A guide to the translation of the Global Initiative for Asthma (GINA) strategy into improved care

In 1995, the Global Initiative for Asthma (GINA) published an evidence-based workshop report as a guide to clinicians managing asthma patients, and has updated it annually to ensure that recommendations remain current. Although the report has been widely disseminated and influenced clinical practice and research, its major objective, of forming the basis for local and national initiatives to improve services for asthma patients, remains to be achieved. Over recent years, the science of guideline implementation has progressed, and encouraging examples of successful asthma programmes have been published. This report is intended to draw on this experience and assist with the translation of asthma guideline recommendations into quality programmes for patients with asthma using current knowledge translation principles. It also provides examples of successful initiatives in various socioeconomic settings

Cost-effectiveness analysis of a state funded programme for control of severe asthma

Abstract Background Asthma is one of the most common chronic diseases and a major economical burden to families and health systems. Whereas efficacy of current therapeutical options has been clearly established, cost-effectiveness analysis of public health interventions for asthma control are scarce. Methods 81 patients with severe asthma (12–75 years) joining a programme in a reference clinic providing free asthma medication were asked retrospectively about costs and events in the previous 12 months. During 12 months after joining the programme, information on direct and indirect costs, asthma control by lung function, symptoms and quality of life were collected. The information obtained was used to estimate cost-effectiveness of the intervention as compared to usual public health asthma management. Sensitivity analysis was conducted. Results 64 patients concluded the study. During the 12-months follow-up within the programme, patients had 5 fewer days of hospitalization and 68 fewer visits to emergency/non scheduled medical visits per year, on average. Asthma control scores improved by 50% and quality of life by 74%. The annual saving in public resources was US$387 per patient. Family annual income increased US$512, and family costs were reduced by US$733. Conclusion A programme for control of severe asthma in a developing country can reduce morbidity, improve quality of life and save resources from the health system and patients families.</p

Poverty, dirt, infections and non-atopic wheezing in children from a Brazilian urban center

BACKGROUND: The causation of asthma is poorly understood. Risk factors for atopic and non-atopic asthma may be different. This study aimed to analyze the associations between markers of poverty, dirt and infections and wheezing in atopic and non-atopic children. METHODS: 1445 children were recruited from a population-based cohort in Salvador, Brazil. Wheezing was assessed using the ISAAC questionnaire and atopy defined as allergen-specific IgE ≥ 0.70 kU/L. Relevant social factors, environmental exposures and serological markers for childhood infections were investigated as risk factors using multivariate multinomial logistic regression. RESULTS: Common risk factors for wheezing in atopic and non-atopic children, respectively, were parental asthma and respiratory infection in early childhood. No other factor was associated with wheezing in atopic children. Factors associated with wheezing in non-atopics were low maternal educational level (OR 1.49, 95% CI 0.98-2.38), low frequency of room cleaning (OR 2.49, 95% CI 1.27-4.90), presence of rodents in the house (OR 1.48, 95% CI 1.06-2.09), and day care attendance (OR 1.52, 95% CI 1.01-2.29). CONCLUSIONS: Non-atopic wheezing was associated with risk factors indicative of poverty, dirt and infections. Further research is required to more precisely define the mediating exposures and the mechanisms by which they may cause non-atopic wheeze

Causes of variation in BCG vaccine efficacy: examining evidence from the BCG REVAC cluster randomized trial to explore the masking and the blocking hypotheses.

BCG protection varies and in some places (nearest the equator) is low or absent. Understanding this variation can inform the efforts to develop new vaccines against tuberculosis. Two main hypotheses are used to explain this variation: under masking, new vaccines are unlikely to increase protection; under blocking new vaccines have a greater potential to be effective when BCG is not. We conducted a cluster randomized trial to explored the masking and blocking hypotheses by studying BCG vaccine efficacy of neonatal vaccination and when administered for the first or a second (revaccination) time at school age in two sites (Manaus close and Salvador further south from the equator). Seven hundred and sixty three state schools were matched on socio economic characteristics of the neighborhood and 239,934 children were randomized to vaccine (BCG vaccination at school age) or control group. Protection by first BCG vaccination at school age was high in Salvador (34%, 95% CI 7-53%, p=0.017) but low in Manaus (8%, 95% CI t0 39-40%, p=0.686). For revaccination at school age, protection was modest in Salvador (19%, 95% CI 3-33%, p=0.022) and absent in Manaus (1%, 95% CI to 27-23%, p=0.932). Vaccine efficacy for neonatal vaccination was similar in Salvador (40%, 95% CI 22-54%, p<0.001) and Manaus (36%, 95% CI 11-53%, p=0.008). Variation in BCG efficacy was marked when vaccine was given at school age but absent at birth, which points towards blocking as the dominant mechanism. New tuberculosis vaccines that overcome or by pass this blocking effect could confer protection in situations where BCG is not protective

Architectural optimization framework for earth-observing heterogeneous constellations : marine weather forecast case

Earth observation satellite programs are currently facing, for some applications, the need to deliver hourly revisit times, subkilometric spatial resolutions, and near-real-time data access times. These stringent requirements, combined with the consolidation of small-satellite platforms and novel distributed architecture approaches, are stressing the need to study the design of new, heterogeneous, and heavily networked satellite systems that can potentially replace or complement traditional space assets. In this context, this paper presents partial results from ONION, a research project devoted to studying distributed satellite systems and their architecting characteristics. A design-oriented framework that allows selecting optimal architectures for the given user needs is presented in this paper. The framework has been used in the study of a strategic use-case and its results are hereby presented. From an initial design space of 5586 potential architectures, the framework has been able to preselect 28 candidate designs by an exhaustive analysis of their performance and by quantifying their quality attributes. This very exploration of architectures and the characteristics of the solution space are presented in this paper along with the selected solution and the results of a detailed performance analysis.Postprint (author's final draft

Asthma Mortality Inequalities in Brazil: Tolerating the Unbearable

Asthma is responsible for a high morbidity, resulting in hospitalizations, recurrent asphyxiation, and eventually death. In Brazil, where asthma is the third cause of hospitalizations for clinical illnesses and the fourth cause of death from respiratory diseases, some 20% of the population present wheezing. We evaluated the asthma mortality rates in the period between 1998 and 2009, using linear regressions, using the National Mortality Database (Ministry of Health of Brazil). The annual mortality rate (per 100,000 inhabitants) ranged from 1.68 in 1998 to 1.32 in 2009 (mean : 1.49). Brazil presents a slight tendency of reduction in asthma mortality. Asthma mortality rates trends declined in the most developed regions of the country:  Midwest, South, and Southeast, but it increased in the underprivileged regions: North (not statistically significant) and Northeast. This terrible sort of inequality requires urgent reaction from the public health authorities