Global strategy for asthma management and prevention

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma

ContextDevelopers of health care software have attributed improvements in patient
care to these applications. As with any health care intervention, such claims
require confirmation in clinical trials.ObjectivesTo review controlled trials assessing the effects of computerized clinical
decision support systems (CDSSs) and to identify study characteristics predicting
benefit.Data SourcesWe updated our earlier reviews by searching the MEDLINE, EMBASE, Cochrane
Library, Inspec, and ISI databases and consulting reference lists through
September 2004. Authors of 64 primary studies confirmed data or provided additional
information.Study SelectionWe included randomized and nonrandomized controlled trials that evaluated
the effect of a CDSS compared with care provided without a CDSS on practitioner
performance or patient outcomes.Data ExtractionTeams of 2 reviewers independently abstracted data on methods, setting,
CDSS and patient characteristics, and outcomes.Data SynthesisOne hundred studies met our inclusion criteria. The number and methodologic
quality of studies improved over time. The CDSS improved practitioner performance
in 62 (64%) of the 97 studies assessing this outcome, including 4 (40%) of
10 diagnostic systems, 16 (76%) of 21 reminder systems, 23 (62%) of 37 disease
management systems, and 19 (66%) of 29 drug-dosing or prescribing systems.
Fifty-two trials assessed 1 or more patient outcomes, of which 7 trials (13%)
reported improvements. Improved practitioner performance was associated with
CDSSs that automatically prompted users compared with requiring users to activate
the system (success in 73% of trials vs 47%; P = .02)
and studies in which the authors also developed the CDSS software compared
with studies in which the authors were not the developers (74% success vs
28%; respectively, P = .001).ConclusionsMany CDSSs improve practitioner performance. To date, the effects on
patient outcomes remain understudied and, when studied, inconsistent.

Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review.

Organisms require an appropriate balance of stability and reversibility in gene expression programmes to maintain cell identity or to enable responses to stimuli; epigenetic regulation is integral to this dynamic control. Post-translational modification of histones by methylation is an important and widespread type of chromatin modification that is known to influence biological processes in the context of development and cellular responses. To evaluate how histone methylation contributes to stable or reversible control, we provide a broad overview of how histone methylation is regulated and leads to biological outcomes. The importance of appropriately maintaining or reprogramming histone methylation is illustrated by its links to disease and ageing and possibly to transmission of traits across generations.

/pdf/histone-methylation-a-dynamic-mark-in-health-disease-and-53e9mgdnmh.pdf

Histone methylation: a dynamic mark in health, disease and inheritance

Background: The assessment of asthma control is pivotal to the evaluation of treatment response in individuals and in clinical trials. Previously, asthma control, severity, and exacerbations were defined and assessed in many different ways.Purpose: The Task Force was established to provide recommendations about standardization of outcomes relating to asthma control, severity, and exacerbations in clinical trials and clinical practice, for adults and children aged 6 years or older.Methods: A narrative literature review was conducted to evaluate the measurement properties and strengths/weaknesses of outcome measures relevant to asthma control and exacerbations. The review focused on diary variables, physiologic measurements, composite scores, biomarkers, quality of life questionnaires, and indirect measures.Results: The Task Force developed new definitions for asthma control, severity, and exacerbations, based on current treatment principles and clinical and research relevance. In view of current knowledge ...

/pdf/an-official-american-thoracic-society-european-respiratory-18b801porh.pdf

An official American Thoracic Society/European Respiratory Society statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and clinical practice.

https://www.cell.com/current-biology/pdf/S0960-9822(10)00054-0.pdf

Methylation of H3K4 Is Required for Inheritance of Active Transcriptional States

Background—A study was undertaken to identify asthma patients at risk of an attack and to assess the economic impact of treatment strategies. Methods—A retrospective cohort analysis of a representative data set of 12 203 patients with asthma in the UK over a one year period was performed. Logistic multiple regression was used to model the probability of an attack occurring using a set of categorised predictor factors. Health service costs were calculated by applying published average unit costs to the patient resource data. The main outcome measures were attack incidence, health service resource use, drug treatment, and cost estimates for most aspects of asthma related health care. Results—Children under five years of age accounted for 597 patients (5%), 3362 (28%) were aged 5‐15 years, 4315 (35%) 16‐44, 3446 (28%) 45‐74, and 483 (4%) were aged over 74 years. A total of 9016 patients (74%) were on some form of prophylactic asthma medication; 2653 (22%) experienced an attack in the year data collection occurred. Overall health care expenditure was estimated at £2.04 million. The average cost per patient who had an attack was £381 compared with £108 for those who did not, an increase of more than 3.5 times. In those aged under five and those over 75 years of age there were no significant markers to identify risk, but both groups were small in size. The level of treatment step in the British Thoracic Society (BTS) asthma guidelines was a statistically significant factor for all other age groups. Night time symptoms were significant in the 5‐15, 16‐44 and 45‐74 age groups, exercise induced symptoms were only significant for the 5‐15 age group, and poor inhaler technique in the 16‐44 age group. Conclusions—Patients at any treatment step of the BTS asthma guidelines are at risk of an asthma attack, the risk increasing as the treatment step increases. Poorly controlled asthma may have a considerable impact on health care costs. Appropriate targeting of preventive measures could therefore reduce overall health care costs and the growing pressures on hospital services associated with asthma management. (Thorax 2000;55:19‐24)

https://thorax.bmj.com/content/thoraxjnl/55/1/19.full.pdf

Risk factors and costs associated with an asthma attack

BACKGROUND: IVF and embryo transfer has become an established and increasingly successful form of treatment for infertility, yet significant numbers of couples discontinue treatment without achieving a live birth. This study aims to identify major factors that influence the decision to discontinue IVF treatment. METHODS: Questionnaires were sent to 1510 couples who had undergone IVF treatment at Ninewells Hospital and Medical School, Dundee, Scotland, between January 1995 and December 2001. The main outcome measure was the number of couples who discontinue treatment and the reasons for discontinuation including live birth, lack of success, lack of funding, psychological stress, medical advice, physical discomfort, personal and other reasons. RESULTS: The response rate was 55% (732/1327) with 183 questionnaires returned as address unknown. A total of 515 couples had discontinued treatment at time of response, with 266 (52%) having achieved a live birth. Achieving a live birth was the reason for discontinuation where a single reason was given. Those who did not conceive gave a combination of reasons. Lack of personal and/or National Health Service funding was cited by 23% of couples as a reason. Lack of success and psychological stress were reported as factors by 23 and 36% of couples respectively. These two factors are very strongly associated (P < 0.001), both being reported by 18% of couples with a reciprocal increase in those quoting lack of success and psychological stress as reasons for discontinuation with increasing number of attempts (P < 0.0005). Changes in personal circumstances were reported by 30% and <10% gave general discomfort or advice from medical staff as reasons. CONCLUSIONS: Though funding is an important issue, factors including lack of success and psychological stress play a greater role in influencing the decision to discontinue treatment. Better information and support are needed to improve the continuation rates.

/pdf/reasons-for-discontinuation-of-ivf-treatment-a-questionnaire-177a6k7rxq.pdf

Reasons for discontinuation of IVF treatment: a questionnaire study.

Body mass index (BMI) relates weight to height and reflects the shape of a child, but because of age dependency it has not been used conventionally for the estimation of fatness in children. From measurements of Tayside children (n = 34,533) centile charts were constructed for BMI (wt/ht2) from the raw data of height and weight, using Cole's LMS method for normalised growth standards. These data were compared with the only available European BMI charts published from data of French children obtained over a period of 24 years from 1956-79. British children appear to be 'fatter'. Within a subgroup (n = 445) the BMI values were correlated with estimations of body fat, for boys and girls, from skinfold thickness (r = 0.8 and 0.81) and bioelectrical impedance (r = 0.65 and 0.7). The limits of acceptable BMI have yet to be defined.

https://adc.bmj.com/content/archdischild/72/1/38.full.pdf

Body mass index centile charts to assess fatness of British children.

Objective: To investigate whether asthma or its treatment impairs children9s growth, after allowing for socioeconomic group. Design: 4 year follow up of a cohort of children aged 1-15. Setting: 12 general practices in the Tayside region of Scotland. Subjects: 3347 children with asthma or features suggestive of asthma registered with the general practices. Main outcome measures: Height and weight standard deviation scores. Results: Children who lived in areas of social deprivation (assessed by postcode) had lower height and weight than their contemporaries (mean standard deviation score −0.26 (SD 1.02) and −0.18 (1.15) respectively, P Conclusion: Most children with asthma were of normal height and weight and had normal growth rates. However, children receiving high doses of inhaled steroids and requiring both general practice and hospital services had a significant reduction in their stature. This effect was independent from but smaller than the effect of socioeconomic group on stature. Key messages Social deprivation has an adverse effect on the height and weight of children irrespective of any disease process Neither asthma nor its treatments had any noticeable effect on the height and weight of most of the children in this primary care study Children who received high doses of inhaled corticosteroids and used hospital services for asthma were shorter and lighter than their contemporaries after social deprivation was allowed for Children receiving high doses of inhaled corticosteroids had lower than normal growth rates

https://www.bmj.com/content/bmj/316/7132/668.1.full.pdf

Effect of asthma and its treatment on growth: four year follow up of cohort of children from general practices in Tayside, Scotland

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