Symptom control among asthmatics with a clinically significant smoking history: a cross-sectional study in Finland.

BACKGROUND: Surprisingly little is known about asthma control among asthmatics who smoke. The aim of this cross-sectional study was to investigate asthma symptom control according to the GINA guidelines among asthmatics with a clinically significant smoking history. METHODS: One hundred ninety asthmatics from primary care in Finland were investigated. The patients were current or previous cigarette smokers with a history of 10 or more pack-years. They completed a questionnaire including questions on asthma symptoms and reliever use so that their level of asthma symptom control (well controlled, partly controlled, or uncontrolled) according to GINA could be determined. RESULTS: Sixty-six (34.7%) patients had their asthma well controlled, 81 (42.6%) had their asthma partly controlled, and 43 (22.6%) had uncontrolled asthma. Current smokers had uncontrolled asthma more often than ex-smokers, OR 2.54 (95% CI 1.25-5.14, p = 0.01). Patients with moderate to severe asthma exacerbation during the previous year had uncontrolled asthma more often than patients without an exacerbation, OR 2.17 (95% CI 1.06-4.47, p = 0.04), and patients with FEV1 <  80% of predicted had uncontrolled asthma more often than patients with FEV1 > 80% of predicted, OR 2.04 (95% CI 1.02-4.08, p = 0.04). CONCLUSIONS: Asthmatic patients with a clinically significant smoking history often do not have well controlled asthma. Poor asthma symptom control was associated with current smoking status, history of exacerbations and impaired lung function. Therefore, every attempt should be made to help asthmatics who smoke to quit smoking.

Reflux symptoms and side effects among patients with gastroesophageal reflux disease at baseline, during treatment with PPIs, and after Nissen fundoplication.

BACKGROUND: There are no prospective studies available on the behavior of extraesophageal and esophageal symptoms and treatment-related side effects in patients without effective antireflux medication, receiving the most effective antireflux medication, and after laparoscopic fundoplication. METHODS: Extraesophageal and esophageal reflux symptoms and treatment-related side effects were assessed in 60 patients while they were on no effective antireflux medication (three-week washout period), after three month of treatment with double-dose esomeprazole, and 3 months after laparoscopic Nissen fundoplication. Esophageal and extraesophageal reflux symptoms, rectal flatulence, and bloating were analyzed with the visual analog scale. In addition, dysphagia, rectal flatulence, and bloating were recorded as none, mild, moderate, or severe. RESULTS: Both extraesophageal and esophageal reflux symptoms decreased after treatment with esomeprazole and were further reduced after fundoplication. Dysphagia and flatulence did not increase from baseline after surgery. Bloating decreased both after treatment with esomeprazole and after fundoplication. In contrast, dysphagia and increased flatus were found more often after surgery than during treatment with esomeprazole. Dysphagia and rectal flatulence were less common during treatment with esomeprazole than at baseline or after surgery. CONCLUSIONS: Both extraesophageal and esophageal reflux symptoms decreased after treatment with esomeprazole and were reduced further after fundoplication. Any treatment-related side effect was not increased after surgery when compared to baseline. However, compared to esomeprazole there was more dysphagia and flatulence after fundoplication.

Effect of esomeprazole 40 mg once or twice daily on asthma: a randomized, placebo-controlled study.

RATIONALE: Gastroesophageal reflux disease (GERD) is common among patients with asthma; however, studies investigating the effect of proton pump inhibitors on asthma outcomes report conflicting results. OBJECTIVES: To investigate the effect of esomeprazole 40 mg once or twice daily on asthma outcomes in patients with concomitant symptoms of GERD. METHODS: This 26-week, randomized, double-blind, placebo-controlled study (NCT00317044) included adult patients (18-70 yr) with moderate-to-severe asthma and symptomatic GERD. The change in morning peak expiratory flow (primary variable), evening peak expiratory flow, FEV(1), asthma symptoms, Asthma Quality of Life Questionnaire, Reflux Disease Questionnaire, and tolerability were assessed. MEASUREMENTS AND MAIN RESULTS: A total of 961 patients were randomized and 828 completed the study. Relative to baseline, improvement in morning peak expiratory flow was observed for both esomeprazole 40 mg once daily (+3.5 L/min; 95% CI, -3.2 to 10.2) and 40 mg twice daily (+5.5 L/min; 95% CI, -1.2 to 12.2), although no statistically significant between-treatment differences were apparent. At treatment end, both doses of esomeprazole significantly improved FEV(1) versus placebo (+0.09 L and +0.12 L; P = 0.0039 and P < 0.0001, respectively). However, only esomeprazole 40 mg twice daily demonstrated a significant improvement when FEV(1) was calculated over the entire 26-week period (+0.07 L; P = 0.0042). Significant improvements in Asthma Quality of Life Questionnaire total score were demonstrated for both esomeprazole doses compared with placebo (+0.28 and +0.41; P = 0.0006 and P < 0.0001, respectively). CONCLUSIONS: Esomeprazole may improve pulmonary function and asthma-related quality of life. However, the improvements were minor and of small clinical significance.

[The effect of public defense of a doctoral thesis on the heart rate of the doctoral candidate]. / Väitöstilaisuuden vaikutus väittelijän sydämen syketaajuuteen.

The effect of public defense of a doctoral thesis on the heart rate of the doctoral candidate Most doctoral candidates find the public defense of a doctoral thesis an exciting and stressful experience. In this study, Holter recording during the defense was made for four doctoral candidates of the Faculty of Medicine. Maximum heart rate among the subjects was on the average 172 beats/min with a median heart rate of 116 beats/min. Sympathicotonia and release of stress hormones associated with the defense raise the heart rate to levels that may be very high for several hours. This is a risk factor for a coronary event and should be considered, if the doctoral candidate has coronary heart disease, carries risk factors for coronary heart disease, or is an elderly person.

Annual costs of chronic obstructive pulmonary disease in Finland during 1996-2006 and a prediction model for 2007-2030.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a major burden for the health care system, but the exact costs are difficult to estimate and there are insufficient data available on past and future time trends of COPD-related costs. AIMS: The aim of the study was to calculate COPD-related costs in Finland during the years 1996-2006 and estimate future costs for the years 2007-2030. METHODS: COPD-related direct and indirect costs in the public health care sector of the whole of Finland during the years 1996-2006 were retrieved from national registers. In addition, we made a mathematical prediction model on COPD costs for the years 2007-2030 on the basis of population projection and changes in smoking habits. RESULTS: The total annual COPD-related costs amounted to about 100-110 million Euros in 1996-2006, with no obvious change, but there was a slight decrease in direct costs and an increase in indirect costs during these years. The estimation model predicted a 60% increase up to 166 million Euros in COPD-related annual costs by the year 2030. This is caused almost entirely by an increase in direct health care costs that reflect the predicted ageing of the Finnish population, as older age is a significant factor that increases the need for hospitalisation. CONCLUSIONS: The total annual COPD-related costs in Finland have been stable during the years 1996-2006, but if management strategies are not changed a significant increase in direct costs is expected by the year 2030 due to ageing of the population.

Prevalence of asthma-COPD overlap syndrome among primary care asthmatics with a smoking history: a cross-sectional study.

BACKGROUND: The overlap between asthma and chronic obstructive pulmonary disease (COPD) is an important clinical phenomenon. However, the prevalence of asthma-COPD overlap syndrome (ACOS) is not known. AIMS: To investigate the prevalence of ACOS among asthmatic patients with a smoking history, and evaluate the factors predicting ACOS in this patient group. METHODS: We investigated 190 primary care asthma patients with no previous diagnosis of COPD, but who were either current or ex-smokers, with a smoking history of at least 10 pack-years. Spirometry was performed on all the patients while they were taking their normal asthma medication. Patients were considered to have ACOS if their postbronchodilator forced expiratory volume in 1 s/forced vital capacity was < 0.70. RESULTS: Fifty-two (27.4%) of the patients were found to have ACOS. Age ⩾ 60 years and smoking for ⩾ 20 pack-years were the best predictors of ACOS. If both of these criteria were met, the odds ratio (95% confidence interval) for ACOS was 6.08 (2.11-17.49), compared with the situation where neither of these criteria were fulfilled. CONCLUSIONS: There is a high prevalence of ACOS among primary health care asthmatics with a positive smoking history but no previous diagnosis of COPD. In this population, age over 60 years and a smoking history of more than 20 pack-years were the best predictors of ACOS.

The role of proton pump inhibitors in the management of gastroesophageal reflux disease-related asthma and chronic cough.

Gastroesophageal reflux disease (GERD) occurs in at least one third of patients with asthma and is recognized as a potential trigger for asthma symptoms. The results of studies conducted in patients with both asthma and GERD, in which proton pump inhibitor (PPI) therapy is used to evaluate its effect on asthma outcome, are inconsistent, and many of these studies suffer from different design flaws. However, it does appear that PPI treatment may improve nocturnal asthma symptoms in patients who also have GERD. Moreover, both daytime asthmatic symptoms and pulmonary function seem to improve in some patients with PPI treatment. There is evidence that more severe GERD might predict a more favorable asthma outcome with PPI therapy. For effective management of GERD-related asthma, PPIs should be used at a dose double that of the standard dose for a minimum of 2 to 3 months. Although GERD is also known to be an important cause of chronic cough, there have been only 2 placebo-controlled trials investigating the efficacy of PPI on GERD-related chronic cough. Results of both of these trials suggest that PPI treatment relieves GERD-related chronic cough. As with GERD-related asthma, it would seem reasonable to use a double-standard dose of a PPI for a minimum of 2 to 3 months in the management of GERD-related chronic cough. However, larger, adequately planned studies are needed to confirm the role of PPIs in the management of GERD-related asthma and chronic cough.

The prevalence of gastroesophageal reflux disease in adult asthmatics.

BACKGROUND: Asthma and gastroesophageal reflux disease (GERD) often coexist. However, the results of the studies investigating the prevalence of GERD among patients with asthma vary greatly. STUDY OBJECTIVE: To investigate the prevalence of GERD in adult patients with asthma. SUBJECTS AND METHODS: The basic study population consisted of 2,225 asthmatic patients who were treated in six specialist-headed hospitals during 1 year. From the common computer-based discharge register, every 14th patient was randomly selected for the study. Ninety of the 149 contacted patients (60%) agreed to participate in the study. Twenty-four-hour esophageal pH monitoring was performed on all patients. RESULTS: GERD was found in 32 of the patients (36%). Eight of these patients (25%) were free from classical reflux symptoms. Forty-seven of the 90 patients (52%) presented with typical reflux symptoms. Twenty-four of these patients (51%) were found to have abnormal acidic reflux. CONCLUSIONS: According to the current study, one third of adult patients with asthma have GERD. These patients often do not have typical reflux symptoms. However, the presence of typical reflux symptoms in an asthmatic patient does not seem to guarantee the presence of abnormal acidic reflux.

Comparison of the effects of esomeprazole and fundoplication on airway responsiveness in patients with gastro-oesophageal reflux disease.

INTRODUCTION: Gastro-oesophageal reflux disease (GORD) is suggested to cause or aggravate several respiratory conditions. Studies with proton pump inhibitors have resulted in only minor improvements in pulmonary outcomes in patients with GORD. It has been speculated that operative treatment of GORD might be more efficient as it also diminishes non-acidic reflux. OBJECTIVES: To compare the effects of esomeprazole 40 mg bid and fundoplication on airway responsiveness, forced expiratory volume in 1 s (FEV1), exhaled nitric oxide (NO) and respiratory symptoms in patients with moderate-to-severe GORD. METHODS: Sixty-nine GORD patients had methacholine inhalation challenge performed on them, and FEV1, exhaled NO and respiratory symptoms were measured at baseline, after a 3-month treatment with esomeprazole and 3 months after fundoplication. Primary outcome variable was dose-response slope (DRS), i.e. decline in FEV1 during methacholine challenge divided with the amount of methacholine administered (%/µmol). Pre-defined subgroup analysis was performed among those with concomitant asthma (n = 12). RESULTS: There was no improvement in DRS, FEV1 or exhaled NO after esomeprazole treatment or fundoplication. Cough and dyspnoea measured with visual analog scale improved with esomeprazole treatment (P < 0.001), and further after fundoplication (P < 0.001). Among those with concomitant asthma, significant improvements in St George Respiratory Questionnaire (SGRQ) scores could be seen after fundoplication. CONCLUSIONS: Neither esomeprazole treatment nor fundoplication diminishes airway responsiveness or exhaled NO, or improves FEV1 in patients with GORD. Improvements in respiratory symptoms and SGRQ scores after GORD treatments could be detected. However, as this was not a placebo-controlled study, the findings in these secondary endpoints should not be emphasised. ClinicalTrials.cov: NCT00994708.

Effects of esomeprazole 40 mg twice daily on asthma: a randomized placebo-controlled trial.

RATIONALE: Gastroesophageal reflux disease (GERD) is common in patients with asthma, suggesting an interaction between the two conditions. OBJECTIVES: To assess the effect of gastric acid suppression with the proton pump inhibitor esomeprazole on asthma outcomes in subjects with persistent moderate to severe asthma treated with antiinflammatory asthma medication. METHODS: In this double-blind study, subjects were randomized to receive esomeprazole 40 mg or placebo twice daily for 16 wk. According to nocturnal respiratory symptoms (NOC) and GERD, subjects were divided into three strata: GERD-/NOC+, GERD+/NOC-, and GERD+/NOC+. MEASUREMENTS AND MAIN RESULTS: A total of 770 subjects were randomized. There was no statistically significant improvement in morning peak expiratory flow (PEF) over placebo in the overall study population: 6.3 L/min (p = 0.061). Over the whole treatment period, in GERD+/NOC+ subjects (n = 350), esomeprazole provided an 8.7-L/min improvement (p = 0.03) in morning PEF, and a 10.2-L/min improvement (p = 0.012) in evening PEF over placebo. Among 307 subjects taking long-acting beta2-agonists, improvements over placebo were observed in morning PEF (12.2 L/min, p = 0.017) and in evening PEF (11.1 L/min, p = 0.024); these improvements were more pronounced in GERD+/NOC+ subjects. Esomeprazole 40 mg twice daily was well tolerated and no safety concerns were noted. CONCLUSIONS: Esomeprazole improved PEF in subjects with asthma who presented with both GERD and NOC. In subjects without both GERD and NOC, no improvement could be detected.

Gastroesophageal reflux and bronchial responsiveness: correlation and the effect of fundoplication.

BACKGROUND: A causal relationship between gastroesophageal reflux (GER) and asthma has been suggested. Should this be the case, one could expect treatment of GER to diminish bronchial sensitivity. There has been a lack of trials evaluating the efficacy of antireflux surgery on airway reactivity. OBJECTIVES: To investigate the correlation between GER and bronchial responsiveness, and to determine the efficacy of Nissen fundoplication on bronchial responsiveness and pulmonary function. METHODS: A methacholine inhalation challenge was performed on 15 consecutive GER patients preoperatively and approximately 5 months after Nissen fundoplication. Airway responsiveness was quantified with a dose-response slope (DRS), calculated by dividing the decrease in FEV(1) (%) with the dose of methacholine administered (micromoles). RESULTS: A positive correlation between the severity of distal esophageal reflux and bronchial responsiveness was found (r = 0.83, p < 0.001). There was an improvement in FEV(1) after fundoplication (p = 0.03). All 3 asthmatic patients participating in the study presented with bronchial hyperresponsiveness (BHR) which improved clearly in all of these patients after fundoplication. This resulted in an apparent trend for DRS to improve when the entire study population was considered (p = 0.12). CONCLUSIONS: According to the current study there seems to be a positive correlation between the severity of distal esophageal reflux and bronchial responsiveness. These data suggest that operative treatment of GER may ameliorate BHR in asthmatic patients. Moreover, the results of the present study suggest that fundoplication may improve pulmonary function in patients with GER.