Multi-colored simplified asthma guideline reminder

Asthma is a chronic disease that is highly prevalent around the world with increasing societal and economic burden. National Asthma Educational and Preventive Program (NAEPP) and Global Initiative for Asthma (GINA) are evidence-based documents designed to help clinicians make appropriate decisions for their patients and to reduce undesirable variation in the care of asthmatic patients. It is a generally accepted fact that asthma specialists achieved better and improved asthma outcomes for their patients when compared with primary care physicians (PCPs). These outcome differences are somewhat related to PCPs' poor adherence to published NAEPP guidelines. Multi-Colored Simplified Asthma Guideline Reminder (MSAGR) is the first user-friendly single-sheet convenient asthma tool designed for clinicians after barriers to the poor adherence to asthma guidelines in primary care settings were identified. Voluntary acceptance and utilization of MSAGR resulted in fewer emergency room visits and hospitalizations for their patients. General acceptance of MSAGR (more than 1 million copies requested by clinicians globally), and overwhelming positive comments by asthma care providers, strongly advocate a need for real-time, pragmatic clinical tools not only in asthma, but also in other chronic diseases such as chronic obstructive pulmonary disease, diabetes mellitus, hypertension, and depression, etc. In this brief review, we discuss how clinicians, patients, and payers are utilizing these simplified asthma tools to improve asthma care in their community.     

Measuring asthma disparities in Hispanics: adherence to the national guidelines for asthma treatment in emergency departments in Puerto Rico.

BACKGROUND: Puerto Rico has the highest prevalence of asthma in the United States. Currently, there are no data on actual care given to asthmatic patients. OBJECTIVE: To determine the prevalence of documented adherence to the 1997 National Asthma Education Prevention Program guidelines regarding care given in emergency departments (EDs) in Ponce, Puerto Rico. METHODS: A case series was conducted using 6,002 ED records with a physician-based diagnosis of asthma for 1999 through 2001. RESULTS: A history of asthma attack was documented in 82.0% of the cases and in all age groups. In-home beta-agonist use was recorded in only 5.7% of the medical records. Documentation of previous admissions to the ED and the intensive care unit were found in 3.5% and 0.33% of the records, respectively. Nocturnal symptoms before the ED visit were found in only 6.4% of the records, and asthma treatment at home was found in 39.9%. Accessory muscle retraction was documented in 99.1% of the cases, and oxygen saturation was found in 23.2%. Treatment with nebulized beta-agonist was found in 72.1% of the records, and intravenous or oral corticosteroid use was found in 84.1%. Follow-up appointments were detected in 64.8% of the cases, and referrals to specialists were given in only 5.3%. Rate ratios between our data and those of other researchers indicate that there are geographical differences in compliance with the guidelines. CONCLUSION: Of the variables tested, only one had acceptable levels of compliance, as evidenced in the patient's records, indicating that there are alarming differences in ED evaluation and treatment compared with the 1997 National Asthma Education Prevention Program guidelines.     

Physician adherence to the national asthma prescribing guidelines: evidence from national outpatient survey data in the United States.

BACKGROUND: The Expert Panel 2 Guidelines for the Diagnosis and Management of Asthma (EPR-2 guidelines) were developed to improve medication prescribing for patients with persistent asthma and to control acute exacerbations of asthma. In addition, these guidelines also encourage physician-provided asthma education. Little is known about prescribing adherence to EPR-2 guidelines. OBJECTIVES: To examine physician adherence to EPR-2 asthma medication prescribing guidelines and determine patient and physician factors associated with prescribing of asthma medications. METHODS: This study was a cross-sectional retrospective analysis of National Ambulatory Medical Care Survey physician visit survey data from 1998 through 2004. Data were extracted on all patients with an International Classification of Diseases, Ninth Revision (ICD-9) code for asthma (493.XX) and reason for visit as asthma. The unit of analysis was individual patient visit. The dependent variables in analyses were specific type of drug class. The independent variables were various patient and physician factors. Logistic regression analysis was used to evaluate study objectives. RESULTS: Asthma patients in 2002 had 3.3 times more odds of being prescribed controller medications compared with asthma patients in 1998. Findings in 2004 were not significant. Elderly patients had 54% less odds of receiving controller medication compared with those in the 35- to 64-year-old age group. Patients in the other race category are 40% as likely to receive controller asthma medication compared with white patients. Physicians in 2002 had 6.3 times more odds of prescribing long-acting beta-agonists compared with those in 1998. Physicians without ownership stake in their practice had 1.9 times more odds of providing asthma education to their patients compared with those who owned their practice. CONCLUSION: Physician prescribing of asthma pharmacotherapy does not adequately comply with EPR-2 treatment guidelines.     

Low adherence to national guidelines for thyroid screening in Down syndrome

PurposeTo determine adherence to the American Academy of Pediatrics guidelines for thyroid screening in children with Down syndrome among primary care providers in the states of Oklahoma and Nebraska.MethodsWe sought to identify all children with Down syndrome born in Oklahoma and Nebraska between 1994 and 2004 and review their medical records for evidence of thyroid screening. Patients were identified through a State Department of Health birth defects registry in Oklahoma and through participation in genetics clinics and laboratories in Nebraska and Oklahoma. Charts obtained from primary care providers were reviewed and the number of actual thyroid screens was compared with the number of recommended screens for each individual during the study period.ResultsIn Oklahoma, 13% of participating children received all thyroid screens recommended in the guidelines. In Nebraska, 14% of children received all recommended thyroid screenings. Among participants in Oklahoma, a mean of 34% of recommended thyroid screenings were performed. In Nebraska, a mean of 45% of recommended thyroid screenings were performed.ConclusionsThe level of adherence to the American Academy of Pediatrics guidelines for thyroid screening in children with Down syndrome is low. Factors contributing to this low level of adherence need to be identified and addressed.     

Barriers to adherence to asthma management guidelines among inner-city primary care providers

BACKGROUND: Health care provider adherence to national asthma guidelines is critical in translating evidence-based recommendations into improved outcomes. Unfortunately, provider adherence to the National Heart, Lung, and Blood Institute (NHLBI) guidelines remains low. OBJECTIVE: To identify barriers to guideline adherence among primary care professionals providing care to inner-city, minority patients with asthma. METHODS: We surveyed 202 providers from 4 major general medicine practices in East Harlem in New York, New York. The study outcome was self-reported adherence to 5 NHLBI guideline components: inhaled corticosteroid (ICS) use, peak flow (PF) monitoring, action plan use, allergy testing, and influenza vaccination. Potential barriers included lack of agreement with guideline, lack of self-efficacy, lack of outcome expectancy, and external barriers. RESULTS: Most providers reported adhering to the NHLBI guidelines for ICS use (62%) and for influenza vaccinations (73%). Self-reported adherence was 34% for PF monitoring, 9% for asthma action plan use, and 10% for allergy testing. Multivariate analyses showed that self-efficacy was associated with increased adherence to ICS use (odds ratio [OR], 2.8; P = .03), PF monitoring (OR, 2.3; P = .05), action plan use (OR, 4.9; P = .03), and influenza vaccinations (OR, 3.5; P = .05). Conversely, greater expected patient adherence was associated with increased adherence to PF monitoring (OR, 3.3; P = .03) and influenza vaccination (OR, 3.5; P = .01). Familiarity with specific guideline components and higher level of training were also predictors of adherence. CONCLUSIONS: Lack of outcome expectancy and poor provider self-efficacy prevent providers from adhering to national asthma guidelines. Efforts to improve provider adherence should address these specific barriers.     

Positioning of glucocorticosteroids in asthma and allergic rhinitis guidelines (versus other therapies)

Asthma and allergic rhinitis are both characterized by airway inflammation, and glucocorticosteroids form the cornerstone of their pharmacologic treatment. All patients with asthma should be prescribed rapid-acting inhaled beta2-agonists as needed to use as rescue therapy in case of symptoms. As soon as patients experience symptoms at least once a week, controller medications should be started on a daily basis to achieve and maintain control of their asthma. Intranasal corticosteroids are given as first-line therapy for moderate to severe persistent rhinitis. Depending on the dominant symptom, H1-antihistamines, decongestants, or ipratropium can be added after re-evaluation.     

Use of the PATH Alliance database to measure adherence to IDSA guidelines for the therapy of candidemia

Candidemia is an increasing complication of the care of complex patients. Adherence to Infectious Diseases Society of America (IDSA) guidelines for the treatment of candidemia was investigated to assess the impact of compliance on outcomes of therapy. Data on the epidemiology, diagnosis, and treatment of patients with invasive fungal infections (IFIs) was extracted from the PATH Alliance registry, a prospective, multicenter, observational database of invasive fungal infections. Patients with proven candidemia were evaluated for adherence to the IDSA guidelines in terms of choice, dosage, and duration of antifungal therapy. Removal of central venous catheters and time to treatment initiation were assessed. Four-week survival data were compared. Of the 418 patients with candidemia who were included in the study, 361 patients with the necessary data sets were identified, of whom 262 (72.6%) were treated within the IDSA guidelines for the treatment of candidemia (IDSA group); the remaining 99 (27.4%) patients received treatment different from the guidelines (non-IDSA group). Kaplan-Meier (KM) survival analysis for patients in the IDSA and non-IDSA group showed mortality rates of 21.9 and 13.6%, respectively; the difference between the two groups was not statistically significant (P = 0.093). Following the exclusion of patients requiring mechanical ventilation or acute cardiac support, the modified survival KM curves were similar between the two groups. Significantly more patients in the IDSA group required mechanical ventilation and tunneled central catheters, had a concomitant IFI, and received caspofungin. The duration of treatment and inappropriate dosing did not appear to have had a significant impact on survival. Most of the deviations from IDSA guidelines were due to the inappropriate duration and dosing of therapy. No significant difference in mortality was noted between the IDSA and non-IDSA groups. The basis of these differences merit further study. Presented in part at the 44th Annual Meeting of Infectious Disease Society of America, Toronto, Canada, 2006.     

Microbial adherence on poly(methyl methacrylate) (PMMA) surfaces.

Infection remains a major complication following the use of implanted biomaterials. Often these infections are caused by low-virulence organisms or by a mixture of organisms (polymicrobial). In this study two methods were used to quantitate the bacteria which had adhered to poly(methyl methacrylate) (PMMA) samples. The bacteria were eluted from the sample using an ultrasonic cleaner. The number eluted was then counted by colony counts, which determines viable organisms and by particle counting which counts both viable and nonviable organisms. A known adherent strain of Staphylococcus epidermidis and a strain of Proteus mirabilis were used. In general the adherence of S. epidermidis was greater than that of Proteus. When the two organisms were used together, there was an alteration in the adherence pattern which generally increased the adherence of Proteus and had no effect or decreased the adherence of S. epidermidis. The use of both quantitation techniques provided important information on the adherence of organisms to PMMA to which gentamicin had been added. It was evident that organisms did adhere to the PMMA plus gentamicin samples but were not viable when eluted. The amount of adherence to PMMA plus gentamicin was similar to that of PMMA alone at 30 min but was markedly decreased at 24 h. There was a considerable dead biofilm mass on the PMMA plus gentamicin samples which might be a significant promoter of late infections by providing a surface attractive to other strains of bacteria.     

Harmonization of immunotoxicity guidelines in the ICH process--pathology considerations from the guideline Committee of the European Society of Toxicological Pathology (ESTP) .

As part of the ICH process of harmonization of testing guidelines for immunotoxicity, the European Society of Toxicologic Pathology (ESTP) has contributed to the scientific discussion on methods and evaluation of immunotoxicity studies with technical and scientific recommendations on toxicologic pathology. The weighing and sampling of immune organs is discussed taking into consideration specifically the value of lymph node weighing and the selection of appropriate lymph nodes for the detection of local and systemic effects. The different techniques of bone marrow preparation are considered for routine and extended investigations. Criteria are given for the gross and histopathological detection of effects in Peyer's patches. For the histopathological evaluation it is strongly recommended that each compartment within the different lymphoid organs is investigated separately and semiquantitatively since this approach has shown to increase the sensitivity and specificity of immunohistopathology.     

International variation in adherence to referral guidelines for suspected cancer: a secondary analysis of survey data

Background

Variation in cancer survival persists between comparable nations and appears to be due, in part, to primary care practitioners (PCPs) having different thresholds for acting definitively in response to cancer-related symptoms.

Aim

To explore whether cancer guidelines, and adherence to them, differ between jurisdictions and impacts on PCPs’ propensity to take definitive action on cancer-related symptoms.

Design and setting

A secondary analysis of survey data from six countries (10 jurisdictions) participating in the International Cancer Benchmarking Partnership.

Method

PCPs’ responses to five clinical vignettes presenting symptoms and signs of lung (n = 2), colorectal (n = 2), and ovarian cancer (n = 1) were compared with investigation and referral recommendations in cancer guidelines.

Results

Nine jurisdictions had guidelines covering the two colorectal vignettes. For the lung vignettes, although eight jurisdictions had guidelines for the first, the second was covered by a Swedish guideline alone. Only the UK and Denmark had an ovarian cancer guideline. Survey responses of 2795 PCPs (crude response rate: 12%) were analysed. Guideline adherence ranged from 20–82%. UK adherence was lower than other jurisdictions for the lung vignette covered by the guidance (47% versus 58%; P <0.01) but similar (45% versus 46%) or higher (67% versus 38%; P <0.01) for the two colorectal vignettes. PCPs took definitive action least often when a guideline recommended a non-definitive action or made no recommendation. UK PCPs adhered to recommendations for definitive action less than their counterparts (P <0.01). There wasno association between jurisdictional guideline adherence and 1-year survival.

Conclusion

Cancer guideline content is variable between similarly developed nations and poor guideline adherence does not explain differential survival. Guidelines that fail to cover high-risk presentations or that recommend non-definitive action may reduce definitive diagnostic action.     

Erythrocyte adherence to the marginal zone of mouse spleen follicle mediated by receptor(s) for neuraminic acid.

Erythrocytes of different species (chicken, sheep, man, mouse, rat, guinea pig) except rabbit erythrocytes strongly adhere to the marginal zone of mouse spleen follicles in frozen sections. This adherence reaction (AR) is not restricted to red blood cells but is also observed with human lymphocytes. Pretreatment of the tissue sections with trypsin, mercaptoethanol, periodate, chloroform/methanol, acetone, and heating the sections abolishes AR whereas neuraminidase (VCN) treatment of the sections has an amplifying effect. AR is inhibited by preincubation of the neuraminidase- or untreated sections with neuraminic acid (NA). Treatment of the erythrocytes with VCN completely abolishes AR whereas treatment with other enzymes (hyaluronidase, collagenase) is ineffective in this respect. Determination of NA in the erythrocyte membrane before and after VCN treatment reveals a positive correlation between the amount of NA and AR. Rabbit red blood cells have the lowest NA content in their membranes and, in addition, there is little effect of VCN treatment in further reducing it. It is possible that a lectin-like substance is responsible for AR. The biologic significance of AR is hypothetical, but since AR occurs in an area of the spleen playing a role in antigen trapping it is conceivable that this trapping may be mediated by interaction of NA and NA receptor(s).     

CD11/CD18-independent neutrophil adherence to inducible endothelial-leucocyte adhesion molecules (E-LAM) in vitro

We examined the mechanisms involved in neutrophil adherence to cultured human umbilical vein endothelial cells (HEC) induced by direct stimulation of the neutrophils by phorbol myristate acetate (PMA), formylmethionyl-leucyl-phenylalanine (FMLP), or the calcium ionophore A23187 (neutrophil-dependent adherence), or by pretreatment of HEC with interleukin-1 (IL-1), tumour necrosis factor (TNF) or lipopolysaccharide (LPS) (endothelial-dependent adherence). Two distinct mechanisms for neutrophil adherence to HEC were demonstrated by performing adherence assays: (i) at 37 degrees versus 4 degrees; (ii) in the presence of Ca2+ only versus Mg2+ only; and (iii) in the presence or absence of monoclonal antibodies (mAb) to the CD11/CD18 adhesion complex of neutrophils. A CD11/CD18-dependent mechanism (i.e. inhibited by anti-CD18 mAb) was identified that was active in the presence of Mg2+ only but not of Ca2+ only, and at 37 degrees but not at 4 degrees. A CD11/CD18-independent mechanism (i.e. not inhibited by anti-CD18 mAb) was active at 4 degrees and at 37 degrees, and in the presence of Ca2+ only and of Mg2+ only. Neutrophil-dependent adherence induced by FMLP or PMA occurred solely via the CD11/CD18-dependent mechanism, whereas endothelial-dependent adherence induced by a 4-hr pretreatment with IL-1, TNF, or LPS involved both CD11/CD18-dependent and/independent mechanisms. CD11/CD18-deficient neutrophils isolated from a patient with leucocyte adherence deficiency (LAD) maintained the ability to adhere to LPS-pretreated HEC in the presence of Ca2+ only, indicating that this mechanism of adherence involves a receptor on the neutrophil distinct from CD11/CD18. Furthermore, the disappearance of the CD11/CD18-independent, but not of the CD11/CD18-dependent mechanism of adherence, in HEC treated with TNF for 24 hr suggests that the two mechanisms of neutrophil adherence also involve distinct inducible endothelial-leucocyte adhesion molecules (E-LAM).     

AID and partners: for better and (not) for worse

Post-rearrangement diversification of the antibody repertoire relies on a DNA editing factor, the cytidine deaminase AID. How B lymphocytes avoid generalized mutagenesis while expressing high levels of AID remained a long-standing question. Genome-wide studies of AID targeting combined to the discovery of several co-factors controlling its recruitment and its local activity shed new light on this enigma.     

Association between sensitization to Aureobasidium pullulans (Pullularia sp) and severity of asthma.

BACKGROUND: Recent data indicate that fungi may contribute to increased severity of asthma. OBJECTIVES: To determine the prevalence of allergy to 15 mold allergens among patients hospitalized because of exacerbation of asthma and to evaluate the relationship between the severity of the disease and allergy to particular molds. METHODS: Skin prick tests with standard aeroallergens of airborne allergens, including grass, tree, Dermatophagoides pteronyssinus, Dermatophagoides farinae, feather, and cat and dog fur, and a panel of mold allergens, including Alternaria, Cladosporium, Aspergillus, Penicillium, Trichothecium, Chaetomium globosum, Epicoccum, Epidermophyton, Helminthosporium, Aureobasidium pullulans, Rhizopus nigricans, Fusarium, Mucor, Merulius lacrymans, and yeast mix, were performed in 105 asthmatic patients and 30 controls. RESULTS: Positive skin prick test results were found in 98% of asthmatic patients and 66% of controls. Sensitivity to A pullulans was significantly associated with more severe asthma (odds ratio, 1.4; 95% confidence interval, 1.09-1.75; P = .006). Sensitization to Helminthosporium was associated with an increased number of asthma exacerbations that required hospitalization (17% vs 38%; chi2 test P = .03). CONCLUSION: Sensitization to A pullulans is a risk factor for severe asthma. Sensitization to Helminthosporium may be related to asthma exacerbation that requires hospitalization.     

Providing dust mite-proof covers improves adherence to dust mite control measures in children with mite allergy and asthma.

INTRODUCTION: The most critical dust mite avoidance technique for asthmatic children with mite allergy is the use of dust mite-proof bedding covers. Adherence to allergen control measures is poor due to cost. The purpose of this study was to determine whether giving families mite-proof bedding encasings at the time of the diagnosis with mite allergy would improve adherence at a home visit 2 months later. METHODS: Parents of children (mean age 7.7 years) with asthma and positive skin tests for dust mite were assigned either to an intervention group, which received dust mite covers upon enrollment or a comparison group, which did not. Both groups were instructed in dust mite control measures by a medical provider and told to invest in the covers as part of standard care. Two months after enrollment, parent report and observational measures from each family were obtained during a home visit. RESULTS: The group provided allergen encasings was found to be significantly more likely to have used the casings at the home visit, t(22) = 2.77, P < 0.05. There were no differences between groups in adherence to other mite control strategies. Parenting stress was significantly related to poorer mite control compliance. The most common reason reported for nonadherence to control measures was cost. CONCLUSIONS: Providing mite bedding encasings at the time of diagnosis significantly increases compliance at a 2-month home visit. Medicaid and insurance companies should be encouraged to pay for casings as a cost effective measure to improve asthma care in children with mite allergy.