchial asthma such as bronchoconstriction but effects on other respiratory symptoms remain poorly assessed. Current levels of exposure to tobacco smoke may also be responsible for the development of chronic cough in both children and adults. The present study analyses the effects of tobacco smoke exposure as potential causes of chronic cough. A panel of PubMed-based searches was performed relating the symptom of cough to various forms of tobacco smoke exposure. It was found that especially prenatal and postnatal exposures to ETS have an important influence on children's respiratory health including the symptom of cough. These effects may be prevented if children and pregnant women are protected from exposure to ETS. Whereas the total number of studies adressing the relationship between cough and ETS exposure is relatively small, the present study demonstrated that there is a critical amout of data pointing to a causative role of environmental ETS exposure for the respiratory symptom of cough. Since research efforts have only targeted this effect to a minor extent, future epidemiological and experimental studies are needed to further unravel the relation between ETS and cough.

The role of air nicotine in explaining racial differences in cotinine among tobacco-exposed children

OBJECTIVE

African-American children have higher rates of tobacco-associated morbidity. Few studies have objectively measured racial differences in the exposure of children to tobacco smoke. The objective of this study was to test whether African-American children have higher levels of cotinine compared to white children while accounting for ambient measures of tobacco smoke.

SETTING

Community-based sample of asthmatic children (n = 220) enrolled in an environmental tobacco smoke (ETS) reduction trial.

PARTICIPANTS

A biracial sample (55% African American) of children with asthma aged 5 to 12 years who were routinely exposed to ETS.

MEASUREMENTS

We measured cotinine levels in serum and hair samples at baseline, 6 months, and 12 months. We measured the level of ETS exposure over a 6-month period by placing air nicotine dosimeters in the homes of the children at baseline and at 6-month study visits.

RESULTS

African-American children had significantly higher levels of cotinine at all time points in the study. At the 12-month visit, African-American children had higher levels of serum cotinine (1.39 mug/dL vs 0.80 mug/dL, p = 0.001) and hair cotinine (0.28 ng/mg vs 0.08 ng/mg, p < 0.0001) when compared with white children. In a repeated-measures analysis, African-American children had significantly higher levels of serum cotinine (beta = 0.28, p = 0.04) and hair cotinine (beta = 1.40, p < 0.0001) compared with white children. Air nicotine levels and housing volume were independently associated with higher levels of cotinine.

CONCLUSIONS

Among children with asthma, African-American children have higher levels of serum and hair cotinine compared with white children.

Modifiable risk factors for acute lower respiratory tract infections

OBJECTIVE

Acute respiratory infection is a leading cause of morbidity and mortality in under five children in developing countries. Hence, the present study was undertaken to identify various modifiable risk factors for acute lower respiratory tract infections (ALRI) in children aged 1 mth to 5 yr.

METHODS

104 ALRI cases fulfilling WHO criteria for pneumonia, in the age group of 1 mth to 5 yr were interrogated for potential modifiable risk factors as per a predesigned proforma. 104 healthy control children in the same age group were also interrogated.

RESULTS

The significant sociodemographic risk factors were parental illiteracy, low socioeconomic status, overcrowding and partial immunization, [p value < 0.05 in all]. Significant nutritional risk factors were administration of prelacteal feeds, early weaning, anemia, rickets and malnutrition, [p value < 0.05 in all]. Significant environmental risk factors were use of kerosene lamps, biomass fuel pollution and lack of ventilation [p value < 0.05 in all]. On logistic regression analysis, partial immunization, overcrowding and malnutrition were found to be significant risk factors.

CONCLUSION

The present study has identified various socio-demographic, nutritional and environmental modifiable risk factors for ALRI which can be tackled by effective education of the community and appropriate initiatives taken by the government.

Family Attitudes About Tobacco Smoke Exposure of Young Children at Home

PURPOSE

To explore families' attitudes about smoking and their perceptions of the effects of environmental tobacco smoke (ETS) exposure on their children.

STUDY DESIGN AND METHODS

Qualitative study using face-to-face interviews with a semistructured guide in 20 households containing a child under age 5. Content analysis was done on the interview data.

RESULTS

Families identified "health protection" as the parental responsibility for children and emphasized helping children make decisions not to smoke. Some reported negative experiences with ETS exposure as children themselves or health problems in their children, reinforcing their opposition to smoke exposure for their children. Most parents said they did not allow smoking in their homes, but some later disclosed that they made exceptions for family and friends. Some parents, however, limited their children's contact with smoking members of their families. Smoking parents expressed guilt about ETS exposure of their children and tried to limit smoking to certain areas of their houses, such as the basement. Other parents, mostly the nonsmokers, did not identify ETS as a problem. Families who maintained smoke-free households identified that family and friends had to "respect" their wishes.

CLINICAL IMPLICATIONS

To protect children from the negative effects of ETS exposure, nurses should discuss not only if parents smoke but also if family members and friends are allowed to smoke in the home. It would be helpful to assess the priority that parents set on ETS and how they attempt to prevent it in their daily lives.

Clinical course in Crohn's disease: results of a five-year population-based follow-up study (the IBSEN study)

BACKGROUND

There are few population-based, prospective studies on the clinical course in patients with Crohn's disease (CD).

AIM

To extend the observation period in a population-based prospective study (the IBSEN study) to find out more about the initial 5-year clinical course in CD patients and to relate the findings to the Vienna classification.

METHODS

All patients diagnosed with inflammatory bowel disease (IBD) in southeastern Norway in the 4 years 1990-1993 were followed prospectively. The patients were invited to a systematic follow-up visit at their local hospital 1 and 5 years after inclusion in the study. The visits included a structured interview, a clinical examination and colonoscopy.

RESULTS

Out of 843 patients initially diagnosed with IBD, 200 patients with definite CD were alive and had sufficient data for analysis 5 years after diagnosis. Changes in disease localization and behaviour in relation to the Vienna classification were observed in 27 (13.5%) and 35 patients (17.5%), respectively. During the observation period, 56 patients (28%) underwent surgery with intestinal resection, and half of these had disease localized in the terminal ileum. At the time of the 5-year visit, oral sulfasalazin and 5-aminosalicylic acid (5-ASA) were the most frequently used medications (by 54% of the patients), while oral glucocorticosteroids and azathioprine were being used by 25% and 13%, respectively. Seventy-two percent of the patients had taken oral glucocorticosteroids at some time in the course of the 5-year period. The majority of the patients had intestinal symptoms at 5 years, but only 16% had symptoms that interfered with everyday activities. Fourteen percent of the patients had had a relapse-free 5-year course; however, relapse was not related to the initial Vienna classification. When the patients described the clinical course, 44% reported an improvement in symptoms during the follow-up period.

CONCLUSIONS

The 5-year clinical course in an unselected cohort of CD patients was mostly mild. The frequency of surgery was lower than that observed in other studies and only a minority of the patients had symptoms that interfered with everyday activities 5 years after the initial diagnosis. The Vienna classification predicted the risk of surgery, but did not predict symptoms at 5 years, relapses during the observation period or the course of disease as described by the patients.

Patient preferences between surgical and medical treatment in Crohn's disease

PURPOSE

Crohn's disease poses difficult choices in which the most appropriate treatment option is not always obvious. When this state of uncertainty exists, patients' preferences should have an increasingly important part of clinical decision making. The purpose of this study was to compare patients' preferences for surgical intervention in Crohn's disease with the preferences of surgeons and gastroenterologists.

METHODS

Outpatients with Crohn's disease were interviewed to quantify their preferences for six scenarios by using the prospective preference measure. An identical questionnaire was mailed to all Australian and New Zealand colorectal surgeons and a random sample of 300 Australian gastroenterologists.

RESULTS

Forty-one of 123 patients with Crohn's disease (33 percent), 92 of 127 colorectal surgeons (72 percent), and 74 of 272 gastroenterologists (27 percent) participated. There were significant differences between patients and gastroenterologists for three of six scenarios and between surgeons and gastroenterologists in four of six scenarios. Seventy-six percent of gastroenterologists were willing to gamble to avoid an ileocolic resection compared with 37 percent of surgeons (chi-squared = 25.44; P < 0.0001) and 39 percent of patients (chi-squared = 15.44; P < 0.001).

CONCLUSIONS

Patients and clinicians were able to trade and gamble life expectancy as a measure of preference for varying hypothetical surgical treatments, even though these treatment options impacted on quality of life rather than survival. Patients' preferences did not align with clinicians. For most scenarios, colorectal surgeons' preferences were significantly different to those of gastroenterologists.

Relationships between cotinine, lower respiratory tract infection, and eosinophil cationic protein in children

INTRODUCTION

The aim of this study was to investigate the effect of passive smoking on urine eosinophil cationic protein (u-ECP) in children with lower respiratory tract infections (LRTI).

METHOD

This was a case-control study. The study cohort consisted of 150 children with LRTI (case group) and 150 healthy children (control), all from a urban setting. The statistical parameters were: a minimum of 139 children for a 95% confidence interval (95% CI), 80% power, and a possible exposure prevalence of 50%. The u-cotinine and u-ECP levels were measured by radioimmunoassay and fluoroimmunoassay methods, respectively. Data were analyzed by the McNemar chi-square test, t-test, and Pearson correlation.

RESULTS

When the generally accepted cut-off level of 30 ng/mg urinary cotinine/creatinine was applied, 87.3% of the children with LRTI and 84.7% of healthy children were passive smokers. Using a cut-off level of 60 ng/mg, passive smoking increased the prevalence of LRTI by 4.7-fold (p=0.000). The mean u-ECP values were significantly higher in the case group than in the healthy control group (p=0.018). A positive association was found between u-cotinine and u-ECP values in children with LRTI (p=0.034).

CONCLUSION

The results of this study indicate that passive smoking may play an important role in the development of respiratory infections and can cause airway inflammation in children with existing LRTI.

Association between passive smoking and infection with Mycobacterium tuberculosis in children

OBJECTIVE

Tuberculosis and smoking are both significant public health problems. The association between passive smoking and Mycobacterium tuberculosis infection is not well documented. The objective of this study was to examine the influence of passive smoking on M. tuberculosis infection in children.

METHODS

A community survey was conducted in 15% of addresses in 2 adjacent low-income suburbs in Cape Town, South Africa. All children (< 15 years of age) and their adult household members residing at these addresses were included in the study. Children underwent tuberculin skin testing. An induration of > or = 10 mm was considered to define M. tuberculosis infection. Passive smoking was defined as living in the household with at least 1 adult who smoked for at least 1 year. Random-effects logistic regression analysis was performed, and odds ratios were adjusted for age, presence of a patient with tuberculosis in the household, average household income, and clustering at the household level.

RESULTS

Of 1344 children, 432 (32%) had a positive tuberculin skin test. Passive smoking was significantly associated with M. tuberculosis infection in the unadjusted analyses but not in the adjusted analyses. In the 172 households with a patient with tuberculosis, passive smoking was significantly associated with a positive tuberculin skin test but not in the 492 households without a patient with tuberculosis.

CONCLUSIONS

Passive smoking is associated with M. tuberculosis infection in children living in a household with a patient with tuberculosis. More studies are needed to confirm this observation, but the possible association is a cause of great concern, considering the high prevalence of smoking and tuberculosis in most developing countries.

Follow-up study of a randomized controlled trial of postnatal dexamethasone therapy in very low birth weight infants: effects on pulmonary outcomes at age 8 to 11 years

OBJECTIVE

To determine whether postnatal dexamethasone (DEX) exposure affects pulmonary outcomes at school age in children born with very low birth weight (VLBW).

STUDY DESIGN

Follow-up study of 68 VLBW children who participated in a randomized controlled trial of postnatal DEX. Pulmonary function was assessed by spirometry. Current asthma status was obtained from a parent.

RESULTS

Sixty-eight percent of the placebo group had below-normal forced expiratory volume in 1 second (FEV1), compared with 40% of the DEX group (chi2 = 4.84; P = .03), with trends for lower forced vital capacity (FVC) and FEV1 values in the placebo group. Fifty percent of the placebo group and 34% of DEX group had below normal FEV1/FVC (chi2 =1.59; P =.21). Parent-reported prevalence of asthma did not differ between groups. Logistic regression analysis suggested that the positive effects of DEX on pulmonary function at follow-up were mediated in part by shortened exposure to mechanical ventilation.

CONCLUSIONS

Postnatal DEX exposure was associated with higher expiratory flow with no adverse effects on pulmonary outcomes at school age. The prevalences of asthma and impaired pulmonary function underscore the influence of neonatal illness on health at school age, and stress the importance of repeated follow-up examinations of these children.

Parental smoking and children's respiratory health: independent effects of prenatal and postnatal exposure

OBJECTIVES

Adverse effects have been reported of prenatal and/or postnatal passive exposure to smoking on children's health. Uncertainties remain about the relative importance of smoking at different periods in the child's life. We investigate this in a pooled analysis, on 53,879 children from 12 cross-sectional studies--components of the PATY study (Pollution And The Young).

METHODS

Effects were estimated, within each study, of three exposures: mother smoked during pregnancy, parental smoking in the first two years, current parental smoking. Outcomes were: wheeze, asthma, "woken by wheeze", bronchitis, nocturnal cough, morning cough, "sensitivity to inhaled allergens" and hay fever. Logistic regressions were used, controlling for individual risk factors and study area. Heterogeneity between study-specific results, and mean effects (allowing for heterogeneity) were estimated using meta-analytical tools.

RESULTS

There was strong evidence linking parental smoking to wheeze, asthma, bronchitis and nocturnal cough, with mean odds ratios all around 1.15, with independent effects of prenatal and postnatal exposures for most associations.

CONCLUSIONS

Adverse effects of both pre- and postnatal parental smoking on children's respiratory health were confirmed. Asthma was most strongly associated with maternal smoking during pregnancy, but postnatal exposure showed independent associations with a range of other respiratory symptoms. All tobacco smoke exposure has serious consequences for children's respiratory health and needs to be reduced urgently.

Disadvantaged mothers, young children and smoking in the home: mothers' use of space within their homes

Breathing tobacco smoke is linked to poor health in young children, with their homes identified as the primary place of exposure. This UK study uses focus group discussions to explore how mothers living in disadvantaged areas use space within their homes to smoke while looking after children aged 0-4 years, and critically examines how they define non-smoking or smoking homes. Many women imposed temporary and ad hoc restrictions, and this research highlights how the mothers' desire to create a smoke-free environment for their children competes with their caring responsibilities, and how their efforts are restricted by the limitations of the physical environment of their homes.

Clinical risk scoring beyond initial troponin values: results from a large, prospective, unselected acute chest pain population

BACKGROUND

Risk stratifying the diverse group of patients who present to hospital with chest discomfort remains challenging. Current clinical risk models, typically derived from selected populations, are limited by their relative complexity and the absence of a well-defined role of troponin.

OBJECTIVE

To derive a simple clinical risk score from a large, unselected population of patients with chest discomfort and to delineate the prognostic value of an initial troponin measurement.

METHODS

Prospective, consecutive data were collected from patients who presented to a tertiary care hospital. Multivariate analysis was used to identify variables predictive of the primary end point: death, nonfatal myocardial infarction or revascularization at 30 days. Integer values were assigned, generating a risk score to quantify individual patient risk.

RESULTS

Among 1054 patients, predictor variables included ST-segment deviation (strongest predictor -- assigned two points), male sex, prior congestive heart failure, three or more cardiac risk factors and prior acetylsalicylic acid use (one point each). There was a progressive increase in events with increasing total score (P<0.0001), with a 15-fold gradient from scores of 0 to 4 and greater. Although a negative troponin measurement was associated with fewer events for all scores, patients with higher scores remained exposed to substantial risk. A negative initial troponin measurement conferred a negative predictive value of 97.3% (95% CI 93.7% to 99.1%) among patients with a risk score of 0.

CONCLUSION

Significant 30-day events occurred in patients with elevated risk scores, despite negative initial troponin measurements, emphasizing the importance of clinical risk stratification. This simple clinical risk score, in conjunction with a single troponin I measurement, facilitates triage of patients who present to hospital with chest discomfort.

A practical approach with outcome for the prognostic assessment of non-ST-segment elevation chest pain and normal troponin

Patients with non-ST-elevation chest pain constitute a heterogeneous population. Our aim is to compare the outcome of patients with chest pain, non-ST-segment deviation, and normal troponin, categorized using a risk score, with that of patients with ST depression or troponin increase. A total of 1,449 patients with non-ST-elevation chest pain were evaluated. A validated risk score (using pain characteristics and risk factors) was applied to patients without ST depression or troponin increase. Accordingly, 4 risk categories were defined: group 1, no troponin increase, no ST depression, and risk score <3 points (n = 633); group 2, no troponin increase, no ST depression, but risk score > or = 3 points (n = 158); group 3, no troponin increase, ST depression (n = 106); and group 4, troponin increase (n = 552). Median follow-up was 26 months, and the end point was death or myocardial infarction. Group 1 experienced fewer events at 30 days (1.7%, p = 0.0001) and long-term follow-up (9.4%, p = 0.0001) than groups 2 (10.8% and 26%), 3 (6.6% and 30%), and 4 (9.5% and 25%). Kaplan-Meier curves overlapped among groups 2, 3, and 4, whereas group 1 showed a flatter curve (p = 0.0001). Using multivariate analysis, risk group (group 1 vs remaining groups) predicted 30-day (p = 0.0003) and long-term (p = 0.0001) outcome. There were no differences among groups 2, 3, and 4. In conclusion, application of a risk score to patients without troponin increase or ST deviation identified a high-risk group with prognosis similar to that of patients with troponin increase or ST depression and affords a practical classification for the full spectrum of non-ST-elevation chest pain.

Thalidomide in luminal and fistulizing Crohn's disease resistant to standard therapies

BACKGROUND

Thalidomide has been shown to be an effective treatment in Crohn's disease.

AIM

To assess the efficacy and tolerability of thalidomide in refractory Crohn's disease patients.

METHODS

Twenty-five patients were treated. Retrospective 'estimated' Crohn's Disease Activity Indices were assessed at baseline and at the end of follow-up. Clinical response was defined as symptomatic improvement and a reduction in the 'estimated' Crohn's Disease Activity Index of >100 points, > or =50% reduction in draining fistulas or clinical improvement in perianal ulcers. Clinical remission was defined as symptom resolution and an 'estimated' Crohn's Disease Activity Index <150, complete fistula closure or complete ulcer healing.

RESULTS

Six of eight patients treated for luminal disease responded to thalidomide at a median follow-up of 12 months (three clinical responses, three clinical remissions). The median reduction in 'estimated' Crohn's Disease Activity Index was 212 points (P = 0.005). Nine of 11 patients with active fistulizing disease responded to thalidomide (six responses; three remissions). The four patients treated for both luminal and fistulizing disease had fistula response. Three of them had a response in luminal disease activity. One of two patients with ulcerating perianal disease responded. Twelve patients discontinued treatment because of adverse effects (three sedation; two abdominal pain; one leucopoenia; six neuropathy).

CONCLUSION

Thalidomide is an effective short- to medium-term treatment in selected patients with refractory luminal and fistulizing Crohn's disease. Its long-term use is limited by toxicity.

Sixty-four–slice computed tomographic coronary angiography: will the “triple rule out” change chest pain evaluation in the ED?

Sixty-four-slice computed tomographic (CT) coronary angiography is a new technique for the noninvasive visualization of the coronary arteries. It enables noninvasive detection of coronary plaque and determination of severity without instrumentation of the heart. Although not yet commonly used in the emergency department setting, it stands poised to dramatically change the way that patients with chest pain are evaluated. In addition to evaluation of the coronary arteries, CT angiography has long been used to evaluate patients for other dangerous causes of chest pain such as aortic dissection and pulmonary embolus. Although these new scanners excel at all of these diagnostic modalities, the true excitement is in the possibility of combining several different protocols into one, allowing for multiple causes of chest pain to be "ruled out" simultaneously. This article describes the current state of the art of cardiac CT, current state of research, and current areas of controversy.

Paraneoplastic syndromes in patients with primary head and neck cancer

Paraneoplastic syndromes represent the clinical manifestations of the indirect and remote effects produced by tumor metabolites or other products. The clinical spectrum of the various paraneoplastic syndromes related to primary malignancies of the head and neck region is presented. A review of the literature on paraneoplastic syndromes in patients with primary head and neck cancer was carried out. Paraneoplastic syndromes related to primary malignancies of the head and neck region can be categorized as: endocrine, cutaneous or dermatologic, hematologic, neurologic, osteoarticular or rheumatologic, ocular syndromes. Sometimes, paraneoplastic syndromes can be more serious than the consequences of the primary tumor itself and can precede, follow or be concurrent to the diagnosis of a malignancy; moreover, they can dominate the clinical picture and thus lead to errors with respect to the origin and type of the primary tumor. Physicians who deal with cancer-associated syndromes should be able to differentiate the paraneoplastic syndromes from the benign disorders that mimic them. Patients with a suspected paraneoplastic disorder should undergo a complete panel of laboratory studies, in addition to imaging studies and endoscopy. Identification of paraneoplastic syndromes allow the clinician to make an early diagnosis and to provide adequate treatment of tumors, with a favorable oncologic outcome and improved life expectancy for the patient. These syndromes can follow the clinical course of the tumor and thus be useful for monitoring its evolution.

Biomarkers of exposure to environmental tobacco smoke in infants

Non-invasive biomonitoring of exposure to environmental tobacco smoke (ETS) by means of hair is attractive in children, although systematic evaluation is required in infants. The objective was to compare nicotine and cotinine concentrations in hair and plasma and parentally reported exposure to ETS in a birth cohort of 411 infants. Plasma was collected from 356 six-month-old infants and hair samples were collected from 368 one-year-old infants. Concentrations of nicotine and cotinine were measured by an optimized gas chromatography-mass spectrometry (GC/MS)-based method requiring 4 mg hair or 200 microl plasma. Information was obtained on the number of days with ETS exposure during the first year of life, the smoking habits of the parents, and the number of cigarettes smoked per day in the home. All three parentally reported indices of ETS exposure were significantly associated with the biomarkers, with clear dose response relationships. There was a significant association between days with ETS exposure and nicotine in hair at relatively low exposure levels (10-99 days per year), whereas the other biomarkers only showed significant increases at higher exposure levels. In conclusion, nicotine in hair appears to be the biomarker most strongly associated with parental reports on exposure to ETS in infants.

Target-controlled infusion during monitored anesthesia care in patients undergoing EUS: propofol alone versus midazolam plus propofol. A prospective double-blind randomised controlled trial

BACKGROUND

It has been speculated that midazolam may be effective in reducing the required dose of propofol during sedation.

AIM

To evaluate the sparing effect of midazolam during target-controlled propofol infusion.

METHODS

Two hundred-seventy patients undergoing upper endoscopic ultrasound were randomised to receive sedation with propofol plus placebo (group A) or plus midazolam (group B). Outcome parameters were the procedure duration, the discharge time and the satisfaction of patients, operator and nurse about the quality of sedation.

RESULTS

The mean propofol dose administered was 364+/-207 mg in group A and 394+/-204 mg in group B. Mean procedure duration (group A: 32+/-17 min, group B: 35+/-22 min) and discharge time (group A: 39+/-30 min, group B: 38+/-24 min) were similar in both groups. No severe complications were observed. The quality of sedation was judged satisfactory for all patients by both the endoscopist and the nurse assistant without any difference between the two groups. No patient remembered the procedure or reported it as unpleasant.

CONCLUSIONS

Target-controlled propofol infusion provides safe and effective sedation; premedication with low dose of midazolam does not reduce the total amount of propofol administered. Further studies are needed to compare propofol alone with propofol co-administered with opioid.

Multidetector row CT of superior mesenteric artery syndrome

GOALS

The purpose of this case series is to illustrate the diagnostic criteria of superior mesenteric artery syndrome (SMAS) using 16-slice multidetector row computed tomography (MDCT) angiography with multiplanar and 3-dimensional reconstructions.

BACKGROUND

SMAS is a rare condition causing functional obstruction of the third portion of the duodenum. When suspected, diagnostic imaging can be performed with upper gastrointestinal, arteriography, or CT.

STUDY

Four patients with clinical symptoms and correlative CT evidence of SMAS are described. Axial, multiplanar, and 3-dimensional rendered MDCT images were retrospectively reviewed by 1 investigator, who measured the aortomesenteric angle and aortomesenteric distance on a sagittal maximum intensity projection rendering, and compared these values with normal ranges described in the literature.

RESULTS

In each patient, MDCT demonstrated gastric and proximal duodenal dilatation with abrupt narrowing of the third portion of the duodenum between the aorta and SMA. Sagittal maximum intensity projection images reliably demonstrated the decreased aortomesenteric angle (mean in subjects 13.5 degrees, normal range 28 to 65 degrees) and distance (mean in subjects 4.4 mm, normal range 10 to 34 mm) in all 4 patients.

CONCLUSIONS

As opposed to traditional imaging modalities like upper gastrointestinal and mesenteric arteriography, which depict either the bowel or vasculature respectively, CT enables direct visualization of obstructed bowel owing to duodenal compression by the SMA. Multiplanar MDCT with 3-dimensional rendering provides sagittal reconstructions that can be used to confirm the CT criteria of decreased aortomesenteric angle and distance in SMAS.

Sustainability of the prevention of passive infant smoking within well-baby clinics

This study assessed the antecedents of continued use of an education program to prevent passive smoking in infants. It consists of a booklet for parents and a manual for health professionals describing a five-step procedure for discussing passive smoking. A questionnaire was sent to 67 managers, 670 nurses, and 335 physicians working in well-baby clinics (response rate: 70%, 53%, 47% respectively). Questions concerned the completeness of use, level of institutionalization, and characteristics of the organization, the user, and the dissemination strategy. Seventy-one percent of nurses and 42% of physicians worked with the program. They foremost provided the first three steps of the five-step procedure. Physicians' completeness of use was related to their perceived responsibility in providing this education, and nurses' use was related to their perceived self-efficacy, responsibility, training attendance, participation in the adoption decision, and level of institutionalization. Diffusion efforts should focus on improving the completeness of use and level of institutionalization.

Migrating gallstone: from Bouveret's syndrome to distal small bowel obstruction

Gallstone ileus is an uncommon cause of small bowel obstruction. When the gallstone lodges inside the duodenum and causes gastric outlet obstruction, it is termed Bouveret's syndrome. However, it is rather unusual to seen the evolution of a migrating gallstone (from duodenum to distal small bowel) in a patient during the same hospital admission. We report a case of gallstone ileus from the initial presentation of gastric outlet obstruction to the development of distal small bowel obstruction within the same hospital admission, and its total laparoscopic treatment.

Deficiency of INFgamma producing cells in adenoids of children exposed to passive smoke

Exposure to passive smoke is a very common event associated with increased susceptibility to respiratory tract infections. Many related adverse effects result from the ability of cigarette smoke extracts to interfere with the immune system, but the mechanism is not yet completely understood. The aim of the present study is to evaluate the intracellular cytokine profile in adenoids and peripheral blood cells of children exposed to passive smoke. Children undergoing adenoidectomy exposed or not exposed to passive smoke were studied. The intracellular cytokine profile of lymphocyte subsets in adenoids and in peripheral blood were evaluated by flow cytometry analysis. Children exposed to tobacco smoke showed a significantly lower percentage of INF-gamma producing CD4+ and CD8+ cells in adenoids. Moreover a significant correlation was observed between the quantity of exposure and reduction in Th1 (CD4+INFgamma+ and CD8+INFgamma+) cells in adenoids. This reduction may be a contributing factor in the increasing susceptibility to respiratory tract infection in children exposed to tobacco smoke.

Investigating indicators and determinants of asthma in young adults

BACKGROUND

In epidemiological studies on asthma determinants an extreme variability in results exists, probably due to different criteria utilised for defining of an asthma 'case' and for measuring determinants. We aimed to assess multiple indicators and multiple determinants of asthma in young adults by applying latent variable mixture models (LVMMs), a novel statistical modelling with hidden (or latent) variables.

METHODS

We consider the pooled data of 1103 subjects (aged 20-44 years) from the three Italian centres of the European Community Respiratory Health Survey (ECRHS 1), a standardised database. Underlying multiple asthma indicators (clinicians' diagnosis, self-report symptoms, respiratory trials) both a latent two-class of asthma syndrome, and three continuous latent variables (severity of diagnosed asthma, severity of asthma symptoms, and severity of respiratory function) were investigated.

RESULTS

Family history was the more relevant predictor of the two-class of asthma syndrome with a risk increase of about 60% per 1 relative with early life events (OR = 1.60, 95% CI: 1.30-1.97). Smoking, active and passive, are predictive for the indicators of severity of asthma symptoms. On average the risk increase of about 10% (OR = 1.10, 95%CI: 1.01-1.20) either per 1 source point of environmental tobacco smoke (ETS) or per 1 packet a day per 10 years. While, the risk of the indicators of both severity of asthma symptoms (OR = 1.59, 95%CI: 1.23-2.06) and severity of respiratory function (OR = 1.37, 95%CI: 1.03-1.82) increase in women compared to men, the risk of the indicators of severity of diagnosed asthma (OR = 0.57, 95%CI: 0.35-0.91) decreases.

CONCLUSIONS

Considering latent modelling perspective for formulating plausible hypotheses in asthma research, this study highlighted that the host (genetic) component measured as number of relatives with life-events of asthma and/or allergies seems to be the primary determinants of overall observed asthma indicators summarised by hidden two-class of asthma syndrome. Furthermore, a secondary (or trigger) role of smoking on the continuous latent variable of severity of asthma symptoms, and a gender reversal effect were suggested.

Chronic myelomonocytic leukaemia after platinum-based therapy for non-small cell lung cancer: case report and review of the literature

Chronic myelomonocytic leukaemia (CMML) is a preleukaemic condition with myeloproliferative features, and classified as a part of myelodysplastic syndrome (MDS). Other than alkylating agents and topoisomerase II inhibitors, there is less evidence that chemotherapeutic drugs are associated with therapy-related CMML, acute leukaemia or MDS. We present a patient who developed CMML within 2 years of platinum-based chemotherapy for a metastatic non-small cell lung cancer. He received a cumulative dose of 240 mg/m(2) of cisplatin, and 1123 mg/m(2) of carboplatin before developing CMML. The cytogenetic study revealed trisomy 8. This is the first reported case that links platinum-based therapy with development of CMML with trisomy 8. Although the relationship between platinum therapy and the development of CMML is difficult to assess due to combinational nature of therapy in most cases, physicians should consider the possibility of CMML in patients with symptoms or signs suggestive of haematologic malignancy after platinum therapy.

Effective antitussives for the cough patient: an unmet need

Chronic cough is a prevalent symptom in the community but it is likely that only a small fraction of chronic coughers seek medical attention. Chronic cough can be controlled by addressing the 'cause' of the cough, but not all cough is controlled using this approach; an 'idiopathic' cough or cough of unknown aetiology is becoming more well-recognized. In these patients and in those whose cough has not responded to treatment of the cause(s), there is a lack of efficacious antitussive therapies ('non-specific' antitussives). Even in those whose cough is controlled by treatment of the cause, an efficacious antitussive for symptomatic relief would be useful for breakthrough symptoms. It is necessary to address the mechanisms underlying chronic cough, particularly the process of sensitization, both peripherally and centrally, that is the basis of chronic cough; such a process may persist even in the absence of the initiating event that first induced the cough. Currently-available antitussives in both acute and chronic cough are not very effective. Novel targets that may result in effective antitussives have been identified and with the development of clinical tools to measure cough accurately and reliably (e.g. cough counts and cough-specific quality-of-life questionnaires) and the evoked cough response (e.g. citric acid or capsaicin challenges), clinical trials should be performed. The chronic cough population is clinically heterogeneous but is characterized by an enhanced cough reflex; this should be the target population for study. Patients with chronic cough are in desperate need of effective antitussives that can be used either on demand or on a long-term basis.

Population level policy options for increasing the prevalence of smokefree homes

OBJECTIVE

To identify and evaluate the options for population level government policies to increase the prevalence of homes free of secondhand smoke.

METHODS

The literature was searched for population level policy options and evidence on them. Three criteria were used to evaluate the policy options: effectiveness, the reductions on inequalities in secondhand smoke exposure, and cost effectiveness. The setting was four developed, English speaking jurisdictions: Britain, USA, Australia, and New Zealand.

RESULTS

Evidence from all four countries shows some association between relatively comprehensive tobacco control programmes and lower prevalence levels of smoking in homes. The evidence of the effect of such programmes on inequalities in smokefree home prevalence is limited. No published evidence was found of the cost effectiveness of the programmes in achieving changes in smokefree homes. Within comprehensive programmes, there is some indirect evidence that some mass media campaigns could increase the prevalence of smokefree homes. Structural options that have potential to support smokefree homes include smokefree places legislation, and laws for the protection of children.

CONCLUSION

The available evidence to date suggests that comprehensive tobacco control programmes (to reduce the prevalence of smoking in the total population) are likely to be the most effective and sustainable option for increasing the prevalence of smokefree homes.

Prevalence and predictors of home and automobile smoking bans and child environmental tobacco smoke exposure: a cross-sectional study of U.S.- and Mexico-born Hispanic women with young children

BACKGROUND

Detrimental effects of environmental tobacco smoke (ETS) exposure on child health are well documented. Because young children's primary exposure to ETS occurs in homes and automobiles, voluntary smoking restrictions can substantially reduce exposure. We assessed the prevalence of home and automobile smoking bans among U.S.- and Mexico-born Hispanics in the southwestern United States, and examined the influence of mother's country of birth and smoking practices on voluntary smoking bans and on child ETS exposure.

METHODS

U.S.- and Mexico-born Hispanic mothers of children aged 2 through 12 years were systematically sampled from health clinics in Albuquerque, New Mexico. In-person interviews were conducted with 269 mothers (75.4% response rate) to obtain information on main study outcomes (complete versus no/partial home and automobile smoking bans; child room and automobile ETS exposure) and risk factors (mother's country of birth, maternal and household smoking behaviors). Data were analyzed with chi square tests and logistic regression models.

RESULTS

Three-fourths (74-77%) of U.S.-born and 90-95% of Mexico-born mothers reported complete automobile and home smoking bans. In multivariate analyses, mother's U.S nativity, mother's current smoking, and presence of other adult smokers in the home were associated with significantly increased odds of not having a complete home or automobile smoking ban. Mother's smoking was associated with child ETS exposure both indoors (odds ratio [OR] = 3.31) and in automobiles (OR = 2.97). Children of U.S.-born mothers had increased odds of exposure to ETS indoors (OR = 3.24; 95% confidence interval [CI]: 1.37-7.69), but not in automobiles. Having complete smoking bans was associated with substantially reduced odds of child ETS exposure both indoors (OR = 0.10; 95% CI: 0.04-0.27) and in automobiles (OR = 0.14; 95% CI: 0.05-0.36).

CONCLUSION

This study of Hispanic mothers in the southwestern U.S. indicates that there are substantial differences between U.S.- and Mexico-born mothers in the prevalence of home and automobile smoking bans, and resulting child ETS exposure. Tobacco interventions to increase smoke-free environments for U.S. Hispanic children should focus on both home and automobile smoking practices, especially among U.S.-born mothers, and utilize strategies that impact smoking practices of all household members.

Smoking hygiene: reducing infant exposure to tobacco

The American Academy of Pediatrics recently removed nicotine from the list of drugs contraindicated during breastfeeding. The objective of this study was to evaluate the feasibility of determining the effect of a smoking hygiene intervention on infants of breastfeeding mothers who smoke cigarettes. An experimental design with repeated measures was used. A convenience sample of 35 mother-infant dyads from seven sites was recruited and randomly assigned to the intervention or control group. Of the 27 dyads completing the study, 16 were in the experimental group and 11 were in the control group. Smoking hygiene was introduced when infants were 2 weeks old and reinforced when they were 3 and 5 weeks old. At these three data points, infant health and urinary nicotine and cotinine levels were measured, as well as the mothers' breast-milk nicotine and cotinine levels and smoking hygiene behaviors. Recruiting and retaining a sample of breastfeeding mothers who smoke proved difficult. Only 27% of women in the intervention group implemented all aspects of the smoking hygiene intervention behaviors. Repeated-measures ANOVA revealed no difference in a) infant urinary nicotine and cotinine levels or b) breast-milk nicotine and cotinine levels between the two groups. The McNemar test for related samples revealed no difference between frequency of respiratory symptoms in either the control or intervention groups when Week 2 levels were compared with levels at Weeks 3 and 5. Mothers were not successful in adhering to the smoking hygiene intervention. To adequately test interventions, strategies must be developed to help women incorporate health-promoting behaviors into their lives.

[Bronchial asthma. Update 2006]

Bronchial asthma, with a prevalence in Germany of 5% among adults and 10% among children, remains a frequent disease. Newer cell biological data show a separate regulation of the allergy (interleukin 4, IL-4, pathway) and of the eosinophilic inflammation in asthma (IL-5 pathway). Both conditions require a therapeutic approach. To prevent irreversible bronchial remodeling, early diagnosis and targeted therapy are decisive. Bronchial asthma is regarded as evident when the paroxysmal character of the disease is confirmed and an-at least intermittent-obstructive ventilation disorder is apparent which responds well to short-acting beta2-adrenergic agents. Current asthma treatment has been assured in many studies (evidence level A) and is based on therapy in stages which classifies therapeutic measures depending on four grades of severity. Accordingly, most patients are largely without complaints, and nocturnal attacks are now rare. New medications are intended to overcome any remaining therapeutic weak points. Antileukotrienes and anti-IgE antibodies can contribute to reducing the necessary corticosteroids. Pharmaceutical agents that intervene in the IL-4 or IL-5 regulation or prevent remodeling are being developed.

Biliary stone causing afferent loop syndrome and pancreatitis

We report the case of an 84-year-old female who had a partial gastrectomy with Billroth-II anastomosis 24 years ago for a benign peptic ulcer who now presented an acute pancreatitis secondary to an afferent loop syndrome. The syndrome was caused by a gallstone that migrated through a cholecystoenteric fistula. This is the first description in the literature of a biliary stone causing afferent loop syndrome.

Troponin assays for the diagnosis of myocardial infarction and acute coronary syndrome: where do we stand?

Under normal circumstances, most intracellular troponin is part of the muscle contractile apparatus, and only a small percentage (< 2-8%) is free in the cytoplasm. The presence of a cardiac-specific troponin in the circulation at levels above normal is good evidence of damage to cardiac muscle cells, such as myocardial infarction, myocarditis, trauma, unstable angina, cardiac surgery or other cardiac procedures. Troponins are released as complexes leading to various cut-off values depending on the assay used. This makes them very sensitive and specific indicators of cardiac injury. As with other cardiac markers, observation of a rise and fall in troponin levels in the appropriate time-frame increases the diagnostic specificity for acute myocardial infarction. They start to rise approximately 4-6 h after the onset of acute myocardial infarction and peak at approximately 24 h, as is the case with creatine kinase-MB. They remain elevated for 7-10 days giving a longer diagnostic window than creatine kinase. Although the diagnosis of various types of acute coronary syndrome remains a clinical-based diagnosis, the use of troponin levels contributes to their classification. This Editorial elaborates on the nature of troponin, its classification, clinical use and importance, as well as comparing it with other currently available cardiac markers.

Glutathione s-transferases M1 and P1 prevent aggravation of allergic responses by secondhand smoke

RATIONALE

Secondhand tobacco smoke (SHS) and traffic-related air pollutants are associated with asthma and allergy. Diesel exhaust particles (DEPs) and SHS can interact with allergens in exacerbating allergic airway diseases through generation of reactive oxygen species. Glutathione S-transferases (GSTs) metabolize reactive oxygen species and detoxify electrophilic xenobiotics present in SHS and DEPs.

OBJECTIVES

We tested the hypotheses that functional GSTM1-null genotype and GSTP1 codon 105 variants (Ile105 and Val105) are determinants of allergic responses to SHS, and that responses to SHS and DEPs are correlated.

METHODS AND MEASUREMENTS

In a randomized, placebo-controlled crossover trial, 19 ragweed allergen-sensitive subjects who had previously participated in a DEP trial were challenged intranasally with allergen after having been exposed to either clean air or SHS at separate visits. Nasal allergen-specific IgE, histamine, IL-4, and IFN-gamma levels were measured before and after allergen challenge.

MAIN RESULTS

Individuals with GSTM1-null or GSTP1 Ile105 genotypes showed larger nasal responses to allergens with SHS compared with clean air. GSTM1-null subjects had a larger increase in IgE than GSTM1-present subjects (median, 173.3 vs. 46.7 U/ml; p = 0.03), and the Ile105 GSTP1 genotype subjects had increased histamine (median, 10.2 vs. 4.6 nM; p = 0.01) after SHS plus allergen challenge. Responses to SHS and DEPs were correlated. Enhancement of IgE and histamine was greatest in the subjects with both the GSTM1-null and GSTP1 Ile/Ile genotypes.

CONCLUSIONS

GSTM1 and GSTP1 are important cytoprotective factors that reduce SHS and DEP exacerbation of allergic responses.

The prevalence of atopy in asthmatic children correlates strictly with the prevalence of atopy among nonasthmatic children

BACKGROUND

Because asthma preferentially burdens persons with atopy, atopy is simplistically considered a primary 'cause' of asthma. Yet at the population level, the percentage of asthma cases 'attributable' to atopy ranges from less than 10% to more than 60%. Seeking to understand the rationale for the variability of atopy-attributable cases of asthma, we systematically reviewed the results of our own previous epidemiological studies and several studies conducted by others in children.

METHODS

From each of the 37 random pediatric populations selected by a Medline search combining the key words 'IgE or skin tests or hypersensitivity, immediate' with 'epidemiological studies, cross-sectional, case-control, prevalence, longitudinal, epidemiology of asthma' (12 from our previous pediatric surveys and a further 25 reported from 19 studies in children), we extracted the population prevalence of asthma and atopy among asthmatic subjects and among the nonasthmatic part of the population.

RESULTS

No correlation was found between the prevalence of asthma (range 1.8-44.1%) and atopy (range 5.8-63.9%) in these 37 populations of children (r = 0.052, p = 0.761). Nevertheless, the prevalence of atopy among asthmatics strictly correlated with the prevalence of atopy in nonasthmatics (r = 0.900, p < 0.001, slope 1.364).

CONCLUSION

The prevalence of asthma and atopy varies worldwide and at various time points and independently undergoes the influence of powerful environmental factors. The almost perfect correlation we found between atopy in asthmatics and atopy in the nonasthmatic part of the childhood population shows that the prevalence of atopy in asthma depends on environmental factors that simultaneously induce atopy in asthmatic and nonasthmatic subjects.

Predictors of the participation of smoking parents in a proactive telephone-based smoking cessation program

OBJECTIVE

The objective of this study is to identify the predictors of participation by smoking parents in a proactive telephone-based smoking cessation program.

METHODS

The smoking parents of young children from a birth cohort were interviewed and invited to take part in a telephone-based smoking cessation program. The characteristics of the parents and the predictors of participation were analyzed by chi-square test and by logistic regression.

RESULTS

A total of 952 (82.9%) out of the 1149 smoking parents who were interviewed agreed to participate in the smoking cessation program. The analysis showed that the predictors of participation in a pro-active smoking cessation program are being from a middle-income household, being currently employed, having recently had a medical consultation or been hospitalized, being at the stage of contemplating a change in behavior, and perceiving the importance of quitting smoking.

CONCLUSIONS

Recruitment approaches should be refined according to the identified factors to target those who might decline an invitation to participate in a smoking cessation program.

Sedation in endoscopic practice

Sedation impacts every aspect of endoscopy practice--the quality fo the examination, the satisfaction of endoscopist and of patient, the efficiency and cost of delivering services, and the compliance of patients with surveillance guidelines. New sedation agents and improved patient-monitoring and drug-delivery technologies are challenging traditional practices. Increasing demand for endoscopic services, shrinking reimbursements, and competing diagnostic technologies are prompting recognition that new approaches to sedation can improve practice efficiency and patient outcome. This article discusses new developments in endoscopic sedation and their implications for practice management.

Long-term outcome after intestinal resection for Crohn's disease

OBJECTIVE

To assess the need for intestinal repeat resection for recurrence of Crohn's disease in patients observed for more than 20 years after the first resection.

MATERIAL AND METHODS

Data were gathered retrospectively from the medical records of 53 (28 F) consecutive patients with Crohn's disease from May 1954 to December 2002. Median age at first intestinal resection was 24.5 (range 13-65) years, and median observation time thereafter was 26.5 (20.1-48.6) years. Disease location and behaviour were defined according to the Vienna classification.

RESULTS

The 53 patients had an average 2.7 and a median 2 intestinal resections. Out of 144 intestinal resections (77.1%) 111 were performed during the first three operations; no alterations in distribution of ileal, ileocolic and colic resections were found. From the first to the third operation there was an increase in penetrating disease from 15% to 39% (p=0.046) concomitant with a decrease in stricturing disease from 72% to 44% (p=0.048) of the patients. There was also a corresponding decrease in ileocolic disease from 45% to 5% (p=0.003) and a tendency towards an increase in ileal disease from 38% to 67%. One patient died (1.8%) from rectosigmoid perforation after the third resectional operation. Six patients needed reoperation (11.3%) for ileus, anastomotic bleeding, rectosigmoidal perforation and abdominal pain. Thirty-four patients (64.2%) needed intestinal repeat resection (median 8.3 years) during 25.3 years after the first repeat resection.

CONCLUSIONS

This study indicates a diminution of Crohn's disease activity with time, as demonstrated by no need for intestinal repeat resection more than 25 years after the first resection.

Prognostic usefulness of white blood cell count on admission and one-year outcome in patients with non-ST-segment elevation acute chest pain

Little is known about the prognostic value of leukocyte count on admission for patients with chest pain. In total, 1,461 patients who presented to the emergency department with non-ST-segment elevation chest pain were studied by clinical history, electrocardiography, serial troponin I determination, and leukocyte count on admission. End points were 1-year mortality and major events (mortality or infarction). Overall patient distribution by quartiles of leukocyte count showed increased mortality (6%, 7%, 6%, and 17%, p = 0.0001) and major events (13%, 13%, 15%, and 24%, p = 0.0001) in the fourth quartile. After adjustment for other risk factors, the fourth quartile cut-off value (>10,000 cells/ml) predicted mortality (hazard ratio 2.0, 95% confidence interval 1.4 to 2.8, p = 0.0001) but not major events (p = 0.07). When analysis was performed to assess troponin status, in the subgroup with increased troponin (n = 634, 16% mortality), a leukocyte count >10,000 cells/ml was related to mortality (hazard ratio 2.2, 95% confidence interval 1.5 to 3.4, p = 0.0001). However, in the subgroup with normal troponin levels (n = 827, 4.2% mortality), there were no differences in mortality between patients with or without a leukocyte count >10,000 cells/ml (4.4% vs 4.2%, p = 0.8), with survival curves showing a tight overlap (p = 0.9). Further, in the subgroup with normal troponin levels, leukocyte count was not significantly different between patients with or without ST depression (7,969 +/- 2,171 vs 8,108 +/- 2,356 cells/ml, p = 0.6) and was not associated with mortality in patients with ST depression (p = 0.7). In conclusion, leukocyte count on admission is predictive of mortality in patients with chest pain and non-ST-segment elevation myocardial infarction. However, in the absence of myocardial necrosis, leukocyte count lacks prognostic value.

Factors affecting recurrence in patients with Crohn's disease under nutritional therapy

PURPOSE

This retrospective study was designed to determine risk factors for recurrence of Crohn's disease under enteral nutrition.

METHODS

The clinical course of 145 patients with Crohn's disease, who were primarily induced into remission by total parenteral nutrition, was reviewed. The patients were classified into two groups: enteral nutrition group (n = 98; >/=1,200 kcal/day of enteral nutrition), or nonenteral nutrition group (n = 47;<1,200 kcal/day of enteral nutrition) according to the amount of their daily elemental or polymeric diet. Contributions of enteral nutrition and other clinical variables to the recurrence were analyzed retrospectively. A Crohn's disease activity index of >150 plus an increase in Crohn's disease activity index of >70 from the baseline value was defined as recurrence.

RESULTS

Forty-two patients in the enteral nutrition group and 29 patients in the nonenteral nutrition group recurred during periods ranging from 3 to 159 months. The cumulative rate of recurrence was significantly higher in the nonenteral nutrition group than in the enteral nutrition group (P = 0.047). Among the Crohn's disease patients in the enteral nutrition group, penetrating type (relative risk, 3.89; 95 percent confidence interval, 1.58-9.62), colonic involvement (relative risk, 3.10; 95 percent confidence interval, 1.39-6.9), and previous history of surgery (relative risk, 2.48; 95 percent confidence interval, 1.16-5.33) were factors that significantly affected recurrence. In contrast, penetrating type was the only possible factor associated with recurrence in the nonenteral nutrition group (relative risk, 2.75; 95 percent confidence interval, 0.96-7.81).

CONCLUSIONS

Among patients with Crohn's disease under maintenance enteral nutrition, the risk of recurrence differs according to the disease type and the site of involvement. The maintenance treatment by enteral nutrition alone seems insufficient for patients with penetrating type or with colonic involvement.

Eosinophilic disorders: molecular pathogenesis, new classification, and modern therapy

Before the 1990s, lack of evidence for a reactive cause of hypereosinophilia or chronic eosinophilic leukemia (e.g. presence of a clonal cytogenetic abnormality or increased blood or bone marrow blasts) resulted in diagnosticians characterizing such nebulous cases as 'idiopathic hypereosinophilic syndrome (HES)'. However, over the last decade, significant advances in our understanding of the molecular pathophysiology of eosinophilic disorders have shifted an increasing proportion of cases from this idiopathic HES 'pool' to genetically defined eosinophilic diseases with recurrent molecular abnormalities. The majority of these genetic lesions result in constitutively activated fusion tyrosine kinases, the phenotypic consequence of which is an eosinophilia-associated myeloid disorder. Most notable among these is the recent discovery of the cryptic FIP1L1-PDGFRA gene fusion in karyotypically normal patients with systemic mast cell disease with eosinophilia or idiopathic HES, redefining these diseases as clonal eosinophilias. Rearrangements involving PDGFRA and PDGFRB in eosinophilic chronic myeloproliferative disorders, and of fibroblast growth factor receptor 1 (FGFR1) in the 8p11 stem cell myeloproliferative syndrome constitute additional examples of specific genetic alterations linked to clonal eosinophilia. The identification of populations of aberrant T-lymphocytes secreting eosinophilopoietic cytokines such as interleukin-5 establish a pathophysiologic basis for cases of lymphocyte-mediated hypereosinophilia. This recent revival in understanding the biologic basis of eosinophilic disorders has permitted more genetic specificity in the classification of these diseases, and has translated into successful therapeutic approaches with targeted agents such as imatinib mesylate and recombinant anti-IL-5 antibody.