References unknown, although findings suggest links with

1. Morrison W, Derrington SF. Stories and the longitudinal patient
relationship: what can clinical ethics consultants learn from palliative
care? J Clin Ethics. 2012;23(3):224-230.
2. Maung AA, Toevs CC, Kayser JB, Kaplan LJ. Conflict management
teams in the intensive care unit: a concise definitive review. J Trauma
Acute Care Surg. 2015;79(2):314-320.
3. Carter BS, Wocial LD. Ethics and palliative care: which consultant
and when? Am J Hosp Palliat Care. 2012;29(2):146-150.
4. Aulisio MP, Chaitin E, Arnold RM. Ethics and palliative care
consultation in the intensive care unit. Crit Care Clin. 2004;20(3):
505-523. x-xi.
Association Between
Attention-Deficit/
Hyperactivity Disorder and
Asthma Among Adults
A Case-Control Study
To the Editor:
Recently, we showed in a meta-analysis that in children
there is an association between attention-deficit/
hyperactivity disorder (ADHD) and atopic diseases,
especially asthma.1 The nature of this relationship is still
environmental and/or genetic risk factors contributing
to inflammatory mechanisms.2 Not much is known
about this association among adults. The aim of the
present study was to investigate associations between the
presence of ADHD and the presence and severity of
asthma in adults. As a secondary aim we investigated the
association between ADHD and the presence of eczema
and allergic rhinitis.
We conducted a case-control study using the University
of Groningen pharmacy prescription database, which is
representative of the Netherlands. Case subjects were
defined as adults aged between 18 and 50 years with at
least two prescriptions for ADHD medication within the
past 12 months. Control subjects were defined as adults
without any history of ADHD medication prescriptions
and were matched (4:1) on age and sex for each case.
The presence of asthma, eczema, and allergic rhinitis,
and asthma severity, were based on the type and
frequency of the prescription of drugs used to treat the
specific atopic allergy (e-Appendix 1). Multivariable
logistic regression analyses were applied to control for
urbanization and the presence of two of the other atopic

TABLE 1 ] Cohort Characteristics of Patients With ADHD and the Matched Comparator Group
Patients With Control Subjects Without
ADHD Medication ADHD Medication
(3,987) (15,948) P Value
Sex (female) 1,652 (41.4) 6,608 (41.4)
Age, mean (SD), y 32.4 (8.2) 32.8 (8.3) .147a
Urbanization level b
< .001c
1 1,248 (31.3) 4,610 (28.9)
2 1,123 (28.2) 3,823 (24.0)
3 811 (20.3) 3,260 (20.4)
4 437 (11.0) 1,868 (11.7)
5 323 (8.1) 2,124 (13.3)
Missing 45 (1.1) 263 (1.6)
Rhinitis 310 (7.8) 651 (4.1) < .001c
Eczema 222 (5.6) 534 (3.3) < .001c
Asthma 387 (9.7) 499 (3.1) < .001c
d
Asthma severity
Intermittent 45 (1.1) 64 (0.4) < .001c
Persistent mild 129 (3.2) 193 (1.2) < .001c
Persistent moderate-severe 137 (3.4) 168 (1.1) < .001c

Data are presented as No. (%) unless otherwise indicated. ADHD ¼ attention-deficit/hyperactivity disorder.
a
Student t test.
b
1 ¼ 2,500 or more addresses per km2; 2 ¼ 1,500-2,500 addresses per km2; 3 ¼ 1,000-1,500 addresses per km2; 4 ¼ 500-1,000 addresses per km2; and
5 ¼ fewer than 500 addresses per km2.
c
Pearson c2 test.
d
Asthma severity was estimated on the basis of various medication proxies (e-Appendix 1).

1406 Correspondence [ 151#6 CHEST JUNE 2017 ]

 4.0 Groningen, the Netherlands
3.5 Tjalling W. de Vries, MD, PhD
Leeuwarden, the Netherlands
Adjusted odds ratio

3.0 2.9 2.8

2.5 Pieter J. Hoekstra, MD, PhD
2.4 2.3
2.0 Eelko Hak, PhD
1.5 1.5 Groningen, the Netherlands
1.4
1.0
AFFILIATIONS: From the PharmacoTherapy, -Epidemiology, and
0.5 -Economics Research Group (Mr van der Schans, Ms Aikman, and
Dr Hak), Groningen Research Institute of Pharmacy, University of
0.0
Groningen; the Medical Center Leeuwarden (Dr de Vries); and the
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University Medical Center Groningen, University of Groningen.

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FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

od
CORRESPONDENCE TO: Jurjen van der Schans, MSc, PharmacoTherapy,

M
Figure 1 – Multivariable conditional logistic regression model, with
95% confidence intervals, of the association between attention-deficit/
hyperactivity disorder in adults and atopy defined according to condi-
tion and level of severity. The odds ratio is adjusted for age, sex, ur-
banization level, and other atopic diseases (asthma, eczema, and
rhinitis). Asthma severity was estimated on the basis of various medi-
cation proxies (see e-Appendix 1).
diseases (asthma, eczema, and rhinitis). Urbanization of
the living area was measured to correct for the
association between high urbanization levels and a
higher prevalence of asthma.3,4
We identified a total of 3,987 individuals being treated
with ADHD medication and matched them with 15,948
control subjects. Table 1 shows the characteristics of the
study population. The multivariable analysis revealed that
asthma, rhinitis, and eczema were significantly more
common in case subjects than in control subjects, with
asthma showing the strongest preponderance (Fig 1). No
significant association was seen between asthma severity
and the presence of ADHD.
Similar studies also found a higher co-occurrence of
both diseases than would be expected by chance.5
However, in our study we determined an association of a
history of asthma before the first prescription of ADHD
medication.
This study supports the hypothesis that in adults asthma
is more common among patients with ADHD than in
the general population. ADHD and asthma both have an
early onset, and it is therefore difficult to determine the
effect of asthma on ADHD in adults. Future studies
should determine the underlying mechanism and the
possible clinical implications of the association between
ADHD and asthma.
Jurjen van der Schans, MSc
Brech Aikman, MSc
-Epidemiology, and -Economics, Groningen Research Institute of
Pharmacy, University of Groningen, Antonius Deusinglaan 1, Groningen
9713 AV, the Netherlands; e-mail: j.van.der.schans@rug.nl
Copyright Ó 2017 American College of Chest Physicians. Published
by Elsevier Inc. All rights reserved.
DOI: http://dx.doi.org/10.1016/j.chest.2017.03.052
Acknowledgments
Additional information: The e-Appendix can be found in the
Supplemental Materials section of the online article.
References
1. van der Schans J, Cicek R, de Vries TW, Hak E, Hoekstra PJ.
Association of atopic diseases and attention-deficit/hyperactivity
disorder: a systematic review and meta-analyses. Neurosci Biobehav
Rev. 2017;74(Pt A):139-148.
2. Fasmer OB, Riise T, Eagan TM, et al. Comorbidity of asthma with
ADHD. J Atten Disord. 2011;15(7):564-571.
3. Elholm G, Linneberg A, Husemoen LL, et al. The Danish urban-rural
gradient of allergic sensitization and disease in adults. Clin Exp
Allergy. 2016;46(1):103-111.
4. Pitts M, Mangle L, Asherson P. Impairments, diagnosis and
treatments associated with attention-deficit/hyperactivity disorder
(ADHD) in UK adults: results from the lifetime impairment survey.
Arch Psychiatr Nurs. 2015;29(1):56-63.
5. Instanes JT, Klungsøyr K, Halmøy A, Fasmer OB, Haavik J. Adult
ADHD and comorbid somatic disease: a systematic literature review
[published online ahead of print September 22, 2016]. J Atten Disord.
http://dx.doi.org/10.1177/1087054716669589.
Pretest Probability in the
Assessment of Acute
Dyspnea in the ED
To the Editor:
It is with great interest that we read the article by
Zanobetti et al1 published in this issue of CHEST
regarding point-of-care ultrasonography (PoCUS) and
its implications in the diagnosis of acute dyspnea in the
ED. In this study, the authors found that the average
time needed to formulate a diagnosis by using PoCUS
was significantly shorter than that of a typical ED
diagnosis.

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