Age and sex distribution of adult asthma admission : a study of the five-year cumulative prevalence

The objective of this study is to describe the age and sex distribution of adult patients (ages 15-59) in Malta, admitted because of severe acute asthma. The study was designed using a retrospective review of all acute adult asthma admissions to determine the 5-year cumulative prevalence of acute asthma admission from 1989 to 1993 to St. Luke’s Hospital, the only acute medical facility serving the whole of the island of Malta. The results of this study showed that the female predominance in adult asthma admission rates reflects a larger number of female patients who require hospital admission rather than higher admission rates per person in females as compared to males.peer-reviewe

Paediatric wheezy admissions at and around school holiday periods

Objective: To study the influence of school holidays on paediatric admissions with wheezing. Design, setting and patients: Retrospective analysis of all admissions due to wheeze in the paediatric age group. Regional hospital catering for all such admissions, subdivided by age group. Outcome measures: Comparison of hospitalisations due to wheezing before, during and after school holiday periods. Results: Summated admissions showed an increase in admissions over the Christmas period for preschool children, and a decrease for school age children. In Easter and at the start of the summer holidays, admissions decreased in all age groups, except for the late school age group which showed increased admissions in April-May. After the summer holidays, a rise in admissions was noted for all ages. Conclusions: Our findings support the multiphenotypic theory for the precipitation of wheezy attacks, with a changeover from a predominantly viral respiratory trigger to a more atopic form of the disease at around 10 years of age. Prophylaxis during school periods is especially important, and advice leading to prophylaxis dose reduction in the benign summer months should be accompanied by advice to restart adequate prophylaxis medication prior to restarting school.peer-reviewe

Predictors of seasonal influenza vaccination in chronic asthma

Background: Guidelines advise annual influenza vaccination in chronic asthma. The aim of this study was to determine uptake of the influenza vaccine in a group of patients (n = 146) with moderate to severe chronic asthma and establish the main predictors of vaccination. Method: Patients attending a hospital asthma clinic were asked to complete a questionnaire in February 2012 (n = 146). These same patients were contacted a year later via telephone (n = 109 responded), and they were asked to complete the same questionnaire. Results: Vaccination rate was 50.3% in winter 2011/12, and 57.8% in 2012/13. Using binary logistic regression, the predictors for vaccination in 2012 were patient advice (Odds ratio [OR] 15.37 p = 0.001), female gender (OR 2.75, p = 0.028), past side effects (OR 0.21, p = 0.001) and comorbidity (OR 0.39, p = 0.013). Stepwise regression resulted in age as predictor (T value = 3.99, p = 0.001). On analyzing the responses from the second questionnaire at one year after attendance to asthma clinic, predictors changed to compliance to medication (OR 9.52, p= 0.001) and previous exacerbations (OR 4.19, p = 0.026). Out of the 56 patients vaccinated in 2011/12, 33 reported asthma exacerbations before 2012, and 29 reported asthma exacerbations after receiving the influenza vaccine. Out of the 46 unvaccinated patients in 2012, 27 had asthma exacerbations before 2012 and 19 patients had exacerbations in 2013. Patients vaccinated in 2011/12 needed 0.59 courses of steroid/patient/year, and 1.23 visits for nebulizer/patient/year while non-vaccinated patients needed 0.18 courses of steroids/patient/year (p = 0.048), and 0.65 visits for nebulized/patient/year (p = 0.012). Patients’ subjective statements broadly confirmed the predictors. 16/69 (23.1%) received the vaccine in winter 2012/13 despite reporting previous side effects. Conclusions: Advice to patient, female gender and patients’ age predicted vaccination, while past side effects to the influenza vaccine, and presence of comorbidities predicted non vaccination. Symptomatic asthma patients are more likely to be vaccinated. One year after the first contact, treatment compliance and previous asthma exacerbations gained statistical significance as predictors of vaccination.peer-reviewe

E-learning : are all users in front of the computer all the time?

e-Learning has been shown to be an effective and useful tool in medical education. An e-learning project was part financed through EU funds project ESF1.19 (Malta). Objective. To assess if medical students using e-learning are in front of the screen while using the e-lectures. Method. Eighty-seven finalyear medical students were encouraged to complete an online respiratory course (13 streamed lectures+13 quizzes) on a voluntary basis and were offered a reward on completion. A moodle e-learning management system collected data regarding user activity, in particular the duration of participation. A group of 14 core medical trainees who were forewarned of detection of possible irregular activity was also observed as a reference group. Results. Forty-three medical students completed all modules. Six lectures with corresponding quizzes were analysed; 65.5% (male 66.7%, female 64.1%) of the lectures were completed within the expected time frame; in 19% of lectures, users logged in for a period of 5 minutes less than the duration of the lecture, while 14.7% of users logged in for a duration that was twice as long as the total duration of the lecture. Only 16.3% of students completed all lectures within the established period; 27.9%, 20.9%, and 18.6% missed one, two, and three, lectures respectively; and 16.3% missed more than four lectures. In the other group (the 14 forewarned core medical trainees), 65 modules amongst 12 trainees showed that trainees completed a module in a mean of 113.25% (95% confidence interval 109.72–116.78) of the actual duration of a lecture. Conclusion. The study indicates that in 83.7% of the cases, there was at least one instance per user during which the user was not physically present throughout the presentation of a lecture. The e-learning management systems should be robust so as to detect this kind of behaviour before certification.peer-reviewe

What lies behind this late-onset wheeze?

A 67-year-old male retired police officer presented to the casualty department in May 2005 with worsening dyspnoea on exertion and cough productive of yellowish sputum. He was being treated for hypertension and had been diagnosed with asthma by his general practitioner in March 2005. He had a 15 pack-year smoking history, until the age of 35 years. On examination, pulse rate was 110 beats per min, temperature 37.5°C and blood pressure 130/80 mmHg. A diffuse wheeze across both lung fields was noted on chest examination. Chest radiography was unremarkable (figure 1). The patient was diagnosed with an infective exacerbation of asthma and received: co-amoxiclav 1.2 g i.v. 8-hourly; hydrocortisone 100 mg i.v. 8-hourly; and salbutamol and ipratropium by nebuliser 6-hourly with good effect. He was discharged in good condition and given a follow-up appointment at the asthma clinic.peer-reviewe

Atypical neuroleptic malignant syndrome with type 2 respiratory failure treated with non-invasive ventilation

Neuroleptic malignant syndrome (NMS) is characterized by hyperthermia, severe rigidity, and autonomic instability that is life-threatening if not treated promptly by intensive supportive care. However, there have been numerous reports of “atypical NMS” where the diagnostic criteria of NMS are only partially satisfied. We present a case of an elderly male who presented with atypical NMS secondary to antidopaminergic drug administration which precipitated acute respiratory failure. Our patient exhibited features of severe rigidity and autonomic instability, without hyperthermia. He developed tachypneic hypoventilation with type 2 hypercapneic respiratory failure which was treated with non-invasive ventilation (NIV). The patient recovered after three days with resolution of rigidity and was transferred to a normal medical ward on oxygen via a facemask, where he gradually improved. This study highlights that non-invasive ventilation may have a role in treating respiratory failure in mild to moderate cases of atypical NMS, avoiding the need for intubation.peer-reviewe

Predictors of correct technique in patients using pressurized metered dose inhalers

Background: Correct inhaler technique is recommended by guidelines for optimum asthma care. The objective of the study is to determine real life predictors of correct pressurized metered dose inhaler (pMDI) technique in Asthma and COPD patients. Methods: Two hundred eight adult patients aged 18+ from respiratory outpatients (69.2%) and the community on regular pMDI for a diagnosis of Asthma (78.9%) or COPD, were recruited. A questionnaire containing 31 possible predictors was administered and pMDI technique with or without spacer was observed by trained researchers on 12 point steps, of which 4 were considered critical. Results: 23.1% of patients had no errors in inhaler technique and 32.2% had no critical errors. Patients had a median of 10 correct steps (IQR9-11), and 3(IQR2-4) correct critical steps. Using binary logistic regression the predictors of 10 correct steps were, other healthcare professional (pharmacist, nurse, physiotherapist) explained OR 3.73(1.63–8.54, p = 0.001), male gender 2.70(1.35–5.39, p = 0.004), self-score 1–10 1.21(1.05–1.39, p = 0.007), spacer use 0.38(0.19–0.79, p = 0.007), inhaled steroid 3.71(1.34–10.25, p = 0.01), heart disease 0.31(0.13–0.77, p = 0.01), pneumococcal vaccine 2.48(1.0–6.15, p = 0.043), education level 1–4 1.44(1.00–2.06, p = 0.05) and respiratory physician explained 0–7 times, 1.11(0.99–1.26, p = 0.08). Using ordinal logistic regression, predictors for correct critical steps 0–4, were: technique self-score 1–10 1.2(1.05–1.42, p = 0.006), inhaled corticosteroid use 2.78(1.1–7.31, p = 0.03) and education level 1–4 1.41(1.02–1.95, p = 0.03 Times respiratory physician explained inhaler technique 0–7 1.1(0.98–1.24, p = 0.1), married status 1.55(0.85–2.82, p= 0.15), hypercholesterolaemia 0.52(0.25–1.01, p = 0.054) and male gender 1.76(0.97–3.18, p = 0.06). Conclusions: Known predictors of correct pMDI use, such as gender and education level were confirmed, while age and concomitant use of dry powder inhaler were not. Pneumococcal vaccination and awareness of steroid side effects were possible novel positive predictors, while the use of a spacer and co-morbidity with heart disease were found to be negative predictors. Patients’ self-assessment correlated well with actual performance. This information may be useful in defining approaches to optimize inhaler techniques which are so susceptible to human error.peer-reviewe

Kyphoscoliosis complicating asthma with fixed airway obstruction

Introduction: Kyphoscoliosis is present in up to 2% of the juvenile population and can have deleterious effects on respiratory mechanics, leading to chronic respiratory failure later on in adult life.Case presentation: Hereby we describe a 53-year-old patient with severe uncontrolled asthma who presented with chronic hypercapnic respiratory failure. During her medical workup, she was noted to have several comorbidities leading to her respiratory failure. The patient had radiological evidence of bronchiectasis with recurrent episodes of infection, and a severe deformity of the spine due to Kyphoscoliosis. Probably the kyphotic component of this deformity had worsened due to a long history of oral steroid use leading to severe osteoporosis and consequent vertebral compression fractures reaching a Cobb angle of 73 degrees. This was probably caused by the patient’s non-compliance with inhaler therapy and an excessive reliance on oral steroid use. Her respiratory failure was treated with domiciliary noninvasive positive pressure ventilation and 24-hour oxygen therapy and her symptoms improved.Conclusion: A multidisciplinary approach across different specialities is necessary when managing such a patient with kyphoscoliosis, bronchiectasis, asthma with airflow limitation with respiratory failure.peer-reviewe

Type 2 respiratory failure secondary to left hemidiaphragmatic paralysis

This case describes an uncommon presentation of type 2 respiratory failure secondary to left hemidiaphragmatic paralysis. Emphasis is on the multitude of possible causes of hemidiaphragmatic paralysis and how to manage such a presentation. A 73-year-old man presented to the emergency department with worsening orthopnoea and exertional dyspnoea. He denied any other cardiorespiratory symptoms. The patient had a body mass index (BMI) of 23.3 kg·m−2 (height 163 cm, weight 62 kg). Lung function tests 3 months before admission showed a ratio of forced expiratory volume in 1 s (FEV1) to forced vital capacity (FVC) of 88%. He had a past medical history of hypothyroidism, for which he was on levothyroxine 50 μg daily, and type 2 diabetes mellitus, for which he was on metformin 500 mg twice daily. Past surgical history included a gastrectomy 3 years prior to admission performed for gastric cancer, which was subsequently complicated by a subphrenic abscess, pancreatitis and residual pancreatic insufficiency. The patient was a lifelong non-smoker, worked in construction, reared birds as a hobby, and lived in an urban area. He was not on any other medication. [extract]peer-reviewe

Total serum IgE and specific IgE levels in 10-15 year old children with respiratory symptoms and healthy controls in Sicily and Malta

Introduction: The RESPIRA study (EU Funded-Italia-Malta) was performed in the district of Gela (Southern Sicily) and Malta in 2012/3 in 10-15 years old schoolchildren (n=2,047) by means of standard respiratory questionnaires (ISAAC),and clinical exam of case and control subjects. Aims and Objectives: To measure total serum IgE levels in cases (n=127, males=45) and controls (n=142, Males=64), specific IgEs in cases (n=90, Males=53), and controls (n=82, Males=38). Materials and Methods: Cases reported wheeze and/or use of asthma medications in the last 12 months, while controls answered negatively to both and rhinitis. Results: Total Serum IgE (n=269) was raised (>144 IU/l) in 70/127 cases vs 25/142 controls (p=.0001). In males 30/76 of cases vs 11/64 controls (p=.005), while in females cases 15/51 vs 14/78, (p=.14). Positive specific IgE (>0.34 U/ml) was noted for at least one allergen in 54/90 cases vs 30/82 controls (p=.002). House dust mite (HDM) was positive in 27/90 cases vs 12/82 controls (p=.0001), Parietaria positive 12/90 cases vs 2/82 controls (p=.011), cat 22/90 vs 13/82 controls (p=.19), while in male subgroup 14/53 of cases were positive vs 4/38 controls (p=.06). Dog 9/90 cases vs 8/82 controls (NS). Olive positive in 13/90 cases vs 8/82 controls (NS). Alternaria positive in 6/90 cases vs 2/82 controls (NS). Goldenrod Solidago Virgaurea positive in 2/90 cases vs 1/82 controls, and Cladosporium 0/90 cases, 1/82 controls. Conclusion: Positive Total serum IgE and specific IgE to HDM and Parietaria in all patients and cat in males only were higher in cases than in controls.peer-reviewe