GASTROESOPHAGEAL REFLUX DISEASE PREVALENT IN PATIENTS WITH ASTHMA

Gastroesophageal reflux disease (GERD) is highly prevalent in adults with asthma, according to a study in the November Chest. Toni O. Kiljander, MD, PhD, and Jukka O. Laitinen, MD, PhD, recruited 90 patients with asthma who were evaluated for GERD using 24-hour esophageal pH monitoring.

Results were considered abnormal if pH value was less than 4 in the distal esophagus for 5.4% of the total monitoring time. Patients were expected to carry out their daily routines during pH monitoring. In addition, all patients were asked to discontinue histamine type-2 blocker or proton-pump inhibitor therapy for at least one week before pH monitoring, as well as antacid therapy for at least three days before pH monitoring.

Drs. Kiljander and Laitinen also performed flow-volume spirometry on all study participants. Patients whose FEV₁ was greater than 45% of predicted underwent a methacholine bronchial challenge. If the patient’s FEV₁ decreased by 20% or more during the challenge he or she was considered to have bronchial hyperresponsiveness. The researchers restricted all the patients from using inhaled sympathomimetics for at least eight hours, oral sympathomimetics and inhaled anticholinergics for at least 12 hours, and theophylline for at least 48 hours before flow-volume spirometry and methacholine bronchial challenge were performed.

Results indicated that 32 patients had abnormal acid reflux into the distal esophagus. Of these patients, eight were free from typical GERD symptoms. Forty-seven patients showed typical GERD symptoms, 24 of whom were found to have GERD during pH monitoring. Furthermore, 75 patients with FEV₁ greater than 45% of predicted underwent methacholine bronchial challenge; 52 of these patients had bronchial hyperresponsiveness.

No significant correlation was found between FEV₁ parameters and pH parameters in either the distal esophagus or the proximal esophagus.

Drs. Kiljander and Laitinen concluded that there is a high prevalence of GERD among patients with asthma. They added that “substantial acid reflux can be present in patients with asthma without typical reflux symptoms. However, the presence of classical reflux symptoms in an asthmatic patient does not seem to guarantee the presence of pathologic acidic esophageal reflux.”

Kiljander TO, Laitinen JO. The prevalence of gastroesophageal reflux disease in adult asthmatics. Chest. 2004;126:1490-1494.

ADVERSE EVENTS AFTER PNEUMOCOCCAL VACCINATION IN CHILDREN

The majority of adverse events reported in the first two years following pneumococcal conjugate vaccine licensure are minor, according to a study in the October 13 JAMA. Robert P. Wise, MD, MPH, of the Food and Drug Administration in Rockville, Maryland, and colleagues analyzed data from children younger than 18 who had been vaccinated in the two years following pneumococcal conjugate vaccine licensure. They found a total of 4,154 reports of adverse events—13.2 reports per 100,000 doses distributed—most of which were minor events and reflected those noted in clinical trials.

The researchers found that the most frequently reported adverse events included fever, injection site reactions, fussiness, rashes, and urticaria. Common symptoms in children who received repeated doses of pneumococcal conjugate vaccine included allergic reactions, prolonged or abnormal crying, fussiness, dyspnea, and GI distress. About 14.6% (n = 608) of reports described serious events including death, seizures, anaphylactic or anaphylactoid reactions, serum sickness, thrombocytopenia, and invasive pneumococcal infections. There were 117 deaths, of which “only one had an infection with a pneumococcal serotype included in the vaccine.” Furthermore, of the 393 reports of seizures, most were febrile or occurred in children with a prior history of seizure.

According to the researchers, interpretation of these incidents “requires caution because many reported events may not be due to the vaccine.”

The researchers concluded that, although the majority of adverse events were minor, the occurrence of allergic reactions, prolonged or abnormal crying, fussiness, dyspnea, and GI distress after repeated doses of the vaccine warrants further investigation.

Wise RP, Iskander J, Pratt RD, et al. Postlicensure safety surveillance for 7-valent pneumococcal conjugate vaccine. JAMA. 2004;292:1702-1710.

RISK OF DEATH IN THE ICU ON THE WEEKEND

Weekend admission to the surgical ICU may be associated with an increased hospital mortality rate, according to a study in the October Chest. Researchers, led by S. Allen Ensminger, MD, performed a retrospective cohort study of 29,084 patients “to determine the relationship between weekend ICU admission and the adjusted hospital mortality rate of critically ill patients in a tertiary care academic medical center, with relatively uniform staffing and availability of diagnostic and therapeutic options.”

The researchers reviewed data from the APACHE III database and found that the overall adjusted hospital mortality rate of patients admitted on a weekend was not significantly higher than that of patients admitted on a weekday. According to the researchers, the mortality rate of patients admitted to the ICU on a weekend was 11.3%, whereas the mortality rate of those admitted to the ICU on a weekday was 7%. Furthermore, when adjusting for factors such as ICU admission source or intensity of treatment, no significant difference in hospital mortality was found between admissions occurring on a weekend and those on a weekday.

Dr. Ensminger and his colleagues said that compared to patients admitted to the ICU on weekdays, those admitted on the weekend “were less likely to be admitted from recovery rooms or operating rooms, or to have a postoperative diagnosis.” They were also more likely to have been transferred from an emergency department or another hospital.

However, the researchers found that weekend admission to the surgical ICU was associated with increased hospital mortality rates. They offered several explanations for this: First, the proportion of medical emergencies increases on the weekend; second, a delay in seeking and delivering medical assistance may have influenced the outcomes of surgical patients during the weekend; and third, the APACHE III system has “been shown not to perform well in predicting mortality in surgical patients.”

The researchers ultimately concluded that “as long as adequate staffing is maintained, and necessary diagnostic and therapeutic modalities are available, weekend ICU admission need not be associated with poor patient outcome.”

Ensminger SA, Morales IJ, Peters SG, et al. The hospital mortality of patients admitted to the ICU on weekends. Chest. 2004;126:1292-1298.

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