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Biomedical subjects

Mike Thomas

Publications and source records attributed to Mike Thomas.

At least 19 recordsLinked to original sources
PubMed2006

Allergic rhinitis: evidence for impact on asthma.

BACKGROUND: This paper reviews the current evidence indicating that comorbid allergic rhinitis may have clinically relevant effects on asthma. DISCUSSION: Allergic rhinitis is very common in patients with asthma, with a reported prevalence of up to 100% in those with allergic asthma. While the temporal relation of allergic rhinitis and asthma diagnoses can be variable, the diagnosis of allergic rhinitis often precedes that of asthma. Rhinitis is an independent risk factor for the subsequent development of asthma in both atopic and nonatopic individuals. Controlled studies have provided conflicting results regarding the benefits for asthma symptoms of treating comorbid allergic rhinitis with intranasal corticosteroids. Effects of other treatments for comorbid allergic rhinitis, including antihistamines, allergen immunotherapy, systemic anti-IgE therapy, and antileukotriene agents, have been examined in a limited number of studies; anti-IgE therapy and antileukotriene agents such as the leukotriene receptor antagonists have benefits for treating both allergic rhinitis and asthma. Results of observational studies indicate that treating comorbid allergic rhinitis results in a lowered risk of asthma-related hospitalizations and emergency visits. Results of several retrospective database studies in the United States and in Europe indicate that, for patients with asthma, the presence of comorbid allergic rhinitis is associated with higher total annual medical costs, greater prescribing frequency of asthma-related medications, as well as increased likelihood of asthma-related hospital admissions and emergency visits. There is therefore evidence suggesting that comorbid allergic rhinitis is a marker for more difficult to control asthma and worsened asthma outcomes. CONCLUSION: These findings highlight the potential for improving asthma outcomes by following a combined therapeutic approach to comorbid allergic rhinitis and asthma rather than targeting each condition separately.

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

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

Preventing low birth weight in Illinois: outcomes of the family case management program.

OBJECTIVES: In the mid 1980's the federal government passed legislation allowing states to expand their Medicaid programs for pregnant women. States were also offered matching funds for "enhanced" prenatal care services. The Illinois Family Case Management (FCM) Program targets low-income women and aims to reduce barriers to prenatal care and infant healthcare utilization and also provides health education. We evaluated the outcome of the Illinois Family Case Management Program (FCM) in preventing low birth weight in Winnebago County. METHODS: A total of 6,440 participants were included in this study. Logistic regression was used to test whether number of visits or total hours of visitation were significant protective factors against low birth weight. RESULTS: While participating in the FCM Program resulted in a lower rate of low birth weight delivery, neither increasing time with a family case manager nor increasing number of visits showed statistically significant additional protection against low birth weight delivery after adjustment for potential confounding factors. CONCLUSION: In order to further improve program outcomes, efforts need to include improving quality of interventions or developing new interventions rather than simply increasing the amount of current intervention for each participant. The cost effectiveness of shifting FCM Program efforts away from infants (aged 0-1 year) towards improved prenatal interventions should be evaluated.

Adult↗
PubMed2006

Atopic wheezing and early life antibiotic exposure: a nested case-control study.

Several factors including early-life antibiotic usage have been implicated in the rising prevalence of allergic sensitization and asthma. A nested case-control study comparing antibiotic exposure of 37 sensitized children with recurrent wheeze (age 3-5 yr) and 37 non-sensitized children who had never wheezed was carried out within a population-based birth cohort (matching for age, sex, parental atopy, allergen exposure, and pet ownership). We collected data on antibiotic prescriptions during first 3 yr of life (timing, type, indication) from the primary care medical records. Significantly, more cases than controls received one or more antibiotic courses during the first year of life (92% vs. 70%, p = 0.04). The median time to first antibiotic course was shorter for the cases than the controls (6 vs. 8 months, p = 0.03). The total number of antibiotic receipts was greater amongst cases in each of the first 3 yr of life, but this reached significance only when the whole three-year period was considered (249 vs. 182 courses, p = 0.05). The increased ratio of antibiotic receipt in cases over controls was highest in the first year of life (1.32, 95% CI 0.99-1.78). Significantly more cases than controls were prescribed antibiotics for lower respiratory tract infection during the first 3 yr (p = 0.007), but not during the first year of life (p = 0.52). Antibiotics use by class was similar in the two groups. Our data support the hypothesis that early life exposure to broad-spectrum antibiotics may have a causative role in sensitisation and the expression of wheeze.

Anti-Bacterial Agents↗
PubMed2006

High-dose inhaled corticosteroid use in childhood asthma: an observational study of GP prescribing.

Inhaled corticosteroids are effective and safe treatments for childhood asthma in standard doses, yet at high dosages they may be associated with adverse events and suboptimal outcomes; add-on therapy is, therefore, recommended to minimise their use. We quantified prescribing of high-dose inhaled corticosteroids and add-on therapy in children in July 2003 and found that high-dose inhaled corticosteroids were prescribed to 10% of children aged 5-11 years and 6% of under-5's who were treated for asthma. Add-on therapy was lacking for almost half of these individuals. Some children were receiving treatment not in accord with current licences and evidence-based recommendations and, as such, may be at risk of adverse outcomes.

Administration, Inhalation↗
PubMed2005

The national montelukast survey.

BACKGROUND: Randomized controlled trials have demonstrated the efficacy of montelukast for treating asthma; whether this can be extrapolated to clinical effectiveness in routine practice has yet to be established. OBJECTIVE: To examine the use, effectiveness, and tolerability of montelukast in clinical practice for treating asthma and to explore prognostic factors that could predict a favorable response to the drug. METHODS: This was a retrospective, cross-sectional, observational study of clinical outcomes seen in patients prescribed montelukast for asthma that used routinely collected clinical information. Data were collected on all consenting patients who had been prescribed montelukast for asthma irrespective of the continuation or duration of treatment. Independent observers, treating physicians, and patients assessed certain outcomes after the initiation of montelukast, including the general asthma response and changes in activity-related symptoms. RESULTS: Fifty-six centers in the United Kingdom (20 primary care and 36 secondary care) participated. The analysis was based on 1351 eligible patients for whom essential data were available. Eight hundred thirty patients (66.4%; 95% CI, 63.8% to 69.0%) were recorded as having shown an improvement in their asthma control, and 103 (8.2%; 95% CI, 6.8% to 9.9%) experienced a dramatic improvement. The greatest proportion of patients responding was seen in those with mild to moderate asthma. Montelukast was well tolerated; no new adverse events were recorded. CONCLUSIONS: Montelukast is an effective, well-tolerated treatment for asthma in routine practice. The overall response rate and tolerability seen in this survey are similar to those reported in randomized clinical trials.

Acetates↗
PubMed2005

The prevalence of dysfunctional breathing in adults in the community with and without asthma.

Functional breathing problems, including symptomatic hyperventilation, may impair quality of life. Symptoms associated with functional breathing disorders have been reported as being common in secondary care settings, and can affect 29% of adults with current asthma in the community. The prevalence of dysfunctional breathing in the general adult population is unknown. The Nijmegen Questionnaire has been reported to have useful sensitivity and specificity for diagnosing dysfunctional breathing. A cross-sectional postal survey of adults without current asthma was undertaken in a single UK general practice. The results were analysed in conjunction with a previously described survey of adults with current asthma from the same population. The questionnaire was posted to a random sample of 300 people aged 16-65 without current asthma, and 69% were returned. 8% (95% confidence intervals 4-12%) had positive screening scores. Positive screening scores were more common in women (14%, 7-20%) than men (2%, 0-5%, p=0.003). Comparison with the previous survey showed that the prevalence of positive screening scores was higher in those with current asthma than those without (29% vs. 8%, p<0.001). Dysfunctional breathing may affect up to one in 10 people, and is more common in women and in people with asthma.

Journal Article↗
PubMed2005

An innovation in partnership among first responders and public health: bridging the gap.

To properly prepare for and respond to bioterrorism and other urgent public health threats and emergencies, response disciplines must work together in well coordinated efforts to address the preparedness needs of their communities and the nation. Traditional public health workforce and first responder roles have been challenged and new partnerships have emerged, increasing the need for innovative education and training. This article provides a review of an approach the Heartland Center for Public Health Preparedness took to foster these partnerships and increase the provision of competency-based, integrated responder education and training in the St. Louis, MO, metropolitan area.

Bioterrorism↗
PubMed2005

Gastroesophageal reflux disease and asthma: a longitudinal study in UK general practice.

STUDY OBJECTIVES: Gastroesophageal reflux disease (GERD) and asthma are common causes for consultation in primary care, but the relationship between the two remains unclear. The aim of our study was to investigate the temporal relationship between first diagnoses of GERD and asthma in general practice. METHODS: We used the UK General Practice Research Database to identify a cohort of patients with a first diagnosis of GERD (n = 5,653) and another cohort of patients with a first diagnosis of asthma (n = 9,712) during 1996, which we compared with age-matched and sex-matched control cohorts drawn from the general population without either diagnosis. We investigated the incidence of a GERD diagnosis among the asthma patients and control subjects, and the incidence of an asthma diagnosis among the GERD patients and control subjects during a mean follow-up period of 3 years. We calculated the relative risk (RR) of these diagnoses using Cox regression analysis and examined the risk associated with medication use using nested case-control analysis. RESULTS: The incidence rates of GERD and asthma among the control cohorts were 4.4 and 3.8 per 1,000 person-years, respectively. During the follow-up period, the RR of an incident asthma diagnosis in patients with a new diagnosis of GERD was 1.2 (95% confidence interval [CI], 0.9 to 1.6), while the RR of an incident GERD diagnosis among patients with a new diagnosis of asthma was 1.5 (95% CI, 1.2 to 1.8) after adjustment for age, sex, smoking, prior comorbidity, and number of health-care contacts. This increased risk was mainly seen during the first year of follow-up. The prior use of prescription medications for asthma and GERD had no significant effects on the risk of GERD and asthma diagnosis, respectively. CONCLUSIONS: Patients with asthma are at a significantly increased risk of developing GERD, mainly during the first year following diagnosis. A nonsignificant increase in the risk of developing asthma was evident among GERD patients. The relationship between GERD and asthma warrants further investigation.

Adolescent↗
PubMed2005

Asthma-related health care resource use among asthmatic children with and without concomitant allergic rhinitis.

OBJECTIVE: To determine the incremental effect of allergic rhinitis on health care resource use in children with asthma. DESIGN: Population-based historical cohort study. SETTING: Data in a general practice database in the United Kingdom during 1998 to 2001. PATIENTS: Children 6 to 15 years old with asthma and with >or=1 asthma-related visits to a general practitioner (GP) during a 12-month follow-up period. MAIN OUTCOME MEASURES: Asthma-related hospitalizations, GP visits, and prescription drug costs during the 12-month follow-up period for patients with and without comorbid allergic rhinitis. RESULTS: Of 9522 children with asthma, 1879 (19.7%) had allergic rhinitis recorded in the GP medical records. Compared with children with asthma alone, children with comorbid allergic rhinitis experienced more GP visits (4.4 vs 3.4) and more of them were hospitalized for asthma (1.4% vs 0.5%) during the 12-month follow-up period. In multivariable regression analyses, comorbid allergic rhinitis was an independent predictor of hospitalization for asthma (odds ratio: 2.34; 95% confidence interval [CI]: 1.41-3.91) and was associated with increases in the number of asthma-related GP visits (mean increase: 0.53; 95% CI: 0.52-0.54) and asthma drug costs (mean increase pound: 6.7; 95% CI: 6.5-7.0). The association between allergic rhinitis and higher costs of prescriptions for asthma drugs was independent of asthma severity, measured indirectly by the intensity of use of asthma drugs. CONCLUSIONS: Children with comorbid allergic rhinitis incurred greater prescription drug costs and experienced more GP visits and hospitalizations for asthma than did children with asthma alone. A unified treatment strategy for asthma and allergic rhinitis, as recommended by the Allergic Rhinitis and Its Impact on Asthma initiative, might reduce the costs of treating these conditions.

Adolescent↗
PubMed2004

The views and attitudes of general practitioners and smokers toward provision of smoking cessation advice: a qualitative study.

OBJECTIVES: To identify common themes between general practitioners (GP's) and patients on smoking cessation in primary care in order to inform the development of acceptable guidelines, thus maximising the chance that recommendations will be received positively and implemented. DESIGN: Qualitative study using focus groups and individual interviews with GPs and patients. SETTING: North East Scotland. SUBJECTS: 10 general practitioners and 20 patients (10 smokers and 10 patients who described themselves as ex-smokers). RESULTS: Both general practitioners and patients agreed that the GP has a key role in providing a range of advice and support for smoking cessation. Both parties expressed views at variance with current guidelines but agreed that, for support and advice to be successful, it needs to comply with four of the five main themes identified; that it should be practical, pertinent to the consultation, personalised to the smoker's clinical need, and should emphasise the positive health gains from quitting. CONCLUSION: The considerable concordance between the perceptions of GPs and their patients about smoking cessation care suggests potential for a more positive partnership in working towards reduction of smoking in the UK.

Journal Article↗
PubMed2004

Community-acquired pneumonia mortality: a potential link to antibiotic prescribing trends in general practice.

BACKGROUND: Community prescribing of antibiotics has decreased substantially in the UK in recent years. We examine the association between pneumonia mortality and recent changes in community-based antibiotic prescribing for lower respiratory tract infections (LRTI). METHODS: Retrospective analysis of aggregated data for pneumonia mortality, influenza incidence, and antibiotic prescribing for LRTI in England and Wales during 12-week winter periods between 1993/94 and 1999/2000. RESULTS: Winter antibiotic prescribing for LRTI showed a 30.0% decline since 1995/96. Over the same period, there was a 50.6% increase in winter excess pneumonia mortality adjusted for influenza incidence. Negative binomial regression analysis showed that the incidence of influenza alone had a significant association with winter pneumonia mortality (P<0.001). The analysis also showed the reduction in antibiotic prescribing had a small but significant association with mortality (P<0.001), when simultaneously modelling for influenza incidence. CONCLUSIONS: Our findings suggest an association between recent reductions in antibiotic prescribing for LRTI in general practice and an increase in pneumonia mortality in England and Wales. This retrospective study of aggregate data represents the first attempt to assess the effect of limiting antibiotic prescribing on patient outcomes, and highlights the need to identify which patients benefit from antibiotic treatment for LRTI.

Anti-Bacterial Agents↗
PubMed2004

Evaluating the effectiveness of asthma treatment in real-life practice.

RATIONALE, AIMS AND OBJECTIVES: The randomized controlled trial (RCT) is considered the gold standard methodology for determining the efficacy and tolerability of new treatments. However, RCTs cannot provide information on the effectiveness of interventions as they are used in real life. This study was conducted to investigate the effectiveness of montelukast, a leukotriene receptor antagonist, in the real-world management of asthma, through a large-scale, retrospective, observational study: the National Montelukast Survey. METHODS: In order to ensure a robust methodology for the National Montelukast Survey we performed three pilot studies involving a total of almost 400 patients. During the pilots, the design of the study was extensively modified from a simple prescriber questionnaire used in the first pilot to the 'triangulated' methodology encompassing the perspectives of patient, prescriber and independent observer used in the National Montelukast Survey. Good levels of interobserver agreement confirmed the robustness of the final methodology. CONCLUSIONS: Achieving a robust methodology was dependent on the extensive piloting. It is possible to collect reliable observational data relating to treatment outcomes. We believe our methods are likely to have more widespread applicability and offer a potential improvement over postmarketing surveillance.

Acetates↗