摘要:

Emotional factors are an obstacle in the diagnosis and management of asthma. This review discusses three problem patterns: negative emotions in relatively normal patients with asthma; patients presenting possible functional symptoms and; patients presenting asthma in conjunction with psychiatric deviations. Negative emotions influence the symptoms and management of asthma, even in relatively normal patients. Psychogenic symptoms appear normal, but culminate in functional symptoms in a minority of patients. Diagnosing and treating asthma in patients with comorbid asthma and psychiatric symptoms is very difficult. On the one hand, treating asthma may often be just treating the emotions. On the other hand, negative emotions make the treatment of asthma guesswork.Physicians should estimate emotional influences in their patients' symptoms for an optimal evaluation of medication efficacy. Assessment and analysis of emotional factors surrounding exacerbations seems essential, e.g. emotional precipitants of asthma and asthma-evoked negative emotions. Moreover, patients should be informed about stress-induced breathlessness and the consequences of overuse of bronchodilators. When patients present with atypical symptoms, or do not properly respond to asthma medication, functional symptoms should be suspected. Psychiatric analysis may often lead to the conclusion that symptoms have a functional basis. In patients with comorbid asthma and anxiety disorders, asthma should be the focus for treatment since difficult-to-control asthma often causes anxiety problems in the first place. Moreover, panic-like symptoms in asthma are often related to sudden onset asthma exacerbations. However, in patients with comorbid asthma and depression, depression should become the focus of treatment. The reason is that optimal treatment of depressive asthmatics is probably impossible. Special issues include specific problems with children, compliance problems, and physicians' dilemmas regarding the simultaneous treatment of asthma and psychiatric symptoms.

ISSN:1175-6365    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

Asthma is a significant and increasing health problem. Airway inflammation and hyperresponsiveness are key pathophysiological mechanisms underlying asthma. Currently, effective treatments target these two processes and can lead to clinically important improvements in disease control. At present, decisions to initiate or modify therapy are based on symptoms and measures of airway caliber, with no direct assessment of airway inflammation or hyperresponsiveness. It is now possible to measure airway inflammation using noninvasive markers such as exhaled gases, induced sputum and serum measurements. Exhaled nitric oxide (eNO) and induced sputum eosinophils show the greatest promise as clinically useful markers of airway inflammation in asthma. Induced sputum can now be applied to the diagnosis of airway diseases, based on its ability to detect eosinophilic bronchitis in cough, and to differentiate between eosinophilic and non-eosinophilic asthma. The place of induced sputum and eNO in the ongoing monitoring of patients with asthma are now being investigated in controlled trials.

ISSN:1175-6365    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

Obstructive sleep apnea hypopnea syndrome (OSAHS) is a prevalent disorder associated with substantial cardiovascular and neurobehavioral morbidity. Yet this is a disorder for which there are no widely effective pharmacotherapies. The pathophysiology of obstructive sleep apnea namely, normal respiration in waking with disordered breathing only in sleep, suggests that this disorder should be readily amenable to drug therapy. Over the past 10 years, we have gained tremendous insight into the neurochemical mechanisms involved in state-dependent control of respiration. It is apparent from this work that there are many potential avenues for pharmacotherapies, including several seemingly conflicting directions for serotonergic therapies.Serotonin delivery is reduced to upper airway dilator motor neurons in sleep, and this contributes, at least in part, to sleep-related reductions in dilator muscle activity and upper airway obstruction. The dilator motor neuron post-synaptic serotonin receptors are 5-HT2Aand 5-HT2Csubtypes, and in adults the presynaptic 5-HT receptor in motor nuclei is 5-HT1B, an inhibitory receptor. Serotonin receptors are also found within central respiratory neuronal groups, and these receptor subtypes include 5-HT1A(inhibitory) and 5-HT2receptors. Peripherally, stimulation of 5-HT2A, 5-HT2Cand 5-HT3receptor subtypes have an inhibitory effect on respiration via action at the nodose ganglion. Many of these receptor subtypes and their signal transduction pathways may be affected by oxidative stress in obstructive sleep apnea. These alterations will make finding drug therapies for sleep apnea more challenging, but not insurmountable. Future directions are suggested for elucidating safe, well-tolerated serotonergic drugs for this disorder.Tryptophan was one of the first serotonergic drugs tested for OSAHS. This drug was withdrawn from the market as a result of reports linking tryptophan use with eosinophilic myalgia syndrome and life-threatening pulmonary hypertension. Newer drugs with serotonergic activity tested in persons with sleep-disordered breathing include buspirone, fluoxetine and paroxetine. Trials are presently being conducted to evaluate the effects of 5-HT2Aand 5-HT3antagonists on OSAHS. Many of the drugs tested have not shown significant improvement in sleep apnea. However, with continued effort to elucidate the pharmacology of neurochemical control of state-dependent changes in respiratory control, the availability of pharmacological therapy for this disorder is not too far away.

ISSN:1175-6365    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

Chlamydia pneumoniaeis an intracellular pathogen that has been suggested to play a role in the pathology of asthma. However, so far none of the studies have provided clear evidence for a causative role ofC. pneumoniaeinfections in asthma, although there is little doubt that chronicC. pneumoniaeinfection does aggravate asthma and should be treated.The diagnosis ofC. pneumoniaeinfection is still a matter of concern for it is dependent on trained skilled personnel and can vary significantly between different diagnostic laboratories. This fact is also one of the major problems encountered when comparing epidemiological studies investigating the possible role ofC. pneumoniaeinfections and their impact on the pathogenesis of other diseases.With regard to therapy, long-term treatment with macrolides is the best available method to eradicateC. pneumoniae. Successful therapy forC. pneumoniae, however, can also be complicated by the high possibility ofde novoinfection as epidemiological studies have shown that the prevalence of antibodies toC. pneumoniaeincreases with age in all populations studied. In the northern hemisphere the prevalence ofC. pneumoniaeis also affected by seasonal conditions. It is too early to draw any conclusions from the equatorial belt countries. The available data onC. pneumoniaein tropical countries indicate a much faster infection rate during early adulthood with 100% serological prevalence at an age greater than 25 years. This data, if confirmed, would argue againstC. pneumoniaecausing asthma since the asthma prevalence in those countries does not increase in a parallel pattern.An alternative interpretation of most studies could be that the increased rate ofC. pneumoniaeinfections in patients with asthma results from a modified susceptibility towards the microorganism, due to yet unknown changes of the host cell's physiology. It should be kept in mind that increased prevalence ofC. pneumoniaeinfection is not restricted to asthma.Further studies are needed to understand the role ofC. pneumoniae, especially of chronic infection, in the pathogenesis of inflammatory diseases with a specific focus on the effect that the microorganism triggers in the infected host cell. Only when we understand whatC. pneumoniaedoes to its host cell will we be able to judge its impact on the overall status of an affected patient, and this knowledge will help us to develop a successful therapy.

ISSN:1175-6365    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

Severe community-acquired pneumonia (CAP) is a life-threatening condition that requires intensive care unit (ICU) admission. Clinical presentation is characterized by the presence of respiratory failure, severe sepsis, or septic shock. Severe CAP accounts for approximately 5−35% of hospital-treated cases of pneumonia with the majority of patients having underlying comorbidities. The most common pathogens associated with this disease areStreptococcus pneumoniae,Legionellaspp.,Haemophilus influenzae, and Gram-negative enteric rods.Microbial investigation is probably helpful in the individual case but is likely to be more useful for defining local antimicrobial policies. The early and rapid initiation of empiric antimicrobial treatment is critical for a favorable outcome. It should include intravenous β-lactam along with either a macrolide or a fluoroquinolone. Modifications of this basic regimen should be considered in the presence of distinct comorbid conditions and risk factors for specific pathogens. Other promising nonantimicrobial new therapies are currently being investigated.The assessment of severity of CAP helps physicians to identify patients who could be managed safely in an ambulatory setting. It may also play a crucial role in decisions about length of hospital stay and time of switching to oral antimicrobial therapy in different groups at risk. The most important adverse prognostic factors include advancing age, male sex, poor health of patient, acute respiratory failure, severe sepsis, septic shock, progressive radiographic course, bacteremia, signs of disease progression within the first 48−72 hours, and the presence of several different pathogens such asS. pneumoniae,Staphylococcus aureus, Gram-negative enteric bacilli, orPseudomonas aeruginosa. However, some important topics of severity assessment remain controversial, including the definition of severe CAP. Prediction rules for complications or death from CAP, although far from perfect, should identify the majority of patients with severe CAP and be used to support decision-making by the physician. They may also contribute to the evaluation of processes and outcomes of care for patients with CAP.

ISSN:1175-6365    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

For several years there has been discussion of whether first-line pharmacological treatment of allergic rhinitis should be antihistamines or intranasal corticosteroids. No well documented, clinically relevant differences seem to exist for individual nonsedating antihistamines in the treatment of allergic rhinitis. Likewise, the current body of literature does not seem to favor any specific intranasal corticosteroid. When comparing efficacy of antihistamines and intranasal corticosteroids in allergic rhinitis, present data favor intranasal corticosteroids. Interestingly, data do not support antihistamines as superior in treating conjunctivitis associated with allergic rhinitis. Safety data from comparative studies in allergic rhinitis do not indicate differences between antihistamines and intranasal corticosteroids. Combining antihistamines and intranasal corticosteroids in the treatment of allergic rhinitis does not provide additional beneficial effects to intranasal corticosteroids alone.Considering present data, intranasal corticosteroids seem to offer superior relief in allergic rhinitis, when compared with antihistamines.

ISSN:1175-6365    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

IntroductionIn patients with COPD who have recently been hospitalized for their disease, we examined whether treatment with inhaled corticosteroids without or with long-acting β-adrenoceptor agonists (β-agonists) reduced rehospitalization and mortality.Study designRetrospective cohort analysis in the UK General Practice Research Database.MethodsWe compared rehospitalization for a COPD-related medical condition or death within 1 year after first hospitalization, in 3636 COPD patients receiving prescriptions for inhaled corticosteroids or long-acting β-agonists compared with 627 reference patients with COPD who were prescribed short-acting bronchodilators only.ResultsRehospitalization within a year occurred in 13.2% of the reference COPD patients, 14.0% of users of long-acting β-agonists only, 12.3% of users of inhaled corticosteroids only, and 10.4% of users of inhaled corticosteroids and long-acting β-agonists. Death within a year occurred in 24.3% of the reference COPD patients, 17.3% of users of long-acting β-agonists only, 17.1% of users of inhaled corticosteroids only, and in 10.5% of users of inhaled corticosteroids and long-acting β-agonists. In multivariate analyses the risk of rehospitalization or death was reduced by 10% in users of long-acting β-agonists only (NS), by 16% in users of inhaled corticosteroids only, and by 41% in users of combined inhaled corticosteroids and long-acting β-agonists (both p < 0.05).ConclusionUse of inhaled corticosteroids with/without long-acting β-agonists was associated with a reduction of rehospitalization or death in COPD patients.

ISSN:1175-6365    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

Cefepime (Maxipime®, Maxcef®, Cepimax®, Cepimex®, Axepim®1), a parenteral fourth-generation cephalosporin, is active against many organisms causative in pneumonia. Cefepime hasin vitroactivity against Gram-positive organisms includingStaphylococcus aureusand penicillin-sensitive, -intermediate and -resistantStreptococcus pneumoniaesimilar to that of cefotaxime and ceftriaxone. Cefepime also has good activity against Gram-negative organisms, includingPseudomonas aeruginosa, similar to that of ceftazidime. Importantly, cefepime is stable against many of the common plasmid- and chromosome-mediated β-lactamases and is a poor inducer of AmpC β-lactamases. As a result, it retains activity against Enterobacteriaceae that are resistant to third-generation cephalosporins, such as derepressed mutants ofEnterobacterspp. Cefepime may be hydrolyzed by the extended-spectrum β-lactamases produced by some members of the Enterobacteriaceae, but to a lesser extent than the third-generation cephalosporins.Monotherapy with cefepime 1 or 2g, usually administered intravenously twice daily, was as effective for clinical and bacteriological response as ceftazidime, ceftriaxone or cefotaxime monotherapy (1 or 2g two or three times daily) in a number of randomized, clinical trials in hospitalized adult, or less commonly, pediatric, patients with generally moderate to severe community-acquired or nosocomial pneumonia. More limited data indicated that monotherapy with cefepime 2g three times daily was also as effective in treating patients with nosocomial pneumonia as imipenem/cilostatin 0.5g four times daily, and when combined with amikacin, cefepime was as effective as ceftazidime plus amikacin. Patients with pneumonia who failed to respond to previous antibacterial therapy with penicillins or other cephalosporins responded to treatment with cefepime.Cefepime is generally well tolerated, with a tolerability profile similar to those of other parenteral cephalosporins. In clinical trials, the majority of adverse events experienced by cefepime recipients were mild to moderate and reversible. The most common adverse events with a causal relationship to cefepime reported in clinical trials included rash and diarrhea. Other, less common, adverse events included pruritus, urticaria, nausea, vomiting oral candidiasis, colitis, headache, fever, erythema and vaginitis.ConclusionCefepime is an established and generally well tolerated parenteral drug with a broad spectrum of antibacterial activity which, when administered twice daily, provides coverage of most of the pathogens that may be causative in pneumonia. In randomized clinical trials in hospitalized patients with generally moderate to severe community-acquired or nosocomial pneumonia, cefepime monotherapy exhibited good clinical and bacteriological efficacy. Cefepime may become a preferred antibacterial agent for infections caused byEnterobacterspp. With prudent use in order to prevent the emergence of resistant organisms, cefepime will continue to be a suitable option for the empiric treatment of pneumonia.

ISSN:1175-6365    

出版商:ADIS    

年代:2003

数据来源: ADIS