Towards clinical phenotyping of COPD : effects of inhaled corticosteroide in the GLUCOLD study

Patients with Chronic Obstructive Pulmonary Disease (COPD) have a lung disorder that limits daily activities and contributes considerably to physical limitations and emotional distress. Taking into account the large heterogeneity of the disease, it can be expected that specific subtypes of the disease (phenotypes) may benefit from a given treatment. This thesis is based on analyses from the Groningen Leiden Universities Corticosteroids in Obstructive Lung Disease (GLUCOLD) study. The effects of long-term maintenance therapy with inhaled corticosteroids with or without long-acting bronchodilators, and discontinuation were examined on 1) clinical parameters: symptoms, lung function decline, airway hyperreactivity and hyperinflation; and 2) pathological parameters: inflammatory cell counts in bronchial biopsies and induced sputum. The current thesis focused on health status, chronic bronchitis, long-term therapy with inhaled corticosteroids and specific phenotypes that benefit from treatment. By showing that certain subgroups of COPD such as patients with less advanced disease or a subphenotype with less emphysema can benefit from inhaled corticosteroids, our results may offer an indication for a promising perspective for particular, individual patients with COPD towards the potential of slowing down the progression of the disease in the future.Netherlands Organization for Scientific Research (NWO), Netherlands Asthma Foundation (NAF), GlaxoSmithKline (GSK NL), Leiden University Medical Center (LUMC), University Medical Center Groningen (UMCG)UBL - phd migration 201

Effectiveness of myAirCoach: a mHealth self-management system in asthma

BACKGROUND: Self-management programs have beneficial effects on asthma control, but their implementation in clinical practice is poor. Mobile health (mHealth) could play an important role in enhancing self-management.OBJECTIVE: To assess the clinical effectiveness and technology acceptance of myAirCoach-supported self-management on top of usual care in patients with asthma using inhalation medication.METHODS: Patients were recruited in 2 separate studies. The myAirCoach system consisted of an inhaler adapter, an indoor air-quality monitor, a physical activity tracker, a portable spirometer, a fraction exhaled nitric oxide device, and an app. The primary outcome was asthma control; secondary outcomes were exacerbations, quality of life, and technology acceptance. In study 1, 30 participants were randomized to either usual care or myAirCoach support for 3 to 6 months; in study 2, 12 participants were provided with the myAirCoach system in a 3-month before-after study.RESULTS: In study 1, asthma control improved in the intervention group compared with controls (Asthma Control Questionnaire difference, 0.70; P = .006). A total of 6 exacerbations occurred in the intervention group compared with 12 in the control group (hazard ratio, 0.31; P = .06). Asthma-related quality of life improved (mini Asthma-related Quality of Life Questionnaire difference, 0.53; P = .04), but forced expiratory volume in 1 second was unchanged. In study 2, asthma control improved by 0.86 compared with baseline (P = .007) and quality of life by 0.16 (P=.64). Participants reported positive attitudes toward the system.DISCUSSION: Using the myAirCoach support system improves asthma control and quality of life, with a reduction in severe asthma exacerbations. Well-validated mHealth technologies should therefore be further studied. (C) 2020 The Authors. Published by Elsevier Inc. on behalf of the American Academy of Allergy, Asthma & Immunology. This is an open access article under the CC BY-NC-ND license http://creativecommons.org/licenses/by-nc-nd/4.0/).Pathogenesis and treatment of chronic pulmonary disease

Early detection of asthma exacerbations by using action points in self-management plans

Our aim was to validate optimal action points in written action plans for early detection of asthma exacerbations.We analysed daily symptoms and morning peak-flows (PEF) from two previous studies. Potential action points were based on analysis of symptom scores (SDs) percentage of personal best PEF, or PEF variability in relation to a run-in period, or combinations of these measures. Sensitivity and specificity for predicting exacerbations were obtained for each action point. The numbers needed to treat to prevent one exacerbation and the time interval between reaching action point criteria and the start of the exacerbation were calculated. Based on these parameters, the optimal action points for symptoms, PEF, and PEF plus symptoms were determined, and their performance compared to published guidelines action points.The optimal action points were: for symptoms, statistical variability (SDs); for PEF, <70% of personal best. The combination of PEF plus symptoms performed best, with improved specificity and earlier detection. The main benefits associated with using these action points was to reduce false positive rates for detecting exacerbations.Early detection of asthma exacerbations can be improved using a composite action point comprising symptoms and PEF measurements over one week.Medical Decision Makin

Validation of online Asthma Control Questionnaire and Asthma Quality of Life Questionnaire

Objective: Several newly developed eHealth applications use online questionnaires to monitor asthma control. The Asthma Control Questionnaire (ACQ) and Asthma Quality of Life Questionnaire (AQLQ) are two such commonly used questionnaires. These questionnaires are validated for use on paper. This study aims to validate them by assessing the agreement between online and paper versions of the ACQ and AQLQ.Methods: Patients (aged 18 years and older) from the Self-Management in Asthma Supported by Hospitals, ICT, Nurses and General Practitioners (SMASHING)-trial and Davos@home study were included in this study. Patients completed both the paper and online Dutch versions of the ACQ and AQLQ in a random order within a 2-week interval. Agreement between the different versions was assessed with paired t-tests, intraclass correlation coefficients and Bland-Altman plots.Results: In total 44 patients were eligible for analysis. The mean difference between the paper and online versions of the ACQ was 0.04 (p=0.40) and for the AQLQ it was 0.08 (p=0.06). The intraclass correlation coefficient scores were 0.94 for the ACQ and 0.95 for the AQLQ.Conclusion: The online versions of the ACQ and AQLQ show high levels of agreement with the paper versions and can therefore be safely used in eHealth applications to respectively monitor asthma control and quality of life.Analysis and support of clinical decision makin

Internet-based self-management support for adults with asthma: a qualitative study among patients, general practitioners and practice nurses on barriers to implementation

Analysis and support of clinical decision makin

Internet-Based Self-Management Support After High-Altitude Climate Treatment for Severe Asthma: Randomized Controlled Trial

Background: In patients with severe asthma, high-altitude climate treatment has been shown to improve asthma control. However, asthma symptoms and limitations may increase after finishing inpatient rehabilitation programs and returning to sea level.Objective: We assessed the effectiveness of a patient-tailored, internet-based, self-management strategy in addition to usual care after finishing high-altitude climate treatment.Methods: We performed a randomized controlled trial with a 1-year follow-up in patients from a high-altitude asthma center in Davos, Switzerland. At the end of a 12-week multidisciplinary rehabilitation program, 62 adults with asthma were randomized to receive either internet-based self-management support in addition to usual care (n=33) or usual care only after discharge (n=29). The endpoints were changes in asthma-related quality of life according to the Asthma Quality of Life Questionnaire (AQLQ) (a higher score is better) and asthma control according to the Asthma Control Questionnaire (ACQ) (a lower score is better), with a minimally important difference of 0.5 points for both.Results: Asthma-related quality of life and asthma control declined over time in the usual care strategy group, whereas there was a slower decline in the internet-based strategy group. For both endpoints, mixed-model analysis showed a significant positive effect in favor of internet-based self-management during follow-up (mean AQLQ score difference 0.39, 95% CI 0.092-0.69; P=.01 and ACQ score difference -0.50, 95% CI -0.86 to -0.15; P=.006), which was prominent among patients with uncontrolled asthma at discharge (AQLQ score difference 0.59, 95% CI 0.19-0.99; P=.003 and ACQ score difference -0.73, 95% CI -1.18 to -0.28; P=.002).Conclusions: Internet-based self-management support was associated with a smaller decline in quality of life and asthma control as compared with usual care, especially in patients with lower asthma control, after completion of high-altitude climate treatment. Internet-based self-management support in adults with severe asthma seems feasible and effective to maintain quality of life and asthma control.Analysis and support of clinical decision makin

Personalised exhaled nitric oxygen fraction (F (ENO))-driven asthma management in primary care: a F (ENO) subgroup analysis of the ACCURATE trial

Contains fulltext : 225905.pdf (publisher's version ) (Open Access)BACKGROUND: The aim of this study was to identify patients who benefit most from exhaled nitric oxide fraction (F (ENO))-driven asthma management in primary care, based on prespecified subgroups with different levels of F (ENO). METHODS: We used data from 179 adults with asthma from a 12-month primary care randomised controlled trial with 3-monthly assessments of F (ENO), asthma control, medication usage, costs of medication, severe asthma exacerbations and quality of life. In the original study, patients were randomised to either a symptom-driven treatment strategy (controlled asthma (Ca) strategy) or a F (ENO)+symptom-driven strategy (FCa). In both groups, patients were categorised by their baseline level of F (ENO) as low (50 ppb). At 12 months, we compared, for each prespecified F (ENO) subgroup, asthma control, asthma-related quality of life, medication usage, and costs of medication between the Ca and FCa strategy. RESULTS: We found a difference between the Ca and FCa strategy for the mean dosage of beclomethasone strategy of 223 µg (95% CI 6-439), p=0.04) and for the total costs of asthma medication a mean reduction of US$159 (95$33-285), p=0.03) in patients with a low baseline F (ENO) level. No differences were found for asthma control, severe asthma exacerbations and asthma-related quality of life in patients with a low baseline F (ENO) level. Furthermore, in patients with intermediate or high level of F (ENO), no differences were found. CONCLUSIONS: In primary care, F (ENO)-driven asthma management is effective in patients with a low F (ENO) level, for whom it is possible to down-titrate medication, while preserving asthma control and quality of life

Long-Term Outcomes of Internet-Based Self-Management Support in Adults With Asthma: Randomized Controlled Trial

Contains fulltext : 164707.pdf (publisher's version ) (Open Access)BACKGROUND: Long-term asthma management falls short of the goals set by international guidelines. The Internet is proposed as an attractive medium to support guided self-management in asthma. Recently, in a multicenter, pragmatic randomized controlled parallel trial with a follow-up period of 1 year, patients were allocated Internet-based self-management (IBSM) support (Internet group [IG]) or usual care (UC) alone. IBSM support was automatically terminated after 12 months of follow-up. In this study, IBSM support has been demonstrated to improve asthma-related quality of life, asthma control, lung function, and the number of symptom-free days as compared to UC. IBSM support was based on known key components for effective self-management and included weekly asthma control monitoring and treatment advice, online and group education, and communication (both online and offline) with a respiratory nurse. OBJECTIVE: The objective of the study was to assess the long-term effects of providing patients 1 year of IBSM support as compared to UC alone. METHODS: Two hundred adults with physician-diagnosed asthma (3 or more months of inhaled corticosteroids prescribed in the past year) from 37 general practices and 1 academic outpatient department who previously participated were invited by letter for additional follow-up at 1.5 years after finishing the study. The Asthma Control Questionnaire (ACQ) and the Asthma Quality of Life Questionnaire (AQLQ) were completed by 107 participants (60 UC participants and 47 IG participants). A minimal clinical important difference in both questionnaires is 0.5 on a 7-point scale. RESULTS: At 30 months after baseline, a sustained and significant difference in terms of asthma-related quality of life of 0.29 (95% CI 0.01-0.57) and asthma control of -0.33 (95% CI -0.61 to -0.05) was found in favor of the IBSM group. No such differences were found for inhaled corticosteroid dosage or for lung function, measured as forced expiratory volume in 1 second. CONCLUSIONS: Improvements in asthma-related quality of life and asthma control were sustained in patients who received IBSM support for 1 year, even up to 1.5 years after terminating support. Future research should be focused on implementation of IBSM on a wider scale within routine asthma care. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 79864465; http://www.controlled-trials.com/ISRCTN79864465 (Archived by WebCite at http://www.webcitation.org/6J4VHhPk4)

UM ambil alih pelajar Bahasa Jepun UKM

Contains fulltext : 182325.pdf (publisher's version ) (Open Access)While asthma presentation is heterogeneous, current asthma management guidelines in primary care are quite homogeneous. In this study we aim to cluster patients together into different phenotypes, that may aid the general practitioner in individualised asthma management. We analysed data from the ACCURATE trial, containing 611 adult asthmatics, 18-50 year-old, treated in primary care, with one year follow-up. Variables obtained at baseline (n = 14), were assessed by cluster analysis. Subsequently, established phenotypes were assessed separately on important asthma outcomes after one year follow-up: asthma control (Asthma Control Questionnaire (ACQ)), quality of life (Asthma Quality of Life Questionnaire (AQLQ)), exacerbation-rate and medication-usage. Five distinct phenotypes were identified. The first phenotype was predominantly defined by their early onset atopic form of asthma. The second phenotype mainly consisted of female patients with a late onset asthma. The third phenotype were patients with high reversibility rates after bronchodilator usage. The fourth phenotype were smokers and the final phenotype were frequent exacerbators. The exacerbators phenotype had the worst outcomes for asthma control and quality of life and experienced the highest exacerbation-rate, despite using the most medication. The early onset phenotype patients were relatively well controlled and their medication dosage was low. ASTHMA: INDIVIDUALIZING TREATMENT BY PHENOTYPE: Asthma patients should be characterised according to their individual asthma type to ensure more targeted treatment. Even though asthma manifests itself in a wide variety of forms with differing degrees of severity, treatment of the disease often takes a broad, one-size-fits-all approach. To determine if asthma can indeed be split into distinct phenotypes, Rishi Khusial at the Leiden University Medical Center and co-workers across the Netherlands analysed data from 611 adult asthmatics treated in primary care, and followed them up after one year. The team identified five phenotypes in the primary care cohort, including one group with early onset asthma, another whose asthma responded well to bronchodilators, and a group classed as frequent exacerbators. Further analysis of long-term asthma outcomes showed clear differences between phenotypes, particularly in terms of asthma control and quality of life

MANAGEMENT OF MARKETING PROCESSING AND FINANCING ON FAMILY AGRICULTURAL ECONOMY

Tema ovog završnog rada je vezana uz analizu uloge marketinga i menadžmenta u svrhu uspješnog financijskog poslovanja subjekata na poljoprivrednom tržištu. Marketinški menadžment kao koncepcija podrazumijeva orijentaciju na potrošača, razvoj integriranog poslovnog programa i usmjerenost prema ciljevima. U kontekstu članstva Republike Hrvatske u Europskoj Uniji, pružaju se brojne mogućnosti financiranja i potpore organizaciji poslovanja, stoga će praktični dio rada biti napravljen kroz pregled mjera ruralnog razvoja s naglaskom na aplikaciju AgronetThe subject of this final paper is related to the analysis of the role of marketing and management for the purpose of successful financial operations of the entities in the agricultural market. Marketing management as a concept implies consumer orientation, the development of an integrated business program and goal orientation. In the context of Croatia's membership in the European Union, there are numerous opportunities for financing and support for the business organization, so the practical part will be done through an overview of rural development measures, with emphasis on application of Agrone