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Biomedical subjects

David Price

Publications and source records attributed to David Price.

At least 19 recordsLinked to original sources
PubMed2006

Poor communication may impair optimal asthma care: a qualitative study.

BACKGROUND: Despite asthma being primarily managed in general practice and primary care, there is little research into the issues and tools which may impact on managing poorly controlled asthma in this setting. OBJECTIVE: To explore the views of health care professionals (HCPs) towards asthma guidelines and self-management plans (SMPs) to identify why these are not used routinely in general practice. METHODS: Data from 54 HCPs [GPs and practice nurses (PNs)] in north-east Scotland were collected via qualitative interviews and focus groups. Participant views and experience of asthma guidelines and SMPs were explored. RESULTS: Participants had mainly positive attitudes towards guidelines and SMPs, although both were used only when deemed suitable by the individual. Suitability depended on individual patient issues (e.g. psychosocial factors, level of control) and/or professional issues (e.g. ease of use, time available, job roles). Patient issues were viewed as impacting on asthma control directly and, indirectly, as the main reason for not using guidelines or SMPs with a patient. HCPs reported lacking necessary communication skills for dealing with patient asthma control issues, particularly where these were non-medical. Professional and organizational issues such as training and communication were also perceived as impairing asthma management. CONCLUSION: Our findings indicate that guidelines are seen as providing the 'why' of helping asthma patients' self-manage but not the 'what to...' or 'how to...' communicate. Poor professional-patient communication seems largely to explain the poor uptake of SMPs and guideline use in general practice and primary care. This limitation is more obvious to professionals when they are working with patients with poorly controlled asthma. There is a need to identify key communication skills for effective professional-patient partnership in adult asthma management, and to develop robust strategies for effectively training GPs and PNs in enhancing these skills.

Adult↗
PubMed2006

Asthma out of control? A structured review of recent patient surveys.

BACKGROUND: An understanding of the needs and behaviors of asthma patients is important in developing an asthma-related healthcare policy. The primary goal of the present review was to assess patient perspectives on key issues in asthma and its management, as captured in patient surveys. METHODS: Local, national, and multinational asthma surveys were reviewed to assess patient perspectives, and where possible healthcare provider (HCP) perspectives, on key issues, including diagnosis, treatment, control, quality of life, and other patient-centered outcomes. Twenty-four surveys, conducted or published between 1997 and 2003 in Europe and North America, were included in this review. Substantial differences among studies prevented a formal meta-analysis; instead, data were pooled to allow for general comparisons and qualitative analysis. RESULTS: The results indicate that patients' knowledge of the underlying causes of asthma and treatment options remains inadequate. Moreover, patients often tolerate poor symptom control, possess meager knowledge of correct drug usage, and display insufficient adherence to therapy. Many patients have a low expectation of receiving an appropriate therapy or of having a positive encounter with the HCP. Among HCPs, there is evidence of inadequate understanding of disease etiology and poor or unstructured communication with patients, resulting often in inaccurate assessment of disease severity. Moreover, patients often underreport their symptoms and severity, which in turn could lead to misclassification and undertreatment. CONCLUSION: Improving patient education about the importance of achieving optimal asthma control, along with improved communication between patients and HCPs, emphasizing treatment options and optimal treatment of inflammation, may lead to better outcomes and improved asthma management in daily practice.

Adult↗
PubMed2006

Breaking new ground: challenging existing asthma guidelines.

BACKGROUND: While we have international guidelines and various national guidelines for asthma diagnosis and management, asthma remains poorly controlled in many children and adults. In this paper we review the limitations of current asthma guidelines and describe important issues and remaining questions regarding asthma guidelines for use, particularly in primary care. DISCUSSION: Clinical practice guidelines based on evidence from randomized controlled trials are considered the most rigorous and accurate. Current evidence-based guidelines are written predominantly from the perspective of the patient with a clear-cut asthma diagnosis, however, and tend not to consider the heterogeneity of asthma or to accommodate individual patient variations in response to treatment or their needs, differences in practice settings, or local differences in availability and cost of therapies. The results of randomized controlled trials, which are designed to establish efficacy of treatment under ideal conditions, may not apply to 'real-world' clinical practice, where patients are unselected, monitoring is less frequent, and effectiveness--the benefit of treatment in routine clinical practice--is the most relevant outcome. Moreover, most guidelines see asthma in isolation rather than considering other factors that may impact on asthma and response to asthma therapy, particularly age, allergic rhinitis, cigarette smoking, adherence, and genetic factors. When these links are recognized, guidelines rarely provide practical recommendations for treatment in these scenarios. Finally, there is some evidence that general practitioners are not convinced of the applicability of asthma guidelines to their practice settings, especially when those writing the guidelines principally work in specialist practice. CONCLUSION: Developing country-specific guidelines or, ideally, local guidelines could provide more practical solutions for asthma care and could account for regional factors that influence patient choice and adherence to therapy. Pragmatic clinical trials and well-designed observational trials are needed in addition to randomized controlled trials to assess real-world effectiveness of therapies, and such evidence needs also to be considered by guideline writers. Finally, practical tools to facilitate the diagnosis and assessment of asthma and factors responsible for poor control, such as associated allergic rhinitis, limited adherence, and smoking behavior, are needed to supplement treatment information provided in clinical practice guidelines for asthma.

Adult↗
PubMed2006

Treatment and outcomes in patients with asthma and allergic rhinitis in the United kingdom.

BACKGROUND: Since allergic rhinitis in asthma patients is associated with worse asthma control, the treatment of the comorbid condition may improve outcomes. METHODS: A 1-year retrospective study using the UK Mediplus database (2001-2004) included asthmatic patients aged 15-55 with allergic rhinitis. Patients starting therapy based on the Global Initiative for Asthma guidelines, defined as an increase in inhaled corticosteroids (high-dose inhaled corticosteroids, hdICS), or the addition of montelukast (ICS+MON) or long-acting beta-agonists (ICS+LABA) to ICS, were studied. Univariable and multiple logistic regressions evaluated asthma-related outcomes. RESULTS: Among 2,596 asthma and allergic rhinitis patients, 83.2% initiated ICS+LABA, 12.1% hdICS and 4.7% ICS+MON. The mean age was 34 years and 60% were female. ICS+MON patients had more moderate-severe asthma (p = 0.04). Approximately 84% of the ICS+LABA patients experienced an asthma control failure compared to 50% in the other groups (p < 0.0001). The proportions of patients requiring treatment change were 73.8, 22 and 27.3% in the ICS+LABA, hdICS and ICS+MON groups, respectively (p = 0.001). Asthma-related resource use was similar among all groups. The ICS+MON group received fewer mean prescriptions for oral corticosteroids (p = 0.024) than the other groups (p = 0.026). CONCLUSIONS: In asthma and allergic rhinitis, treatment with ICS+MON or hdICS was associated with lower rates of asthma control failure and fewer treatment changes than the ICS+LABA group. MON users also required fewer oral corticosteroids.

Acetates↗
PubMed2006

Short-course montelukast for intermittent asthma in children: a randomized controlled trial.

RATIONALE: In children, intermittent asthma is the most common pattern and is responsible for the majority of exacerbations. Montelukast has a rapid onset of action and may be effective if used intermittently. OBJECTIVES: To determine whether a short course of montelukast in children with intermittent asthma would modify the severity of an asthma episode. METHODS: Children, aged 2-14 years with intermittent asthma participated in this multicenter, randomized, double-blind, placebo-controlled clinical trial over a 12-month period. Treatment with montelukast or placebo was initiated by parents at the onset of each upper respiratory tract infection or asthma symptoms and continued for a minimum of 7 days or until symptoms had resolved for 48 hours. MEASUREMENTS AND MAIN RESULTS: A total of 220 children were randomized, 107 to montelukast and 113 to placebo. There were 681 treated episodes (345 montelukast, 336 placebo) provided by 202 patients. The montelukast group had 163 unscheduled health care resource utilizations for asthma compared with 228 in the placebo group (odds ratio, 0.65; 95% confidence interval, 0.47-0.89). There was a nonsignificant reduction in specialist attendances and hospitalizations, duration of episode, and beta-agonist and prednisolone use. Symptoms were reduced by 14% and nights awakened by 8.6% (p = 0.043), and days off from school or childcare by 37% and parent time off from work by 33% (p < 0.0001 for both). CONCLUSIONS: A short course of montelukast, introduced at the first signs of an asthma episode, results in a modest reduction in acute health care resource utilization, symptoms, time off from school, and parental time off from work in children with intermittent asthma.

Absenteeism↗
PubMed2006

Early evaluation of compound QT prolongation effects: a predictive 384-well fluorescence polarization binding assay for measuring hERG blockade.

INTRODUCTION: A large number of drugs from a variety of pharmacological classes have been demonstrated to cause adverse effects on cardiac rhythm, including the life-threatening arrhythmia Torsades de Pointes. These side effects are often associated with prolongation of the QT interval and are mediated via blockade of the human ether-a-go-go related gene (hERG) encoded potassium channel. In order to manage this risk in the pharmaceutical industry it is desirable to evaluate QT prolongation as early as possible in the drug discovery process. METHODS: Here we describe the development of a 384-well fluorescence polarization (FP) binding assay compatible with high-throughput assessment of compound blockade of the hERG channel during the lead optimisation process. To characterise the fluorescent ligand that was developed, competition binding studies, kinetic studies and electrophysiology studies were performed. Furthermore, to validate the assay as a key screening method a series of competition binding studies were performed and correlated with functional data obtained via patch-clamp. RESULTS: Evaluation of the assay indicates that high quality data is obtained (Z'>0.6), that the K(i) values determined are equivalent to more traditional radiometric methods and that it is predictive for functional hERG blockade as assessed by patch clamp. DISCUSSION: Whilst FP assays, utilizing a variety of fluors, have become well established for the evaluation of G-protein-coupled receptor (GPCRs) and kinase ligand interactions, this technique has not been applied widely to the study of ion channels. Therefore, this represents a novel assay format that is amenable to the evaluation of thousands of compounds per day. Whilst other assay formats have proven predictive or high throughput, this assay represents one of few that combines both attributes, moreover it represents the most cost effective assay, making it truly amenable to early assessment of hERG blockade.

Binding, Competitive↗
PubMed2006

Professional and patient attitudes to using mobile phone technology to monitor asthma: questionnaire survey.

AIMS: There is increasing international interest in using emerging technologies to enhance chronic disease management. We aimed to explore the attitudes of patients and primary care professionals to using mobile technology in order to monitor asthma. METHODS: A piloted questionnaire containing closed and open-ended questions assessing attitudes to using electronic self-monitoring was posted to a random sample of general practitioners, asthma nurses, and people with asthma (12 years and over) in Lothian and Kent, UK, with 2 reminders. In addition to descriptive statistics, patient and clinician responses were compared using Chi-squared or independent sample t-tests. Free-text responses were analysed thematically. RESULTS: Responses were obtained from 130/300 professionals (43%) and 202/389 patients (52%). Patients rated the technology positively and considered that it may help clinicians to provide care, especially during acute attacks. Although rated similarly, professionals were more sceptical about benefits. Both professionals and patients had concerns about the time and cost implications. Of the respondents, 28 professionals (10%) and 62 patients (16%) returned uncompleted questionnaires citing lack of perceived relevance. CONCLUSIONS: The low completion rate probably reflects the current status of mobile phone-facilitated care as a minority interest for 'early adopters' of technology. Even for the enthusiastic minority, using mobile phone technology raised questions of clinical benefit, impact on self-management, and concerns about workload and cost, which will need to be addressed prior to wider acceptance.

Adult↗
PubMed2006

Can a GP be a generalist and a specialist? Stakeholders views on a respiratory General Practitioner with a special interest service in the UK.

BACKGROUND: Primary care practitioners have a potentially important role in the delivery of specialist care for people with long-term respiratory diseases. Within the UK the development of a General Practitioner with Special Interests (GPwSI) service delivered within Primary Care Trusts (PCTs) involves a process of 'transitional change' which impacts on the professional roles of clinicians who may embrace or resist change. In addition, the perspective of patients on the new roles is important. The objective of the current study is to explore the attitudes and views of stakeholders to the provision of a respiratory GPwSI service within the six PCTs in Leicester, UK. METHODS: Using a qualitative design, GPs, nurses, secondary care doctors, nurse specialists, physiotherapists, a healthcare manager and patients with respiratory disease took part in focus groups and in-depth interviews. RESULTS: The 25 participants expressed diverse opinions about the challenge of integrating specialist services with generalist care and the specific contribution that GPs might make to the care of people with chronic respiratory disease. A range of potential roles for a respiratory GPwSI, working as part of a multi-disciplinary team, were suggested, and a number of practical issues were highlighted. Success of the GPwSI role is deemed to be dependent on having the trust of their primary and secondary care colleagues as well as patients, credibility as a practitioner, and being politically astute thereby enabling them to act as a champion supporting the transition process within the local health service. CONCLUSION: The introduction of a respiratory GPwSI service represents a challenge to traditional roles which, whilst broadly acceptable, raised a number of important issues for the stakeholders in our study. These perspectives need to be taken into account if workforce change is to be successfully negotiated and implemented.

Attitude of Health Personnel↗
PubMed2006

High-dose inhaled corticosteroids and add-on therapy use in adults with asthma in the UK in 2003: an observational study.

AIMS: To quantify use of high dose inhaled corticosteroids (ICS) and add-on therapy in adults, and children aged 12 and over, in the community. METHODS: Cross-sectional observational survey of UK general practice prescribing records from July 2002 to June 2003 utilising the Doctors Independent Network clinical database. RESULTS: 30,895 patients aged 12 and over were treated for asthma with inhaled corticosteroids, with a quantifiable daily dose recommendation in 22,027 cases. Twenty-seven percent (95% Confidence Intervals 26-28%) were prescribed 'high-dose' ICS (>800 mcg/day beclomethasone or equivalent). Of these, 32% (31-33%) were not currently prescribed add-on therapy (long acting B2 agonists, leukotriene antagonists, theophylines), and most of these (84%, 82-86%) had never received a prior trial of add-on therapy. CONCLUSIONS: High dose ICS therapy was commonly prescribed to people with asthma, frequently without co-prescribed add-on therapy. Many adults with more severe asthma may be receiving treatment that does not accord with current evidence of best practice.

Administration, Inhalation↗
PubMed2006

Sub-optimal patient and physician communication in primary care consultations: its relation to severe and difficult asthma.

INTRODUCTION: Asthma control can be influenced by a range of non-medical issues, including psychosocial factors. Little is known about the views of patients, particularly those with severe and/or difficult asthma, towards their asthma control and their asthma-related primary care consultations. AIMS AND OBJECTIVES: To explore patients' experiences of their asthma and primary care asthma consultations in order to identify target areas for intervention. METHODS: This was a qualitative study of 14 asthma patients based in grounded theory. Questions were asked about: asthma understanding; control issues; and interactions with primary care health professionals. Data were analysed using the constant comparative method and framework approach. RESULTS: Participants with severe and/or difficult asthma normalised control issues, were reluctant to discuss non-medical factors with healthcare professionals (HCPs), reported poorer communication with HCPs, and were reluctant to raise relevant but non-medical factors in the consultation. CONCLUSIONS: Our data identifies that patients, particularly those with severe and/or difficult asthma and poor control, underplay symptoms and do not discuss non-medical factors which may impact on asthma control in primary care consultations. This poor communication is associated with patients underestimating disease severity and/or what could be achieved in terms of disease control. Training HCPs in the use of patient-centred communication skills may optimise asthma management in primary care.

Adult↗
PubMed2006

Exacerbations of chronic obstructive pulmonary disease--a patients' perspective.

BACKGROUND: Exacerbations are now an important clinical variable for research into, and management of, chronic obstructive pulmonary disease (COPD). Emphasis is usually on reductions in the incidence of exacerbations and their impact on quality of life. For such research to be useful and comparable there needs to be a clearly defined understanding of what is meant by the term 'exacerbation'. The aim of this study was to explore the notion of COPD exacerbations from the viewpoint of patients who had recently suffered an exacerbation. METHODS: Using principles from grounded theory we conducted semi-structured, in-depth interviews with 23 volunteers from Denmark, the Netherlands and the UK who were identified as having had a COPD exacerbation. Interviews were recorded locally and translated into English for analysis. Notable themes were identified for each informant and their occurrences compared. RESULTS: Patients' reasons for consulting fell into four categories: 'frightening change'; 'change in sputum colour'; 'gradual deterioration'; and 'opportunistic diagnosis'. Most patients consulted frequently about their COPD, but did not afford their exacerbations the same degree of prominence as healthcare professionals (HCPs). CONCLUSIONS: These data provide a new way of thinking about COPD exacerbations, offering a greater understanding and classification of the reasons underlying the decision of COPD patients to consult with HCPs. They suggest that the patient perspective of exacerbations is more complex than previously thought. These findings could be applied to clinical practice and research, facilitating focussed decisions on COPD management.

Acute Disease↗
PubMed2006

ARIA update: I--Systematic review of complementary and alternative medicine for rhinitis and asthma.

Complementary-alternative medicines are extensively used in the treatment of allergic rhinitis and asthma, but evidence-based recommendations are lacking. To provide evidence-based recommendations, the literature was searched by using MedLine and the Cochrane Library to March 2005 (Key words: Asthma [OR] Rhinitis, [AND] Complementary [OR] Alternative Medicine, [OR] Herbal, [OR] Acupuncture, [OR] Homeopathy, [OR] Alternative Treatment). Randomized trials, preferably double-blind and published in English, were selected. The articles were evaluated by a panel of experts. Quality of reporting was assessed by using the scale validated by Jadad. The methodology of clinical trials with complementary-alternative medicine was frequently inadequate. Meta-analyses provided no clear evidence for the efficacy of acupuncture in rhinitis and asthma. Some positive results were described with homeopathy in good-quality trials in rhinitis, but a number of negative studies were also found. Therefore it is not possible to provide evidence-based recommendations for homeopathy in the treatment of allergic rhinitis, and further trials are needed. A limited number of studies of herbal remedies showed some efficacy in rhinitis and asthma, but the studies were too few to make recommendations. There are also unresolved safety concerns. Therapeutic efficacy of complementary-alternative treatments for rhinitis and asthma is not supported by currently available evidence.

Acupuncture↗
PubMed2006

Toremifene for the prevention of prostate cancer in men with high grade prostatic intraepithelial neoplasia: results of a double-blind, placebo controlled, phase IIB clinical trial.

PURPOSE: A randomized, double-blind, dose finding, placebo controlled, parallel group clinical study was done to determine the incidence of prostate cancer in men with high grade prostatic intraepithelial neoplasia treated with toremifene. MATERIALS AND METHODS: A total of 514 patients with high grade prostatic intraepithelial neoplasia and no evidence of prostate cancer on screening biopsy were randomized to 20, 40 or 60 mg toremifene, or placebo daily for 12 months. Patients underwent re-biopsy at 6 and 12 months. RESULTS: The number of evaluable patients, that is those with 1 on study biopsy who were compliant, was 447. The cumulative risk of prostate cancer was decreased in patients on 20 mg toremifene compared with placebo (24.4% vs 31.2%, p <0.05). The annualized rate of prevention was 6.8 cancers per 100 men treated. In patients with no biopsy evidence of cancer at baseline and 6 months, the 12-month incidence of prostate cancer was decreased by 48.2% with 20 mg toremifene compared with placebo (9.1% vs 17.4%, p <0.05). The 20 mg dose was most effective but cumulative and 12-month incidences of prostate cancer were lower for each toremifene dose vs placebo with a cumulative risk of 29.2% and 28.1%, and a 12-month incidence of 14.3% and 13.0% for 40 and 60 mg, respectively. Gleason scores were similar across treatments. The overall incidence of drug related and serious adverse events did not differ between any of the toremifene groups and the placebo group. CONCLUSIONS: Toremifene decreased the incidence of prostate cancer by 1 year and had a tolerability profile comparable to that of placebo in a high risk population.

Adult↗
PubMed2006

Self-sampling for group B streptococcus in women 35 to 37 weeks pregnant is accurate and acceptable: a randomized cross-over trial.

OBJECTIVE: In Canada, screening for group B Streptococcus (GBS) in pregnant women is recommended at 35 to 37 weeks' gestation. Since there is normally no other indication for pelvic examination at this stage of pregnancy, women may be more comfortable performing the test themselves. We assessed the accuracy of self- sampling versus clinician sampling for GBS and women's preference for each collection method. METHODS: Consecutive patients presenting between October 2003 and April 2005 to a maternity centre in Hamilton for their 35- to 37-week prenatal visit were randomly allocated to having vaginal-rectal swabs self-collected, and then collected by a clinician, or to having the swabs clinician-collected, and then self-collected. The main outcomes were prevalence of infection and sensitivity of the two methods. Other analyses compared women who refused participation in the study with those who participated, and preference for sampling method before and after conducting the tests. RESULTS: Of the 386 women approached, 330 (85.5%) agreed to participate. The prevalence of GBS was 17.0% (56/330) and 18.8% (62/330) in the self-obtained and clinician-obtained specimens respectively (difference =1.8%; 95% confidence intervals [CI] -2.0-6.0). Sensitivity was 87.5% (95% CI 77.0-93.8) and 96.9% (95% CI 88.7-99.8) for the self-obtained and clinician-obtained specimens respectively. Women who declined to participate in self-sampling were significantly more likely not to have completed high school and to prefer clinician sampling. Prior to testing, 79% of women preferred self-sampling or had no preference. Preference was unchanged for approximately two-thirds of women after sampling. CONCLUSION: Self-sampling for GBS is an accurate and acceptable alternative for the majority of pregnant women. Less-educated women may be hesitant to self-sample, and clinician sampling should remain an option.

Adult↗