This document discusses precision medicine approaches to tailoring COPD management to individual patient needs and phenotypes. It reviews current guidelines for COPD pharmacotherapy and how to optimize therapy for the specific patient. It provides an overview of treatable traits and phenotypes in COPD and examples of targeting treatment based on a patient's profile, such as using ICS for an eosinophilic phenotype. The document also discusses two case scenarios - one involving a patient with recurrent exacerbations and how to determine the best treatment approach, and another involving optimizing therapy for a returning patient.
Safety and Affordabilty: Quantifying the impact of real-world evidenceZoe Mitchell
This document discusses assessing drug safety and risks using real-world evidence from outside of clinical trials. It begins by examining what can be learned about risks and safety from randomized controlled trials (RCTs), noting their limitations in detecting uncommon or long-term adverse events. The document then explores how real-life studies can help evaluate risks in pulmonary diseases by studying more diverse populations over longer time periods. Examples are provided of real-world studies assessing safety issues for COPD and asthma medications. Unmet needs in respiratory medicine are also identified where further safety data is required.
BTS_ICS Guideline for the Ventilatory Management of Acute Hypercapnic Respira...AssessoriadaGernciaG
This document provides guidelines for the ventilatory management of acute hypercapnic respiratory failure in adults, as developed by the British Thoracic Society/Intensive Care Society Acute Hypercapnic Respiratory Failure Guideline Development Group. It includes recommendations on the use of non-invasive ventilation and invasive mechanical ventilation. The guidelines cover various disease states that can cause acute hypercapnic respiratory failure such as COPD, asthma, cystic fibrosis, restrictive lung diseases and obesity hypoventilation syndrome. It also addresses weaning from mechanical ventilation, appropriate care environments, and end-of-life care considerations.
Back to the Bedside: Internal Medicine Bedside Ultrasound ProgramAllina Health
David Tierney, MD. How bedside ultrasound is changing the practice of medicine and how Abbott Northwestern Hospital has become a national leader in integrating bedside ultrasound in its Internal Medicine Residency Program. "As internal medicine physicians, we are finding that everything we do with our hands, eyes and stethoscopes can be done a little better with ultrasound. That means our physical exam, which we consider our bread and butter, has more sensitivity and specificity. This gives us better diagnostic ability and results in earlier and more appropriate treatment."
Respirology - 2022 - Barnett - Thoracic Society of Australia and New Zealand ...AssessoriadaGernciaG
This position paper from the Thoracic Society of Australia and New Zealand provides recommendations for acute oxygen use in adults. Key recommendations include:
1) Pulse oximetry should be routinely recorded along with vital signs to assess oxygenation. Arterial blood gases are still the gold standard but have limitations.
2) Oxygen is a drug that requires prescription documenting flow rate, delivery device, oxygen saturation targets, and criteria for deterioration or improvement.
3) The recommended oxygen saturation target range is 88-92% for those with chronic respiratory disease to avoid hypercapnia, and 92-96% for other situations.
4) Nasal cannulae are the preferred delivery method. Humidified
Child Health Working Group and Small Airways Study Group Joint MeetingZoe Mitchell
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,
Safety and Affordabilty: Quantifying the impact of real-world evidenceZoe Mitchell
This document discusses assessing drug safety and risks using real-world evidence from outside of clinical trials. It begins by examining what can be learned about risks and safety from randomized controlled trials (RCTs), noting their limitations in detecting uncommon or long-term adverse events. The document then explores how real-life studies can help evaluate risks in pulmonary diseases by studying more diverse populations over longer time periods. Examples are provided of real-world studies assessing safety issues for COPD and asthma medications. Unmet needs in respiratory medicine are also identified where further safety data is required.
BTS_ICS Guideline for the Ventilatory Management of Acute Hypercapnic Respira...AssessoriadaGernciaG
This document provides guidelines for the ventilatory management of acute hypercapnic respiratory failure in adults, as developed by the British Thoracic Society/Intensive Care Society Acute Hypercapnic Respiratory Failure Guideline Development Group. It includes recommendations on the use of non-invasive ventilation and invasive mechanical ventilation. The guidelines cover various disease states that can cause acute hypercapnic respiratory failure such as COPD, asthma, cystic fibrosis, restrictive lung diseases and obesity hypoventilation syndrome. It also addresses weaning from mechanical ventilation, appropriate care environments, and end-of-life care considerations.
Back to the Bedside: Internal Medicine Bedside Ultrasound ProgramAllina Health
David Tierney, MD. How bedside ultrasound is changing the practice of medicine and how Abbott Northwestern Hospital has become a national leader in integrating bedside ultrasound in its Internal Medicine Residency Program. "As internal medicine physicians, we are finding that everything we do with our hands, eyes and stethoscopes can be done a little better with ultrasound. That means our physical exam, which we consider our bread and butter, has more sensitivity and specificity. This gives us better diagnostic ability and results in earlier and more appropriate treatment."
Respirology - 2022 - Barnett - Thoracic Society of Australia and New Zealand ...AssessoriadaGernciaG
This position paper from the Thoracic Society of Australia and New Zealand provides recommendations for acute oxygen use in adults. Key recommendations include:
1) Pulse oximetry should be routinely recorded along with vital signs to assess oxygenation. Arterial blood gases are still the gold standard but have limitations.
2) Oxygen is a drug that requires prescription documenting flow rate, delivery device, oxygen saturation targets, and criteria for deterioration or improvement.
3) The recommended oxygen saturation target range is 88-92% for those with chronic respiratory disease to avoid hypercapnia, and 92-96% for other situations.
4) Nasal cannulae are the preferred delivery method. Humidified
Child Health Working Group and Small Airways Study Group Joint MeetingZoe Mitchell
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,
This document provides details of an upcoming allergy working group update meeting, including the date, time, location, chair, and agenda. The agenda includes discussions on research ideas like nasal hyper-responsiveness and urticaria. Proposed actions and studies on these topics are described. New data collection opportunities through adding questions to an existing questionnaire are outlined. Potential integration of questions into an Australian pharmacy study is also discussed.
This document discusses pulmonary hypertension (PH) in patients with rheumatic diseases. It provides recommendations on diagnosing and classifying PH based on guidelines from the European Society of Cardiology and European Respiratory Society. PH is often detected through echocardiogram screening in asymptomatic patients with connective tissue diseases like scleroderma. Right heart catheterization is necessary to confirm a diagnosis of PH. While drug treatments for PH have shown benefits in clinical trials, their effectiveness may be more limited in patients with PH associated with connective tissue diseases compared to those with idiopathic PH. Strict diagnosis and classification of PH type is important to determine appropriate treatment management in rheumatic disease patients.
Presentació resultats Estudi multicèntric amb telemedicina Red Promete per pa...brnmomentum
1) The PROMETE II study was a randomized controlled trial evaluating the use of home telemonitoring (HTM) compared to routine clinical practice (RCP) in elderly patients with severe COPD requiring long-term oxygen therapy.
2) The primary outcome of reducing hospitalizations and emergency room visits was not significantly different between the HTM and RCP groups.
3) However, the duration of hospital stays appeared to be shorter in the HTM group, with the mean duration of hospitalization being approximately 4 days less, though this was not statistically significant.
Dr. Sujay Halkur Shankar presented on the topic of weaning patients from mechanical ventilation. The presentation covered assessing patient readiness, different weaning methods like spontaneous breathing trials, factors that can cause difficulty weaning like respiratory, cardiac and neuromuscular issues, and post-extubation care. Spontaneous breathing trials are the preferred method of weaning and have higher rates of success than pressure support or intermittent mandatory ventilation. Factors that can contribute to weaning failure include increased respiratory load or drive, decreased respiratory muscle strength, and cardiac dysfunction induced by weaning.
This document provides an updated global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (COPD) from the Global Initiative for Chronic Obstructive Lung Disease (GOLD). It discusses definitions of COPD, the disease burden, pathogenesis and pathophysiology. Guidelines are provided on diagnosis, assessment of symptoms and risk, therapeutic options including pharmacologic and non-pharmacologic treatments, management of stable COPD and exacerbations, and management of COPD comorbidities. The document is intended as a tool for healthcare professionals to implement effective COPD management programs.
1) Inhaled iloprost is a prostacyclin analog approved for treatment of pulmonary arterial hypertension. It works by selectively dilating pulmonary arteries and improving ventilation/perfusion matching in the lungs.
2) Clinical studies have shown inhaled iloprost improves exercise capacity and functional class when used alone or in combination with other PAH therapies like bosentan. It also delays time to clinical worsening.
3) When used with sildenafil, inhaled iloprost and oral sildenafil act synergistically to cause strong pulmonary vasodilation, further improving outcomes in patients with severe PAH.
Systemic corticosteroids in the treatment of acute exacerbations of copdChoying Chen
- The patient presented with an acute exacerbation of COPD with respiratory acidosis and was treated with BiPAP, bronchodilators, antibiotics, and systemic corticosteroids.
- Despite treatment, he developed hyperglycemia and hypertension which were managed by adjusting antihyperglycemic and antihypertensive medications.
- He showed improvement in respiratory status and was discharged with a tapering course of prednisolone and other medications while continuing home BiPAP use.
Pulmonary Arterial Hypertension Overview
Michael J. Cuttica MD Assistant Professor of Medicine Northwestern Pulmonary Hypertension Program
Northwestern University
Novel strategies to improve diastolic functiondrucsamal
This document summarizes Gerd Hasenfuss's presentation on novel strategies to improve diastolic function and reduce elevated left atrial pressure in patients with heart failure with preserved ejection fraction (HFpEF). It discusses an inter-atrial shunt device that creates a small permanent connection between the atria, baroreceptor activation therapy, the Aldo-DHF trial which found spironolactone improved diastolic function in HFpEF, and a study showing exercise training improved exercise capacity and quality of life in HFpEF. The presentation emphasizes that high left atrial pressure is a key factor in morbidity and mortality for HFpEF and these strategies aim to reduce left atrial pressure.
Updates On Pharmacological Management Of Stable COPD 2017Ashraf ElAdawy
This document provides guidelines for the pharmacological management of stable COPD. It defines COPD as a preventable disease characterized by airflow limitation caused by exposure to particles or gases. The guidelines describe assessing patients based on symptoms, exacerbation history, and lung function (ABCD assessment). For Group A patients with low symptoms, treatment begins with a short- or long-acting bronchodilator. For Group B patients, treatment begins with a long-acting bronchodilator, escalating to a combination if needed. For Group C patients with exacerbations, treatment begins with a long-acting muscarinic antagonist (LAMA), adding a long-acting beta-agonist if exacerbations persist.
Realistic and possible abilities in prevention of COPD exacerbationDejan Zujovic
1) Hospitalization for an acute exacerbation of COPD is associated with significantly higher mortality than hospitalization for an acute myocardial infarction. Mortality at 12 months following COPD exacerbation hospitalization is between 20-40%.
2) Proper treatment of acute exacerbations, including antibiotics, bronchodilators, corticosteroids, and oxygen therapy can help prevent future exacerbations and readmissions. However, quality of care for COPD exacerbations remains suboptimal in many cases.
3) Smoking cessation, influenza vaccination, pneumococcal vaccination, pulmonary rehabilitation, and adherence to maintenance therapies can help prevent COPD exacerbations but uptake and adherence remain low compared to potential benefits. Improving self
Community-acquired pneumonia (CAP) is a leading cause of death and hospitalization in the United States. Guidelines recommend using severity of illness scores like CURB-65 to determine appropriate site of care and empiric antibiotic therapy including β-lactams with macrolides or fluoroquinolones. Studies show guideline-concordant therapy improves outcomes. Procalcitonin levels may help determine duration of antibiotics, with lower levels associated with shorter treatment. Overall, clinicians should aim for 5-7 days of effective antibiotics guided by clinical and procalcitonin findings to optimize CAP treatment.
This document discusses the development and validation of a multifactorial risk index to predict the risk of postoperative pneumonia in patients undergoing major noncardiac surgery. It describes defining postoperative pneumonia as new radiographic lung findings accompanied by changes in sputum, a positive blood culture, or isolation of a pathogen from respiratory samples. Risk factors identified for the index included age, functional status, weight loss, COPD, anesthesia type, impaired sensorium, steroid use, smoking, and medical history. The risk index stratified patients into five classes from lowest to highest risk of developing postoperative pneumonia.
The document discusses optimizing source control for sepsis patients. It recommends:
1) Identifying and controlling the source of infection as soon as possible after diagnosis, within 6-12 hours for sepsis patients and immediately for septic shock patients.
2) Drainage, debridement, restoration of anatomy and function are ideal source control methods when possible and as soon as medically and logistically practical.
3) A sepsis team approach involving multiple specialties working together improves management and reduces delays in source control and other essential treatments.
VAP bundle compliance in ICU - Clinical Auditfaheta
This study aimed to measure compliance with ventilator-associated pneumonia (VAP) bundle components in an intensive care unit (ICU) in Saudi Arabia. An audit of 88 mechanically ventilated patients found high compliance (87.5-100%) with hand hygiene, mouth care, and avoiding routine ventilator tubing changes. Compliance was lower for head-of-bed elevation (95.2%) and daily sedation vacations (65.5%). No patients received endotracheal tubes with subglottic suction ports due to unavailability. The authors recommend increasing education, minimizing provider workload, improving equipment maintenance, and ensuring access to recommended ventilation equipment.
Estudios que evaluaron el tratamiento actual de la hepatitis C, los cuales fueron presentados en el consenso de viena en abril de 2015.
Forman parte de EASL guidelines HCV 2015.
This document discusses chronic bronchitis and asthma. It provides information on the definition, epidemiology, risk factors, signs and symptoms, diagnosis, and treatment of each condition. For chronic bronchitis, key points include that it is progressive airflow obstruction, affects over 16 million Americans, and smoking is the primary risk factor. Asthma affects 7-10% of the population and prevalence has increased in recent decades. Diagnosis involves assessing severity, controlling triggers, and pharmacological management. Treatment focuses on minimizing symptoms and exacerbations through the use of bronchodilators and anti-inflammatory medications.
The document discusses preoperative preparation and assessment of patients. It outlines the key steps which include gathering relevant medical history, conducting a physical exam, ordering appropriate tests and labs, identifying and managing any medical conditions, developing a treatment plan, discussing risks and obtaining consent. The goals are to optimize the patient's condition, minimize risks and communicate effectively with the surgical team. Key aspects of the physical exam and specific considerations for various medical conditions are also described. Finally, the document discusses arranging the operating room schedule to ensure proper resources and prioritization of patients.
This document provides guidelines for office and out-of-office blood pressure measurement from the 2021 European Society of Hypertension. It recommends using validated automated devices for accuracy and discusses aspects of measurement including white-coat hypertension, masked hypertension, and blood pressure variability. Office blood pressure remains important but can be misleading, so out-of-office methods like ambulatory blood pressure monitoring or home monitoring are recommended when possible to confirm diagnoses and treatment decisions. Standardized measurement techniques aim to improve precision and properly diagnose and manage hypertension.
The document provides details about an upcoming annual general meeting for the Respiratory Effectiveness Group (REG). The meeting will take place on September 26th at the Wyndham Apollo Hotel in Amsterdam. David Price will chair the meeting, which will review REG's activities from 2013 to 2015 and look ahead to future opportunities. Some of the key accomplishments highlighted include establishing a global network of over 270 collaborators across 38 countries, running numerous research studies and task forces, publishing several papers and abstracts, and hosting successful summits in 2014 and 2015. The meeting aims to further develop REG's working groups and collaborative activities to generate real-world evidence that can guide clinical practice and policy.
SNIIRAM: PRIMARY AND SECONDARY CARE RESOURCE USE IN FRANCEZoe Mitchell
This document summarizes information from the SNIIRAM database in France. It discusses:
- SNIIRAM is a national database containing medical claims data from primary, secondary, and tertiary care.
- It allows linkage of data between different levels of care to study patient pathways.
- Examples of studies using SNIIRAM data include analyzing inhaled corticosteroid use patterns in asthma patients, comparing effectiveness of allergen immunotherapy in children with rhinitis, and assessing montelukast's impact on asthma control in infants.
This document provides details of an upcoming allergy working group update meeting, including the date, time, location, chair, and agenda. The agenda includes discussions on research ideas like nasal hyper-responsiveness and urticaria. Proposed actions and studies on these topics are described. New data collection opportunities through adding questions to an existing questionnaire are outlined. Potential integration of questions into an Australian pharmacy study is also discussed.
This document discusses pulmonary hypertension (PH) in patients with rheumatic diseases. It provides recommendations on diagnosing and classifying PH based on guidelines from the European Society of Cardiology and European Respiratory Society. PH is often detected through echocardiogram screening in asymptomatic patients with connective tissue diseases like scleroderma. Right heart catheterization is necessary to confirm a diagnosis of PH. While drug treatments for PH have shown benefits in clinical trials, their effectiveness may be more limited in patients with PH associated with connective tissue diseases compared to those with idiopathic PH. Strict diagnosis and classification of PH type is important to determine appropriate treatment management in rheumatic disease patients.
Presentació resultats Estudi multicèntric amb telemedicina Red Promete per pa...brnmomentum
1) The PROMETE II study was a randomized controlled trial evaluating the use of home telemonitoring (HTM) compared to routine clinical practice (RCP) in elderly patients with severe COPD requiring long-term oxygen therapy.
2) The primary outcome of reducing hospitalizations and emergency room visits was not significantly different between the HTM and RCP groups.
3) However, the duration of hospital stays appeared to be shorter in the HTM group, with the mean duration of hospitalization being approximately 4 days less, though this was not statistically significant.
Dr. Sujay Halkur Shankar presented on the topic of weaning patients from mechanical ventilation. The presentation covered assessing patient readiness, different weaning methods like spontaneous breathing trials, factors that can cause difficulty weaning like respiratory, cardiac and neuromuscular issues, and post-extubation care. Spontaneous breathing trials are the preferred method of weaning and have higher rates of success than pressure support or intermittent mandatory ventilation. Factors that can contribute to weaning failure include increased respiratory load or drive, decreased respiratory muscle strength, and cardiac dysfunction induced by weaning.
This document provides an updated global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (COPD) from the Global Initiative for Chronic Obstructive Lung Disease (GOLD). It discusses definitions of COPD, the disease burden, pathogenesis and pathophysiology. Guidelines are provided on diagnosis, assessment of symptoms and risk, therapeutic options including pharmacologic and non-pharmacologic treatments, management of stable COPD and exacerbations, and management of COPD comorbidities. The document is intended as a tool for healthcare professionals to implement effective COPD management programs.
1) Inhaled iloprost is a prostacyclin analog approved for treatment of pulmonary arterial hypertension. It works by selectively dilating pulmonary arteries and improving ventilation/perfusion matching in the lungs.
2) Clinical studies have shown inhaled iloprost improves exercise capacity and functional class when used alone or in combination with other PAH therapies like bosentan. It also delays time to clinical worsening.
3) When used with sildenafil, inhaled iloprost and oral sildenafil act synergistically to cause strong pulmonary vasodilation, further improving outcomes in patients with severe PAH.
Systemic corticosteroids in the treatment of acute exacerbations of copdChoying Chen
- The patient presented with an acute exacerbation of COPD with respiratory acidosis and was treated with BiPAP, bronchodilators, antibiotics, and systemic corticosteroids.
- Despite treatment, he developed hyperglycemia and hypertension which were managed by adjusting antihyperglycemic and antihypertensive medications.
- He showed improvement in respiratory status and was discharged with a tapering course of prednisolone and other medications while continuing home BiPAP use.
Pulmonary Arterial Hypertension Overview
Michael J. Cuttica MD Assistant Professor of Medicine Northwestern Pulmonary Hypertension Program
Northwestern University
Novel strategies to improve diastolic functiondrucsamal
This document summarizes Gerd Hasenfuss's presentation on novel strategies to improve diastolic function and reduce elevated left atrial pressure in patients with heart failure with preserved ejection fraction (HFpEF). It discusses an inter-atrial shunt device that creates a small permanent connection between the atria, baroreceptor activation therapy, the Aldo-DHF trial which found spironolactone improved diastolic function in HFpEF, and a study showing exercise training improved exercise capacity and quality of life in HFpEF. The presentation emphasizes that high left atrial pressure is a key factor in morbidity and mortality for HFpEF and these strategies aim to reduce left atrial pressure.
Updates On Pharmacological Management Of Stable COPD 2017Ashraf ElAdawy
This document provides guidelines for the pharmacological management of stable COPD. It defines COPD as a preventable disease characterized by airflow limitation caused by exposure to particles or gases. The guidelines describe assessing patients based on symptoms, exacerbation history, and lung function (ABCD assessment). For Group A patients with low symptoms, treatment begins with a short- or long-acting bronchodilator. For Group B patients, treatment begins with a long-acting bronchodilator, escalating to a combination if needed. For Group C patients with exacerbations, treatment begins with a long-acting muscarinic antagonist (LAMA), adding a long-acting beta-agonist if exacerbations persist.
Realistic and possible abilities in prevention of COPD exacerbationDejan Zujovic
1) Hospitalization for an acute exacerbation of COPD is associated with significantly higher mortality than hospitalization for an acute myocardial infarction. Mortality at 12 months following COPD exacerbation hospitalization is between 20-40%.
2) Proper treatment of acute exacerbations, including antibiotics, bronchodilators, corticosteroids, and oxygen therapy can help prevent future exacerbations and readmissions. However, quality of care for COPD exacerbations remains suboptimal in many cases.
3) Smoking cessation, influenza vaccination, pneumococcal vaccination, pulmonary rehabilitation, and adherence to maintenance therapies can help prevent COPD exacerbations but uptake and adherence remain low compared to potential benefits. Improving self
Community-acquired pneumonia (CAP) is a leading cause of death and hospitalization in the United States. Guidelines recommend using severity of illness scores like CURB-65 to determine appropriate site of care and empiric antibiotic therapy including β-lactams with macrolides or fluoroquinolones. Studies show guideline-concordant therapy improves outcomes. Procalcitonin levels may help determine duration of antibiotics, with lower levels associated with shorter treatment. Overall, clinicians should aim for 5-7 days of effective antibiotics guided by clinical and procalcitonin findings to optimize CAP treatment.
This document discusses the development and validation of a multifactorial risk index to predict the risk of postoperative pneumonia in patients undergoing major noncardiac surgery. It describes defining postoperative pneumonia as new radiographic lung findings accompanied by changes in sputum, a positive blood culture, or isolation of a pathogen from respiratory samples. Risk factors identified for the index included age, functional status, weight loss, COPD, anesthesia type, impaired sensorium, steroid use, smoking, and medical history. The risk index stratified patients into five classes from lowest to highest risk of developing postoperative pneumonia.
The document discusses optimizing source control for sepsis patients. It recommends:
1) Identifying and controlling the source of infection as soon as possible after diagnosis, within 6-12 hours for sepsis patients and immediately for septic shock patients.
2) Drainage, debridement, restoration of anatomy and function are ideal source control methods when possible and as soon as medically and logistically practical.
3) A sepsis team approach involving multiple specialties working together improves management and reduces delays in source control and other essential treatments.
VAP bundle compliance in ICU - Clinical Auditfaheta
This study aimed to measure compliance with ventilator-associated pneumonia (VAP) bundle components in an intensive care unit (ICU) in Saudi Arabia. An audit of 88 mechanically ventilated patients found high compliance (87.5-100%) with hand hygiene, mouth care, and avoiding routine ventilator tubing changes. Compliance was lower for head-of-bed elevation (95.2%) and daily sedation vacations (65.5%). No patients received endotracheal tubes with subglottic suction ports due to unavailability. The authors recommend increasing education, minimizing provider workload, improving equipment maintenance, and ensuring access to recommended ventilation equipment.
Estudios que evaluaron el tratamiento actual de la hepatitis C, los cuales fueron presentados en el consenso de viena en abril de 2015.
Forman parte de EASL guidelines HCV 2015.
This document discusses chronic bronchitis and asthma. It provides information on the definition, epidemiology, risk factors, signs and symptoms, diagnosis, and treatment of each condition. For chronic bronchitis, key points include that it is progressive airflow obstruction, affects over 16 million Americans, and smoking is the primary risk factor. Asthma affects 7-10% of the population and prevalence has increased in recent decades. Diagnosis involves assessing severity, controlling triggers, and pharmacological management. Treatment focuses on minimizing symptoms and exacerbations through the use of bronchodilators and anti-inflammatory medications.
The document discusses preoperative preparation and assessment of patients. It outlines the key steps which include gathering relevant medical history, conducting a physical exam, ordering appropriate tests and labs, identifying and managing any medical conditions, developing a treatment plan, discussing risks and obtaining consent. The goals are to optimize the patient's condition, minimize risks and communicate effectively with the surgical team. Key aspects of the physical exam and specific considerations for various medical conditions are also described. Finally, the document discusses arranging the operating room schedule to ensure proper resources and prioritization of patients.
This document provides guidelines for office and out-of-office blood pressure measurement from the 2021 European Society of Hypertension. It recommends using validated automated devices for accuracy and discusses aspects of measurement including white-coat hypertension, masked hypertension, and blood pressure variability. Office blood pressure remains important but can be misleading, so out-of-office methods like ambulatory blood pressure monitoring or home monitoring are recommended when possible to confirm diagnoses and treatment decisions. Standardized measurement techniques aim to improve precision and properly diagnose and manage hypertension.
The document provides details about an upcoming annual general meeting for the Respiratory Effectiveness Group (REG). The meeting will take place on September 26th at the Wyndham Apollo Hotel in Amsterdam. David Price will chair the meeting, which will review REG's activities from 2013 to 2015 and look ahead to future opportunities. Some of the key accomplishments highlighted include establishing a global network of over 270 collaborators across 38 countries, running numerous research studies and task forces, publishing several papers and abstracts, and hosting successful summits in 2014 and 2015. The meeting aims to further develop REG's working groups and collaborative activities to generate real-world evidence that can guide clinical practice and policy.
SNIIRAM: PRIMARY AND SECONDARY CARE RESOURCE USE IN FRANCEZoe Mitchell
This document summarizes information from the SNIIRAM database in France. It discusses:
- SNIIRAM is a national database containing medical claims data from primary, secondary, and tertiary care.
- It allows linkage of data between different levels of care to study patient pathways.
- Examples of studies using SNIIRAM data include analyzing inhaled corticosteroid use patterns in asthma patients, comparing effectiveness of allergen immunotherapy in children with rhinitis, and assessing montelukast's impact on asthma control in infants.
This document summarizes the agenda and key discussion points for several committee meetings taking place on September 26th in Amsterdam. The Research Review committee will discuss priorities for funding respiratory research studies in 2015/2016. They will also evaluate the process for soliciting and reviewing research ideas. The Accreditation committee will discuss accrediting researchers. The Manuscript Review committee will examine their publication process and output over the past year. Overall, the meetings aim to strategize how the organization can best support high-quality respiratory research through prioritizing ideas, funding studies, and disseminating results.
REG Biomarkers Working Group Meeting 26/09/15Zoe Mitchell
This document summarizes the agenda and discussion topics for a biomarker working group meeting on September 25th in Amsterdam. The group will discuss publishing updates, including a perspective article comparing NICE and GINA statements on FeNO and a review on the role of eosinophils in airways disease. They will also discuss potential research ideas using data from the Optimum Patient Care Research Database (OPCRD), including evaluating FeNO and eosinophils as predictors of outcomes in COPD. Additional biomarker data will be added to OPCRD, including IgE testing. The group agreed to further discuss selecting some initial research projects and set a date for their next meeting.
REG COPD Control Working Group Meeting 25/9/15Zoe Mitchell
- The document summarizes a COPD control working group meeting discussing two observational pilot studies in Spain validating the concept of COPD control.
- The first study compares changes in control status to changes in severity over 6 months. The second compares control status to respiratory symptoms.
- It also summarizes a UK database pilot study characterizing COPD patients by control status and its clinical implications using the Optimum Patient Care Research Database.
- The study found that only 3.19% of 2,788 COPD patients were considered controlled based on the defined criteria. Uncontrolled patients were more likely to experience exacerbations.
This document summarizes a workshop on cost-effectiveness analysis for respiratory health technologies. The workshop objectives were to introduce cost-effectiveness modeling, discuss what can and cannot be done with these models, and review current evidence gaps. The document then summarizes a cost-effectiveness model developed for ivacaftor treatment of cystic fibrosis. The model found ivacaftor to be cost-effective compared to usual care. Key gaps in COPD and asthma cost-effectiveness studies were identified. Finally, forming a working group to address these evidence gaps through additional research was discussed.
Using CPCSSN Data for Primary Care Research in CanadaZoe Mitchell
CPCSSN provides de-identified primary care data from across Canada for research purposes. It holds data on demographics, diagnoses, medications, lab results, and other clinical information on over 368,000 patients from 329 physicians. The data requires cleaning and standardization. Research opportunities include epidemiological studies, clinical effectiveness research, quality improvement studies, and examining associations. Researchers must submit a letter of intent outlining their study for approval before gaining access to the de-identified data.
This document provides an overview and agenda for the 2015 REG Winter Summit. It begins with a welcome from David Price, the REG Chairman. It then reviews some of REG's accomplishments in 2014, including publishing papers in a supplement, having proposals accepted at conferences, and growing its network of collaborators and supporters. It discusses REG formalizing its structure with new committees and working groups. It highlights some of REG's research from 2014 focusing on asthma control and severity. It outlines plans and opportunities for REG in 2015, including sessions at respiratory conferences and completing current studies. It closes by welcoming attendees and looking forward to the opportunities to share ideas and strengthen relationships at the summit.
REG Child Health Working Group Meeting 26/09/15Zoe Mitchell
This document provides details of a child health working group meeting, including the agenda, completed work, publication status, and a presentation on a comparative effectiveness study of extra-fine particle inhaled corticosteroids and alternative guideline-recommended step-up options in preschool children with asthma. The meeting will take place on September 26th in Amsterdam, chaired by Steve Turner, and will discuss a real-life MASCOT study, abstracts previously presented, the publication status of three papers, and a proposed comparative effectiveness study using the Optimum Patient Care Research Database to compare outcomes of different treatment approaches for preschool wheeze/asthma.
This document discusses Denmark's national health registries and their use for epidemiological research. It notes that Denmark assigns unique personal identification numbers to all citizens, allowing accurate linkage between various health registries. This enables large population-based cohort studies with long-term follow up. The registries contain information on healthcare utilization, prescriptions, and diagnoses. Several studies are described that use the registries to study topics like MMR vaccination and autism, quality of diabetes care, and blood pressure control. Challenges with using registry data include ensuring validity of diagnoses and missing data. However, strengths include no selection bias, large sample sizes, and prospectively collected data.
The study aims to compare the effectiveness of different step 2 asthma management approaches in pre-school children using a retrospective cohort design. The primary outcome is asthma exacerbations over 1 year as defined by ATS/ERS criteria. Secondary outcomes include acute respiratory events, risk domain asthma control, and reliever medication use. Eligible children aged 5 or under will be identified from UK clinical databases based on wheezing episodes or oral steroid prescriptions in the prior year. They will be matched and compared based on initial step 2 treatment of either EF ICS, NEF ICS, LTRA, or SABA alone. Subgroup analyses are planned based on atopy and demographic factors. An exploratory analysis will also assess outcomes over
REG COPD Control Working Group MeetingZoe Mitchell
1. The REG COPD Control Working Group met on May 17th in Denver, Colorado to discuss plans to validate the concept of control in COPD through several research studies.
2. These included a non-interventional database study using the UK OPCRD, two Spanish pilot studies on changes in control versus severity and symptoms, and an international prospective study to validate the concept of control.
3. The group discussed objectives, timelines, and plans for implementation of these validation studies, as well as identifying new areas of research and disseminating results. The goal was to establish control as a valid concept that could help guide treatment decisions and motivate patients.
The meeting agenda provided an update on research activities and future plans for the REG Interstitial Lung Disease Working Group. David Price discussed ongoing and upcoming research studies, publications, and events. Future plans included a revised staffing structure, working group and council structure, and upcoming events in 2015 and 2016. The meeting also discussed driving quality standards, perspectives from industry supporters, and new funding opportunities like PCORI. An open discussion period concluded the meeting to gather feedback and ideas.
The document summarizes discussions from the Respiratory Effectiveness Group's 2015 Winter Summit held in Rotterdam, Netherlands from January 22-24, 2015. Key topics discussed included maximizing the use of respiratory disease databases for research, identifying new data resources, and the work of the Small Airways Study Group and Adherence Working Group. Presentations were also given on extra-fine inhaled corticosteroids and the emerging area of asthma-COPD overlap syndrome.
Information System for the Enhancement of Research in Primary CareZoe Mitchell
This document describes SIDIAP, a database created in 2010 to promote primary care research using clinical data from electronic medical records of over 5.8 million patients in Catalonia, Spain. SIDIAP contains socio-demographic, clinical, prescription, and hospitalization data. It adds value through high population coverage, validated data, and symbiosis with health providers. Researchers can apply to use de-identified data for studies. Limitations include some unavailable variables, but improvements are being made. Examples of respiratory research include COPD prescription patterns and identifying gaps in alpha-1 antitrypsin deficiency diagnosis.
The document summarizes a meeting of the REG Collaborators at the ERS 2013 conference in Barcelona. The purpose of the meeting was to: 1) provide updates on current REG research activities and quality standards work; 2) generate ideas for new REG activities, including addressing guidelines; and 3) allow collaborators to share information on other projects. The agenda included presentations on ongoing asthma and COPD studies, quality standards highlights, working with guidelines, and an open ideas session for collaborators to discuss other initiatives. The meeting concluded by welcoming new REG collaborators from over 20 countries.
COPD Translating Guidelines into Clinical Pracice part 2Ashraf ElAdawy
A 68-year-old man with COPD and an FEV1 of 65% was recently discharged from the hospital after his first COPD exacerbation. According to the GOLD guidelines, this patient would be classified in Group C as they have an exacerbation history indicating higher risk. The most appropriate initial treatment for this Group C patient would be to continue his albuterol as needed and add the long-acting bronchodilator tiotropium.
Update on the Management of Pulmonary HypertensionSarfraz Saleemi
This document provides an overview of treatment for pulmonary hypertension (PH), including:
- Currently there is no cure, but earlier treatment leads to better outcomes.
- Screening high-risk groups allows for earlier diagnosis.
- Initial treatment involves general measures, supportive therapy, and testing for vasoreactivity.
- Vasoreactive patients may be treated with calcium channel blockers, while others receive PH-specific drugs.
- Combination therapy provides greater improvements in symptoms and hemodynamics than monotherapy, though it also carries higher risk of side effects.
- Over time, treatment advances have significantly improved survival rates for PH patients.
The document provides guidelines for grading and managing COPD according to GOLD guidelines. It discusses diagnosing COPD using spirometry and assessing severity based on symptoms, airflow limitation, and exacerbation risk. COPD is graded into 4 stages based on airflow limitation. Management is guided by combining assessments into Groups A through D, with Group D having the highest risk and most severe airflow limitation. Treatment options include smoking cessation, vaccination, bronchodilators, inhaled corticosteroids, oxygen therapy, and pulmonary rehabilitation.
The latest guidelines on the management of a COPD patient ( Stable COPD, patient with an exacerbation of COPD), latest modalities of treatment of a COPD patient
Treatment strategies for pulmonary hypertensionSarfraz Saleemi
There is currently no cure for pulmonary hypertension (PAH). Treatment aims to alleviate symptoms, improve quality of life, and delay disease progression. Initial treatment involves lifestyle modifications and medications such as prostacyclins, endothelin receptor antagonists, and phosphodiesterase-5 inhibitors. Combination therapy and newer treatments targeting cellular processes show promise. Ongoing monitoring assesses treatment response through physical exams, functional tests, labs, and imaging to optimize therapy.
The past, present and future of lipid managementGreg Searles
This document summarizes a presentation on lipid management given by Dr. Greg Searles. The presentation covered current lipid guidelines, LDL and other lipid profiles, dietary and pharmacological lipid-lowering therapies including statins, cholesterol absorption inhibitors, and PCSK9 inhibitors. It discussed landmark statin trials that demonstrated reductions in cardiovascular outcomes and the additional benefit seen when adding ezetimibe to statin therapy as shown in the IMPROVE-IT trial. The presentation aimed to provide an overview of the past, present, and future of lipid management.
past presnt and futer of dyslidema ttt.pdfAdelSALLAM4
Dr. Greg Searles presented on the past, present, and future of lipid management. He discussed current lipid management guidelines, which recommend statin treatment and LDL-C targets based on risk level. For high-risk patients, the guidelines recommend an LDL-C target of <2.0 mmol/L or >50% reduction from baseline. Dr. Searles reviewed evidence from landmark statin trials demonstrating their efficacy in reducing cardiovascular events. He also discussed current combination therapy options for further LDL-C lowering when targets are not met with statins alone, focusing on the modest additional benefit shown for ezetimibe in the IMPROVE-IT trial.
This document provides guidelines for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (COPD). It defines COPD as a common, preventable and treatable disease characterized by persistent airflow limitation associated with an enhanced chronic inflammatory response in the airways and lungs to noxious particles or gases. The guidelines discuss the underlying mechanisms of airflow limitation in COPD, epidemiology, risk factors, diagnosis, assessment, classification, therapeutic options including pharmacologic and non-pharmacologic treatments, management of stable COPD, and treatment of exacerbations.
This document provides guidelines for the management of chronic obstructive pulmonary disease (COPD). It discusses assessing and monitoring the disease severity using spirometry tests and classifications. It recommends reducing risk factors like smoking and managing stable COPD with bronchodilators, inhaled steroids, oxygen therapy, and exercise training. For exacerbations, it suggests treating with inhaled bronchodilators, oral steroids, antibiotics if infected, and noninvasive ventilation.
This document provides a summary of guidelines for diagnosing, managing, and treating COPD. It discusses COPD pathology, risk factors, diagnostic criteria including spirometry testing, differential diagnosis, treatment recommendations from the WHO, and pharmacological and non-pharmacological treatment options according to disease severity. Treatment involves smoking cessation, vaccinations, pulmonary rehabilitation, oxygen therapy, bronchodilators, corticosteroids, antibiotics for exacerbations, and managing comorbidities. The goal of treatment is to reduce symptoms, improve quality of life and lung function, and prevent disease progression and exacerbations.
1. The document discusses guidelines for treating COPD according to the GOLD (Global Initiative for Chronic Obstructive Lung Disease) classification system.
2. It recommends treating GOLD Group A patients with a short- or long-acting bronchodilator, and escalating to an alternative bronchodilator class if needed.
3. For Group B, treatment begins with a long-acting bronchodilator, escalating to a LAMA/LABA combination for persistent symptoms.
4. Group C patients start on a LAMA, adding a LABA for exacerbations, preferring LAMA/LABA over LABA/ICS due to pneumonia risk with ICS.
REG ACOS Working Group Meeting 25/09/15Zoe Mitchell
The document outlines plans for a proof of concept study to estimate the prevalence of Asthma-COPD Overlap Syndrome (ACOS) using different population datasets and case definitions. It describes four population groups - COPD diagnosis, ACOS diagnosis, asthma diagnosis, and no diagnosis of asthma or COPD - that will be analyzed in eight available databases to compare ACOS prevalence between definitions. The Optimum Patient Care Research Database pilot data will also be used as a case study to categorize patients as COPD, asthma, or ACOS based on coded consultation reasons to identify overlap between the conditions.
Arterial blood gases in ED: Rest in Peace?kellyam18
This document discusses the use of venous blood gas analysis compared to arterial blood gas analysis. It finds that the agreement between venous and arterial measurements is close enough for pH and bicarbonate to be used interchangeably in clinical decision making for conditions like diabetic ketoacidosis and respiratory failure. However, the agreement is not sufficient for pCO2 values due to wider limits of agreement. Venous pCO2 can still serve as a reliable screening test for clinically significant hypercarbia. The evidence for other measurements like base excess, potassium, and lactate is more limited. Overall, venous blood gas analysis may be a suitable replacement for arterial analysis in some, but not all, situations.
This document discusses COPD (chronic obstructive pulmonary disease) and the potential role of telemonitoring in its management. It defines COPD as including asthma, chronic bronchitis, and emphysema. Telemonitoring allows for remote monitoring of COPD patients using devices that transmit health data. It is suggested that telemonitoring may help with earlier detection of exacerbations through reported symptoms. It could also increase disease knowledge and self-care, provide reassurance and support, and reduce hospital admissions. Several studies found telemonitoring improved quality of life and reduced costs, though the evidence base is still developing.
Dr. Nannika Pradhan presented on pulmonary hypertension (PH). The key points discussed include:
1. PH is defined as a mean pulmonary arterial pressure ≥25 mmHg at rest as assessed by right heart catheterization.
2. PH is classified clinically into 5 groups based on etiology.
3. Clinical features include dyspnea, chest pain, syncope, signs of right heart failure. Diagnosis involves echocardiogram, CT scan, ventilation-perfusion scan and right heart catheterization.
4. Treatment depends on disease severity and involves diuretics, oxygen supplementation, calcium channel blockers, endothelin receptor antagonists, phosphodiesterase-5 inhibitors, prostano
Assessment and management of stable copdRashi Vohra
This document discusses the assessment and management of stable COPD. It outlines the goals of assessment as determining airflow limitation, impact on health status, and risk of future events. A comprehensive assessment involves spirometry, symptoms, exacerbation history, and comorbidities. Management goals are to reduce symptoms, improve health and exercise tolerance, and prevent disease progression. Treatment involves smoking cessation, vaccination, lifestyle changes, pharmacotherapy including bronchodilators and inhaled corticosteroids, pulmonary rehabilitation, and managing comorbidities. Effective inhaler technique is important for optimal treatment.
This document summarizes advances in the management of pulmonary hypertension. It discusses the diagnostic approach and classification of pulmonary arterial hypertension. It then reviews the general measures, primary therapies including calcium channel blockers, and supportive therapies such as diuretics, digoxin, and anticoagulation. Recent advances in targeted therapies are discussed including prostanoids, endothelin receptor antagonists, phosphodiesterase-5 inhibitors, riociguat, macitentan, oral treprostinil, selexipag, and imatinib. Combination and sequential therapy are now recommended approaches. Balloon atrial septostomy is described as a palliative procedure to improve hemodynamics in advanced disease.
HYPERTENSION introduction, recommendations for accurate measurements of BP, evaluation of patient with hypertension, management of patient with hypertension, resistant hypertension, hypertensive crisis, hypertensive emergencies
This document provides an overview of the management of stable chronic obstructive pulmonary disease (COPD). It discusses assessing COPD through symptoms, spirometry tests, exacerbation risk and comorbidities. Therapeutic options include smoking cessation, vaccinations, bronchodilators, corticosteroids, pulmonary rehabilitation and treating comorbidities. Guidelines classify COPD severity and recommend treatments based on symptoms, exacerbation risk and spirometry results. Referral to specialists is suggested for uncertain diagnoses, home oxygen/nebulizer assessments, and surgical/transplant evaluations.
Similar to Utilising real-world evidence to achieve precision medicine in COPD (20)
This document summarizes a meeting to discuss a proof of concept study on asthma-COPD overlap syndrome (ACOS) using electronic medical records. The study aims to test various smoking-related ACOS population definitions across databases to evaluate prevalence and agreement. The meeting reviewed results from a UK pilot study using one database and definitions based on clinical diagnoses over 2 years. Prevalence of ACOS varied from 8-32% depending on the source population. The meeting also discussed expanding the study to other eligible databases and characterizing clinical implications of different definitions.
This document summarizes the agenda and attendees for an IPF/ILD working group meeting. The meeting will discuss developing and providing feedback on a questionnaire to characterize diagnostic practices for interstitial lung disease globally. Next steps that will be discussed include identifying national leads, translating and adapting the questionnaire for different regions, disseminating the questionnaire through working group networks, and addressing any missing global regions. The goal is to understand real-world diagnostic practices to inform the design of a future study on diagnostic agreement for IPF.
This document provides a summary of the Respiratory Effectiveness Group (REG) Collaborators' Meeting held at the 2013 European Respiratory Society Congress in Barcelona. The meeting agenda included updates on current REG activities like publications, research studies, and quality standards. Presentations were given on new data from studies on asthma and COPD phenotypes, smoking cessation, and validating real-life asthma endpoints. There was also discussion of developing standards for real-life research, engaging with guidelines, and new initiatives from collaborators. The research update highlighted studies on asthma control and adherence, oral steroid burden in refractory asthma, and predicting asthma risk.
Real Time Research in a Singapore Public Primary Care InstitutionZoe Mitchell
This document summarizes opportunities and challenges for real-time research in Singapore public primary care institutions. It provides an overview of the Singapore healthcare system and SingHealth Polyclinics' (SHP) role in primary care. SHP has integrated electronic health records and databases that can be used for research. However, challenges include integrating different databases, ensuring data access compliance, limited staff research capacity, and competing for research grants. The future includes staff database training, streamlining data access processes while complying with privacy laws, configuring systems to facilitate data mining, and establishing collaborations to expand SHP's research capacity.
This document discusses maximizing patient outcomes in respiratory care. It outlines the founding principles of the Respiratory Effectiveness Group (REG), which aims to better integrate real-world evidence from sources like observational studies and pragmatic trials into clinical practice guidelines. Currently, guidelines are often based primarily on randomized controlled trials, which have limitations and may not generalize to most patients. The document calls for considering a diversity of evidence and tailoring care to individual patient needs and characteristics. It also discusses how databases could help achieve more personalized care by providing real-world data on topics like disease prevalence, treatments, and outcomes across different healthcare systems.
Ron Dandurand presented at the Respiratory Effectiveness Group Summit in Lyon, France on April 15, 2016. His objectives were to prove the non-inferiority of spirometry compared to oscillometry, raise reasonable doubt that spirometry should be abandoned, and present a novel approach to spirometry analysis. He discussed the history and advantages/disadvantages of spirometry versus oscillometry. While oscillometry provides more data points, it is not fair to directly compare the two without accounting for their different information levels. Spirometry, if analyzed beyond typical indices, may be able to approximate small airway function tests and detect disease at earlier stages.
Validation of Real-World Thoracic CT Scanes for Quantitative Analysis of COPDZoe Mitchell
This study evaluated the reproducibility of quantitative CT (QCT) metrics of emphysema using clinical CT scans from multiple centers. The study found that QCT metrics like low attenuation area (LAA) and lung density (LD) were reproducible across different scanners when corrected for actual lung volume. Metrics were more reproducible when corrected for measured total lung capacity (TLC) than predicted TLC. Contrast media was found to alter QCT metrics in a predictable way such that contrast and non-contrast scans could be compared using correction factors. Validating these findings in other cohorts and understanding the lung volume changes with contrast media were identified as important future directions.
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.
REG PCORI Grant Planning Meeting 26/09/15Zoe Mitchell
The document outlines an agenda for a planning meeting between the Respiratory Effectiveness Group (REG) and the Patient-Centered Outcomes Research Institute (PCORI) to discuss potential comparative effectiveness research collaborations. Key items on the agenda include aligning the missions of REG and PCORI, discussing what comparative effectiveness research entails, engaging stakeholders, and generating ideas for potential research topics that could be funded through PCORI. The meeting aims to identify topics of interest to both organizations that incorporate patient-centered outcomes research.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Our backs are like superheroes, holding us up and helping us move around. But sometimes, even superheroes can get hurt. That’s where slip discs come in.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Utilising real-world evidence to achieve precision medicine in COPD
1. 19/04/2016
1
Precision medicine:
tailoring COPD management to specific
patient needs, phenotypespat e t eeds, p e otypes
Alan Kaplan MD CCFP(EM) FCFP
Chairperson Family Physician Airways Group of Canada
Conflicts: Advisory Board or speakers bureau for
Astra Zeneca, Boehringer Ingelheim, Novartis, Takeda,
Merck Frosst, Pfizer, Purdue
1
Objectives
• Review current guidelines for COPD pharmacotherapy
• Review how to tailor our pharmacotherapy to those who
will best benefit from them
– Personalized care vs guideline care
oror
– How to use guidelines in the patient in front of you
• Discuss how to fix it when therapy is perhaps..not as
optimized as it could be!
2
I am not going to talk about
• Making an early diagnosis
• Smoking cessation
• Pulmonary Rehabilitation
• Oxygen therapy
• End of life therapy in COPD
• Multimorbitidity
3
Nice overview to make you consider
the individual patient in front of you
4
2. 19/04/2016
2
TREATABLE TRAITS
(can coexist)
IMP RE
C
DIAGNOSTIC
CRITERIA
TREATMENT MAIN
EXPECTE
D
BENEFIT
First choice Efficacy Second choice*
Airflow limitation +++ +++ FEV1/FVC < 0.7 (or
LLN)
S
Airway smooth
muscle contraction
++ +++ BD Reversibility, PEF
variability, positive PC20
Maintenance: LABA
and/or LAMA
Rescue: SABA or
SAMA
+++ ICS
Bronchial Thermoplastya
S
Loss of elastic recoil
(Emphysema )
+++ ++ CT, DLCO, compliance Smoking cessation + LVRS, Lung transplantation,
a1anti-trypsin replacement if
deficient. Valves, coils
S,P
Airway mucosal
oedema
++ + CT. Spirometry-induced
bronchoconstriction.
ICS ++ OCS. Anti-IL5, IL13, IL4 E
Eosinophilic airway +++ +++ Sputum eos, blood eos, ICS +++ OCS, LTRA, Anti-IgE, Anti- E
Table 1. Pulmonary treatable traits of airway diseases
5
Eosinophilic airway
inflammation (EAI)
Sputum eos, blood eos,
FENO, (periostin)
ICS OCS, LTRA, Anti IgE, Anti
IL5, IL13, IL4
E
Chronic bronchitis ++ +++ Cough and sputum 3
months x 2 yrs. (no EAI)
Smoking cessation + Carbocysteine, macrolides,
roflumilast
E
Airway bacterial
colonization*
++ ++ Sputum culture,
quantitative PCR
Antibiotics ++ Long-term low dose
macrolides, vaccination
E/S
Bronchiectasis* ++ ++ CT Drainage + Macrolides, Nebulized
Antibiotics, Surgery,
Vaccination
E/S
Cough reflex hyper-
sensitivity
++ +++ Capsaicin challenge,
cough counts, cough
questionnaire.
Speech and language
treatment (63)
+ Gabapentin (62)
.
S
Pre-capillary
pulmonary
hypertension*
++ ++ Doppler
echocardiography, BNP
Right-heart
catheterization
LTOT ++ NIV
Lung transplantation
S,E,P
Chronic respiratory
failure*
Arterial hypoxemia +++ +++ PaO2<55 mmHg LTOT ++ P
Arterial hypercapnia +++ +++ PaCO2>45 mmHg + NIV Agusti A et al. 2015
TREATABLE
TRAITS
(can coexist)
IMP RE
C
DIAGNOSTIC
CRITERIA
TREATMENT MAIN
EXPECT
ED
BENEFIT
First choice Efficacy Second choice*
Deconditioning + + CPET, 6MWD Exercise,
rehabilitation
+ S,P
Obesity + +++ BMI Diet, Physical activity + Medication, Bariatric
surgery
S,P
Cachexia + +++ BMI Diet, Physical activity + S, E
OSAS + ++ Questionnaires, PSG CPAP + Weight loss. Mandibular
advancement splint
S,P
Cardiovascular
disease
++ +++ EKG, Doppler
Echocardiography,
BNP
ACE inhibitors,
diuretics,
b-Blockers
++ Surgery S,E,P
GERD (64) + ++ GI endoscopy pH PPI, H2 antagonist + Surgery S
Table 2. Extra-pulmonary treatable traits of airways diseases
6
GERD (64) GI endoscopy, pH
monitoring
PPI, H2 antagonist Surgery S
Upper airway
diseases rhino-
sinusitis
+ ++ History and
examination, imaging
Topical steroids ++ LTRA, antihistamines,
surgery
S, E
Upper airway
diseases
Inducible laryngeal
obstruction (vocal
cord dysfunction)
++ + Fibreoptic
laryngoscopy, flow-
volume curve, dynamic
CT neck
Speech pathology
therapy (63)
++ Laryngeal botulinum toxin
Psychology/psychiatry
S
Psychiatric
disorders:
depression
++ ++ Questionnaires,
psychologist/liaison
psychiatrist
assessment
CBT,
pharmacotherapy
++ S
Psychiatric
disorders
Anxiety:
Anxiety/other
behavioural aspects
including breathing
++ ++ Questionnaires,
psychologist/liaison
psychiatrist
assessment
Anxiety
management,
breathing retraining
+ Anxiolytic/antidepressant
medication, CBT,
Psychotherapy
S
Agusti A et al. 2015
7 8
3. 19/04/2016
3
Let’s deal with two scenarios
1) The patient with recurrent
exacerbations
2) The returning patient on therapy
9
Case 1
• 67 year old woman with established COPD
• No longer golfing due to dyspnea
• On LABA/LAMA plus SABA for breakthrough
• FEV1 40%
• CAT score 15
• Says, ‘I am doing fine’
• Averages two exacerbations yearly, admitted last year once
• You have done all the other little things: CV protection, osteoporosis
screening, mood is ok, weight is stable, referred for pulmonary
rehabilitation
• Is she fine?
• How do you decide?
10
What are your options (for exacerbation
prevention)?
• Add ICS to LABA/LAMA
• Change to ICS/LABA plus LAMA
• Add Roflumilast to LABA/LAMA
f CS/• Add Roflumilast to LAMA plus ICS/LABA
11
Based on combined assessment of airflow limitation, symptoms and exacerbation risk
Exacerb
cationof
ation
(FEV1 < 30%
predicted)
(30% ≤ FEV1 <
50% predicted)
GOLD Group C
ICS + LABA, or LAMA ICS + LABA +/or LAMA
Recommended first choice
GOLD Group D
≥2
or
≥1 leading to
hospital
admission
GOLD Grade 4
LAMA + LABA or
LAMA + PDE-4i or
LABA + PDE-4i
ICS + LABA + LAMA or
ICS + LABA + PDE-4i or
LAMA + LABA or
LAMA + PDE-4i
Alternative choice
Pharmacologic management of COPD
GOLD 2015
GOLD Grade 3
12
Risk
bationhistory
Risk
GOLDclassific
airflowlimit
(50% ≤ FEV1 <
80% predicted)
(FEV1 ≥ 80%
predicted)
LAMA or LABASAMA or SABA p.r.n.
GOLD Group A GOLD Group B
1 (not leading
to hospital
admission)
Symptoms
CAT ≥10CAT <10
mMRC 01 mMRC ≥2
Breathlessness
LAMA or
LABA or
SABA + SAMA
LAMA + LABA
GOLD 2015
CAT, COPD Assessment Test; COPD, chronic obstructive pulmonary disease; GOLD, Global Initiative for Chronic Obstructive Lung Disease;
HRQoL, health-related quality of life; ICS, inhaled corticosteroids; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist; mMRC,
modified Medical Research Council; PDE-4i, phosphodiesterase type 4 inhibitor; SABA, short-acting β2-agonist; SAMA, short-acting muscarinic
antagonist
GOLD Grade 2
GOLD Grade 1
4. 19/04/2016
4
CTS/CHEST Guidelines: AECOPD
EVEN EASIER, RIGHT?
2014 CHEST-CTS Guideline: Prevention of Acute Exacerbation of Chronic Obstructive Pulmonary
Di
COPD Exacerbations: Effects of ICS
(ISOLDE ‐ stratified by FEV1)
2.64
1.86
1.722.0
2.5
3.0
*
*
Placebo
r year)
Fluticasone
1.24
1.41
1.24
0.0
0.5
1.0
1.5
Burge et al. Br Med J. 2000; 320:1297-1303.
FEV1 (litres)
Exacerbations (pe
1.25 ‐ 1.54 >1.54<1.25
14
Impact of ICS on survival without re‐
hospitalisation
• Alberta
• 6,740 patients
• Aged > 65 yrs
ICS 29%
ehospitalisation
1.0
0.9
0 8
Inhaled steroids
Sin DD & Tu JV, AJRCCM 2001; 164: 580-584
• ICS group: 29%
relative risk reduction
for all-cause mortality
and 24% for
re-hospitalisation
Survivalwithoutre
Time from discharge (months)
0.8
0.7
0.6
No inhaled steroids
0 2 4 6 8 10 12
15
TORCH: LABA/ICS Significantly Reduced Rate of
Exacerbations Over 3 Years
exacerbations/year
1.13
0.97*
0.93*
0.85*†‡
SALM/FP
25% reduction
in exacerbations
vs. placebo
0.8
1
1.2
LABA: Long-acting beta2-agonist ; ICS: inhaled corticosteroid
SALM: salmeterol; FP: fluticasone propionate
SALM/FP: salmeterol/fluticasone propionate
*P < 0.001 vs. placebo †P =0.002 vs. SALM ‡P = 0.024 vs. FP
Meannumberofe
0
0.2
0.4
0.6
Placebo SALM FP SALM/FP
Treatment
Adapted from Calverley PM, et al. N Engl J Med. 2007;356:775-789. 16
5. 19/04/2016
5
0.4
0.3
0.2
erbations/patient
TIO + budesonide/formoterol 320/9 µg BID
TIO + placebo
CLIMB: ICS/LABA + Tiotropium Reduced Severe
Exacerbations at 3 Months
A reduction in rate of
exacerbation by 62%
17
0.1
0.0
0 15 30 45 60 75 90
Days since randomisation
Exac
Ratio: 0.38 (95% CI: 0.25–0.57)
P < 0.001*
*Poisson regression
adjusted for
overdispersionSevere exacerbations were defined as worsening of COPD leading to treatment
with systemic steroids (oral or parenteral) and/or hospitalization/emergency room
visits.
Welte T, et al. Am J Respir Crit Care Med 2009; doi:10.1164/rccm.200904-0492OC.
Goal: prevent exacerbations
Goal: decrease symptoms
Bronchodilate!!!
Cough and Sputum: One of the Susceptible
Phenotypes for COPD Exacerbators
*
* p<0.0001
erbationsPerYear
19
Percentwith≥2Exac
Burgel P-R, et al. Chest. 2009;135:975-982.
How about Roflumilast
Proportion of Patients with a Moderate or Severe
Exacerbation
sal or tio + placebo sal or tio + roflumilast 500 µg
20
16
12
acerbation (%)
16
1111
18
Exacerbation rates were based on a Poisson regression model;
Risk ratios (RiR) were based on a log binomial regression model
Fabbri LM, et al. Lancet. 2009 Aug 29;374(9691):695-703.
n = 83/467 n = 51/466 n = 58/372 n = 42/371
RiR = 0.60
(95% CI 0.43, 0.82)
p = 0.0015
RiR = 0.73
(95% CI 0.51, 1.05)
p = 0.0867
Salmeterol study Tiotropium study
12
8
4
0
n=83/467 n=51/466 n=58/372 n=42/371
Patients with an exa
1111
6. 19/04/2016
6
0.60
1.0
REACT – reduction in rate of severe exacerbations
(i.e. events leading to hospitalization and/or death)
Adding Roflumilast to triple therapy
∆ = -24.3%
Rate ratio = 0.757
CI: 0.601, 0.952
p=0.018
All patients
Patients with a
prior hospitalization
Patients without a
prior hospitalization
∆ = -34.9%
Rate ratio = 0.651
CI: 0.477, 0.887
p=0.007
∆ = -7.6%
Rate ratio = 0.924
CI: 0.669, 1.278
p=0.634
cerbationsper
eryear
0.32
0.18
0.24
0.39
0.17
0
0.5
N=319 N=322 N=647 N=647
Analysis of rate of severe exacerbations per patient
per year using a negative binomial regression model, ITT
Martinez FJ, et al. Presented at ERS 2015; OA482
Martinez FJ, et al. Lancet 2015;385:857-66.
Placebo + LABA/ICS
Roflumilast + LABA/ICS
N=966 N=969
NNT = 12.5 NNT = 4.8 NNT = 100.0
Meanrateofexac
patientpe
Roflumilast: Incidence of AEs
( 2.5%)*
Adverse Event
AURA/HERMES
1 year
HELIOS
6 months
Roflumilast
(n=1547)
Placebo
(n=1545)
Tiotropium +
Roflumilast
(n=374)
Tiotropium +
Placebo
(n=369)
COPD 10% 13% 16% 19%
Weight loss 10% 3% 6% <1%
Diarrhea 8% 3% 9% <1%
Nasopharyngiti
s
6% 6% 6% 5%
Nausea 4% 2% 3% 1%
Bronchitis 4% 4% 2% 3%
Headache 3% 2% 2% 0%
Back pain 3% 2% 2% 1%
*Independent of investigator causality assessments
Calverley PM, et al. Lancet. 2009 Aug 29; 374(9691):685-94.
Fabbri LM, et al. Lancet. 2009 Aug 29;374(9691):695-703.
So, where are we?
• Tailor our therapy to our patient
• Bronchodilate aggressively to improve functionality
• Anti-inflammatory to help prevent exacerbations
• Reassess over time
• But what is the real life situation?
• In Canada/ most of the world, there are a large number of patients
with COPD currently on ICS!
23
ICS use in COPD (Real life data in Canada)
Reza Maleki-Yazdi M. et al. ATS 2015, P551 024
7. 19/04/2016
7
So, where are we?
• Tailor our therapy to our patient
• Bronchodilate aggressively to improve functionality
• Anti-inflammatory to help prevent exacerbations
• Reassess over time
• But what is the real life situation?
• In Canada/ most of the world, there are a large number of patients
with COPD currently on ICS!
• Do ICS decrease COPD mortality??
25
TORCH: All‐Cause Mortality at 3 Years
18
16
14
12
10
ofdeath(%)
SALM/FP
17.5% reduction
in mortality vs
placebo
(p=0.052)
No significant
difference of
mortality with ICS
SALM = salmeterol
FP = fluticasone propionate
SALM/FP = salmeterol/fluticasone propionate
8
6
4
2
0
Time to death (weeks)
Probabilityo
0 12 24 36 48 60 72 84 96 108 120 132 144 156
Vertical bars are standard errors
SALM
SALM/FP
FP
Placebo
Adapted from Calverley PMA, et al. N Engl J Med. 2007;356. 26
Case 2
• A different patient with COPD
• FEV1 45%
• No exacerbations needing steroids in five years
• Couple of antibiotics for Sinusitis, did not move into their chest
• CAT score: 18
• On triple therapy: ICS/LABA and LAMA
• Does this patient need their ICS?
• Can you stop it?
• If so, how to stop it?
28
8. 19/04/2016
8
Side effects of ICS in COPD
and type of evidence
Randomised
controlled trial
Observational
study
Systematic
review
Pneumonia X X X
Tuberculosis X
Bone fracture
(no effect on
fracture risk)
X X
fracture risk)
Skin thinning/
easy bruising
X
Cataract X
Diabetes X
Oropharyngeal
candidiasis
X X X
Price D. Prim Care Respir J 2013; 22: 92-100. 29
Risk of Diabetes1 Risk of Bone Fracture2
3.5
3.0
2.5
atio
2 Loke YK et al Thorax 2011;66(8):699-708
31
Meta-analysis of studies including
17,513 patients with COPD
2.0
1.5
1.0
0.5
0 250 500 750 10001250 1500 17502000
Daily dose in fluticasone equivalents (mcg)
Rate Ra
1. Suissa S, et al.: Am J Med 2010; 123(11):1001‐6.
Several recent studies with varying populations/design
have compared bronchodilator therapy with LABA/ICS
OPTIMO – in patients with moderate COPD (FEV1 >50% predicted) and <2 exacerbations,
currently maintained on ICS for past year, ICS withdrawal was not associated with increased
exacerbations, difference in lung function or CAT
(Rossi, et. al. Resp Res 2014; 6 month “real-world” study of ICS withdrawal - decision to maintain or withdraw ICS at discretion of
clinician)
INSTEAD – in patients with moderate COPD (FEV1 40-80% predicted) and no recent
exacerbations, maintained on SFC for > 3 months, indacaterol was NI on lung function
(t h FEV1 9 l) d id f i d b ti(trough FEV1 = -9 ml) and no evidence of increased exacerbations
(Rossi, et. al. ERJ 2014; 26 week randomized, parallel, DB study of withdrawal of ICS from SFC 500/50 to Indacaterol 150 µg)
ILLUMINATE - in patients with moderate COPD (FEV1 40-80% predicted) and no recent
exacerbations, QVA (LABA/LAMA) improved lung function (FEV1AUC0-12 138ml, p<0.001) and
TDI vs LABA/ICS
(Vogelmeier, et. al. Lancet Resp Med 2012, 26 week randomized, parallel, DB study of QVA149 vs SFC 500/50)
LANTERN- in symptomatic patients with moderate to severe COPD (FEV1 30-80) and 0-1
exacerbations on SFC changed to QVA (LABA/LAMA) showed improved lung function
(FEV1 AUC0-4h 122 mL; p<0.001) and decreased exacerbations (HR 0.65 p .028)
(Zhong et al. Int J COPD 2015. A randomized control study of QVA 149 vs SFC)32
9. 19/04/2016
9
Wisdom
Estimated probability of moderate or severe
COPD exacerbation
0.6
0.4
tedprobability
0.3
0.5
Hazard ratio, 1.06 (95% CI, 0.94–1.19)
P=0.35 by Wald’s chi-squared test
1243
1242
1059
1090
927
965
827
825
763
740
646
646
694
688
615
607
581
570
14
19
No. at risk
ICS
ICS withdrawal
0.2
0.0
0 6 12 18 24 30 36 42 48 54
ICS
ICS withdrawal
Estima
Time to events (weeks)
0.1
Magnussen H et al. N Engl J Med DOI 10.1056/NEJMoal407154
-20
0
0 6 12 18 52
SE)change
FEV1(mL)
Week
ICS
38 mL
100 µg BID 0 µg (placebo)250 µg BID
Mean change from baseline in lung function:
FEV1
ICS withdrawal
-80
-60
-40
Adjustedmean(S
frombaselinein
**p<0.01; ***p<0.0001 vs ICS; restricted maximum likelihood repeated measures model; baseline values 970 mL for ICS, 981 mL for ICS withdrawal
ICS
ICS withdrawal
***
**
1223
1218
1135
1135
1114
1092
1077
1058
970
935
n
ICS withdrawal
ICS
43 mL
Magnussen H et al. N Engl J Med DOI 10.1056/NEJMoal407154
Time to first severe and any severity on-
treatment COPD exacerbation
0.975 1.202 1.482
Time to first severe
COPD exacerbation
36
Hazard ratio
Time to first COPD
exacerbation
(any severity)
On-treatment exacerbations assessed; hazard ratio from Cox proportional hazards
model adjusted for baseline FEV1
Favours ICSFavours withdrawal
Magnussen H et al. N Engl J Med DOI 10.1056/NEJMoal407154
10. 19/04/2016
10
So, definitely not with patients with
Asthma-COPD Overlap Syndrome (ACOS)
• Older patients (≥45 years) with chronic airflow
limitation
• Bronchodilator response (>12%, >400 mL)
but not fully reversiblebut not fully reversible
• Family or personal history of asthma, atopy
or allergic rhinitis
• Asthmatic with smoking history or biomass exposure
Dr. Don Sin. 16th Annual Respiratory Medicine Update, 8 February 2014.
Papaiwannou A, et al. J Thoracic Dis 2014;6(S1):S146-S151.
FLAME: QVA149 vs.SFC in terms of rate of all
COPD exacerbations (mild/moderate/severe) for
52 weeks
• moderate to very severe COPD (GOLD 2011),
• a smoking history of ≥10 pack-years,
• one or more 1 COPD exacerbation requiring systemic
corticosteroids and/or antibiotics in the previous 12 months.38
Initial results: press release
39
Does it depend on the eosinophil?
11. 19/04/2016
11
Changes in post-
bronchodilator FEV1 in
patients with or without
sputum eosinophilia
EV1(L)
0.10
*,#
0.15
*,#
With sputum eosinophilia
Without sputum eosinophilia
SputumSputum eosinophiliaeosinophilia and responseand response toto
budesonidebudesonide in COPD:in COPD:
ICSICS worksworks in COPDin COPD withwith sputumsputum eosinophiliaeosinophilia
Leigh et al. ERJ 2006;27:964-971
∆Post-BDFE
-0.05
0.05
0.00
PrednisoneBudesonidePlacebo
*p<0.05 within group (sputum
eosinophilia) vs placebo
#p<0.05 between groups
If blood eosinophils predict response to ICS, what is the
appropriate cutoff?
42
Do eosinophils predict response to ICS beyond
exacerbations? Chiesi data:
43 | QVA Update | Robert Fogel | Canada Advisory Board, Sep 26, 2015 |Business Use Only | Material ID Code:
12. 19/04/2016
12
Taking patients off ICS in COPD
45
Risk of recurrent pneumonia rises with current ICS use,
not linked to past ICS use
46
Eurich DT et al. Clin Infect Dis. 2013; 57 (8): 1138-1144
Discontinuation of ICS reduced the risk of
pneumonia associated with long-term ICS
use
Risk of pneumonia following ICS withdrawal
Retrospective analysis using the Quebec health insurance databases for COPD patients discontinued from ICS during
1990-2005 (n=103,386).
COPD=chronic obstructive pulmonary disease; ICS=inhaled corticosteroid.
Suissa S et al. Chest. 2015;148(5):1177-1183.
13. 19/04/2016
13
Are they eligible for ICS withdrawal? If no reason they should stay on ICS...
PREDICTIVE ACCURACY OF PREDICTING
≥ 2 EXACERBATIONS IN OUTCOME YEAR
Daryl Freeman GP Mundesley North Norfolk,
Clinical Director East of England SCN
(respiratory).
IMPACT study REG sponsored
Odds ratios for ≥ 2 exacerbations from
logistic regression in patients
with CAT score available (n=3,713)
total population n=3,713 Odds Ratio (95% CI) P-value
Baseline number of exacerbations 1.79 (1.68-1.92) <10-10
19% of patients had ≥ 2 exacerbations
FEV1 % predicted per 10% lower 1.06 (1.01-1.12) 0.02
Female gender 1.32 (1.10-1.58) 0.003
Asthma record ever 1.19 (1.00-1.43) 0.052
Nasal polyps ever 2.02 (1.24-3.29) 0.005
Eosinophilia (≥ 0.5 x 10-9 ) in non-smokers 1.42 (1.03-1.97) 0.03
CAT score per 10 units higher 1.26 (1.14-1.40) 1 x 10--5
14. 19/04/2016
14
There may be other factors we can use
• To predict exacerbations
• To predict response to ICS
• To predict response to stopping ICS
o New REG study being done on those with COPD whoy g
have stopped ICS and outcomes
o -unfortunately, numbers are small in GPRD currently.
What does a personalized COPD
assessment look like?
• Symptoms: CAT, MRC, CCQ
• Are they at risk of attack?
– Previous exacerbations, chronic bronchitis, lung function, GERD
• Lung function
• Still smoking?
• Is there Asthma there? Allergy, rhinitis hx?
• Comorbidities: GERD, Depression, Osteoporosis, Anxiety
• Adherence
– Refill prescription rates
• Inhaler technique
• Pulmonary Rehabilitation
• Biomarkers: eosinophils (blood and sputum), FENO?
• Biologics..coming?
• Self management plan
• Pathway to further treatments: oxygen, LVRT, transplant.EOL care! 54
Thank you for any
thoughts you have about
this study!
www fpagc comwww.fpagc.com
for4kids@gmail.com