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The reliability and utility of spirometry performed on people with asthma in community pharmacies.
Objective : To investigate the reliability and utility of spirometry generated by community pharmacists participating in two large asthma intervention trials of 892 people.
Methods : The Pharmacy Asthma Care Program (PACP) and the Pharmacy Asthma Management Service (PAMS) involved up to 4 visits to the pharmacy over 6 months for counseling and goal setting. Pharmacists performed spirometry according to ATS/ERS guidelines to inform management. The proportion of A-E, F quality tests, as per EasyOne™ QC grades, were recorded. Lung function results between visits and for participants referred/not referred to their general practitioner on the basis of spirometry were compared.
Results : Complete data from 2593 spirometry sessions were recorded, 68.5% of spirometry sessions achieved 3 acceptable tests with between-test repeatability of 150 mL or less (A or B quality), 96% of spirometry sessions included at least one test that met ATS/ERS acceptability criteria. 39.1% of participants had FEV1/FVC values below the lower limit of normal (LNN), indicating a respiratory obstruction. As a result of the service, there was a significant increase in FEV1 and FEV1/FVC and asthma control. Lung function values were significantly poorer for participants referred to their general practitioner, compared to those not referred, on the basis of spirometry.
Conclusions : Community pharmacists are able to reliably achieve spirometry results meeting ATS/ERS guidelines in people with asthma. Significant improvements in airway obstruction were demonstrated with the pharmacy services. Pharmacists interpreted lung function results to identify airway obstruction for referral, making this a useful technique for review of people with asthma in the community.
Integration of dose counters in pressurized metered-dose inhalers for patients with asthma and chronic obstructive pulmonary disease: review of evidence.
An important factor responsible for suboptimal treatment in patients with obstructive airway diseases, which is often overlooked, is running out of medication. Addition of a dose counter to a pressurized metered-dose inhaler (pMDI) allows the patient to reliably track number of actuations, identify when the label claim number of actuations has been reached, and when a new inhaler needs to be purchased.
Areas covered: This article discusses the conventional methods for tracking doses in pMDIs, rationale of using dose counters, published evidence of studies, including performance and patient satisfaction with the use of pMDIs with dose counter. A section on the FDA guidance on dose counters and on Cipla's dose counters is also included.
Expert opinion: It has been several years since the US FDA guidance on integration of dose-counting mechanisms into pMDIs and some time since pMDIs with dose counters have been available (albeit not with all pMDIs); but their importance has not been fully realized. This can be due to factors such as lack of adequate understanding about dose tracking, limited pMDIs being available with integrated dose counters and absence of a clear consolidation of the need, advantages, guidelines, types and characteristics of dose counters in published articles.
Update on epigenetics in allergic disease.
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Chronic inflammatory diseases, including allergies and asthma, are the result of complex gene-environment interactions. One of the most challenging questions in this regard relates to the biochemical mechanism of how exogenous environmental trigger factors modulate and modify gene expression, subsequently leading to the development of chronic inflammatory conditions. Epigenetics comprises the umbrella of biochemical reactions and mechanisms, such as DNA methylation and chromatin modifications on histones and other structures.
Recently, several lifestyle and environmental factors have been investigated in terms of such biochemical interactions with the gene expression-regulating machinery: allergens; microbes and microbial compounds; dietary factors, including vitamin B12, folic acid, and fish oil; obesity; and stress. This article aims to update recent developments in this context with an emphasis on allergy and asthma research.
The microbiome in asthma.
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The application of recently developed sensitive, specific, culture-independent tools for identification of microbes is transforming concepts of microbial ecology, including concepts of the relationships between the vast complex populations of microbes associated with ourselves and with states of health and disease. Although most work initially focused on the community of microbes (microbiome) in the gastrointestinal tract and its relationship to gastrointestinal disease, interest has expanded to include study of the relationships of the airway microbiome to asthma and its phenotypes and to the relationships between the gastrointestinal microbiome, development of immune function, and predisposition to allergic sensitization and asthma.
Here we provide our perspective on the findings of studies of differences in the airway microbiome between asthmatic patients and healthy subjects and of studies of relationships between environmental microbiota, gut microbiota, immune function, and asthma development. In addition, we provide our perspective on how these findings suggest the broad outline of a rationale for approaches involving directed manipulation of the gut and airway microbiome for the treatment and prevention of allergic asthma.