Clinical standards for the diagnosis and management of asthma in low- and middle-income countries.

BACKGROUND: The aim of these clinical standards is to aid the diagnosis and management of asthma in low-resource settings in low- and middle-income countries (LMICs).METHODS: A panel of 52 experts in the field of asthma in LMICs participated in a two-stage Delphi process to establish and reach a consensus on the clinical standards.RESULTS: Eighteen clinical standards were defined: Standard 1, Every individual with symptoms and signs compatible with asthma should undergo a clinical assessment; Standard 2, In individuals (>6 years) with a clinical assessment supportive of a diagnosis of asthma, a hand-held spirometry measurement should be used to confirm variable expiratory airflow limitation by demonstrating an acute response to a bronchodilator; Standard 3, Pre- and post-bronchodilator spirometry should be performed in individuals (>6 years) to support diagnosis before treatment is commenced if there is diagnostic uncertainty; Standard 4, Individuals with an acute exacerbation of asthma and clinical signs of hypoxaemia or increased work of breathing should be given supplementary oxygen to maintain saturation at 94-98%; Standard 5, Inhaled short-acting beta-2 agonists (SABAs) should be used as an emergency reliever in individuals with asthma via an appropriate spacer device for metered-dose inhalers; Standard 6, Short-course oral corticosteroids should be administered in appropriate doses to individuals having moderate to severe acute asthma exacerbations (minimum 3-5 days); Standard 7, Individuals having a severe asthma exacerbation should receive emergency care, including oxygen therapy, systemic corticosteroids, inhaled bronchodilators (e.g., salbutamol with or without ipratropium bromide) and a single dose of intravenous magnesium sulphate should be considered; Standard 8, All individuals with asthma should receive education about asthma and a personalised action plan; Standard 9, Inhaled medications (excluding dry-powder devices) should be administered via an appropriate spacer device in both adults and children. Children aged 0-3 years will require the spacer to be coupled to a face mask; Standard 10, Children aged <5 years with asthma should receive a SABA as-needed at step 1 and an inhaled corticosteroid (ICS) to cover periods of wheezing due to respiratory viral infections, and SABA as-needed and daily ICS from step 2 upwards; Standard 11, Children aged 6-11 years with asthma should receive an ICS taken whenever an inhaled SABA is used; Standard 12, All adolescents aged 12-18 years and adults with asthma should receive a combination inhaler (ICS and rapid onset of action long-acting beta-agonist [LABA] such as budesonide-formoterol), where available, to be used either as-needed (for mild asthma) or as both maintenance and reliever therapy, for moderate to severe asthma; Standard 13, Inhaled SABA alone for the management of patients aged >12 years is not recommended as it is associated with increased risk of morbidity and mortality. It should only be used where there is no access to ICS.The following standards (14-18) are for settings where there is no access to inhaled medicines. Standard 14, Patients without access to corticosteroids should be provided with a single short course of emergency oral prednisolone; Standard 15, Oral SABA for symptomatic relief should be used only if no inhaled SABA is available. Adjust to the individual's lowest beneficial dose to minimise adverse effects; Standard 16, Oral leukotriene receptor antagonists (LTRA) can be used as a preventive medication and is preferable to the use of long-term oral systemic corticosteroids; Standard 17, In exceptional circumstances, when there is a high risk of mortality from exacerbations, low-dose oral prednisolone daily or on alternate days may be considered on a case-by-case basis; Standard 18. Oral theophylline should be restricted for use in situations where it is the only bronchodilator treatment option available.CONCLUSION: These first consensus-based clinical standards for asthma management in LMICs are intended to help clinicians provide the most effective care for people in resource-limited settings.

Prevalence of hypertension amongst Mumbai executives.

OBJECTIVE: To find out prevalence of hypertension amongst Mumbai executives. METHODS: Data of annual medical check-up of 1653 executives was evaluated. Blood pressure was measured as per JNC VI/WHO guidelines. RESULTS: Overall prevalence of hypertension amongst Mumbai executives was 26.86%. 21.28% of executives who were hypertensive based on causal reading were later found to have normal or high normal blood pressure. CONCLUSION: For all epidemiological surveys, blood pressure must be recorded on at least two subsequent occasions after initial screening.

Non-pharmacological management of essential hypertension.

Lifestyle modifications are universally accepted, not only as the first step in the management of hypertension but also a way to prevent hypertension. The INTERSALT study of 52 communities worldwide showed that weight, among all measured characteristics except age, had the strongest, significant, most consistent and independent correlation with blood pressure. INTERSALT epidemiological data had demonstrated a positive association between sodium intake and level of blood pressure. A rigorous analysis of 23 randomly controlled trials showed that 100 mmol/day reduction in sodium intake was associated with a decline of 5-7 mm Hg (systolic)/2.7 mm Hg (diastolic) in hypertensive subjects. Excessive alcohol consumption is another important risk factor for hypertension and has been reported to account for 5-30% of all hypertension. Moderately intense exercise at 40 to 60% of maximum oxygen consumption e.g., 30 to 45 minutes of brisk walking on 4-5 days a week, can lower blood pressure. The incidence of stroke and coronary artery disease in hypertensive patients who smoke is 2-3 times greater than in non-smoking patients with comparable blood pressure and stopping smoking rapidly reduces this risk. There have been several studies showing the stress reduction with various behavioural procedures, such as yoga, relaxation biofeedback, transcedental mediation and psychotherapy benefit hypertensive patients by lowering their blood pressure.

Smoking and hypertension: Indian scenario.

In a large multicentre study of 918 hypertensive patients, 28% of subjects were found to be smokers. Smokers had a higher average weight and associated diseases like coronary artery disease and diabetes. It is suggested that higher incidence of coronary artery disease and diabetes in the hypertensive smokers carries a higher risk of further cardiovascular events.

Cold weather and myocardial infarction.

We studied 1217 cases of myocardial infarction, admitted to Patna Medical College Hospital, Patna, during the period 1979 to 1983, and correlated the incidence of the disease with air-temperature, seasons and months. There was no monthly variation in the incidence of the disease. The seasons similarly had no influence on incidence. The frequency of myocardial infarction, however, was significantly higher when the minimum air-temperature was 16 degrees C or less (P less than 0.001). This study indicates that drop in atmospheric temperature below a certain level directly increases the incidence of myocardial infarction and suggests simple prevention measures against the adverse effect of cold.

Effect of labetalol and propranolol on human cutaneous vasoconstrictor response to adrenaline.

Using half-life disappearance of intradermally injected radioiodine as a parameter for cutaneous blood flow, a study was made of the effects of labetalol and propranolol on the vasoconstrictor response to adrenaline at environmental temperatures of 22 degrees C and 32 degrees C in seven healthy volunteers. Iodine clearance was reduced at 22 degrees C, and at both temperatures by 16 pcg of adrenaline. Orally administered propranolol (20 mg) enhanced these effects at the lower temperature and that of adrenaline at both temperatures. This method unequivocally demonstrates the aggravation of adrenaline-induced cutaneous vasoconstriction caused by oral administration of propranolol and distinguishes it from that caused by labetalol.

Effects of labetalol and propranolol on responses to adrenaline infusion in healthy volunteers.

The effects of labetalol and propranolol were compared in eight healthy human volunteers using pulse rate and blood pressure changes in response to low rates of adrenaline infusion. Propranolol not only blocked but reversed the positive chronotropic and vasodepressor effects of adrenaline. Labetalol appeared to block these effects only partially. The alpha blocking property of labetalol may have contributed to this difference and hence is unlikely to cause alpha receptor mediated side-effects of endogenously released adrenaline in stress. This model is able to differentiate with great sensitivity between pure beta blockers and alpha beta blocking agents.

Response to single dose of tetanus vaccine in subjects with naturally acquired tetanus antitoxin.

Tests among 410 Indians not artificially immunised against tetanus showed that 80% had measurable antitoxin. Single doses (100 Lf or 250 Lf) of a potent tetanus toxoid were given to such individuals with naturally acquired antitoxin. The 100 Lf dose produced on average a ten-fold rise in antibody level, and the 250 Lf dose a twenty-fold rise. In adults who had been artificially immunised, a 5 Lf dose produced a four-fold to ten-fold rise in antibody level. In infants three doses of triple vaccine produced satisfactory antitoxin concentrations. The levels of antibody achieved after a single 250 Lf dose should protect for 5 years. Single-dose vaccination may be better than the conventional three-dose scheme for a population that is unlikely to comply with a three-dose regimen and in whom naturally acquired antitoxin is associated with partial tolerance to tetanus toxoid. Naturally acquired antitoxin in Indians is probably the result of chronic clostridial contamination of the small bowel. This contamination can induce immune tolerance in the gut and systemically and may be the reason for the poor responses to vaccination in all except infants.