This document provides an agenda and background information for a meeting of the Small Airways & Child Health Working Group. The agenda includes discussions on ongoing publications regarding chest nomenclature and a systematic review on ICS particle size. Presentations will cover pre-school asthma wheeze, new ideas for the group focusing on implications of ICS particle size on GERD and ACOS, and an oscillometry study overview. Background information is provided on the chest commentary and systematic review, including results showing extra-fine ICS have higher odds of asthma control and lower exacerbation rates than fine particle ICS. A proposed study on pre-school asthma will compare outcomes of EF ICS to NEF ICS, LTRA,
ATS Symposium: Leukotriene Antagonists As First-line Asthma Controller For St...Zoe Mitchell
ATS Symposium session presented by Prof. David Price:
Leukotriene Antagonists As First-line Asthma Controller For Step 2
Presented May 2015 at ATS 2015, Denver, Colorado, USA
An overview of the work and initial results of the REG-EAACI Taskforce assessing the quality of literature in the field of real-world respiratory medicine.
ATS Symposium: Leukotriene Antagonists As First-line Asthma Controller For St...Zoe Mitchell
ATS Symposium session presented by Prof. David Price:
Leukotriene Antagonists As First-line Asthma Controller For Step 2
Presented May 2015 at ATS 2015, Denver, Colorado, USA
An overview of the work and initial results of the REG-EAACI Taskforce assessing the quality of literature in the field of real-world respiratory medicine.
Een nieuw magazine?
Weer een nieuw magazine, weer een nieuwsbrief, hoor ik u zeggen. Inderdaad!
Producten en behandelingen worden steeds beter en technologischer en daarom is kennis delen een must. Want dit is een kans voor ons en de schoonheidsinstituten. Ze hebben nog te veel een stempel van ‘ontspannend en lekker’ en dat is spijtig.
Daarom brengen wij u verschillende keren per jaar via BRANDNEW(S) belangrijke redactionele thema’s zoals de laatste trends, vakbeurzen, evenementen, productinfo over huidverzorging, behandelingen en make-up. Deze visie, samen met de innovatie op productniveau, maakt dat we samen met u positief naar de toekomst kijken, want de komende jaren gaat er heel wat veranderen in de branche.
Ik wens u veel leesplezier. Tot binnenkort
Sam Aga
World Usability Day 2016 in Antwerp, Thursday, November 10th - Natalia Arsand, UX designer at Booking.com
“Designing for the behavior of a sustainable future”
We live in the Planet of Plastic Sea, and we don't usually think this to be our fault, but what if that coffee cup we disposed for recycle is actually part of a Plastic Island at this very moment?
We are consumers and we are designers. That counts as some of the greatest powers someone can have these days. This talk comes to enlighten us on our responsibility as gate keepers, with demonstrations of simple acts we can take as consumers and designers to lead the behavior of a sustainable future.
Natalia has been working with design and technology for more than 8 years now, and she is passionate about it. She believes it can change the world for the best. She loves helping teams understand real life problems from real people, and the many iterations that follow until a suitable solution is found. She enjoys it even more when dealing with society's critical problems.
Presentation deck from the Socitm Supplier Briefing that took place on the 3rd June.
Socitm's New Agenda
Data the Key to Digital
Sponsor Address: A Digital Transformation Approach
Why isn't Digital Catching Fire… and what can suppliers do
Current Priorities for Local Government
The Supplier Partnership Program
Sander Spolspoel at UX Antwerp Meetup - 13 dec 2016UX Antwerp Meetup
UX Antwerp Meetup, 13th of December 2016 - Sander Spolspoel, independent animation movie creator at Swörl (Antwerp, Belgium)
"The language of animation"
Whatever you’re doing right now can be done better (for a small monthly fee). At least, that’s what video animations all over the web are telling you. Some are very convincing, others not so much. If we look at how people processes visual information, we can build a language to tell a story that packs a lot of information. Allow me to show you some techniques in illustration and animation to tell a better visual story.
– Sander creates video animations for companies with a story to tell. His company Swörl (a name that came to him while browsing furniture at IKEA) aims to package information in a nicer box, including 15% humor.
Act training 15 aug 2011 m sills editsMarion Sills
Educational materials (slide-set and accompanying script) used to train-the-trainers in SAFTINet practices on incorporating the Asthma Control Test into their clinical workflow and decision-making for patients with asthma.
For more information on SAFTINet, please see http://www.ucdenver.edu/academics/colleges/medicalschool/programs/outcomes/COHO/saftinet/Pages/default.aspx
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
How STIs Influence the Development of Pelvic Inflammatory Disease.pptx
Child Health Working Group and Small Airways Study Group Joint Meeting
1. SMALL AIRWAYS
& CHILD HEALTH
WORKING GROUP MEETING
DATE: Saturday September 3rd
TIME: 4.00–5.00pm
VENUE: Royal College of General Practitioners; 30 Euston
Square, London, UK
2. Agenda
16.00-16.05 Welcome / Introduction Omar Usmani
16.05–16.15 On-going publications
16.05–16.10 – Chest nomenclature commentary Liz Hillyer
16.10–16.20 – Systematic Review of the comparative Sam Sonnappa
16.20–16.35 Pre-school asthma wheeze Jonathan Grigg
16.35–16.50 New ideas for the group
• Ideas so far Omar Usmani
– Implications of ICS particle size on (on behalf of Nicolas Roche)
• GERD
• ACOS
– Other ideas / Discussion Group
16.50–17.00 Oscillometry – FOT study overview Ron Dandurand
4. Chest Commentary: Nomenclature Update:
Background
• Need for consensus on aerosol particle nomenclature
• Terms used in the published literature:
o Extrafine, ultrafine, small vs. large, standard-size, coarse
• ERS/ISAM Task Force Report (ERJ 2011) includes:
o “Fine-particle dose” (FPD) = mass of drug consisting of
particles <5µm in aerodynamic diameter
o Denotes Qvar and ciclesonide as being “extrafine.”
• Hence our proposal, submitted to Chest last month:
o “Extrafine” particle = MMAD <2µm
o “Fine” particle = MMAD 2-5µm
o “Coarse” particle = MMAD >5µm
5. Chest Commentary: Review 29Aug
Reviewer 1: favorable, two suggestions:
1. Replace the Figure (schematic of lung deposition by particle
size) with a table summarizing evidence basis for nomenclature
proposal:
o This could be added without deleting the figure.
2. Add a proposal for use of the terms extrafine- and coarse-particle
fractions, in accordance with “fine-particle fraction”
o Instead we could propose “extrafine-particle dose” and
“coarse-particle dose,” as per fine-particle dose (FPD)
o The fine-particle fraction (FPF) is variable depending on how
it’s calculated (FPD/emitted dose vs. FPD/nominal metered
dose) & can be the same for two products with different
delivered doses even if the FPD differs
6. Chest Commentary: Review 29Aug
Reviewer 2: “…can’t agree with this simplistic
approach”
• Seven comments, mostly missing the point of our
proposal: ie, it’s strictly about nomenclature.
• His/her comments are focused on the point that there
are “too many other considerations (inhaler design,
formulation, inhalation pattern, lung disease) that
influence lung deposition”
• We agree but want to avoid a literature review
• Plan: address his/her points when possible and push
back when not possible
7. SYSTEMATIC REVIEW OF THE
COMPARATIVE EFFECTIVENESS LITERATURE
ON ICS PARTICLE SIZE
DR SAM SONNAPPA
8. Figure : PRISMA flowchart showing the step-by-step process of the application of
inclusion and exclusion criteria to generate the final number of studies included
in the meta-analysis
Literature Review
9. Figure : Forest plot showing pooled odds ratios (95% CI) for measures of asthma control
Results: Asthma Control
10. Figure: Forest plot showing pooled relative risk ratios (95% CI)
for measures of asthma exacerbations
Results: Exacerbations
11. Summary
• Extra-fine ICS have significantly higher odds of
achieving asthma control with lower exacerbation rates
at significantly lower doses than fine particle ICS
• There is even a potential to change ICS from fine
particle to extra-fine particle as a step-up therapy
before adding LABAs, which is currently not
recognised in asthma guidelines
• Physicians must consider the potential benefits of
prescribing extra-fine formulations of ICS to asthmatics
13. Background / Rationale
• The particle size (and delivery characteristics of EF HFA BDP)
of the aerosol may be particularly relevant for young children
in whom a greater proportion of airways are classified as
small (i.e. <2mm in diameter)1 and airways resistance is low
• There is evidence to suggest that EF HFA BDP is equivalent
to CFC-FP in terms of efficacy and safety in adults and
children (5–12 years) with mild-to-moderate asthma2,3
• Evidence remains lacking as to the role that ICS particle size
may play in the management of asthma/wheeze in younger,
pre-school (<5 years) children
1. Leach CL, et al. Eur Respir J. 1998;12:1346–1353.
2. Aubier M, et al. Respir Med. 2001;95:212–220.
3. Fairfax A, et al. Ann Allergy Asthma Immunol. 2001;86:575–582.
14. • To test the hypothesis that use of EF ICS in pre-school children with
asthma/wheeze will achieve better outcomes than treatment
alternatives (i.e. NEF ICS, LTRA, or SABA)
Study Objectives
• Phase I: a descriptive analysis of treatment patterns in children aged ≤5 years with
wheezing illness
• Phase II: a comparative effectiveness evaluation of guideline-recommended treatment
options in pre-school children newly initiating Step 2 therapy NEF ICS vs EF ICS and
LTRA vs EF ICS over a 1-year outcome period
• Exploratory analysis: an extension of the primary analysis over a 5-year outcome
period to explore whether EF ICS may offer potential disease-modifying effects
compared with alternative treatment options when used in the management of early-life
wheezing illness
Study Phases
15. Data Source
• The UK’s Optimum Patient Care Research Database
(OPCRD)
• Fully anonymised UK primary care data
• Historical medical records for:
o >2.2 million patients, from
o >550 primary care practices across the UK
• Ethical approval for medical research
16. Study Design
Index Date:
Date SABA (control
arm) or of first Step 2
asthma / wheeze
prescription
Baseline year:
12-months prior to index date for Phase I
analysis (mapping prescribing patterns)
and for patient characterisation and
confounder definition
Exploratory 5-year outcome period
Primary 1-year outcome period
REFERENCE ARM
EF ICS
i.e. EF HFA BDP or ciclesonide via pMDI
LTRA
Eligible patients must:
• Have diagnostic evidence of asthma /
wheeze
• be aged ≤5 years
NEF ICS
i.e. FP or NEF BDP via pMDI
Control: SABA
• Index date: date at which patients received their first prescription of ICS via pMDI or
LTRA, or (for the control arm) a repeat prescription for SABA
• Baseline: 1 year before ID
• Outcome: 1 year after ID (and 5-years after ID for exploratory analysis)
17. Inclusion Criteria
• Age: ≤5 years of age at the index date
• Evidence of pre-school wheeze or asthma during the baseline year – defined as either:
o ≥2 wheezing episodes recorded within their primary care records in the baseline year, or
o ≥2 prescriptions (at two different points in time) during the baseline year for any combination
of oral steroids coded for a lower respiratory complaint ± salbutamol
• Active treatment during outcome year:
o Active treatment arms (Step 2 therapy): ≥2 prescriptions (i.e. ≥1 in addition to that
prescribed at index date) for any of the Step 2 treatment options (i.e. any ICS via pMDI or
LTRA)
o Control arm: ≥2 prescriptions for SABA
o Exploratory 5-year outcome analysis: ≥1 prescription of the index date therapy in each of
the outcome years
• At least 2 year’s continuous records: ≥1 year’s continuous baseline records and ≥1 year’s outcome
records
o Eligibility for the exploratory analysis ≥5-years’outcome data
Study Population
Exclusion Criteria
• Have a clinical diagnosis for any chronic respiratory disease, except wheeze or asthma
• Received a combination inhaler in addition to a separate ICS inhaler in baseline;
• Multiple step-up therapies on the same day
• Infants: any child under the age of 1 year (as ≥1 year of baseline data is required)
18. Outcomes/Endpoints
Primary Endpoint:
• Exacerbations (ATS/ERS definition) defined as occurrence of an:
o Asthma-related: Hospital admissions OR A&E attendance; OR
o An acute course of oral steroids (coded for asthma or wheeze)
Secondary Endpoints:
• Acute respiratory event
o Hospital Admissions OR A&E attendance OR
o Acute Oral Steroid Prescriptions
o Antibiotic Prescriptions with LR complaint
• Risk Domain Asthma Control
• Overall Asthma Control (OAC)
• Treatment stability
19. Outcome Definitions
Risk Domain Asthma Control
(RDAC)
Defined as absence of:
Controlled:
• Asthma-related: Hospital admission AND A&E
attendance AND out-patient attendance; AND
• Acute use of oral steroids; AND
• Antibiotics prescribed with lower respiratory
consultation
Uncontrolled: all others
Treatment stability:
Stable:
• Achieved Risk Domain Asthma Control; AND
• No additional therapy defined as no:
• Increased dose of ICS (≥50% increase
of that prescribed at index date) AND/
OR
• Use of additional therapy as defined by:
long-acting bronchodilator (LABA),
theophylline, LTRAs
Unstable: all others
Overall Asthma Control
Defined as absence of:
Controlled:
• RDAC (achievement/non-achievement); plus
• Average daily dose of SABA ≤200mcg salbutamol
Uncontrolled: all others
30. Explore interaction of switch to ICS (I)
• 50-60% of patients in SABA and LTRA arms
received ICS in the outcome year
• Implications…?
• Explore:
o Time to treatment failure
– Addition of new therapy (i.e. ICS) or ≥50% dose
increase in index date therapy
o Time to first exacerbation
31. Time to first exacerbation
& treatment stability
OUTCOME SUMMARY
Time to First Exacerbation
(days)
Time to Treatment Failure
(days)
EF vs NEF ICS
(n=275 v n=1100)
Mean (SD) 61.0 (92.1) 70.2 (100.3) 115.0 (97.3) 129.8 (100.5)
P-value* 0.165 0.145
ICS vs SABA
(n=990 v n=3960)
Mean (SD) 62.7 (97.4) 60.4 (96.7) 128.4 (101.8) 110.0 (99.9)
P-value* 0.489 0.183
ICS vs LTRA
(n=104 v n=104)
Mean (SD) 87.2 (114.3) 83.9 (99.7) 134.8 (110.9) 107.7 (88.7)
P-value* 0.992 0.959
LTRA vs SABA
(n=259 v n=1036)
Mean (SD) 72.0 (97.4) 68.5 (96.9) 104.6 (93.7) 99.5 (94.5)
P-value* 0.594 0.046
No clinically meaningful differences seen
between any choice of treatment
32. Explore interaction of switch to ICS (II)
• In the unmatched population, evaluate the change in
acute respiratory events between baseline and outcome
as a function of consumed ICS dose in the outcome year
(i.e. total mcg prescribed)
• Other possible additional analyses to explore markers for
ICS response:
o Explore whether there is any benefit in ICS treatment in
patients stratified by blood eosinophil threshold (<300 and ≥300)
o Data available for ~9000 patients
34. Discussion
• Key messages:
o Robustly negative study
o The study design works – proven in other age groups
o The results reflect clinical practice observations and results from large trials:
– Pre-school wheeze is a heterogeneous entity
– Variable, often little, treatment response
o There may be some subgroups of patients that are responding to therapy,
but there are no markers for potential response
o New therapeutic modalities are required
o In the absence of better tools to help target treatments, the data suggest a
"wait-and-see approach" in this pre-school population may be sound
• Timeline:
o Statistical adjustments & additional analyses: by October
o Manuscript development over the autumn; submission by December
36. Working title
Implications of inhaled corticosteroid
particle size in the management of asthma in
patients excess weight/obesity and/or GERD
Objective
1. Evaluate the comparative effectiveness of extra-fine
and non extra-fine inhaled corticosteroid (ICS)
treatment in patients with asthma and comorbid
GERD ± obesity
2. Determine the relationship between overweight/
obesity and GERD as determinants of poor asthma
control
Rationale
• Apparent link between obesity and asthma
• Positive correlation BMI and development of asthma.
• GERD is a risk factor for asthma and shares common
pathophysiologic mechanisms that lead to worsening of
asthma symptoms, including mechanical effects and local
and systemic anti-inflammatory effects.
• High BMI and GERD may impair asthma control through:
– Obeisty: systemic inflammation, modified lung
mechanics
– GERD: increased airways inflammation
which could be associated with more distal inflammation
Outputs from the research
• Hypothesis testing: contribute to the evidence for the
presence and potential management implications of
distal airway inflammation in patients with asthma ±
excess weight ± GERD
• Informing targeted management options: inform
management decisions in patients with comorbid
asthma, GERD and obesity
• Research dissemination: Respiratory conference
abstract & open access peer review journal publication
Proposed methodology
Design: 2-year observational matched cohort study study: 1
baseline year; an index date at which patients initiate or step-up
ICS therapy; 1 outcome year
Population: adult asthma patients (i) Population A: initiating
and (ii) Population B: stepping up asthma maintenance therapy
as extra-fine vs non extra-fine ICS will be matched on key
baseline characteristics (age, sex, exacerbations, BMI,
comorbid GERD)
A priori subgroups: (i) asthma only; (ii) asthma+GERD; (iii)
asthma+obesity; (iv) asthma+obesity+ GERD
Outcomes: database measures of asthma control, acute
respiratory events and asthma exacerbation rates.
Asthma & GERD±Obesity Research Concept
Proposed by Nicolas Roche; May 2015
Asthma, GERD, Obesity & extra-fine particle ICS
Therapeutic area(s)
37. Working title
Implications of inhaled corticosteroid
particle size in the management of patients
with a mixed asthma-COPD phenotype
Objective
1. Evaluate the comparative effectiveness of
extra-fine and non extra-fine inhaled
corticosteroid treatment in patients with ACO
(vs asthma vs COPD)
2. Evaluate the consistency of outcomes across
different research definitions of ACO
Rationale
• Patients with an apparently mixed asthma–COPD
phenotype (ACO) have distinct characteristics of each
condition and characteristics common to both.
• Some of the differences in the pathophysiological
mechanisms present in asthma and COPD, may be
attributed to the differential involvement of the distal
airways.
• The distal airways may present a marker of likely ICS
therapy response clinical target to optimise outcomes
in patients with ACO
Outputs from the research
• Improve understanding: of the respective involvement of
distal airways across OLD conditions: asthma, COPD,
ACOS (and sub-categories of ACOS)
• Informing targeted management options: inform ICS
management decisions in patients with a mixed asthma-
COPD phenotype
• Research dissemination: Respiratory conference abstract
& open access peer review journal publication
Proposed methodology
Design: 2-year observational matched cohort study study:
1 baseline year; an index date at which patients initiate or
step-up ICS therapy; 1 outcome year
Population: ACO patients (i) Population A: initiating and (ii)
Population B: stepping up asthma maintenance therapy as
extra-fine vs non extra-fine ICS will be matched on key
baseline characteristics (age, sex, acute respiratory event
rate, ICS dose and OLD diagnosis)
A priori subgroups: (i) asthma only; (ii) COPD; (iii) asthma
+COPD; repeat in different operationalisable definitions of
ACO (defined by the REG ACO Working Group)
Outcomes: database measures of OLD control, acute
respiratory events and OLD exacerbation rates.
ACO Research Concept
Proposed by Nicolas Roche; May 2015 Asthma, COPD & extra-fine particle ICS
Therapeutic area(s)
40. Background
• Small airways are an important site of
pathophysiology in obstructive lung diseases.
• Therapeutic targeting of the small airways is
desirable.
• Easy bedside/clinic technique to evaluate the small
airways remains elusive.
• FOT potentially, may fill this need.
42. Background
• Small amplitude, subsonic, high frequency pressure
waves i.e. infrasound applied at the mouth.
• Acoustic energy absorption estimates lung
mechanics.
• Leverages infrasound’s frequency dependence of
lung penetration.
• Localizes site of airflow limitation to small or large
airways.
55. Objectives
• Establish magnitude of problem
• Propose potential solutions
o Data based devise specific software modifications
o Modify choice of filtre/mouth piece used
• Explore FOT based pharmacotherapy free of
confounding technical issues.
56. Proof-of-Concept (in progress)
• 30 pediatric patients
o Asthma
o BPD
o Healthy Controls
• 3 FOT devises
o iOS
o tremoFlo
o MostGraph-02
• Data for power calculation of larger study
• $20 K or 14 K euros
57. Potential Study
• 300-500 adult and pediatric patients
o Asthma
o COPD
o BPD
o Healthy Controls
• 5 FOT devises
o iOS
o tremoFlo
o MostGraph-02
o i2m
o Resmon
• Based on power calculation from proof-of-concept
• $200 K or 140 K euros
58. Discussion
• Questions
• Study design suggestions
• Potential sources of funding
• Are other similar initiatives in progress?
rdandurand@videotron.ca