Asthma is under-recognised and undertreated in older populations. This is not surprising, given that one-third of older people experience significant breathlessness. The differential diagnosis ...commonly includes asthma, chronic obstructive pulmonary disease (COPD), heart failure, malignancy, aspiration and infections. Because symptoms and signs of several cardiorespiratory diseases are nonspecific in older people and diseases commonly co-exist, investigations are important. A simple strategy for the investigation of breathlessness in older people should include a full blood count, chest radiograph, ECG, peak flow diary and/or spirometry with reversibility as a minimum. If there are major abnormalities on the ECG, an echocardiogram should also be performed. Diurnal variability in peak flow readings >or=20% or >or=15% reversibility in forced expiratory volume in 1 second, spontaneously or with treatment, support a diagnosis of asthma. Distinguishing asthma from COPD is important to allow appropriate management of disease based on aetiology, accurate prediction of treatment response, correct prognosis and appropriate management of the chest condition and co-morbidities. The two conditions are usually readily differentiated by clinical features, particularly age at onset, variability of symptoms and nocturnal symptoms in asthma, supported by the results of reversibility testing. Full lung function tests may not necessarily help in differentiating the two entities, although gas transfer factor is characteristically reduced in COPD and usually normal or high in asthma. Methacholine challenge tests previously mainly used in research are now also used widely and safely to confirm asthma in clinical settings. Interest in exhaled nitric oxide as a biomarker of airways inflammation is increasing as a noninvasive tool in the diagnosis and monitoring of asthma. Regular inhaled corticosteroids (ICS) are the mainstay of treatment of asthma. Even in mild disease in older adults, regular preventive treatment should be considered, given the poor perception of bronchoconstriction by older asthmatic patients. If symptoms persist despite ICS, addition of long-acting beta(2)-adrenoceptor agonists (LABA) should be considered. Addition of LABA to ICS improves asthma control and allows reduction in ICS dose. However, older people have been grossly under-represented in trials of LABA, many trials having excluded those >or=65 years of age. On meta-analysis, beta(2)-adrenoceptor agonists (both short acting and long acting) are associated with increased cardiovascular mortality and morbidity in asthma and COPD. While the evidence for excess cardiovascular mortality is stronger for short-acting beta(2)-adrenoceptor agonists, it would be prudent to exercise particular care in using beta(2)-adrenoceptor agonists (long acting and short acting) in those at risk of adverse cardiovascular outcomes, including older people. Regular review of cardiovascular status (and monitoring of serum potassium concentration) in patients taking beta(2)-adrenoceptor agonists is crucial. The response to LABA should be carefully monitored and alternative 'add-on' therapy such as leukotriene receptor antagonists (LRA) should be considered. LRA have fewer adverse effects and in individual cases may be more effective and appropriate than LABA. Long-term trials evaluating beta(2)-adrenoceptor agonists and other bronchodilator strategies are needed particularly in the elderly and in patients with cardiovascular co-morbidities. There is no evidence that addition of anticholinergics improves control of asthma further, although the role of long-acting anticholinergics in the prevention of disease progression is currently being researched. Older patients need to be taught good inhaler technique to improve delivery of medications to lungs, minimise adverse effects and reduce the need for oral corticosteroids. Nurse-led education programmes that include a written asthma self-management plan have the potential to improve outcomes.
BACKGROUNDPaediatric obesity is a global public health issue. Prenatal maternal mental health is potentially implicated in the development of childhood obesity. This study examined associations ...between prenatal maternal cortisol, self-reported stress, anxiety and depression in the second trimester, and childhood overweight and obesity at 5 years of age.METHODSA nested case-control study was conducted using data from the Irish prospective longitudinal birth cohort SCOPE BASELINE. Cases were children with overweight or obesity, operationalised as having a BMI z-score above +2 standard deviations. Controls were children with a BMI z-score between -0.5 and 0.5 standard deviations at 5 years of age. Two to one matching by sex was conducted. Thirty-eight cases and 83 sex-matched controls were included. Maternal serum cortisol concentration and self-reported stress, anxiety and depression were measured at 15 ± 1 and 20 ± 1 weeks gestation. Conditional logistic regression analyses were conducted to examine associations between prenatal maternal cortisol and self-reported stress, anxiety and depression, and childhood overweight and obesity.RESULTSDespite some evidence for associations between anxiety and depression, and child BMI z-scores in univariate analyses, adjusted models indicated no associations between prenatal maternal stress (OR: 1.02, 95% CI: 0.94-1.12), anxiety (OR: 1.03, 95% CI: 0.97-1.09), depression (OR: 1.04, 95% CI: 0.91-1.19), or cortisol concentration (OR: 0.99, 95% CI: 0.99-1.00) and child BMI z-score.CONCLUSIONOur findings do not provide support for associations between foetal exposure during the second trimester of pregnancy and maternal cortisol, stress and anxiety, and childhood overweight or obesity at 5 years of age.
Engaging with children and adolescents in mental health settings who are exhibiting behaviours that challenge can often result in the use of seclusion, restraint and coercive practices. It is ...recognised that more therapeutic ways to engage this population are needed, adopting trauma informed interventions may provide a solution. The aim of this systematic review is to synthesize the evidence in relation to the effect of trauma-informed interventions on coercive practices in child and adolescent residential settings. The review is guided by elements of the Cochrane Handbook for Systematic Reviews of Interventions and reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist. Results were synthesized and reported narratively. Nine studies met the eligibility criteria for this review. There was a lack of homogeneity amongst the studies. The trauma-informed interventions used were typically multi-faceted, underpinned by a variety of approaches and sought to bring about changes to clinical practice
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Most studies (n = 8) reported significant reductions in the use of restrictive practices following the implementation of a trauma informed approach. The use of a trauma-informed approach, underpinned by an organisational change or implementation strategy, have the potential to reduce coercive practices with children and adolescents. However, the included interventions were insufficiently described to draw strong conclusions.
