Factors associated with treatment response to inhaled corticosteroids : insights from WTC-exposed and chronic users

Treatment response is the result of a complex interaction between host factors, environmental factors and drug-related factors. Those factors were studied separately in order to obtain the best possible picture of the optimal response to inhaled corticosteroids (ICS). First, we characterized the type of lung injury of World Trade Center (WTC)-exposed firefighters, identifying individuals and their characteristics. Host factors associated with prolonged ICS-containing treatment were body mass index, lower post-9 September 2001 (9/11) spirometry and first post-9/11 modified Medical Research Council (mMRC) dyspnea score. Worse baseline forced expiratory volume in 1 second (FEV1) and respiratory symptoms are host factors that predict response to ICS. Regarding biomarkers, a higher blood eosinophil count and increase in IL- 4 were associated with an increased risk of irritant-induced airflow obstruction. Furthermore, low immunoglobulin A (IgA) soon after WTC exposure was associated with lower longitudinal FEV1 measurements, increased risk of airflow obstruction and increased antibiotic treatment. Moreover, low IgA tends to predict response to ICS. Second, the environmental factor associated with prolonged ICS/LABA treatment was high intensity WTC exposure defined by arrival morning of 9/11. Last, drug-related factors associated with the response to ICS treatment were assessed. In a longitudinal study, ICS treatment improved lung function decline in individuals with WTC-related lung injury. This improvement was more pronounced when WTC-exposed firefighters were more adherent to ICS. Pharmaceutical counseling interventions, analyzed through nation-wide pharmacy data, led to a marked improvement in the adherence of asthma patients to ICS. This also resulted in an improved controller-to-total-ratio, indicating an improvement in asthma control. In conclusion, improved adherence to ICS treatment leads to reduced lung function decline and better asthma control

Factors predicting treatment of World Trade Center-related lung injury : a longitudinal cohort study

The factors that predict treatment of lung injury in occupational cohorts are poorly defined. We aimed to identify patient characteristics associated with initiation of treatment with inhaled corticosteroid/long-acting beta-agonist (ICS/LABA) >2 years among World Trade Center (WTC)-exposed firefighters. The study population included 8530 WTC-exposed firefighters. Multivariable logistic regression assessed the association of patient characteristics with ICS/LABA treatment for >2 years over two-year intervals from 11 September 2001-10 September 2017. Cox proportional hazards models measured the association of high probability of ICS/LABA initiation with actual ICS/LABA initiation in subsequent intervals. Between 11 September 2001-1 July 2018, 1629/8530 (19.1%) firefighters initiated ICS/LABA treatment for >2 years. Forced Expiratory Volume in 1 s (FEV1), wheeze, and dyspnea were consistently and independently associated with ICS/LABA treatment. High-intensity WTC exposure was associated with ICS/LABA between 11 September 2001-10 September 2003. The 10th percentile of risk for ICS/LABA between 11 September 2005-10 Septmeber 2007 was associated with a 3.32-fold increased hazard of actual ICS/LABA initiation in the subsequent 4 years. In firefighters with WTC exposure, FEV1, wheeze, and dyspnea were independently associated with prolonged ICS/LABA treatment. A high risk for treatment was identifiable from routine monitoring exam results years before treatment initiation

Student and teacher discourse during whole-class discussions of literature

Influenced by ongoing attention in the field of English Education to the multiple ways language is used to make meaning and to communicate, some teachers have adopted discussion models that promote natural conversations rather than question-and-answer sessions. Authentic classroom discussion may be achieved when teachers foster approaches that are more conversational than the predominant classroom interaction pattern of initiation-response-evaluation (I-R-E). Authentic classroom discussions involve shared power among participants whereby students are encouraged to verbalize independent opinions and to affect the direction and discourse of the discussion. This study examined the complex discourse interactions impacting discussion in classrooms in which teachers attempt to share control with students. ^ The overall goal of the study was to identify characteristics of discourse interactions in selected high school English classrooms in which teachers were explicitly attempting to engage students in authentic discussion of literary texts. To characterize the discourse patterns in these classrooms, the researcher focused data gathering and analysis on the congruence between participants\u27 assumptions and behaviors during discussions. Similarities and differences between semantic, syntactic, and turn taking patterns were examined, and analysis suggested ways that these patterns may impact implicit power structures in classrooms. ^ Using qualitative methods, the researcher observed whole-class discussions of literary texts and interviewed teachers and students in order to compare participants\u27 behaviors during discussion with their beliefs about the goals and outcomes of class discussion. After conducting content analysis with the interview transcripts, the researcher conducted conversation analysis with the discussion transcripts. Finally, cross-case discourse analysis was conducted to examine rhetorical moves related to classroom interaction patterns including questioning, helping, correcting, directing, and attributing the agency or authority behind a contribution. ^ Analysis suggested that teacher-directed interaction patterns were prevalent even in classrooms where authentic discussion behaviors, such as extended student-to-student interactions and participants\u27 challenges of each others\u27 ideas, were encouraged. The researcher proposed that teachers attempting to engage students in authentic discussion should consider their goals and methods for classroom discussion on a continuum between I-R-E sessions and natural conversation and should teach and model strategies for engaging in authentic discussion.

Community pharmacist counseling improves adherence and asthma control : a nationwide study

Background: Pharmaceutical counseling (PC) interventions have been shown to improve adherence to controller medication and asthma control. However, the real-life impact of these PC interventions in difficult-to-control asthma patients remains unclear. We aimed to assess the effectiveness of PC interventions in real life using nationwide claims data. Methods: Demographics and drugs use of patients who received ICS in 2017 with or without pharmaceutical counseling were retrieved from a Belgian claims database. Asthma-related drug use from 1 year before first ICS dispensing in 2017 (reference period) was compared with 1 year after. Outcomes were usage of inhaled corticosteroids (ICS) in defined daily doses (DDD), proportion of users of short-acting beta-agonist (SABA), antibiotics, oral corticosteroids (OCS), asthma biologicals and controller-to-total (CTT) ratio. Results: The study population consisted of difficult-to-control asthma patients aged 5-40 years with at least the first interview within 90 days after first ICS dispensing (n = 1350). ICS usage increased significantly in the year after PC intervention compared with the reference period (+ 43.3 DDD/patient, p < 0.05). A nominal decrease was observed in the proportion of SABA (48.0 to 46.2%) and antibiotics (54.5 to 52.7%) after PC intervention compared with the reference period. CTT ratio significantly increased from 0.671 to 0.749 (p < 0.05). The proportion of biological users was nominally lower in the intervention group compared with a control group (n = 50,477) in the post-intervention time period (0.22% versus 0.30%). Conclusions: This first nationwide study among difficult-to-control asthma patients suggests that community pharmacist counseling is effective in real life to improve controller adherence and asthma control

Determinants of poor inhaler technique and poor therapy adherence in obstructive lung diseases: A cross-sectional study in community pharmacies

Background Correct inhaler use can be challenging in real life, with incorrect use resulting in poor symptom control. The aim of this study was to examine factors associated with poor inhaler technique and poor therapy adherence among patients with obstructive lung disease in community pharmacies. Methods A cross-sectional study was conducted in patients with obstructive lung diseases in nine Belgian community pharmacies. Logistic regression analyses identified factors associated with poor inhaler technique and poor therapy adherence (assessed by the Test of Adherence to Inhalers and the modified Medication Possession Ratio).  Results Seventy obstructively impaired community patients (median age 64 y, 56% females) were included and the technique of 122 inhalers was assessed. Inhaler technique scored generally poor, with half of patients making critical errors in using at least one of their inhalers. In multivariable analysis, the use of multiple devices (adjusted OR, aOR 11.68; 95% CI 3.29 to 41.51) and a diagnosis of asthma-Chronic Obstructive Pulmonary Disease overlap (ACO; aOR 7.06; 95% CI 1.15 to 43.35), were associated with making critical errors in inhaler technique independent of quality of life. Non-Adherence occurred in more than one-Third of patients, and occurred in up to one half of the patients when also taking overuse into account. In multivariable analysis for therapy adherence, current smoking was associated with poor therapy adherence (aOR 0.15; 95% CI 0.02 to 0.96) independently of age and poor treatment knowledge. Therapy adherence was poor in patients with asthma compared with those with ACO. Current smokers and highly educated patients seemed to be at increased risk for inhaler overuse.  Conclusions Given the important role of a correct inhaler technique and therapy adherence in disease control, these findings emphasise the need for patient education and aiming uniformity in the inhaler device. Trial registration number B670201835229