Evaluation of the Modified Asthma Predictive Index in High-Risk Preschool Children

Juan Carlos Ivancevich Monday, 03 February 2014 12:17

Background: Prediction of subsequent school-age asthma during the preschool years has proven challenging. Objective To confirm in a post hoc analysis the predictive ability of the modified Asthma Predictive Index (mAPI) in a high-risk cohort and a theoretical unselected population. We also tested a potential mAPI modification with a 2-wheezing episode requirement (m2API) in the same populations. Methods Subjects (n = 289) with a family history of allergy and/or asthma were used to predict asthma at age 6, 8, and 11 years with the use of characteristics collected during the first 3 years of life. The mAPI and the m2API were tested for predictive value. Results For the mAPI and m2API, school-age asthma prediction improved from 1 to 3 years of age. The mAPI had high predictive value after a positive test (positive likelihood ratio ranging from 4.9 to 55) for asthma development at years 6, 8, and 11. Lowering the number of wheezing episodes to 2 (m2API) lowered the predictive value after a positive test (positive likelihood ratio ranging from 1.91 to 13.1) without meaningfully improving the predictive value of a negative test. Posttest probabilities for a positive mAPI reached 72% and 90% in unselected and high-risk populations, respectively. Conclusions In a high-risk cohort, a positive mAPI greatly increased future asthma probability (eg, 30% pretest probability to 90% posttest probability) and is a preferred predictive test to the m2API. With its more favorable positive posttest probability, the mAPI can aid clinical decision making in assessing future asthma risk for preschool-age children. Timothy S. Chang, Robert F. Lemanske, Theresa W. Guilbert, James E. Gern, Michael H. Coen, Michael D. Evans, Ronald E. Gangnon, C. David Page, Daniel J. Jackson.Evaluation of the Modified Asthma Predictive Index in High-Risk Preschool Children The Journal of Allergy and Clinical Immunology: In Practice - March 2013 (Vol. 1, Issue 2, Pages 152-156, DOI: 10.1016/j.jaip.2012.10.008) Full text.

Inhaled Corticosteroids and the Risk of Pneumonia in people with Asthma: A case control study

Super User Saturday, 01 February 2014 15:35

Abstract: Background: In clinical trials the use of inhaled corticosteroids is associated with an increased risk of pneumonia in people with chronic obstructive pulmonary disease but whether the same is true for people with asthma is not known. Methods: Using primary care data from The Health Improvement Network we identified people with asthma and from this cohort we identified cases with pneumonia/ lower respiratory tract infection, and age and sex matched controls. Conditional logistic regression was used to determine the association between the dose and type of inhaled corticosteroid and risk of pneumonia or LRTI. Results: There was a dose response relationship between strength of dose of inhaled corticosteroid and risk of pneumonia or lower respiratory tract infection (p-trend <0∙001), such that after adjusting for confounders people receiving the highest strength of inhaled corticosteroid (≥1000mcg) had a 2.04 (95% CI 1∙59 to 2∙64) increased risk of pneumonia or lower respiratory infection when compared to people with asthma who did not have a prescription for inhaled corticosteroids within the previous 90 days. Conclusion: People with asthma receiving inhaled corticosteroids are at an increased risk of pneumonia or lower respiratory infection with people receiving higher doses at greater risk. Pneumonia should be considered as a possible side effect of inhaled corticosteroids and the lowest dose of inhaled corticosteroids possible should be used in the management of asthma. McKeever T, Harrison TW, Hubbard R, Shaw D. Inhaled Corticosteroids And The Risk Of Pneumonia In People With Asthma: A Case Control Study Chest. 2013;144(6):1788-1794. doi:10.1378/chest.13-0871

Electronic health record-based assessment of oral corticosteroid use in a population of primary care patients with asthma

Juan Carlos Ivancevich Wednesday, 29 January 2014 15:35

Abstract - Background: Oral corticosteroid prescriptions are often used in clinical studies as an indicator of asthma exacerbations. However, there is rarely the ability to link a prescription to its associated diagnosis. The objective of this study was to characterize patterns of oral corticosteroid prescription orders for asthma patients using an electronic health record database, which links each prescription order to the diagnosis assigned at the time the order was placed. Methods: This was a retrospective cohort study of the electronic health records of asthma patients enrolled in the Geisinger Health System from January 1, 2001 to August 23, 2010. Eligible patients were 12--85 years old, had a primary care physician in the Geisinger Health System, and had asthma. Each oral corticosteroid order was classified as being prescribed for an asthma-related or non-asthma-related condition based on the associated diagnosis. Asthma-related oral corticosteroid use was classified as either chronic or acute. In patient-level analyses, we determined the number of asthma patients with asthma-related and non-asthma-related prescription orders and the number of patients with acute versus chronic use. Prescription-level analyses ascertained the percentages of oral corticosteroid prescription orders that were for asthma-related and non-asthma-related conditions. Results: Among the 21,199 asthma patients identified in the electronic health record database, 15,017 (70.8%) had an oral corticosteroid prescription order. Many patients (N = 6,827; 45.5%) had prescription orders for both asthma-related and non-asthma-related conditions, but some had prescription orders exclusively for asthma-related (N = 3,450; 23.0%) or non-asthma-related conditions (N = 4,740; 31.6%). Among the patients receiving a prescription order, most (87.5%) could be classified as acute users. A total of 60,355 oral corticosteroid prescription orders were placed for the asthma patients in this study---31,397 (52.0%) for non-asthma-related conditions, 24,487 (40.6%) for asthma-related conditions, and 4,471 (7.4%) for both asthma-related and non-asthma-related conditions. Conclusions: Oral corticosteroid prescriptions for asthma patients are frequently ordered for conditions unrelated to asthma. A prescription for oral corticosteroids may be an unreliable marker of asthma exacerbations in retrospective studies utilizing administrative claims data. Investigators should consider co-morbid conditions for which oral corticosteroid use may also be indicated and/or different criteria for assessing oral corticosteroid use for asthma. Felicia C Allen-Ramey, Linda M Nelsen, Joseph B Leader, Dione Mercer, Henry Lester Kirchner and James B Jones. Electronic health record-based assessment of oral corticosteroid use in a population of primary care patients with asthma: an observational study. Allergy, Asthma & Clinical Immunology 2013, 9:27 doi:10.1186/1710-1492-9-27. Open access.

Cost-effectiveness of primary prevention of paediatric asthma: a decision-analytic model

Juan Carlos Ivancevich Friday, 31 January 2014 15:35

Abstract - Background: Many children stand to benefit from being asthma-free for life with primary (i.e., prenatally started) prevention addressing one environmental exposure in a unifaceted (UF) approach or at least two in a multifaceted (MF) approach. We assessed the cost-effectiveness of primary prevention programmes for Dutch children in a decision-analytic framework. Methods A decision-analytic tree model analysing healthcare costs and asthma cases prevented was developed to compare usual care (UC) with two UF and three MF programmes on the primary prevention of asthma amongst children. Programmes were evaluated through incremental cost-effectiveness ratios and net monetary benefits. Decision and parameter uncertainty were subjected to value-of-information analyses. Results:The current UC and one of three MF programmes dominated the other alternatives. The MF programme was more costly but also more effective than UC at an incremental cost-effectiveness ratio of €8,209.20/additional asthma case prevented. The value of perfect information to reduce uncertainty was €291.6M at its lowest. Most of the uncertainty in the cost-effectiveness threshold was attributable to the probability and cost estimates for low-risk children. Conclusion: This study supports the feasibility of a structured programme that simultaneously addresses exposure to house dust mites, pet dander, environmental tobacco, and breast-feeding as a cost-effective alternative to UC in the primary prevention of asthma amongst children. G. Feljandro P. Ramos, Antoinette D. I. van Asselt, Sandra Kuiper, Johan L. Severens, Tanja Maas, Edward Dompeling, J. André Knottnerus, Onno C. P. van SchayckCost-effectiveness of primary prevention of paediatric asthma: a decision-analytic model. The European Journal of Health Economics October 2013. 

Diet and asthma: vitamins and methyl donors

Super User Monday, 27 January 2014 15:35

Summary: Diet changes can partly explain the high burden of asthma in industrialised nations. Findings from experimental studies have stimulated many observational studies of the association between vitamins (A, C, D, and E) or nutrients acting as methyl donors (folate, vitamin B12, and choline) and asthma. However, observational studies are susceptible to several sources of bias; well conducted randomised controlled trials (RCTs) are the gold standard to establish whether diet has an effect on asthma. Evidence from observational studies and a few RCTs strongly justifies ongoing and future RCTs in three areas: vitamin D for the prevention or treatment of asthma, choline supplementation as adjuvant treatment for asthma, and vitamin E to prevent the detrimental effects of air pollution in patients with asthma. At present, insufficient evidence exists to recommend supplementation with any vitamin or nutrient acting as a methyl donor to prevent or treat asthma. Yueh-Ying Han PhD,Josh Blatter MD,John M Brehm MD,Erick Forno MD,Augusto A Litonjua MD,Prof Juan C Celedón MD.The Lancet Respiratory Medicine - 31 July 2013 DOI: 10.1016/S2213-2600(13)70126-7. Full text. 

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Editor: Juan C. Ivancevich, MD

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