Addition to inhaled corticosteroids of long-acting beta2-agonists versus anti-leukotrienes for chronic asthma

Asthma patients who continue to experience symptoms despite being on regular inhaled corticosteroids (ICS) represent a management challenge. Long-acting beta2-agonists (LABA) or anti-leukotrienes (LTRA) are two treatment options that could be considered as add-on therapy to ICS.ObjectivesWe compared the efficacy and safety profile of adding either daily LABA or LTRA in adults and children with asthma who remain symptomatic on ICS.Search strategyWe searched the Cochrane Airways Group Specialised Register (up to and including March 2010). We consulted reference lists of all included studies and contacted authors and pharmaceutical manufacturers for other published or unpublished studies.Selection criteriaWe included randomised controlled trials (RCTs) conducted in adults or children with recurrent asthma that was treated with ICS and where a fixed dose of a long-acting beta2-agonist or leukotriene agent was added for a minimum of 28 days.Data collection and analysisTwo authors independently assessed the risk of bias of included studies and extracted data. We sought unpublished data and further details of study design, where necessary.Main resultsWe included 17 RCTs (7032 participants), of which 16 recruited adults and adolescents (6850) and one recruited children aged 6 to 17 years (182). Participants demonstrated substantial reversibility to short-acting beta-agonist at baseline. The studies were at a low risk of bias. The risk of exacerbations requiring systemic corticosteroids was lower with the combination of LABA and ICS compared with LTRA and ICS, from 11% to 9% (RR 0.83, 95% CI 0.71 to 0.97; six studies, 5571 adults). The number needed to treat (NNT) with LABA compared to LTRA to prevent one exacerbation over 48 weeks was 38 (95% CI 22 to 244). The choice of LTRA did not significantly affect the results. The effect appeared stronger in the trials using a single device to administer ICS and LABA compared to those using two devices. In the absence of data from the paediatric trial and the clinical homogeneity of studies, we could not perform subgroup analyses. The addition to ICS of LABA compared to LTRA was associated with a statistically greater improvement from baseline in several of the secondary outcomes, including lung function, functional status measures and quality of life. Serious adverse events were more common with LABA than LTRA, although the estimate was imprecise (RR 1.35, 95% CI 1.00 to 1.82), and the NNT to harm for one additional patient to suffer a serious adverse event on LABA over 48 weeks was 78 (95% CI 33 to infinity). The risk of withdrawal for any reason in adults was significantly lower with LABA and ICS compared to LTRA and ICS (RR 0.84, 95% CI 0.74 to 0.96).Authors' conclusionsIn adults with asthma that is inadequately controlled on low doses of inhaled steroids and showing significant reversibility with beta2-agonists, LABA is superior to LTRA in reducing oral steroid treated exacerbations. Differences favouring LABA in lung function, functional status and quality of life scores are generally modest. There is some evidence of increased risk of SAEs with LABA. The findings support the use of a single inhaler for the delivery of LABA and inhaled corticosteroids. We are unable to draw conclusions about which treatment is better as add-on therapy for children.PLAIN LANGUAGE SUMMARYWhat are the effects of long-acting beta2-agonists compared with anti-leukotrienes when added to inhaled steroids?People who continue to experience asthma symptoms despite regularly taking inhaled corticosteroids are a challenge for management. It is not clear whether the addition of a long-acting beta2-agonist (LABA) such as formoterol or salmeterol would provide more benefit in comparison with an oral anti-leukotriene agent (LTRA), for example zafirlukast or montelukast.Seventeen trials (16 in adults and one in children) were included in this review and were of good quality. We found that the addition of a LABA provides significantly greater protection against exacerbations requiring oral steroids when compared with a LTRA for adults. Based on the results of our analyses, approximately 38 adults (with a range of between 22 and 244) would need to be treated with a LABA rather than a LTRA for 48 weeks to prevent one experiencing an exacerbation needing a course of oral steroids. The trial on children did not contribute data on the main outcome and therefore we could not draw any conclusions for children.LABAs also led to a greater improvement in lung function, improvement in symptoms, use of rescue medication, quality of life and symptoms compared to the use of LTRAs. The magnitude of the improvements was modest. Serious adverse events were more frequent with LABA than with LTRAs although this result was imprecise. Based on our analyses, around 78 people would need to be treated for 48 weeks with a LABA rather than a LTRA for one of them to experience a serious adverse event. However, due to the lack of precision around our result, the true number could be between 33 and infinity. There are currently insufficient data to draw any conclusions about the effects of these drugs in children

The bond strength of ceramic brackets bonded to remineralized teeth with casein

The aim of this study was to evaluate the shear bond strength of ceramic brackets bonded with different adhesives to remineralized teeth with casein phosphopeptide amorphous calcium phosphate. Premolar teeth (n=120) were used in the study. Teeth were divided into 6 groups (n=20). For 60 teeth in the first 3 groups demineralization was performed before all teeth in the 6 groups were pretreated with CPP-ACP cream (GC Tooth Mousse, GC Corp., Tokyo, Japan) for 30 days. Brackets were bonded with Transbond XT, Fuji Ortho LC and Aegis Ortho. The bond strength was tested with universal testing machine. The amount of adhesive on enamel surfaces was coded using Adhesive Remnant Index (ARI). Statistical analyses were performed (Kruskal Wallis, Dunn’s, Mann-Whitney-U, Chi-square) and significance was predetermined at p<0.05. The mean bond strength of Transbond XT, Fuji Ortho LC and Aegis Ortho in remineralized teeth were found to be 22.58±5.01, 16.26±4.42 and 11.21±2.7 MPa, respectively. The mean bond strength of Transbond XT, Fuji Ortho LC and Aegis Ortho in casein pretreated teeth were measured as 23.08±6.11, 16.9±5.12 and 10.57±4 MPa, respectively. Remineralization did not cause any significant change in the bond strengths of the adhesives. The mean bond strength of Transbond XT was significantly higher than other adhesives. Also the mean bond strength of Fuji Ortho LC was higher than Aegis Ortho. As a result, remineralization with casein does not effect the bond strengths of related adhesives. Fuji Ortho LC and Aegis Ortho can safely be used in patients, who underwent casein prophilaxis

Knowledge Level of the Primary Healthcare Providers on Chronic Obstructive Pulmonary Disease and Pulmonary Rehabilitation

Introduction. Awareness of the healthcare providers on chronic obstructive pulmonary disease (COPD), which is an important cause of mortality and morbidity in our country and all over the world, and on pulmonary rehabilitation (PR) which plays an important role in its nonpharmacological treatment will provide effectiveness in diagnosis and treatment of COPD. The present study aimed at determining knowledge level of the healthcare providers about COPD and PR. Materials and Methods. In this cross-sectional study, family practitioners and staff of home-care in central county of Manisa City were applied a questionnaire in order to determine their knowledge level on COPD and pulmonary rehabilitation during the in-service training on “pulmonary rehabilitation, home-care services for the pulmonary diseases, and respiratory exercises.” Results. 65.5% of the healthcare providers responded to the survey. Rate of those correctly knowing at least one of four items was 97.2%. No responder knew all items correctly. Average value for correct answers was 5.30 ± 2.1 (range: 1–10). The physicians, men, and those working in family health centers had higher level of knowledge on COPD compared to nonphysician healthcare providers (p=0.006), women (p=0.002), and those working in other practices (p=0.019), respectively. Conclusion. Knowledge level of the primary healthcare providers on COPD and PR remains inadequate. Dynamic postgraduate training on this topic will be useful in referring the patients to centers giving service for this condition

Elderly and aged asthma have different characteristics: results of a multicenter study

Background/aim: Characteristics of asthma in the elderly population is not well-known. The aim of the present study was to evaluate asthma in the elderly population, to compare disease characteristics between patients diagnosed <60 (aged asthma) and ≥60 (elderly asthma) years of age. Materials and methods: The study was a prospective, multicenter, cross-sectional type. A questionnaire was filled out to patients 60 years of age and over, that have been followed for asthma for at least 3 months. Asthma Control Test (ACT), eight-item Morisky Medication Adherence Scale (MMAS-8) was filled out, inhaler device technique was assessed. Results: A total of 399 patients were included from 17 tertiary care centers across the country. Mean age was 67.11 years and 331 (83%) were female. The age at asthma diagnosis was ≥60 in 146 (36.6%) patients. Patients diagnosed ≥60 years were older (p < 0.001), had higher education level (p < 0.001), more commonly had first-degree relative with asthma (p = 0.038), asthma related comorbidities (p = 0.009) and accompanying rhinitis/rhinosinusitis (p = 0.005), had better asthma control (p = 0.001), were using less controller medications (p = 0.014). Inhaler technique was correct in 37% of the patients with no difference in between the groups. Treatment compliance was better in elderly asthma patients (p < 0.001). In the multivariate logistic regression analysis, having well-controlled asthma (odds ratio = 1.61, CI = 1.04-2.51), and high medication adherence rate (odds ratio = 2.43, CI = 1.48-4.0) were associated with being in the elderly asthma group. Conclusion: The characteristics of asthma are different among patients aged 60 years and over which seems to be related to onset age of asthma. In our cohort, the elderly asthma patients had higher education level, and treatment adherence and asthma control was better. Patients diagnosed ≥60 years of age did not have more severe disease

Could albumin level explain the higher mortality in hemodialysis patients with pulmonary hypertension?

BACKGROUND: The pathogenesis of pulmonary hypertension (PH) in hemodialysis is still unclear. The aim of this study was to identify the risk factors associated with the presence of PH in chronic hemodialysis patients and to verify whether these factors might explain the highest mortality among them. METHODS: We conducted a retrospective study of hemodialysis patients who started treatment from August 2001 to October 2007 and were followed up until April 2011 in a Brazilian referral medical school. According to the results of echocardiography examination, patients were allocated in two groups: those with PH and those without PH. Clinical parameters, site and type of vascular access, bioimpedance, and laboratorial findings were compared between the groups and a logistic regression model was elaborated. Actuarial survival curves were constructed and hazard risk to death was evaluated by Cox regression analysis. RESULTS: PH > 35 mmHg was found in 23 (30.6%) of the 75 patients studied. The groups differed in extracellular water, ventricular thickness, left atrium diameter, and ventricular filling. In a univariate analysis, extracellular water was associated with PH (relative risk = 1.194; 95% CI of 1.006 – 1.416; p = 0.042); nevertheless, in a multiple model, only left atrium enlargement was independently associated with PH (relative risk =1.172; 95% CI of 1.010 – 1.359; p = 0.036). PH (hazard risk = 3.008; 95% CI of 1.285 – 7.043; p = 0.011) and age (hazard risk of 1.034 per year of age; 95% CI of 1.000 – 7.068; p = 0.047) were significantly associated with mortality in a multiple Cox regression analysis. However, when albumin was taken in account the only statistically significant association was between albumin level and mortality (hazard risk = 0.342 per g/dL; 95% CI of 0.119 – 0.984; p = 0.047) while the presence of PH lost its statistical significance (p = 0.184). Mortality was higher in patients with PH (47.8% vs 25%) who also had a statistically worse survival after the sixth year of follow up. CONCLUSIONS: PH in hemodialysis patients is associated with parameters of volume overload that sheds light on its pathophysiology. Mortality is higher in hemodialysis patients with PH and the low albumin level can explain this association

Trends in prescribing montelukast in patients with asthma in real-life: Results from the Turkish adult asthma registry

Montelukast, a leukotriene receptor antagonist (LTRA) approved for the treatment of asthma and allergic rhinitis, is widely used, though real-world data on its application in asthma management remain limited. This registry-based study evaluated the use of montelukast in adult asthma patients, examining demographic and disease characteristics, asthma control status, asthma phenotypes, presence of atopy, and treatment regimens. Among 2053 patients analyzed, 61.76% (n = 1268; mean age: 46.2 ± 14.3 years), predominantly females (~76%), received montelukast. Montelukast users showed higher rates of allergic rhinitis (P < 0.001), hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) (P = 0.008), and chronic rhinosinusitis (P = 0.008). Montelukast group also had higher atopy and total IgE levels and tended to be more eosinophilic. Montelukast was commonly preferred in allergic, eosinophilic, NSAID-exacerbated respiratory disease, and severe asthma phenotypes (P < 0.001). Patients receiving Steps 4 and 5 treatments are more likely to be prescribed montelukast (P < 0.001). Montelukast usage was higher among patients with uncontrolled asthma [ACT< 20 (OR:1.29, 95%CI:1.052-1.582, P = 0.014)]. In addition, logistic regression analyses identified the main factors associated with increased montelukast use as; female gender (OR:1.33, 95%CI:1.041-1.713, P = 0.02), presence of atopy (OR:1.46, 95%CI:1.157-1.864, P = 0.002), comorbid allergic rhinitis (OR:2.12, 95%CI:1.679-2.293, P < 0.001), and severe asthma (OR:2.18, 95%CI:1.712-2.784, P < 0.001). These findings reveal that montelukast use is prevalent among asthma patients, particularly in females, middle-aged adults, and those with comorbid allergic rhinitis, uncontrolled asthma, or specific asthma phenotypes, underscoring the factors that influence its prescription in asthma management

What does radiologic assessment contribute to asthma: a subanalysis of the turkish adult asthma registry

Objectives: It is aimed to assess how physicians use chest imaging in asthma and the relationship between the pathological findings and related disease characteristics in the radiological imaging of asthmatic patients. Background: The daily practice of imaging and its contribution to the management of asthma are not well defined. It is common to use radiological imaging to investigate pathologies that cause respiratory symptoms and to evaluate differential diagnoses in asthma patients. In this study, as a subanalysis of the Turkish Adult Asthma Registry, radiological findings and outcomes of asthmatic patients were examined. Methods: Between March 2018 and March 2022, the data of asthma patients in 36 secondary and tertiary health care centers was recorded using a web-based application. Patients with chest X-ray, computed thorax tomography, and paranasal sinus tomography data in the asthma database were statistically evaluated for sub-analysis. Results: The study included 2053 patients. Chest X-rays were taken in the majority of the cases (n:1739; 84.7%). Computed thorax tomography was performed in 869 (42.3%) patients and paranasal sinus tomography in 388 (18.9%) patients. The most common pathological findings on chest X-rays of asthmatic patients were increased bronchovascular branching and dirty lung appearance, whereas they were linear atelectasis, and bronchial wall thickening on computed thorax tomography bronchiectasis. Soft tissue in the sinuses and nasal polyps were the most common pathological findings in paranasal sinus tomography. Pathological findings were much more common in the radiological evaluations of patients with eosinophilic and allergic phenotypes and in patients with severe asthma. Conclusion: The radiological findings of asthma vary depending on the phenotype and severity of the disease. Patients with asthma, particularly those in the high-risk group, should be evaluated from a radiological perspective