ARIA 2016: care pathways implementing emerging technologies for predictive medicine in rhinitis and asthma across the life cycle

The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative commenced during a World Health Organization workshop in 1999. The initial goals were (1) to propose a new allergic rhinitis classification, (2) to promote the concept of multi-morbidity in asthma and rhinitis and (3) to develop guidelines with all stakeholders that could be used globally for all countries and populations. ARIA-disseminated and implemented in over 70 countries globally-is now focusing on the implementation of emerging technologies for individualized and predictive medicine. MASK [MACVIA (Contre les Maladies Chroniques pour un Vieillissement Actif)-ARIA Sentinel NetworK] uses mobile technology to develop care pathways for the management of rhinitis and asthma by a multi-disciplinary group and by patients themselves. An app (Android and iOS) is available in 20 countries and 15 languages. It uses a visual analogue scale to assess symptom control and work productivity as well as a clinical decision support system. It is associated with an inter-operable tablet for physicians and other health care professionals. The scaling up strategy uses the recommendations of the European Innovation Partnership on Active and Healthy Ageing. The aim of the novel ARIA approach is to provide an active and healthy life to rhinitis sufferers, whatever their age, sex or socio-economic status, in order to reduce health and social inequalities incurred by the disease.European Innovation Partnership on Active and Healthy Ageing Reference Site MACVIA-France, EU Structural and Development Fund Languedoc-Roussillon, ARIA.info:eu-repo/semantics/publishedVersio

How to Deliver a Successful Learning Package for Family Medicine Trainees?

Like most learners, FM trainees are eager to learn to become competent professionals. It is the task of tutors and course organisers to guarantee the quality of learning. In order to be successful, learning programmes require a certain number of features. Family Medicine has been in the front line of innovation in designing learning and teaching programmes to fit the objectives and learning needs of trainees (1). Furthermore, it has published guidance and developed several courses to allow the development of teaching skills of tutors and teachers in family medicine (2,3). What Makes a Teaching Programme Successful? This text will review some of the characteristics of a teaching package that can include in-person learning, such as small group work modules combined with distance learning, mostly using problem based learning and integrating practical work in a real primary care setting. Learning objectives and content can be adapted to work with small groups, individual learning or one-to-one teaching in a residency programme. We will consider the six key features that make such a comprehensive programme effective. How to Deliver a Successful Learning Package for Family Medicine Trainees? (PDF Download Available). Available from: https://www.researchgate.net/publication/284726251_How_to_Deliver_a_Successful_Learning_Package_for_Family_Medicine_Trainees [accessed Jan 25 2018].info:eu-repo/semantics/publishedVersio

Routine primary care data: the new crystal ball?

[Excerpt] In their 2014 recommendation update, the Global Initiative for Asthma (GINA) called for a more risk-focused approach to management. If used appropriately primary care records capturing routine data can be used not only to characterize current asthma control and current/prior practice, but also to “predict future risk”. By considering aggregate patient data, it is possible to identify common characteristics associated with future events and to explore combinations of factors that, together, may have a stronger association with specific future risks, such as exacerbations, multiple exacerbations, hospitalisations. Used in this way, clinical records can point to opportunities to modify risk and to intervene to mitigate against future events. [...](undefined)info:eu-repo/semantics/publishedVersio

Screening for helicobacter pylori

The aim of this review is to assess whether a screening programme for Helicobacter pylori will be both successful and cost-effective. Method: We searched the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and the NHS Database of Abstracts of Reviews of Effectiveness; MEDLINE; EMBASE; SilverPlatter, Biological Abstracts and Science Citation Index-Expanded. We used the search terms Helicobacter pylori and (diagnos$or identif$ or find$) and (systematic review$ or meta-anal$), and searched for articles in all languages and limited the search to humans. Evaluation of the Level of Evidence: We used the rating system of the American Family Physician journal: Level A (randomized controlled trial/meta-analysis); Level B (other evidence); and C (consensus/expert opinion). Results: Serological tests: Antibody levels persist in serum for many years and do not permit us to distinguish between past and present infection or to identify treatment failures. Saliva and urine tests: A saliva test had sensitivity of 81% and specificity of 73%. A urine test had sensitivity of 86-89% and specificity of 69-91%. Breath urea tests: The tests have a high sensitivity and specificity but require expensive equipment. Stool tests: showed a high sensitivity and specificity. The European Helicobacter study group recommends either the breath urea or stool antibody tests in the initial diagnosis of H. pylori. Tests for specific gene sequences showed a high sensitivity and specificity. Endoscopy: is invasive, uncomfortable for patients, and expensive. The cost-effectiveness of tests for H. pylori: The better accuracy of the stool and breath tests, despite their greater cost, make them more cost-effective than the serology or near-patient tests. Conclusions: Tests with good sensitivity and specificity are available. The costs of non-invasive diagnostic tests acceptable to patients have been worked out, and the cost-effective dominance of stool and particularly urea breath tests over serological tests has been determined in a systematic review. What remains is to implement and test further the cost-effectiveness of national testing strategies

The relationship of H. pylori infection and gastric cancer

Introduction: The aim of this review is to assess whether there is a relationship between Helicobacter pylori infection and gastric cancer. Method: We searched the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and the NHS Database of Abstracts of Reviews of Effectiveness; MEDLINE; EMBASE, Biological Abstracts and Science Citation Index-Expanded. We used the search terms Helicobacter pylori and (gastric or stomach) and (cancer$or neoplasm$) and (systematic review$or meta-anal$), and searched for articles in all languages and limited the search to humans. Evaluation of the Level of Evidence: We used the rating system of the American Family Physician journal: Level A (randomized controlled trial/meta-analysis); Level B (other evidence); and C (consensus/expert opinion). Results: H. pylori increases the odds ratio of gastric cancer in various studies. H. pylori is associated with the development of both types of gastric adenocarcinoma. On average only three per cent of those who carry H. pylori develop gastric carcinoma. The risk of gastric cancer is also increased if the individual has polymorphisms that result in the expression of higher than average levels of the cytokine IL-1β. There is no evidence that nutritional supplements prevent gastric cancer. Conclusions: Gastric cancer is preceded by a long latency period. Infection with H. pylori is a primary cause of the precancerous cascade from gastritis to dysplasia, and eradicating H. pylori by antibiotic therapy results in a modest retardation of the cancerous process. The research to date reviewed above suggests that the best strategy is twofold. Firstly, focus on high risk individuals with known risk factors of H. pylori exposure treat them for H. pylori and screen them endoscopically for the development of early gastric cancers which can be ideally resected endoscopically. Secondly, screen younger individuals (< 45 years) at risk for H. pylori who have not been exposed to H. pylori for as long and treat them.O objectivo da presente revisão é avaliar se existe uma relação entre a infecção por Helicobacter pylori e cancro gástrico. Pesquisámos o Cochrane Central Register of Controlled Trials, o Cochrane Database of Systematic Reviews e o NHS Database of Abstracts of Reviews of Effectiveness; MEDLINE; EMBASE; Silver- Platter, Biological Abstracts and Science Citation Index-Expanded. Usámos os termos de pesquisa Helicobacter pylori e (gastric or stomach) and (cancer$or neoplasm$) e (systematic review$or meta-anal$), e pesquisámos artigos de todas as línguas limitando a pesquisa a humanos. Avaliação do Nível de Evidência: usámos o sistema de classificação da revista American Family Physician: Nível A (ensaios clínicos aleatorizados/meta-análises). Nível B (outras fontes de evidência). Nível C (consensos/opinião de peritos). O H. Pylori aumenta a OR para cancro de estômago em vários estudos. O H. Pylori está associado ao desenvolvimento de ambos os tipos de adenocarcinoma gástrico. Em média, apenas três por cento dos portadores de H. Pylori desenvolvem carcinoma gástrico. O risco de cancro de estômago está igualmente aumentado se o indivíduo tem polimorfismos que resultam numa expressão maior do que os níveis médios da citocina IL-1β. Não existe evidência que os suplementos nutricionais previnam o cancro gástrico. O cancro gástrico é precedido por um longo período de latência. A infecção por H. pylori é uma causa primária da cascata pré-cancerosa da gastrite à displasia e a erradicação do H. pylori por terapêutica antibiótica resulta num atraso moderado do processo canceroso. A investigação apresentada revista até hoje sugere que a melhor estratégia é, primeiro, incidir nos indivíduos de alto risco com factores de risco conhecidos de exposição ao H. pylori e rastreá-los endoscopicamente para o desenvolvimento de cancros gástricos iniciais que podem ser ressecados endoscopicamente; seguidamente, rastrear indivíduos mais novos (< 45 anos) em risco para H. pylori que não foram expostos ao H. pylori por um período tão longo e tratá-los

Capacitação dos doentes e gestão da asma : um estudo em medicina geral e familiar

Tese de doutoramento em Medicina (área de especialização em Medicina)Asthma is a common condition in general practice but is frequently under-diagnosed. There is wide variation in the reported incidence and prevalence rates of asthma but these rates are believed to be increasing. Research on the magnitude of this problem has met with methodological obstacles because it has been difficult to define and diagnose asthma in epidemiological terms. There is evidence that the control of asthma involving self-assessment by patients and a stronger doctor-patient relationship can improve compliance to therapeutic plans and lead to better outcomes for patients. Evidence is lacking on the influence of the level of patient empowerment on the quality of life and level of control of asthma. The objectives of the three studies in the present thesis were to assess how physicians in a sentinel practice network perform using standardized diagnostic criteria, to estimate the true prevalence of asthma by gender and age groups in the population of the area covered by one urban Health Centre in Portugal, to assess the severity of asthma, medication use, asthma control, the level of patient enablement and the quality of life in a population of asthmatic patients treated in primary care, and to study the relationship between enablement and the quality of life of asthma patients. Methods In the first of three studies conducted for this thesis the incidence of asthma was calculated. Patients consulting physicians from the Portuguese Sentinel Practice Network with complaints suggestive of asthma were enrolled in the study over a four year period. Frequencies of symptoms and diagnoses of asthma were tabulated. Diagnostic accuracy was computed by dividing the rate of asthma diagnosis by the true rate using established diagnostic criteria. In the second survey, an observational study was conducted in 2009 at the Horizonte Family Health Unit in Matosinhos, Portugal to calculate the prevalence of asthma. A random sample of 590 patients, stratified by age and gender was obtained from the practice database of registered patients. Data was collected using a patient questionnaire based on respiratory symptoms and the physician’s best knowledge of the patient’s asthma status. The prevalence of asthma was calculated by age and gender. The third survey was a cross-sectional study conducted in an urban population in northern Portugal to assess the relationships between patient empowerment, asthma control and quality of life. Data were collected from both clinical records and questionnaires administered to a stratified random sample of asthma patients treated in this clinic. The patient enablement instrument (PEI) was used to assess enablement and the asthma quality of life questionnaire (AQLQ) was used to assess quality of life. Asthma control was assessed using the asthma control test (ACT). Pulmonary function was assessed by measuring peak expiratory flow (PEF) and forced expiratory volume at one second (FEV1). The associations between patient empowerment, asthma control and quality of life were tested using linear and logistic regression models. Results In the first study 43 physicians followed 32,103 patients for 4 years and diagnosed asthma in 310 patients. The diagnosis was confirmed in 260 cases giving a true incidence rate of 2.02/ 1000/ year (95% confidence interval 2.12 to 2.46) and an accuracy of diagnosis of 84%. In the second study, data were obtained from 576 patients with a 97.6% response rate. The mean age for patients with asthma was 27.0 years (95% CI: 20.95 to 33.16). Asthma was diagnosed in 59 persons giving a prevalence of 10.24% (95% CI: 8.16 to 12.32). There was no statistically significant difference in the prevalence of asthma by gender. The third study included 180 patients. 68% of the patients were female. Over half of the patients (57%) had forms of persistent asthma and 43% had intermittent asthma. The mean patient enablement (PEI) scores were significantly higher for patients with intermittent asthma compared to those with persistent forms (p<0.01). There was a strong and statistically significant correlation between asthma control and quality of life (r2 Discussion =0.64). A weak correlation between patient enablement and asthma control and quality of life was found. Asthma incidence in the Portuguese population in the first study approaches published rates. The prevalence of asthma found in the second study was higher than that found in some studies, though lower than that found in other studies. The findings of the third study confirm the correlation between good asthma control and quality of life. The finding of a weak correlation between scores on the patient enablement instrument and asthma control requires further study to determine if interventions to improve patient empowerment can improve asthma outcomes Conclusions Asthma is a common problem in general practice in Portugal. Adherence to international diagnostic guidelines can improve the rates of diagnosis. Adherence to therapeutic guidelines can improve asthma control and quality of life for patients. Attention to patient enablement may also have a role to play in the care of asthma patients.A asma é frequentemente sub-diagnosticada existindo grande variação nas taxas de incidência e prevalência que se pensa estarem a aumentar, mas a investigação sobre a sua magnitude tem encontrado obstáculos metodológicos, uma vez que tem sido difícil de definir e diagnosticar asma em termos epidemiológicos. Existe evidência de que o controlo da asma envolvendo autoavaliação pelos doentes e uma forte relação médico-doente podem melhorar a adesão aos planos terapêuticos e levar a melhores resultados. Há pouca evidência sobre a influência do nível de capacitação do doente sobre a qualidade de vida e o nível de controle da asma. Os objectivos dos estudos incluídos na presente tese foram: avaliar como os médicos de uma rede sentinela diagnosticam asma usando critérios padronizados de diagnóstico, estimar a prevalência de asma por sexo e grupo etário na população de um Centro de Saúde urbano em Portugal, avaliar a gravidade da asma, o uso de medicamentos, o controle da asma, o nível de capacitação do doente e a qualidade de vida numa população de doentes asmáticos em cuidados primários e estudar a relação entre capacitação e qualidade de vida nestes doentes. Métodos No primeiro estudo da tese calculou-se a incidência de asma. Os doentes que consultaram um dos médicos da Rede Médicos Sentinela com queixas sugestivas de asma foram incluídos no estudo por um período de quatro anos. As frequências de sintomas e os diagnósticos de asma foram calculados. A precisão diagnóstica foi calculada dividindo-se a taxa de diagnóstico de asma pela taxa real usando critérios diagnóstico estabelecidos. O segundo trabalho foi um estudo observacional tendo sido realizado em 2009 na Unidade de Saúde Familiar Horizonte, em Matosinhos. Foi obtida uma amostra aleatória de 590 pessoas, estratificada por idade e sexo a partir da base de dados de inscritos na USF. Os dados foram obtidos através de questionários dirigidos a doentes e a médicos baseados na presença de sintomas respiratórios e no melhor conhecimento do médico do estado de asma do paciente. A prevalência de asma foi calculado por idade e sexo. O terceiro estudo foi um estudo transversal realizado numa população urbana no norte de Portugal. Os dados foram recolhidos a partir dos registos clínicos e de questionários aplicados a uma amostra aleatória estratificada de pacientes com asma tratados na USF. O Patient Enablement Instrument (PEI) foi usado para avaliar a capacitação e o Asthma Quality of Life Questionnaire (AQLQ) foi usado para avaliar a qualidade de vida. O controlo da asma foi avaliado pelo Teste de Controle da Asma (ACT). A função pulmonar foi avaliada pelo débito expiratório máximo instantâneo (PEF) e o volume expiratório forçado no primeiro segundo (FEV1). As associações entre capacitação do doente, o controle da asma e a qualidade de vida foram testados usando modelos de regressão linear e logística. Resultados No primeiro estudo 43 médicos seguiram 32.103 utentes durante quatro anos tendo diagnosticado asma em 310. O diagnóstico foi confirmado em 260 casos, obtendo-se assim uma taxa de incidência de 2,02 /1000 /ano (IC 95%: 2,12-2,46) e uma precisão de diagnóstico de 84%. No segundo estudo os dados foram obtidos a partir de 576 pacientes (97,6% taxa de resposta). A idade média dos doente com asma foi 27,0 anos (IC 95%: 20,95-33,16). Foi diagnosticada asma a 59 pessoas dando uma prevalência de 10,24% (IC 95%: 8,16-12,32). Não houve diferenças estatisticamente significativas na prevalência de asma por sexo. O terceiro estudo incluiu 180 doentes, 68% do sexo feminino. Mais de metade dos doentes (57%) tinham formas de asma persistente e 43% intermitente. As pontuações médias do PEI foram significativamente maiores em doentes com asma intermitente em comparação com as formas persistentes (p<0,01). Observou-se uma correlação forte e estatisticamente significativa entre o controle da asma e qualidade de vida (r2 Discussão =0,64). Observou-se uma fraca correlação entre a capacitação dos doentes e controlo da asma e qualidade de vida. A incidência de asma é semelhante à existente na literatura se forem utilizados critérios consensuais. A prevalência de asma encontrada foi maior do que a de alguns estudos, embora menor que a encontrada noutros. As conclusões confirmam a correlação entre bom controlo da asma e qualidade de vida. A fraca correlação entre a pontuação no PEI e o controlo da asma requer um estudo mais aprofundado para determinar se as intervenções para melhorar a capacitação do doente conseguem melhorar os resultados em saúde. Conclusões A asma é um problema comum em medicina geral e familiar em Portugal. A adesão a normas de orientação internacionais pode melhorar as taxas de diagnóstico. A adesão às recomendações terapêuticas pode melhorar o controle da asma e qualidade de vida para os doentes. A atenção para a capacitação pode ter um papel a desempenhar nos cuidados a doentes com asma

Inhaler technique education in elderly patients with asthma or COPD: impact on disease exacerbations-a protocol for a single-blinded randomised controlled trial

Chronic Obstructive Pulmonary Disease (COPD)and asthma affect more than 10% of the population. Most patients use their inhaler incorrectly, mainly the elderly, thereby becoming more susceptible to poor clinical control and exacerbations. Placebo device training is regarded as one of the best teaching methods, but there is scarce evidence to support it as the most effective one to improve major clinical outcomes. Our objective is to perform a single-blinded RCT to assess the impact of this education tool in these patients. Introduction Chronic Obstructive Pulmonary Disease (COPD)and asthma affect more than 10% of the population. Most patients use their inhaler incorrectly, mainly the elderly, thereby becoming more susceptible to poor clinical control and exacerbations. Placebo device training is regarded as one of the best teaching methods, but there is scarce evidence to support it as the most effective one to improve major clinical outcomes. Our objective is to perform a single-blinded RCT to assess the impact of this education tool in these patients. Methods and analysis A multicentre single-blinded Randomised Controlled Trial (RCT) will be set up, comparing an inhaler education programme with a teach-to-goal placebo-device training versus usual care, with a 1-year follow-up, in patients above 65 years of age with asthma or COPD. Intervention will be provided at baseline, and after 3 and 6 months, with interim analysis at an intermediate time point. Exacerbation rates were set as primary outcomes, and quality of life, adherence rates, clinical control and respiratory function were chosen as secondary outcomes. A sample size of 146 participants (73 in each arm) was estimated as adequate to detect a 50% reduction in event rates. Two-sample proportions χ² test will be used to study primary outcome and subgroup analysis will be carried out according to major baseline characteristicsFaculty of Health Sciences at the University of Beira Interior and Life and Health Sciences Research Institute (ICVS)/3B’s at University of Minho in Portugal. This work was prepared with scientific support from Harvard Medical School, in accordance with the Portuguese Clinical Scholarship Research Training Program

Aprendizagem da técnica inalatória em doentes com DPOC

Objetivos: Avaliar se o ensino correto da técnica inalatória em doentes com DPOC a pode melhorar de uma forma sustentada e quais as caraterísticas dos inaladores e dos doentes que lhe estão associados.Métodos: Doentes ≥ 40 anos com DPOC estável e diagnosticados de acordo com os critérios do GOLD foram avaliados em duas consultas médicas com um intervalo de dez a doze meses entre elas. Inicialmente foi aplicado um questionário demográfico e clínico e o Questionário de Crenças sobre Medicamentos. Na avaliação da técnica inalatória foi usada uma tabela de passos necessários para um correto uso dos inaladores e erros críticos. Posteriormente, a todos os participantes foi feito ensino e permitido treino com inaladores contendo placebo, até ao seu uso correto. Na segunda consulta foi feita uma reavaliação da técnica inalatória.Resultados: Avaliamos 170 participantes realizando 266 manobras inalatórias com 10 diferentes inaladores. Registou-se uma melhoria no número de erros críticos em todos os tipos de inaladores, com significado estatístico naqueles que mais facilmente informavam o doente de que a inalação fora correta. A melhoria da técnica inalatória relacionou-se significativamente com o score do CAT. No subgrupo de doentes que melhoraram sua técnica inalatória, os homens tiveram uma média do score de necessidades do BMQ significativamente maior do que as mulheres.Conclusões: Uma significativa melhoria da técnica inalatória foi observada nos inaladores que mais facilmente informam o doente sobre a correção da técnica inalatória. Os doentes mais sintomáticos mantiveram uma correta técnica inalatória de forma mais sustentada. As crenças sobre a necessidade do uso de inaladores estão associadas a uma melhor aprendizagem da técnica inalatória nos homens com DPOC

Faculty development for teachers of family medicine in Europe: Reflections on 16 years' experience with the international Bled course

Background: Instruction in principles and methods of medical education is a core component of the training of medical teachers. Curricula for new medical teachers have developed across Europe, but few European courses have had the success of the EURACT Bled course for teachers of family medicine. The course focuses on practical issues in medicine and the professional development of physicians. This article describes 16 years' experience with the Bled course for teachers in general practice/family medicine (GP/FM). Course structure: The course is centred on the preparation of a teaching module, exploring a specific theme in family medicine. The main teaching methods used are: keynote lectures, small group sessions, field work and preparation of a teaching module by the participants. Outcomes: This course has attracted 555 participants from 20 countries since 1992. The course and its outputs have been applied in undergraduate and postgraduate teaching, and in continuous professional development (CPD) in several countries. It is a respected forum for faculty development. The experience of the Bled course suggests that academic medicine may be better able to fulfil its responsibilities by paying attention to relevant topics and using appropriate methods in undergraduate and postgraduate medical curricula.info:eu-repo/semantics/publishedVersio