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Comparative outcomes of leukotriene receptor antagonists and long-acting β-agonists as add-on therapy in asthmatic patients: A population-based study.

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Recent evidence suggests that the use of leukotriene receptor antagonists (LTRAs) in addition to inhaled corticosteroids (ICSs) in asthmatic patients provides comparable benefits to the addition of long-acting β-agonists (LABAs) to ICSs. OBJECTIVE: We sought to compare, in a unified framework, adherence, outcomes, and costs associated with ICS+LTRA versus ICS+LABA as step-up therapies for asthma.

METHODS: Using the administrative databases of British Columbia, Canada (years 1997-2007), we created a propensity score-matched sample of asthmatic patients (12-45 years old) receiving ICS+LTRA therapy versus ICS+LABA therapy after a period of monotherapy with an ICS. We compared the outcomes using 2 analyses: an intention-to-treat (ITT) analysis that followed subjects for a fixed period of 2 years and an uninterrupted treatment analysis that followed subjects for as long as they continuously dispensed their index medications.

RESULTS: The matched cohort consisted of 1032 subjects in each group (mean age at entry, 27.4 years; 52.5% female). Adherence, which was defined as the proportion of days covered, was higher in the ICS+LABA group compared with the ICS+LTRA group. In both the ITT and uninterrupted treatment analyses, use of ICS+LTRA therapy was associated with more asthma-related outpatient visits, asthma-related medication dispensations, and dispensation of reliever medications. Dispensation of oral corticosteroids and rate of asthma exacerbations were higher in the ICS+LTRA group in the uninterrupted treatment analysis but not in the ITT analysis.

CONCLUSIONS: In a real-world clinical setting subjects were more adherent to ICS+LABA therapy than ICS+LTRA therapy. ICS+LABA therapy seems to be more effective than ICS+LTRA therapy in the management of asthma, regardless of adherence.

High Economic Burden of Caring for Patients With Suspected Extraesophageal Reflux.

Extraesophageal symptoms are common manifestations of gastroesophageal reflux disease (GERD). Lack of a definitive diagnostic or treatment standards complicate management, which often leads to multiple specialty consultations, procedures, pharmaceuticals and diagnostic tests. The aim of this study was to determine the economic burden associated with extraesophageal reflux (EER).

METHODS:Direct costs of evaluation were estimated for patients referred with symptoms attributed to EER between 2007 and 2011. Medicare payment for evaluation and management and pharmaceutical prices was used to calculate first year and overall costs of evaluating and treating extraesophageal symptoms attributed to reflux.

RESULTS:Overall, 281 patients were studied (cough (50%), hoarseness (23%), globus/post-nasal drainage (15%), asthma (9%), and sore throat (3%)). Over a median (interquartile range) of 32 (16-46) months follow-up, patients had a mean (95% confidence interval) of 10.1 (9.4-10.9) consultations with specialists and underwent 6.4 (3-9) diagnostic procedures. Overall, the mean initial year direct cost was $5,438 per patient being evaluated for EER. Medical and non-medical components contributed $5,154 and $283. Of the overall cost, 52% were attributable to the use of proton pump inhibitors. During the initial year, direct costs were 5.6 times higher than those reported for typical GERD ($971). A total of 54% of patients reported improvement of symptoms. Overall cost per improved patient was $13,700.

CONCLUSIONS:EER contributes substantially to health-care expenditures. In this cohort, the cost for initial year's evaluation and treatment of EER symptoms was quintuple that of typical GERD. Prescription costs and, in particular, proton pump inhibitors were the single greatest contributor to the cost of EER management.Am J Gastroenterol advance online publication, 2 April 2013; doi:10.1038/ajg.2013.69.

The long-term course of ground-glass opacities detected on thin-section computed tomography

Available online 17 March 2013
Publication year: 2013
Source:Respiratory Medicine



Background Focal ground-glass opacity (GGO) is becoming a major concern because of its possible association with lung cancer. In this study, we analyzed the long-term progression of GGOs that persisted for more than 2 years. Methods We reviewed focal GGOs identified by thin-section computed tomography that persisted for more than 2 years. Results We enrolled a total of 114 patients with 175 GGO lesions. The median patient age was 61 years (range, 37–92 years) and 42 (36.8%) patients were male. Mean initial GGO size was 7.8 ± 4.4 mm. Median follow-up duration was 45 months. Forty-six (26.3%) GGOs had significant size increases (≥2 mm in the longest diameter) with a mean volume doubling time of 1041 days. In a multivariate analysis, large size (≥10 mm), the presence of a solid portion (mixed GGO) and old age (≥65 years) were risk factors for significant size increase, with odds ratios (95% CI) of 6.46 (2.69–15.6), 2.69 (1.11–6.95) and 2.55 (1.13–5.77), respectively. GGOs with character changes from pure to mixed or mixed to solid showed more rapid volume expansion. Conclusions GGOs which persisted for several years showed an indolent course. Large lesions with a solid portion and GGOs in male or elderly individuals may be cause for more concern, as these factors were associated with size increase. Resection should be considered if GGOs show character changes, as these may be associated with rapid size progression.




Prevalence and diagnosis of chronic obstructive pulmonary disease among smokers at risk. A comparative study of case-finding vs. screening strategies

April 2013
Publication year: 2013
Source:Respiratory Medicine, Volume 107, Issue 4



Background Early diagnosis of chronic obstructive pulmonary disease (COPD) remains the main intervention to prevent disease progression. However, conflicting results exist on the utility of two different diagnostic strategies that preclude freely recommending one strategy in favor of the other. Spirometry was used to determine the effectiveness of a symptom-based (case-finding) strategy vs. a screening strategy to detect COPD in smokers. Methods The case-finding strategy was undertaken during the COPD Day campaign in smokers with respiratory symptoms who were willing to submit to lung function testing. Screening was carried out with smokers attending a smoking cessation program. A short standardized questionnaire on respiratory symptoms along with spirometry were carried out and analyzed for both strategies. Results We evaluated 2781 smokers (mean pack/years 23.38): 1999 from the case-finding strategy and 782 from the smoking cessation program strategy (SCS). Prevalence of COPD according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria was 10.1 and 13.3%, respectively (p < 0.01). With the exception of dyspnea (70.6% vs. 72.5%, p = 0.72), prevalence of symptoms such as cough (61.5 vs. 37, p < 0.001), phlegm (60.4 vs. 38.2, p < 0.001) and wheezing (56.7 vs.15.06, p < 0.001) was higher among smokers from the case-finding strategy. Multivariate logistic regression analysis showed that dyspnea [OR = 2.09 (95% CI 1.41–3.1)] was the only common predictor of COPD after jointly and separately analyzing case-finding and screening strategies. Conclusions For early diagnosis of COPD in a primary care setting, a screening strategy aimed at all smokers may be more useful than a case-finding strategy.




Intravenous and nebulized magnesium sulfate for treating acute asthma in adults and children: A systematic review and meta-analysis

This systematic review and meta-analysis was conducted to estimate the effects of intravenous and nebulized magnesium sulfate on treating adults and children with acute asthma.

Methods Electronic literature search and the manual search of key respiratory journals were performed up to October 18, 2011. Randomized controlled trials were included if patients had been treated with intravenous or nebulized magnesium sulfate in combination with β2-agonists and were compared with the use of β2-agonists. Standardized mean differences (SMDs) and the relative risks (RRs) were calculated for pulmonary functions and hospital admission respectively.

Results 25 trials (16 intravenous, 9 nebulized) involving 1754 patients were included. In adults intravenous treatment was associated with a significant effect upon respiratory function (SMD, 0.30; 95% confidence interval (CI), 0.05 to 0.55; p = 0.02) but weak evidence of effect upon hospital admission (RR 0.86,95% CI 0.73 to 1.01; p = 0.06) in adults, and in children with significant effects upon both respiratory function (SMD, 1.94; 95% CI, 0.80 to 3.08; p = 0.0008) and hospital admission (RR, 0.70; 95% CI, 0.54 to 0.91; p = 0.008). Nebulized treatment was associated with significant effects upon respiratory function (SMD, 0.23; 95% CI, 0.06 to 0.41; p = 0.009) and hospital admission (RR, 0.63; 95% CI, 0.43 to 0.92; p = 0.02) in adults.

Conclusion The use of intravenous magnesium sulfate, in addition to β2-agonists and systemic steroids, in the treatment of acute asthma appears to produce benefits with respect to improve pulmonary function and reduce the number of hospital admissions for children, and only improve pulmonary function for adults. However, the use of nebulized magnesium sulfate just appears to produce benefits for adults.

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