Most nocturnal asthma symptoms occur outside of exacerbations and associate with morbidity.

BACKGROUND: Although nocturnal awakenings help categorize asthma severity and control, their clinical significance has not been thoroughly studied. OBJECTIVE: We sought to determine the clinical consequences of nocturnal asthma symptoms requiring albuterol (NASRAs) in children with mild-to-moderate persistent asthma outside of periods when oral corticosteroids were used for worsening asthma symptoms. METHODS: Two hundred eighty-five children aged 6 to 14 years with mild-to-moderate persistent asthma were randomized to receive one of 3 controller regimens and completed daily symptom diaries for 48 weeks. Diary responses were analyzed for the frequency and consequences of NASRAs. RESULTS: NASRAs occurred in 72.2% of participants at least once, and in 24.3% of participants, they occurred 13 or more times. The majority (81.3%) of nocturnal symptoms occurred outside of exacerbation periods and were associated the next day with the following events: albuterol use (56.9% of days preceded by nocturnal symptoms vs 18.1% of days not preceded by nocturnal symptoms; relative risk [RR], 2.3; 95% CI, 2.2-2.4), school absence (5.0% vs 0.3%; RR, 10.6; 95% CI, 7.8-14.4), and doctor contact (3.7% vs 0.2%; RR, 8.8; 95% CI, 6.1-12.5). Similar findings were noted during exacerbation periods (RRs of 1.7 for albuterol use, 5.5 for school absence, and 4.9 for doctor contacts). Nocturnal symptoms did not predict the onset of exacerbations. CONCLUSION: Nocturnal symptoms requiring albuterol in children with mild-to-moderate persistent asthma receiving controller therapy occurred predominantly outside of exacerbation periods. Despite being poor predictors of exacerbations, they were associated with increases in albuterol use, school absences, and doctor contacts the day after nocturnal symptom occurrences.

Urinary leukotriene E4/exhaled nitric oxide ratio and montelukast response in childhood asthma.

BACKGROUND: A subset of children with asthma respond better to leukotriene receptor antagonists than to inhaled corticosteroids. Information is needed to identify children with these preferential responses. OBJECTIVE: We sought to determine whether the ratio of urinary leukotriene E(4) (LTE(4)) to fractional exhaled nitric oxide (FE(NO)) delineates children with preferential responsiveness to montelukast compared with fluticasone propionate (FP) therapy. METHODS: Data from 318 children with mild-to-moderate asthma enrolled in 2 National Heart, Lung, and Blood Institute Childhood Asthma Research and Education Network studies (Characterizing the Response to a Leukotriene Receptor Antagonist and an Inhaled Corticosteroid [CLIC] and the Pediatric Asthma Controller Trial [PACT]) were analyzed. The association between LTE(4)/FE(NO) ratios at baseline and improved lung function or asthma control days (ACDs) with montelukast and FP therapy was determined, and phenotypic characteristics related to high ratios were assessed. RESULTS: LTE(4)/FE(NO) ratios were associated with a greater response to montelukast than FP therapy for FEV(1) measurements (2.1% increase per doubling of ratio, P = .001) and for ACDs per week (0.3-ACD increase, P = .009) in the CLIC study. In PACT the ratio was associated with greater ACD responsiveness to MT than FP therapy (0.6 ACD increase, P=.03) [corrected]. In a combined study analysis, LTE(4): FE(NO) ratios were associated with greater response to MT than FP therapy for FEV(1) (1.8% increase, P =.0005) and ACDs (0.4 increase, P =.001)[corrected].Children with LTE(4)/FE(NO) ratios at or above the 75th percentile were likely (P < .05) to be younger and female and exhibit lower levels of atopic markers and methacholine reactivity. CONCLUSION: LTE(4)/FE(NO) ratios predict a better response to montelukast than FP therapy in children with mild-to-moderate asthma.

Self-reported exposure to pesticides in residential settings and risk of breast cancer: a case-control study.

BACKGROUND: Pesticides are widely used in households to control insects and weeds. Several studies, over the past decades, have examined the possible relationship of serum concentration of organochlorine pesticides and the development of breast cancer. However, little data exists regarding an association between self-reported, residential exposure to pesticides and breast cancer risk. We, therefore, present a case-control study examining self-reported exposure to household pesticides with regard to associated risk of breast cancer. METHODS: This study was conducted in the area in and around New York City, NY and included 1205 patients (447 cases and 758 controls). Cases were defined as women with newly diagnosed breast cancer or carcinoma in-situ, while controls included women with benign breast diseases or those undergoing non-breast related surgery. All patients were asked a series of questions to determine their pesticide exposure, including the type of pesticide, location of exposure (inside vs. outside the home), who applied the pesticide (self vs. a professional) and duration of pesticide use. Logistic regression models were used to estimate unadjusted and adjusted odds ratios (OR) and corresponding 95% confidence intervals (CI). RESULTS: The most common pests encountered in participants' homes were ants, carpenter ants, and cockroaches. The calculated adjusted odds ratios for both self and professionally applied pesticides, specifically against the above mentioned insects, with regard to breast cancer risk were 1.25 (95% CI: 0.79-1.98) and 1.06 (95% CI: 0.65-1.73), respectively. Similarly, odds ratios and confidence intervals were calculated for other types of pesticides. CONCLUSIONS: Overall, the results of our study did not show an association between self-reported exposure to pesticides and breast cancer risk. Future studies, utilizing a larger sample size and more specific detail on time frame of pesticide exposure, are needed to further explore this question.

Physical therapy alone compared with core decompression and physical therapy for femoral head osteonecrosis in sickle cell disease. Results of a multicenter study at a mean of three years after treatment.

BACKGROUND: Osteonecrosis of the femoral head is a common complication in patients with sickle cell disease, and collapse of the femoral head occurs in 90% of patients within five years after the diagnosis of the osteonecrosis. However, the efficacy of hip core decompression to prevent the progression of osteonecrosis in these patients is still controversial. METHODS: In a prospective multicenter study, we evaluated the safety of hip core decompression and compared the results of decompression and physical therapy with those of physical therapy alone for the treatment of osteonecrosis of the femoral head in patients with sickle cell disease. Forty-six patients (forty-six hips) with sickle cell disease and Steinberg Stage-I, II, or III osteonecrosis of the femoral head were randomized to one of two treatment arms: (1) hip core decompression followed by a physical therapy program or (2) a physical therapy program alone. Eight patients withdrew from the study, leaving thirty-eight who participated. RESULTS: Seventeen patients (seventeen hips) underwent decompression combined with physical therapy, and no intraoperative or immediate postoperative complications occurred. Twenty-one patients (twenty-one hips) were treated with physical therapy alone. After a mean of three years, the hip survival rate was 82% in the group treated with decompression and physical therapy and 86% in the group treated with physical therapy alone. According to a modification of the Harris hip score, the mean clinical improvement was 18.1 points for the patients treated with hip core decompression and physical therapy compared with 15.7 points for those treated with physical therapy alone. With the numbers studied, the differences were not significant. CONCLUSIONS: In this randomized prospective study, physical therapy alone appeared to be as effective as hip core decompression followed by physical therapy in improving hip function and postponing the need for additional surgical intervention at a mean of three years after treatment.

Diabetes nurse case management and motivational interviewing for change (DYNAMIC): study design and baseline characteristics in the Chronic Care Model for type 2 diabetes.

BACKGROUND: Despite evidence that diabetes is costly and devastating, the health care system is poorly equipped to meet the challenges of chronic disease care. The Penn State Institute of Diabetes & Obesity is evaluating a model of managing type 2 DM which includes nurse case management (NCM) and motivational interviewing (MI) to foster behavior change. The primary care intervention is designed to improve patients' self care and to reduce clinical inertia through provider use of standardized clinical guidelines to achieve better diabetes outcomes. METHODS: This RCT tests the efficacy of an enhanced NCM intervention on type 2 DM (n=549) patient outcomes mediated by changes in self-care behavior and diabetes management. Outcome measures include: (a) effect on clinical parameters such as HbA1c (<7), BP (<130/80), and LDL (<100), depression scores and weight; (b) process measures such as complication screening; (c) patient psychological and behavioral outcomes as measured by emotional distress (PAID), diabetes-specific quality of life (ADDQoL), patient satisfaction (DTSQ), self-care activities (SDSCA); and (d) physician satisfaction and cost-effectiveness of the intervention. CONCLUSIONS: Baseline includes (mean) age=58; BMI=34.4; 57% females; 47% Caucasian, and 39% Hispanic. Patients had elevated HbA1c (8.4), BP (137/77) and LDL (114). Overall, patients were depressed (CES-D=21.6) and had an extremely negative quality of life (ADDQoL=-1.58). We believe that enhanced NCM will both improve self-care and reduce emotional distress for patients with diabetes. If proven effective, enhanced NCM may be translated to other chronic illnesses.