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Previous studies showed that general practitioners have problems in diagnosing asthma accurately, resulting in both under and overdiagnosis. To support general practitioners in their diagnostic process, an asthma diagnostic consultation service was set up. We evaluated the performance of this asthma diagnostic consultation service by analysing the (dis)concordance between the general practitioners working hypotheses and the asthma diagnostic consultation service diagnoses and possible consequences this had on the patients' pharmacotherapy. In total 659 patients were included in this study. At this service the patients' medical history was taken and a physical examination and a histamine challenge test were carried out. We compared the general practitioners working hypotheses with the asthma diagnostic consultation service diagnoses and the change in medication that was incurred. In 52% (n = 340) an asthma diagnosis was excluded. The diagnosis was confirmed in 42% (n = 275). Furthermore, chronic rhinitis was diagnosed in 40% (n = 261) of the patients whereas this was noted in 25% (n = 163) by their general practitioner. The adjusted diagnosis resulted in a change of medication for more than half of all patients. In 10% (n = 63) medication was started because of a new asthma diagnosis. The 'one-stop-shop' principle was met with 53% of patients and 91% (n = 599) were referred back to their general practitioner, mostly within 6 months. Only 6% (n = 41) remained under control of the asthma diagnostic consultation service because of severe unstable asthma. In conclusion, the asthma diagnostic consultation service helped general practitioners significantly in setting accurate diagnoses for their patients with an asthma hypothesis. This may contribute to diminish the problem of over and underdiagnosis and may result in more appropriate treatment regimens. ASTHMA: SERVICE HELPS GENERAL PRACTITIONERS MAKE ACCURATE DIAGNOSES: A consultation service can help general practitioners more accurately diagnose asthma and select the appropriate treatments for their patients. Researchers in The Netherlands, led by Frank Smeenk from Catharina Hospital in Eindhoven, describe an asthma diagnostic consultation service they created to support GPs in their diagnostic process for patients suspected of having asthma. Over a four-year period, the service received a total of 659 referrals and only confirmed the diagnosis of asthma in 275 cases. Another 20 patients had asthma overlapping with chronic obstructive pulmonary syndrome. The service also picked up other diseases, such as rhinitis, that general practitioners had missed. Overall, because of the consultation service and its revised diagnoses, more than half of all patients adjusted their medications. Most patients required only a single consultation and could then be referred back to their physicians.

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We describe the case of a 47-year-old Caucasian male patient who developed sarcoidosis 18 months after he was diagnosed with pulmonary tuberculosis for which he was treated according to guidelines. The presentation of sarcoidosis was very similar to his first presentation when he was diagnosed with tuberculosis. Mycobacterium tuberculosis as a possible aetiological agent in sarcoidosis has been point of debate since many years and has been studied thoroughly. Recent advances in immunologic and molecular techniques have strengthened the association between mycobacteria and sarcoidosis.(1) Sarcoidosis is a systemic inflammatory disorder of unknown aetiology, characterised by the presence of non-caseating epitheloid cell granulomas. It is generally agreed that this is a tissue reaction to environmental agents in a genetically susceptible individual.(2) Tuberculosis is an infectious disease caused by M. tuberculosis and characterised by caseating granulomas. In both clinical and histopathological features sarcoidosis is remarkably similar to tuberculosis and therefore can be difficult to distinguish. First, this case report demonstrates the need of diagnostic testing when reactivation of tuberculosis is suspected. And second the role of M. tuberculosis in the aetiology of sarcoidosis will be discussed.

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This study was designed to investigate whether the administration of the anabolic steroid nandrolone decanoate is able to antagonize the loss in diaphragm function induced by long-term administration of a low-dose of methylprednisolone in emphysematous hamsters. Normal and emphysematous male hamsters were randomized to receive either saline or methylprednisolone 0.2 mg x kg(-1) x day(-1) for 9 months, with or without nandrolone decanoate 1 mg x kg(-1) x week(-1) i.m. during the final 3 months. Diaphragm contractile properties and myosin heavy chain composition were determined. Compared to control hamsters, the force generating capacity of isolated diaphragm strips decreased by approximately 12% in the emphysema group and by approximately 22% in the emphysema plus methylprednisolone group. Addition of nandrolone decanoate to the emphysema plus methylprednisolone hamsters significantly improved force generation. The atrophy of type IIa and IIx diaphragm fibres in the emphysema plus methylprednisolone group was completely reversed to the level of control hamsters by the addition of nandrolone decanoate. In conclusion, nandrolone decanoate in part reversed the loss in diaphragm force-generating capacity in emphysematous hamsters treated with methylprednisolone, and reversed type IIa and IIx fibre atrophy completely.

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The effects of corticosteroid (CS) treatment (prednisolone continuously administered subcutaneously at a flow rate of 2.5 microl/h, daily dose 5.6 mg/kg, for 3 wk) on neuromuscular junction (NMJ) morphology and neuromuscular transmission in rat diaphragm muscle (Dimus) were compared with weight-matched (Sham) and ad libitum fed control (Ctl) groups. Fibers were classified on the basis of myosin heavy chain (MHC) isoform expression. CS treatment caused significant atrophy of fibers expressing MHC2X (type IIx), either alone or with MHC2B (type IIx/b). Fibers expressing MHCslow (type I) and MHC2A (type IIa) were unaffected by CS. The planar areas of nerve terminals and motor endplates at type IIx/b fibers were smaller in CS-treated Dimus compared with Sham and Ctl. However, CS-induced atrophy of type IIx/b fibers exceeded changes in NMJ morphology. Thus, when normalized for fiber diameter, NMJs were relatively larger in the CS-treated group compared with Ctl. Neuromuscular transmission failure, assessed in vitro by comparing force loss during repetitive (40 Hz) nerve vs. direct muscle stimulation, was less in CS-treated Dimus. These results indicate that alterations in NMJ morphology after CS treatment are dependent on fiber type and may contribute to improved neuromuscular transmission.

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Animal and clinical studies have shown respiratory muscle dysfunction caused by treatment with glucocorticoids. The present study was designed to investigate whether anabolic steroids are able to antagonize the loss of diaphragm force induced by long-term low-dose methylprednisolone (MP) administration. Male adult rats were randomized to receive saline or MP (0.2 mg . kg-1 .day-1 sc) during 9 mo, with or without nandrolone decanoate (ND; 1 mg . kg-1 . wm -1 im) during the last 3 mo. The approximately 10% reduction in force generation of isolated diaphragm bundles induced by MP was completely abolished by addition of ND. The MP-induced decrease in number of fibers expressing type IIb myosin heavy chains was not reversed by ND. MP slightly reduced type I, IIa, and IIx fiber cross-sectional areas (CSA), but not type IIb fiber CSA. Addition of ND abolished the reduction in IIa and IIx fiber CSA. The MP-induced alterations in glycogenolytic activity and fatty acid oxidation capacity were not reversed by ND. In conclusion, the marked reduction in diaphragm force caused by long-term low-dose MP was completely abolished by addition of ND. ND in part also antagonized the effects of MP on diaphragm morphology but showed no beneficial effects on biochemical changes.

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The effects of corticosteroids (CS) on diaphragm muscle (Diam) fiber morphology and contractile properties were evaluated in three groups of rats: controls (Ctl), surgical sham and weight-matched controls (Sham), and CS-treated (6 mg . kg-1 . day-1 prednisolone at 2.5 ml/h for 3 wk). In the CS-treated Diam, there was a selective atrophy of type IIx and IIb fibers, compared with a generalized atrophy of all fibers in the Sham group. Maximum isometric force was reduced by 20% in the CS group compared with both Ctl and Sham. Maximum shortening velocity in the CS Diam was slowed by approximately 20% compared with Ctl and Sham. Peak power output of the CS Diam was only 60% of Ctl and 70% of Sham. Endurance to repeated isotonic contractions improved in the CS-treated Diam compared with Ctl. We conclude that the atrophy of type IIx and IIb fibers in the Diam can only partially account for the CS-induced changes in isotonic contractile properties. Other factors such as reduced myofibrillar density or altered cross-bridge cycling kinetics are also likely to contribute to the effects of CS treatment.

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In animal studies, high dosages of corticosteroids cause changes in diaphragm structure and function. The present study was designed to investigate the effects of long-term low-dose methylprednisolone (MP) administration on rat diaphragm contractile properties and morphology. Thirty adult rats were treated with saline or MP (0.2 mg/kg/day s.c.) during 6 months. Contractile properties of isolated diaphragm strips, immunohistochemical characteristics analyzed by means of antibodies reactive with myosin heavy chain isoforms, and enzyme activities were determined in the diaphragm muscle. MP significantly reduced diaphragm force generation by -15% over a wide range of stimulation frequencies. The number of type IIb fibers was reduced by MP. There was a mild but significant decrease in type I and IIa fiber cross-sectional area (CSA), whereas type IIx and IIb CSA did not change. These changes resulted in a reduction in the relative contribution of type IIb fibers to total diaphragm muscle area. Biochemically, MP decreased glycogenolytic activity, while fatty acid oxidation and oxidative capacity were increased. In conclusion, long-term low-dose MP administration caused a marked impairment in diaphragm function. This is accompanied by changes in diaphragm muscle morphology and enzyme capacity.

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The aim of this study was to investigate 1) the effects and time course of single doses of salbutamol on isometric contractile properties of isolated rat diaphragm strips and 2) whether these effects were caused by a direct effect on the muscle. Two experiments were performed. In one, salbutamol was administered subcutaneously in doses of 12.5, 25, 50, or 100 micrograms/kg (25 and 50 micrograms/kg sc resulted in serum concentrations of approximately 9 and approximately 15 micrograms/l, respectively, 0.5 h after injection) and in vitro contractile properties were determined 0.5, 1, 2, or 4 h after administration; in the other, salbutamol was added to the tissue bath in a concentration of < or = 2, approximately 10, approximately 20, and approximately 80 micrograms/l. Twice force, maximal tetanic force, and twitch force-to-tetanic force ratio all increased in a dose-dependent way in both experiments. The increases in force generation were slightly higher after subcutaneous administration. Force-frequency curves were shifted upward in both experiments. No significant effects of time of salbutamol administration were found, but the increase in force generation was most pronounced within 2 h after subcutaneous administration. In conclusion, in vitro force generation can be improved by low concentrations of salbutamol. The slightly higher increases in force generation after subcutaneous administration suggest that in vivo salbutamol may have additional positive inotropic actions on diaphragm contractility besides a direct beta 2-adrenergic effect on the muscle itself.

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Systemic corticosteroid therapy may affect diaphragm structure and function. We postulated that functional, immunohistochemical and biochemical characteristics of rat diaphragm were less affected by alternate-day methylprednisolone (MP) administration, and more by repeated bursts of MP, in comparison to daily s.c MP. Sixty adult rats were randomized into four groups: saline s.c.; MP continuously (MP-C), 1 mg.kg-1 daily, MP alternate-day therapy (MP-A), 2 mg.kg-1 every other day; or MP in bursts (MP-B), MP 2 mg.kg-1 daily for 2 weeks, saline for 4 weeks, MP 2 mg.kg-1 daily for 2 weeks. The total treatment period was 8 weeks. Contractile properties of isolated diaphragm strips were measured. Antibodies reactive with type I, IIa, IIx and IIb myosin heavy chains were used for immunohistochemical analysis. Biochemical evaluation included markers of fast energy supply, glycogenolytic activity, beta-oxidation capacity and oxidative capacity. The force-frequency curve was depressed in all MP groups. Fibre type I, IIx and IIb cross-sectional area (CSA) decreased in all MP groups. Burst therapy decreased the contribution of type IIb fibres to total diaphragm muscle area. MP-A affected glycogenolytic activity less than MP-C. Burst MP therapy reduced creatine kinase (CK) activity and beta-oxidation capacity compared to MP-C. Oxidative capacity was increased in all MP groups. In conclusion, although the methylprednisolone treatment regimens affected diaphragm muscle morphology and bioenergetic enzyme activities in different ways, force generation decreased in all methylprednisolone treated groups to the same extent.

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Corticosteroids may cause myopathy of both skeletal and respiratory muscles. This is of specific clinical importance in patients with chronic obstructive pulmonary disease (COPD), who already have impaired respiratory muscle function. After treatment with fluorinated steroids, side-effects occur more frequently and are worse compared to treatment with non-fluorinated steroids. Acute myopathy and atrophy are caused by short-term high-dose corticosteroid administration, resulting in rhabdomyolysis, diffuse muscle weakness and severe dyspnoea. In contrast, chronic myopathy occurs after prolonged treatment with corticosteroids, and results in proximal muscle weakness and type IIb fibre atrophy. The pathophysiology of steroid myopathy is unknown, but reduction in protein synthesis and increased glycogen accumulation may play a major role. Animal models have demonstrated weakening of the diaphragm and a decrease in body and diaphragm mass after corticosteroid administration. In humans, a reduction in respiratory and peripheral muscle strength, an elevation of urinary creatine excretion and selective type IIb fibre atrophy may be observed. Treatment of corticosteroid-induced myopathy consists of tapering the dose of steroids or switching to non-fluorinated steroids.

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