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Biomedical subjects

Pierre Ernst

Publications and source records attributed to Pierre Ernst.

At least 19 recordsLinked to original sources
PubMed2007

The impact of over-the-counter simvastatin on the number of statin prescriptions in the United Kingdom: a view from the General Practice Research Database.

PURPOSE: The United Kingdom (UK) government changed the prescription policy of statins, making low-dose simvastatin (10 mg) available as an over-the-counter (OTC) drug in August 2004. We assessed the impact of this policy change on statin prescribing. METHODS: We examined all statin prescriptions in the General Practice Research Database (GPRD), a well-validated database of approximately 3.5 million patients, from the first quarter of 2001 to the second quarter of 2005. RESULTS: From 2001, the number of statin prescriptions written for GPRD patients was increasing by approximately 437 prescriptions per 100,000 people per quarter until the time of the policy change. Over the four quarters post-policy implementation, however, this trend changed abruptly (p < 0.0001) with a decrease of 281 prescriptions per 100,000 people per quarter. This decrease was not restricted to prescriptions of 10 mg statins but was also observed for statin prescriptions of >or=20 mg. Several other cardiovascular medications displayed a similar trend as that observed in the number of statin prescriptions. This trend was not observed among non-cardiovascular control medications. CONCLUSIONS: Our study suggests that the policy allowing the OTC sale of 10 mg simvastatin has had a significant impact on statin prescriptions by general practitioners. However, this new policy may also be leading to less aggressive statin therapy. An alternative explanation for the observed decrease in statin prescriptions may be related to the unknown factors responsible for the overall decrease observed with other cardiovascular prescription drugs.

Databases, Factual↗
PubMed2006

Safety and effectiveness of long-acting inhaled beta-agonist bronchodilators when taken with inhaled corticosteroids.

Long-acting beta-agonists are a pillar of therapy for many patients with asthma because they are the preferred add-on therapy to inhaled corticosteroids. However, a recent meta-analysis documented a substantial increase in severe exacerbations requiring hospital admission and life-threatening asthma exacerbations in patients treated with long-acting beta-agonists. A careful evaluation of this meta-analysis raises several concerns about its applicability to current practice. Pivotal trials evaluating the benefit of adding long-acting beta-agonists to inhaled corticosteroids were not included. The authors of the current paper call for physicians to continue their usual practice of using long-acting beta-agonists as adjunctive therapy, as well as for an independent meta-analysis of individual patients using inhaled corticosteroids and long-acting beta-agonists concomitantly.

Administration, Inhalation↗
PubMed2006

Airway inflammation assessed by invasive and noninvasive means in severe asthma: eosinophilic and noneosinophilic phenotypes.

BACKGROUND: Airway inflammation assessed by bronchial biopsies demonstrates distinct eosinophilic and noneosinophilic phenotypes in severe asthma, but their relationship to other biomarkers of disease (induced sputum and nitric oxide [NO]) is not clear. OBJECTIVES: We sought to compare airway inflammation using noninvasive (induced sputum, exhaled NO), and invasive (bronchial biopsies) methods in moderate and severe asthma and to assess whether induced sputum and exhaled NO would allow the identification of eosinophilic and noneosinophilic phenotypes in severe asthma. METHODS: We performed a cross-sectional study of 32 subjects with severe asthma and 35 subjects with moderate asthma, from whom we obtained bronchial biopsies, induced sputum, and exhaled NO measurements. RESULTS: Among subjects with severe asthma, we identified eosinophilic and noneosinophilic phenotypes using both bronchial biopsies and sputum cell counts. However, the vast majority of subjects with high sputum eosinophil counts did not have high mucosal eosinophil counts. Exhaled NO was increased in the eosinophilic phenotype as judged from bronchial biopsy findings, but not on the basis of induced sputum. Subjects with high sputum eosinophil counts experienced more asthma exacerbations than the subjects with low sputum eosinophil counts. In contrast, we did not find any differences in the clinical characteristics between eosinophilic and noneosinophilic phenotypes that were identified by bronchial biopsies. CONCLUSION: The use of sputum cell counts allowed the identification of a subgroup of subjects with severe asthma who were at risk of more frequent asthma exacerbations. CLINICAL IMPLICATIONS: Monitoring sputum eosinophil counts in subjects with severe asthma may allow identifying the subjects with the greatest disease activity.

Asthma↗
PubMed2006

The determinants of prevalence of health complaints among young competitive swimmers.

OBJECTIVES: Chloramines, which are produced by the reaction of chlorine with the organic matter present in indoor pools, are potential airway irritants in swimmers. The objective of this study was to compare the prevalence of health complaints of young swimmers and young indoor soccer players and to evaluate the relationship between chloramine concentrations and the athletes' health complaints. METHODS: Health complaints were first (Part 1) documented by questionnaire in 305 competitive swimmers and 499 indoor soccer players of the Québec City region (Canada). Then, (Part 2) health complaints were documented during five training sessions in 72 competitive swimmers in comparison to 73 soccer players. The chloramines in the swimming pool air and water were measured as well as the peak expiratory flow (PEF) before and after the training session. RESULTS: In Part 1, the swimmers reported more lower (adjusted OR: 1.5; IC95%= 1.0-2.2) and upper respiratory symptoms (adjusted OR: 3.7; IC95%= 2.4-5.8). In Part 2, the swimmers experienced more frequent lower (adjusted OR: 3.5; IC95%= 2.0-6.0) and upper respiratory symptoms (adjusted OR: 3.1; IC95%= 1.8-5.4). Overall, swimmers exposed to the highest levels of chloramines in the air and water had more respiratory complaints. CONCLUSIONS: Swimmers exposed to chlorination by-products in both the water and air of indoor swimming pools experience frequent respiratory symptoms that could potentially be reduced by limiting exposure to these products.

Adolescent↗
PubMed2006

Leflunomide use and the risk of interstitial lung disease in rheumatoid arthritis.

OBJECTIVE: Spontaneous reports of interstitial lung disease (ILD) in patients with rheumatoid arthritis (RA) treated with leflunomide, a disease-modifying antirheumatic drug (DMARD), have been appearing recently. To assess this risk, we conducted a population-based epidemiologic study. METHODS: A cohort of 62,734 patients with RA to whom a DMARD had been dispensed between September 1, 1998 and December 31, 2003 was formed using the PharMetrics claims database. A nested case-control design was used, in which each case of serious ILD requiring hospitalization was matched to 100 controls according to age (calendar time) and equal or greater duration of followup, to estimate adjusted rate ratios (RRs) of serious ILD associated with DMARD use. RESULTS: There were 74 cases of serious ILD, which corresponds to a rate of 8.1 per 10,000 patients per year. The risk of ILD was increased with the use of leflunomide (adjusted RR 1.9 [95% confidence interval (95% CI) 1.1-3.6]). Among subjects with no previous methotrexate use and no history of ILD, the risk associated with leflunomide treatment was not elevated (RR 1.2 [95% CI 0.4-3.1]), but it was elevated among the remaining subjects (RR 2.6 [95% CI 1.2-5.6]). Patients with a history of ILD were twice as likely to have been prescribed leflunomide as any other DMARD. CONCLUSION: The reports of ILD associated with leflunomide use are likely the result of channeling of high-risk patients to leflunomide treatment, particularly those with a history of methotrexate use or preexisting ILD. Patients with no history of ILD and no previous methotrexate use show no excess risk of developing ILD with leflunomide treatment.

Antirheumatic Agents↗
PubMed2006

Women and asthma: lessons from a gender analysis of the asthma in Canada survey.

OBJECTIVE: To compare the degree of asthma control achieved by men and women with asthma in Canada and to explore differences in patient perspectives, treatments used, and health care resources used between men and women with asthma. 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 were interviewed over the telephone. Analysis was performed on the data from a subgroup of 20- to 50-year-old patients with asthma who participated in the original survey (329 women and 183 men). RESULTS: Women and men were equally likely to be poorly controlled (58% vs. 56%, p > 0.05) as defined by failing to meet two or more of six symptom-based criteria listed by the 1996 Canadian Asthma Consensus (CAC) Guidelines as appropriate treatment targets. However, there were significant differences in medication used; women were more likely than men to use an inhaled corticosteroid in the treatment of their asthma (59% vs. 45%, p < 0.05) and were more knowledgeable about their appropriate use (62% vs. 46%, p < 0.05), and were more likely to be satisfied with their physicians' care. Despite this, women were more likely than men to have required urgent care for their asthma in the year preceding the survey (50% vs. 36%, p < 0.05). CONCLUSION: Women report greater need for urgent asthma care despite more frequent use of inhaled corticosteroids and better asthma knowledge scores than men.

Adult↗
PubMed2006

Implementing practice guidelines: a workshop on guidelines dissemination and implementation with a focus on asthma and COPD.

The present supplement summarizes the proceedings of the symposium "Implementing practice guidelines: A workshop on guidelines dissemination and implementation with a focus on asthma and COPD", which took place in Quebec City, Quebec, from April 14 to 16, 2005. This international symposium was a joint initiative of the Laval University Office of Continuing Medical Education (Bureau de la Formation Médicale Continue), the Canadian Thoracic Society and the Canadian Network for Asthma Care, and was supported by many other organizations and by industrial partners. The objectives of this meeting were to examine the optimal implementation of practice guidelines, review current initiatives for the implementation of asthma and chronic obstructive pulmonary disease (COPD) guidelines in Canada and in the rest of the world, and develop an optimal strategy for future guideline implementation. An impressive group of scientists, physicians and other health care providers, as well as policy makers and representatives of patients' associations, the pharmaceutical industry, research and health networks, and communications specialists, conveyed their perspectives on how to achieve these goals. This important event provided a unique opportunity for all participants to discuss key issues in improving the care of patients with asthma and COPD. These two diseases are responsible for an enormous human and socioeconomic burden around the world. Many reports have indicated that current evidence-based guidelines are underused by physicians and others, and that there are many barriers to an effective translation of recommendations into day-to-day care. There is therefore a need to develop more effective ways to communicate key information to both caregivers and patients, and to promote appropriate health behaviours. This symposium contributed to the initiation of what could become the "Canadian Asthma and COPD Campaign", aimed at improving care and, hence, the quality of life of those suffering from these diseases. It is hoped that this event will be followed by other meetings that focus on how to improve the transfer of key recommendations from evidence-based guidelines into current care, and how to stimulate research to accomplish this.

Asthma↗
PubMed2006

Oral corticosteroid use and the risk of acute myocardial infarction in chronic obstructive pulmonary disease.

BACKGROUND: Given the limited efficacy of oral corticosteroids in treating chronic obstructive pulmonary disease (COPD), the possible cardiac side effects of oral corticosteroids are of particular concern in an elderly population. The impact of the use of oral corticosteroids on the risk of acute myocardial infarction (AMI) in a cohort of patients with COPD was studied. METHODS: The Saskatchewan health services databases were used to form a population-based cohort of 5648 patients aged 55 years or older who received a first treatment for COPD between 1990 and 1997. A nested case-control analysis was conducted: 371 cases presenting with a first myocardial infarction were matched with 1864 controls according to the length of follow-up, the date of cohort entry and age. Conditional logistic regression was used to adjust for sex, severity of COPD, systemic hypertension, diabetes and prior cardiovascular disease. RESULTS: Only the current use of corticosteroids was associated with an increased risk of AMI (adjusted RR=2.01 [95% CI 1.13 to 3.58]), particularly when the current dose was larger than 25 mg/day of prednisone or the equivalent (adjusted RR=3.22 [95% CI 1.42 to 7.34]). This observed increase in risk rapidly returned to baseline after the cessation of the medication, suggesting that the use of such high doses reflected the treatment of acute exacerbations of the disease. CONCLUSIONS: An association was found between the current use of oral corticosteroids and the occurrence of an AMI, suggesting that acute exacerbations of COPD are associated with an increased risk of acute coronary syndromes.

Acute Disease↗
PubMed2005

Canadian Pediatric Asthma Consensus guidelines, 2003 (updated to December 2004): introduction.

BACKGROUND: Although guidelines for the diagnosis and management of asthma have been published over the last 15 years, there has been little focus on issues relating to asthma in childhood. Since the last revision of the 1999 Canadian asthma consensus report, important new studies, particularly in children, have highlighted the need to incorporate this new information into asthma guidelines. OBJECTIVES: To review the literature on asthma published between January 2000 and June 2003 and to evaluate the influence of new evidence on the recommendations made in the Canadian Asthma Consensus Report, 1999 and its 2001 update with a major focus on pediatric issues. METHODS: Diagnosis of asthma in young children, prevention strategies, pharmacotherapy, inhalation devices, immunotherapy and asthma education were selected for review by small expert resource groups. In June 2003, the reviews were discussed at a meeting under the auspices of the Canadian Network For Asthma Care and the Canadian Thoracic Society. Data published up to December 2004 were subsequently reviewed by the individual expert resource groups. RESULTS: This report evaluates early life prevention strategies and focuses on treatment of asthma in children. Emphasis is placed on the importance of an early diagnosis and prevention therapy, the benefits of additional therapy and the essential role of asthma education. CONCLUSION: We generally support previous recommendations and focus on new issues, particularly those relevant to children and their families. This guide for asthma management is based on the best available published data and the opinion of health care professionals including asthma experts and educators.

Administration, Inhalation↗
PubMed2005

Childhood predictors of smoking in adolescence: a follow-up study of Montreal schoolchildren.

BACKGROUND: The factors that cause children to become smokers in adolescence remain unclear. Although parental smoking and peer pressure may play a role, physiological factors such as lung volume have also been identified. METHODS: To investigate these and other possible childhood predictors of teenage smoking, we gathered follow-up data on 191 Montréal schoolchildren, aged 5-12 years (average 9.2 yr) when first examined. At an average age of 13.0 years, they answered further questions on their health and smoking behaviour and provided a second set of spirometric measurements. RESULTS: At the second survey, 80% of the children had entered high school and 44% had become smokers. Reaching puberty between the surveys was the most significant determinant of becoming a smoker: 56.4% of the 124 children postpubertal at the second survey had taken up smoking, versus 17.9% of the 67 who were still prepubertal (p = 0.001). We found salivary cotinine level, a measure of uptake of environmental tobacco smoke, to be an independent predictor of becoming a teenage smoker; even after adjustment for sex, socioeconomic status of parents, a crowding index, and the numbers at home of siblings, adult smokers and cigarettes smoked, it remained significant for both groups: postpubertal (odds ratio [OR] 1.2, 95% confidence interval [CI] 1.2-3.0) and prepubertal (OR 2.1, 95% CI 1.0- 4.5). The influence of forced vital capacity was marginally significant only in the postpubertal group (OR 5.0, 95% CI 0.88-28.3). INTERPRETATION: The proportion of nicotine absorbed from that available in environmental tobacco smoke during childhood is associated with subsequent smoking in adolescence. The more efficient absorption of nicotine seen in some children may be related to physiological factors such as lung capacity.

Absorption↗
PubMed2005

Bias in observational study of the effectiveness of nasal corticosteroids in asthma.

BACKGROUND: A recent observational study suggests that intranasal corticosteroids used to treat allergic rhinitis are effective at preventing asthma outcomes, such as emergency visits. The approach to data analysis may have led to biased results because of misclassification of immortal time. OBJECTIVE: To illustrate the bias in the cohort approach and to present the proper time-dependent analysis by replicating the recent study using data from another source. METHODS: From an existing cohort of 30,569 patients with asthma age 5 to 44 years and identified from the Saskatchewan Health databases (1975-1997), we formed the cohort of all subjects who were in the source population between January 1, 1989, and December 31, 1991. Subjects were followed to the first asthma hospitalization. All prescriptions dispensed during follow-up were identified. We replicated the time-fixed approach to data analysis used in the recent study and compared it with time-dependent approaches. RESULTS: The cohort included 20,173 subjects, of whom 1849 were hospitalized for asthma between January 1, 1989, and December 31, 1991. The time-fixed approach misclassified more than 5000 person-years of follow-up, corresponding to 44% of the exposed person-time. As a result, the rate ratio of asthma hospitalization after any use of nasal corticosteroids (NCSs) was 0.57 by the biased time-fixed approach compared with 1.13 by the proper time-dependent approach. The time-fixed approach produced a paradoxical protective effect of NCS with 1 or less canisters dispensed per year (odds ratio, 0.47), which was further exaggerated when the cohort was extended to 5 years (odds ratio, 0.33). Adjusted time-dependent analyses found no protective effect, even when NCSs were dispensed regularly (rate ratio, 1.10; 95% CI, 0.54-2.21). CONCLUSION: The time-fixed approach to the analysis of the effectiveness of NCSs on asthma outcomes leads, by its inherent misclassification of immortal time, to a considerable exaggeration of the protective effect of these medications in preventing severe asthma exacerbations.

Administration, Inhalation↗
PubMed2005

Differences in airway remodeling between subjects with severe and moderate asthma.

BACKGROUND: Airway remodeling in asthma comprises a range of structural changes. Several studies have suggested an association between these changes and disease severity. The relationship between the extent of remodeling and lung function is not well defined. OBJECTIVE: We sought to contrast the structural changes in the airways of well-defined groups of subjects with severe and moderate asthma and to correlate the extent of remodeling with disease severity. METHODS: Endobronchial biopsy specimens were obtained from 15 subjects with severe and 13 subjects with moderate asthma. Epithelial integrity, cell-layer areas, subepithelial fibrosis, and the distance between epithelial and airway smooth muscle (ASM) layers were measured by means of image analysis. Collagen was identified by using Van Giesen stain, and ASM was defined by using smooth muscle alpha-actin immunostaining. Specific immunostains were performed for the evaluation of RANTES, IL-8, and eotaxin expression as markers of ASM phenotype. RESULTS: ASM area was greater in subjects with severe (0.24+/- 0.03 mm(2)) than in subjects with moderate (0.05+/- 0.01 mm(2)) asthma (P<.001). The distance between the epithelial and ASM layers was less in the severe group (0.12+/- 0.01 mm) than in the moderate group (0.24+/- 0.02, P<.001). A trend toward greater subepithelial fibrosis in subjects with severe asthma did not reach statistical significance. IL-8 and eotaxin expression, but not RANTES expression, were increased in the ASM of subjects with severe asthma compared with in subjects with moderate asthma. CONCLUSION: Smooth muscle alteration is the key structural change that distinguishes severe from moderate asthma, and phenotypic change in ASM might contribute to the difficulty in obtaining adequate control in some subjects with severe asthma.

Adult↗
PubMed2005

Correlates of quality of life in patients with asthma.

BACKGROUND: Health-related quality of life (HRQOL) is a major outcome in asthma, but the relationships among HRQOL, characteristics of asthma, type of supervision, and sociodemographic characteristics of patients have not been thoroughly explored. OBJECTIVE: To identify major correlates of HRQOL in a survey of patients with asthma. METHODS: Patients with asthma were identified by their usual caregivers, either general practitioners or respiratory physicians. In a standardized interview, data were collected on patients' sociodemographic characteristics, medical history, medical resource use in the past 12 months, and asthma QOL. Intensity of asthma therapy was evaluated from the use of inhaled controllers and oral corticosteroids in the past 12 months, and number of asthma attacks during the same period was used as an indicator of level of asthma symptoms. RESULTS: Ninety-nine patients with asthma were identified (median age, 36 years; 62.6% women). In multivariate analysis, major correlates for lower HRQOL scores were having at least 5 asthma attacks and the number of medical visits in the past 12 months (P < .001 for both). Other significant positive associations were unemployment (P = .01) and female sex (P = .05), but not intensity of therapy, age, or type of asthma supervision (general practitioner vs respiratory physician). CONCLUSIONS: In this survey, HRQOL scores seem to be primarily related to asthma symptoms, as indicated by the number of attacks experienced by the patients and the frequency of medical contacts in a previous period. The relationships among HRQOL, therapy, and the determinants of control should be investigated in prospective studies.

Adolescent↗
PubMed2005

Cardiovascular morbidity and mortality in COPD.

STUDY OBJECTIVE: COPD and cardiovascular disease (CVD) share common risk factors. We undertook to estimate rates of hospitalization and death from CVD in COPD patients relative to the general population. DESIGN AND SETTING: A cohort of patients > or = 55 years old receiving a first treatment for COPD between 1990 and 1997 was formed from the Saskatchewan Health databases. All hospitalizations and deaths between cohort entry and the end of 1999 were identified. RESULTS: The cohort included 5,648 individuals and generated 23,426 person-years (PY) of follow-up. The overall rates of cardiovascular morbidity and mortality were 177.2 and 41 per 1,000 PY, respectively. Cardiovascular morbidity and mortality rates were higher in the COPD cohort than in the general population (standardized rate ratios of 1.9 and 2.0, respectively). More hospitalizations for CVD than for COPD itself were reported. Among CVDs, heart failure represented the most frequent cause of hospitalization (58.8 per 1,000 PY). CVD and more specifically ischemic heart disease (19.6 per 1,000 PY) were reported as a more frequent cause of death than COPD itself (15.5 per 1,000 PY). CONCLUSION: CVD is more frequent in COPD patients than in the general population and may represent a burden greater than that of lung disease itself.

Aged↗
PubMed2004

Newer disease-modifying antirheumatic drugs and the risk of serious hepatic adverse events in patients with rheumatoid arthritis.

BACKGROUND: Spontaneous cases of hepatic adverse events have been reported in patients with rheumatoid arthritis who were being treated with leflunomide, one of the newer disease-modifying antirheumatic drugs (DMARDs). We assessed the risk of hepatic events associated with the use of leflunomide and other DMARDs. METHODS: Two cohorts comprising 41,885 patients with rheumatoid arthritis who had been dispensed a DMARD between September 1, 1998, and December 31, 2001, were formed using claims databases. Follow-up was from the first dispensing date to the occurrence of a serious or nonserious hepatic event. A nested case-control approach was used to estimate adjusted rate ratios of hepatic events associated with DMARDs dispensed during the prior year, as compared with methotrexate monotherapy. RESULTS: There were 25 cases of serious hepatic events (rate, 4.9 per 10,000 per year) and 411 nonserious hepatic events (rate, 80.0 per 10,000 per year). There was no increase in the rate of serious hepatic events with either leflunomide (rate ratio [RR] = 0.9; 95% confidence interval [CI]: 0.2 to 4.9) or traditional DMARDs (RR = 2.3; 95% CI: 0.8 to 6.5). However, the rate was increased with biologic DMARDs (RR = 5.5; 95% CI: 1.2 to 24.6). The rate of nonserious hepatic events was also increased with biologic DMARDs (RR = 1.5; 95% CI: 1.0 to 2.3), but not with leflunomide (RR = 0.9; 95% CI: 0.7 to 1.3) and traditional DMARDs (RR = 1.1; 95% CI: 0.8 to 1.4). CONCLUSIONS: We found no evidence of an excess risk of serious or nonserious hepatic events with the use of leflunomide as compared with methotrexate. Still, the increased risk observed with the new biologic DMARDs should be investigated further.

Adult↗
PubMed2004

Safety and efficacy of HFA-134a beclomethasone dipropionate extra-fine aerosol over six months.

OBJECTIVE: To compare the systemic safety and efficacy of hydrofluoroalkane beclomethasone dipropionate (HFA-BDP) extra-fine aerosol 800 microg/day with chlorofluorocarbon (CFC)-BDP 1500 microg/day. DESIGN: Six-month, randomized, parallel-group, double-blind, double-dummy study. PATIENTS: Patients (n=141) with moderate to severe asthma adequately controlled by CFC-BDP 1000 microg/day to 2000 microg/day. INTERVENTIONS: Patients received CFC-BDP 1500 microg/day during a two-week run-in period and were then randomized to either HFA-BDP (n=70) or CFC-BDP (n=71). RESULTS: Similar proportions of HFA-BDP and CFC-BDP patients had a 24 h urinary free cortisol values below the reference range at month 6 (15% versus 25%, P=0.35). Measures of adrenocorticotrophic hormone stimulation and morning plasma cortisol levels were also similar in each group. The frequency of skin bruising and oral candidiasis was low for both treatments. No change in intraocular pressure was reported for either treatment. Pulmonary function was similar in both groups; however, the onset of the first asthma exacerbation or increased asthma symptoms tended to be earlier for CFC-BDP than for HFA-BDP (P=0.076); 27% of CFC-BDP patients reported increased asthma symptoms, compared with 14% of HFA-BDP patients (P=0.095). CONCLUSIONS: HFA-BDP 800 microg/day has a systemic adverse event profile comparable to that of CFC-BDP 1500 microg/day, and further control of asthma symptoms may be achieved after a switch from CFC-BDP 1500 microg/day to HFA-BDP 800 microg/day.

Administration, Inhalation↗