Biomedical subjects

K R Chapman

Publications and source records attributed to K R Chapman.

136 records · Page 8Linked to original sources

PubMedDate not supplied

Corticosteroid therapy for patients with acute exacerbations of chronic obstructive pulmonary disease: a systematic review.

OBJECTIVE: To determine whether systemic corticosteroids are of benefit to patients with acute exacerbations of chronic obstructive pulmonary disease (COPD). METHODS: An English-language search of MEDLINE (1966 to February 2002) and the Cochrane Library and a bibliographic review was performed to identify published clinical trials of systemic corticosteroid administration in acute exacerbations of COPD. All relevant English-language, randomized, placebo-controlled clinical trials were considered. Trials investigating the adverse effects of systemic steroids were also retrieved. Studies were assigned a quality rating according to explicit criteria. Clinically relevant end points, such as treatment failure and duration of hospital stay, were considered preferentially. To compare outcomes across all qualifying studies, we considered the difference in spirometric measures between treatment and placebo groups. Potential confounding factors and bias relating to patient selection, treatment protocols, and outcome measurement were considered independently for each study. RESULTS: Among the 8 studies that met all criteria, 5 found that significant improvement in forced expiratory volume in 1 second (>20%) was associated with steroid administration. Two studies found improvement in clinically relevant outcomes. One published study and 2 study abstracts did not find significant improvement in spirometric measures with corticosteroid administration. CONCLUSION: Short courses of systemic corticosteroids in acute exacerbations of COPD have been shown to improve spirometric outcomes (good-quality evidence) and clinical outcomes (good-quality evidence).

Acute Disease↗

PubMedDate not supplied

Effect of high dose inhaled acetic acid on airway responsiveness in Fischer rats.

BACKGROUND: Sudden, severe airway injury has been associated with an acute, and at times persisting, airway hyper-responsiveness with clinical features of asthma, termed reactive airways dysfunction syndrome (RADS). An attempt was made to develop a rat model of RADS by exposing inbred Fischer rats to inhaled 8 N acetic acid for 2 mins (13 N inhalation was lethal). METHODS: Lung resistance (RL) and lung elastance (EL) were measured in 14 eight- to 10-week old male rats. Baseline responsiveness to methacholine was quantified by calculating the dose required for doubling of RL. The next day, the study group (n=11) was exposed to aerosolized acetic acid. Control animals (n=3) were similarly exposed to buffered saline solution. RESULTS: Acetic acid exposure resulted in a significant (P<0.02) increase in RL (by 80%) and EL (by 67%), lasting less than 10 mins postexposure, but no significant change in methacholine responsiveness at one day and seven days postexposure. CONCLUSIONS: Failure to induce persistent airway hyper-responsiveness may relate to the choice of animal, choice of irritant, or insufficient level or duration of exposure, or may reflect a lack of individual predisposing cofactors such as smoking or underlying asthmatic predisposition.

Acetic Acid↗

PubMedDate not supplied

The patient level cost of asthma in adults in south central Ontario. Pharmacy Medication Monitoring Program Advisory Board.

OBJECTIVE: To assess the annual cost of asthma per adult patient from the perspectives of society, the Ontario Ministry of Health and the patient. DESIGN: Prospective cost of illness evaluation. SETTING: Ambulatory out-patients residing in southern central Ontario. POPULATION STUDIED: Nine hundred and forty patients with asthma over 15 years of age studied between May 1995 and April 1996. OUTCOME MEASURES: Direct costs, such as respiratory-related visits to general/family practitioners, respiratory specialists, emergency rooms, hospital admissions, laboratory tests, prescription medications, dispensing fees, devices and out-of-pocket expenses, were calculated. Indirect costs, such as absences from work or usual activities, and travel and waiting time, were studied. MAIN RESULTS: Unadjusted annual costs were $2,550 per patient. Hospitalizations and medications each accounted for 22% of the total cost and indirect costs 50% of the total costs. More severe disease, older age, smoking, drug plan availability and retirement were significant predictors of costs. Annual costs per patient varied from $1,255 (95% CI $1,061 to $1,485) in young nonsmokers with no drug plan and mild disease to $5,032 (95% CI $4,347 to $5,825) in older smokers with drug plans and severe disease. Clinically important reductions in the quality of life occurred with increasing severity. CONCLUSIONS: Interventions aimed at reducing productivity losses, admissions to hospital and medication costs may result in savings to society, the provincial government and the patient. The quality of policy and allocation decisions may be enhanced by cost of illness estimates that are comprehensive, precise and incorporate multiple perspectives.

Absenteeism↗

PubMedDate not supplied

Inhaler education for hospital-based pharmacists: how much is required?

OBJECTIVE: To compare the effectiveness of a more intensive educational intervention with a less intensive intervention on the ability of hospital pharmacists to be prepared to educate patients regarding inhaled device technique. DESIGN: Randomized controlled trial. Inhaler technique and knowledge were assessed pre-education, immediately after and three months after education by a research assistant blinded to the educational allocation. SETTING: Tertiary hospital pharmacy department. POPULATION STUDIED: Hospital-based pharmacists. INTERVENTION: A 1 h 'hands-on' session with feedback (more intense education, MIE) or written materials describing inhaler use (less intense education, LIE). MAIN RESULTS: The change in overall score from pre-education to early posteducation for MIE was greater than for LIE (mean [95% CI]) (2.64 [1.27 to 4.01] versus 1.26 [0.05 to 2.47], P<0.001). Assessment scores improved for all device demonstrations and general knowledge. The change in score from the pre-education to the late posteducation period was only slightly higher in the MIE group than the LIE group, a difference that was not statistically significant (1.78 [0.82 to 2.74] versus 1. 22 [0.06 to 2.39], P=0.09). Scores in both groups were lower in the late posteducation period compared with the early posteducation period. Greater increases in total score in the immediate posteducation period were associated with a low baseline score and the MIE intervention. CONCLUSION: Individual coaching in inhaler technique produces greater improvement in inhaler knowledge among hospital pharmacists than provision of written materials. However, the advantage of the more intensive intervention was short-lived, with little advantage evident in three months.

Administration, Inhalation↗

PubMedDate not supplied

Salmeterol and fluticasone propionate (50/250 microg) administered via combination Diskus inhaler: as effective as when given via separate Diskus inhalers.

OBJECTIVE: To compare the efficacy and safety of a new combination Diskus inhaler containing both salmeterol 50 mg and fluticasone propionate 250 mg (Seretide) with the two drugs delivered via separate Diskus inhalers. DESIGN: A multicentre, double-blind, double-dummy study. Three hundred and seventy-one symptomatic asthma patients (age range 13 to 75 years, mean 42 years) receiving inhaled corticosteroids were randomly assigned to two treatment groups: 28 weeks' treatment with either salmeterol/fluticasone propionate (50/250 microg bid) via a single Diskus inhaler (combination) and placebo bid via another Diskus inhaler, or salmeterol 50 microg bid via one Diskus inhaler and fluticasone propionate 250 microg bid via another (concurrent). Morning peak expiratory flow rate (PEFR) and symptoms were measured for the first 12 weeks and safety data were collected throughout the study. RESULTS: Over weeks 1 to 12, adjusted mean improvements in morning PEFR were 43 and 36 L/min for combination and concurrent therapies, respectively. The difference between the two treatment arms was 6 L/min (90% CI -13 to 0 L/min; P=0.114), which was within the predefined criteria for clinical equivalence. Adjusted mean improvements in forced expiratory volume in 1 s from baseline for week 28 were also similar between the two therapies. Thirty-five per cent of patients receiving combination inhaler and 31% of those receiving concurrent therapy had a mean daytime symptom score of zero over weeks 1 to 12 compared with 1% and 2%, respectively, at baseline. There was no difference in the incidence of adverse events between the two treatment arms. Mean serum cortisol levels were similar, and no differences in frequency of abnormal results were noted between the two groups. CONCLUSIONS: This study shows that the combination of salmeterol and fluticasone propionate in a single inhaler is as efficacious in achieving asthma control and as well tolerated over a 28-week period as the two drugs administered individually.

Adolescent↗

PubMedDate not supplied

Difficult asthma: consider all of the possibilities.

Asthma is a common respiratory disease that can often be managed successfully. However, there are patients that do not respond to the maximum doses of standard therapy and subsequently have a reduced quality of life. Many factors can contribute to a failure to respond to treatment, and a comprehensive approach is important when assessing and evaluating these patients. This report describes a patient referred for 'difficult to control asthma' who had multiple emergency department visits and hospitalizations. In addition to a history of wheezing, spirometry showed impaired flow and vital capacity was reduced. Further investigation showed a normal total lung capacity, and a computed tomography scan revealed main bronchus blockage by a tumour, which was confirmed by bronchoscopy. This led to a surgical resection of a mucoepidermoid carcinoma. This case highlights the need to consider all possibilities during the evaluation of patients with difficult asthma.

Adult↗

PubMedDate not supplied

Control of asthma in Canada: failure to achieve guideline targets.

OBJECTIVE: To assess the degree of asthma control achieved by patients with asthma in Canada and to describe the impact of poor asthma control. DESIGN: Population-based, cross-sectional telephone interview survey of Canadians with doctor-diagnosed asthma. SUBJECTS AND METHODS: Random digit dialing was used to identify a representative sample of Canadians with asthma. A total of 801 adults and 200 parents of children aged four to 15 years were interviewed over the telephone. Telephone interviews were also conducted with 266 physicians. RESULTS: Only 24% of patients achieved disease control by meeting the six symptom-based criteria listed by the 1996 Canadian Asthma Consensus Guidelines as appropriate treatment targets. Fifty-seven per cent of patients failed to meet two or more of the six control criteria and were considered poorly controlled. Fifty-one per cent had required urgent care for out of control asthma at least once in the year before the survey. Nonetheless, 91% of patients thought that their asthma was adequately controlled. Physicians shared this optimism: 77% of family physicians and 90% of respirologists believed that they were usually able to achieve optimal asthma control in their patients. Few physicians gauged asthma control by tracking more than one or two symptoms, and just over one-half (54%) of patients surveyed recalled ever having had a lung function test. One-half (48%) of patients with poorly controlled asthma who used inhaled steroids did not understand the role of inhaled steroids; one-third (32%) of patients with poorly controlled asthma who used short acting bronchodilators misunderstood the action of quick relief bronchodilators. CONCLUSIONS: The majority of Canadians with asthma suffer from inadequate control of their disease. Suboptimal control of asthma is associated with excess health care use. Inadequate monitoring by physicians and poor patient education may be factors contributing to this problem.

Anti-Asthmatic Agents↗

PubMedDate not supplied

What is new since the last (1999) Canadian Asthma Consensus Guidelines?

The objective of the present document is to review the impact of new information on the recommendations made in the last (1999) Canadian Asthma Consensus Guidelines. It includes relevant published studies and observations or comments regarding what are considered to be the main issues in asthma management in children and adults in office, emergency department, hospital and clinical settings. Asthma is still insufficiently controlled in a large number of patients, and practice guidelines need to be integrated better with current care. This report re-emphasises the need for the following: objective measures of airflow obstruction to confirm the diagnosis of asthma suggested by the clinical evaluation; identification of contributing factors; and the establishment of a treatment plan to rapidly obtain and maintain optimal asthma control according to specific criteria. Recent publications support the essential role of asthma education and environmental control in asthma management. They further support the role of inhaled corticosteroids as the mainstay of anti-inflammatory therapy of asthma, and of both long acting beta2-agonists and leukotriene antagonists as effective means to improve asthma control when inhaled corticosteroids are insufficient. New developments, such as combination therapy, and recent major trials, such as the Children's Asthma Management Project (CAMP) study, are discussed.

Adrenergic beta-Agonists↗

PubMedDate not supplied

The impact of a nationally coordinated pharmacy-based asthma education intervention.

OBJECTIVE: To assess the impact of a nationally coordinated pharmacy-based educational intervention on self-management behaviour and markers of asthma control in self-referred patients with asthma. DESIGN: An asthma clinic day was set up by a national chain of community pharmacies whereby pharmacists used a structured questionnaire to assess asthma control and self-care among self-referred patients with doctor-diagnosed asthma. In a one-on-one counselling session, each patient's educational needs were identified and the appropriate education offered. A telephone follow-up 30 days later assessed the impact of teaching. SETTING: Community pharmacies across Canada. OUTCOME MEASURES: The follow-up questionnaire quantified the number of wheezing episodes or other symptoms per week, the number of night-time awakenings per week, and the frequency of use of reliever and preventive medications. RESULTS: Of 4080 patients assessed, 22.2% used an inadequate inhaler technique, 16.4% used a short acting beta2-agonist excessively and 21.0% were not using an inhaled corticosteroid daily despite a frequency of symptoms that would suggest that it was needed. Common educational interventions included a review of inhaler technique (41.9%), a recommendation for regular inhaled corticosteroids (31.5%) and a referral to the primary care physician (21.0%). Thirty days after the educational intervention, patients reported significant decreases in the frequency of daytime asthma symptoms, the frequency of nocturnal symptoms and the frequency with which short acting beta2-agonists were used, while reporting significant increases in their use of preventive medication. CONCLUSIONS: A brief assessment and an educational intervention in the community pharmacy can produce significant short term improvements in patient-reported symptom control and appropriate self-management behaviour.

Adolescent↗

PubMedDate not supplied

Alpha1-antitrypsin deficiency: a position statement of the Canadian Thoracic Society.

OBJECTIVE: To prepare new guidelines for the Canadian Thoracic Society (CTS) regarding severe alpha1-antitrypsin (AAT) deficiency and AAT replacement therapy. MATERIALS AND METHODS: Previously published guidelines and the medical literature about AAT deficiency and AAT replacement were reviewed. The prepared statement was reviewed and approved by the CTS Standards and Executive Committees. RESULTS: Three studies evaluated AAT replacement. The National Heart, Lung and Blood Institute's AAT Registry was a nonrandomized comparison of patients receiving and not receiving AAT replacement, and evaluated the decline in forced expiratory volume in 1 s (FEV1) in 927 subjects. The rate of FEV1 decline was significantly less in those receiving AAT treatment (66 +/- SE 5 mL/year versus 93 +/- SE 11 mL/year; P=0.03) only in the subgroup with FEV1 35% to 49% predicted. In another study comparing 198 German patients receiving weekly AAT infusions and 97 untreated Danish patients, the mean annual decline in FEV1 was significantly less in treated patients only in the subgroup with FEV1 31% to 65% predicted (62 mL versus 83 mL, P=0.04). Neither of these studies was a randomized, controlled study and, thus, cannot be taken as proof of efficacy. A randomized, double-blind, placebo controlled trial of monthly replacement therapy over three years in 56 exsmokers with severe AAT deficiency and moderate emphysema showed a trend (P=0.07) favouring slower progression of emphysema by computed tomography scan in the group receiving AAT replacement. CONCLUSIONS: AAT replacement therapy has not been proven definitively to be clinically effective in reducing the progression of disease in AAT-deficient patients, but there is a possible benefit to selected patients. A placebo controlled, randomized clinical trial of AAT replacement therapy is required. The authors recommend reserving AAT replacement therapy for AAT-deficient patients with impaired FEV1 of 35% to 50% predicted who have quit smoking and are on optimal medical therapy but continue to show a rapid decline in FEV1, and participation of all AAT-deficient subjects in the Canadian AAT Registry.

Canada↗