Pharmacogenomics is one of the first clinical applications of the postgenomic era. It promises personalized medicine rather than the established "one size fits all" approach to drugs and dosages. The ...expected reduction in trial and error should ultimately lead to more efficient and safer drug therapy. In recent years, commercially available pharmacogenomic tests have been approved by the Food and Drug Administration (FDA), but their application in patient care remains very limited. More generally, the implementation of pharmacogenomics in routine clinical practice presents significant challenges. This article presents specific clinical examples of such challenges and discusses how obstacles to implementation of pharmacogenomic testing can be addressed.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
In the Netherlands, Combined Lifestyle Interventions (CLIs), offered in primary care, aim to reduce the number of children with overweight or obesity. CLIs are carried out by a multidisciplinary team ...and focus on dietary advice and guidance, exercise and behaviour change. These CLIs are not uniformly designed and vary in protocols to suit the local circumstances. Due to the variation in content of CLIs it is difficult to investigate their effectiveness. To enable a proper evaluation of CLIs, we first need to unravel the 'black boxes' of CLIs by identifying the various potentially effective components. First of all we identified potentially effective components in literature. Subsequently we organized an online consultation with experts with diverse backgrounds and asked if they could add potentially effective components. These components were then assembled into a checklist meant to determine the presence or absence of potentially effective components in CLIs for children. 42 experts participated. We identified 65 potentially effective components for CLIs for children with overweight or obesity that we categorized into three themes: content, organisation and implementation. Based on literature and expert opinions we developed a practical 65-item checklist to determine the presence of potentially effective components in a CLI. This checklist can be used in the development of CLIs as well as evaluation of CLIs.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Parents' underestimation of their child's weight status can hinder active participation in overweight prevention programs. We examined the level of agreement between the parents' perception of their ...child's weight status and the child's actual weight status, moderating factors, and change over time.
This cross-sectional study used data collected in 2009 (n = 8105), 2013 (n = 8844) and 2017 (n = 11,022) from a community-based survey conducted among parents of children age 2-12 years in the Netherlands. Parents classified their perception of their child's weight status on a 5-point Likert scale. In 2009 and 2013, the child's BMI was calculated from self-reported data by parents. The level of agreement between the parent's perception of the weight status and the actual weight status was examined using Cohen's kappa. The role of demographic factors on parents' perception were examined using logistic regression.
In 2009, 2013 and 2017, 6%, 6% and 5% of the parents, respectively, classified their child as heavy/extremely heavy. In 2009 and 2013, 64.7% and 61.0% of parents, respectively, underestimated the weight status of their overweight child. This was even higher among parents of obese children. Overall, the agreement between the parents' perception and the actual weight status improved from 2009 (kappa = 0.38) to 2013 (kappa = 0.43) (p<0.05), but remained unsatisfactory. The parents' underestimation of their child's overweight/obesity status was associated with the child's age in 2009 and 2013 (2-7 years; OR: 0.18), the child's gender in 2009 (male; OR: 0.55), and the parents' education level in 2009 (middle and high education; OR: 0.56 and 0.44 respectively).
Parents' underestimation of their child's weight status remains alarmingly high, particularly among parents of young, obese children. This underestimation is a barrier to preventing childhood overweight/obesity. Healthcare professionals should take this underestimation into consideration and should actively encourage parents to take steps to prevent overweight/obesity in their children.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background Aiming at partly controlled asthma (PCa) instead of controlled asthma (Ca) might decrease asthma medication use. Biomarkers, such as the fraction of exhaled nitric oxide (F eno ), allow ...further tailoring of treatment. Objective We sought to assess the cost-effectiveness and clinical effectiveness of pursuing PCa, Ca, or F eno -driven controlled asthma (FCa). Methods In a nonblind, pragmatic, cluster-randomized trial in primary care, adults (18-50 years of age) with a doctor's diagnosis of asthma who were prescribed inhaled corticosteroids were allocated to one of 3 treatment strategies: (1) aiming at PCa (Asthma Control Questionnaire ACQ score <1.50); (2) aiming at Ca (ACQ score <0.75); and (3) aiming at FCa (ACQ score <0.75 and F eno value <25 ppb). During 12 months' follow-up, treatment was adjusted every 3 months by using an online decision support tool. Outcomes were incremental cost per quality-adjusted life year gained, asthma control (ACQ score), quality of life (Asthma Quality of Life Questionnaire score), asthma medication use, and severe exacerbation rate. Results Six hundred eleven participants were allocated to the PCa (n = 219), Ca (n = 203), or FCa (n = 189) strategies. The FCa strategy improved asthma control compared with the PCa strategy ( P < .02). There were no differences in quality of life ( P ≥ .36). Asthma medication use was significantly lower for the PCa and FCa strategies compared with the Ca strategy (medication costs: PCa, $452; Ca, $551; and FCa, $456; P ≤ .04). The FCa strategy had the highest probability of cost-effectiveness at a willingness to pay of $50,000/quality-adjusted life year (86%; PCa, 2%; Ca, 12%). There were no differences in severe exacerbation rate. Conclusion A symptom- plus F eno -driven strategy reduces asthma medication use while sustaining asthma control and quality of life and is the preferred strategy for adult asthmatic patients in primary care.
Training health professionals in smoking cessation Carson, Kristin V; Verbiest, Marjolein EA; Crone, Mathilde R ...
Cochrane database of systematic reviews,
05/2012, Letnik:
2013, Številka:
12
Journal Article
Recenzirano
Odprti dostop
Background
Cigarette smoking is one of the leading causes of preventable death world wide. There is good evidence that brief interventions from health professionals can increase smoking cessation ...attempts. A number of trials have examined whether skills training for health professionals can lead them to have greater success in helping their patients who smoke.
Objectives
To determine the effectiveness of training health care professionals in the delivery of smoking cessation interventions to their patients, and to assess the additional effects of training characteristics such as intervention content, delivery method and intensity.
Search methods
The Cochrane Tobacco Addiction Group’s Specialised Register, electronic databases and the bibliographies of identified studies were searched and raw data was requested from study authors where needed. Searches were updated in March 2012.
Selection criteria
Randomized trials in which the intervention was training of health care professionals in smoking cessation. Trials were considered if they reported outcomes for patient smoking at least six months after the intervention. Process outcomes needed to be reported, however trials that reported effects only on process outcomes and not smoking behaviour were excluded.
Data collection and analysis
Information relating to the characteristics of each included study for interventions, participants, outcomes and methods were extracted by two independent reviewers. Studies were combined in a meta‐analysis where possible and reported in narrative synthesis in text and table.
Main results
Of seventeen included studies, thirteen found no evidence of an effect for continuous smoking abstinence following the intervention. Meta‐analysis of 14 studies for point prevalence of smoking produced a statistically and clinically significant effect in favour of the intervention (OR 1.36, 95% CI 1.20 to 1.55, p= 0.004). Meta‐analysis of eight studies that reported continuous abstinence was also statistically significant (OR 1.60, 95% CI 1.26 to 2.03, p= 0.03).
Healthcare professionals who had received training were more likely to perform tasks of smoking cessation than untrained controls, including: asking patients to set a quit date (p< 0.0001), make follow‐up appointments (p< 0.00001), counselling of smokers (p< 0.00001), provision of self‐help material (p< 0.0001) and prescription of a quit date (p< 0.00001). No evidence of an effect was observed for the provision of nicotine gum/replacement therapy.
Authors' conclusions
Training health professionals to provide smoking cessation interventions had a measurable effect on the point prevalence of smoking, continuous abstinence and professional performance. The one exception was the provision of nicotine gum or replacement therapy, which did not differ between groups.
Background
In people with chronic obstructive pulmonary disease (COPD) there is considerable variation in symptoms, limitations and well‐being, which often complicates medical care. To improve ...quality of life (QoL) and exercise tolerance, while reducing the number of exacerbations, a multidisciplinary program including different elements of care is needed.
Objectives
To evaluate the effects of integrated disease management (IDM) programs or interventions in people with COPD on health‐related QoL, exercise tolerance and number of exacerbations.
Search methods
We searched the Cochrane Airways Group Register of trials, CENTRAL, MEDLINE, EMBASE and CINAHL for potentially eligible studies (last searched 12 April 2012).
Selection criteria
Randomized controlled trials evaluating IDM programs for COPD compared with controls were included. Included interventions consisted of multidisciplinary (two or more health care providers) and multi‐treatment (two or more components) IDM programs with a duration of at least three months.
Data collection and analysis
Two review authors independently assessed trial quality and extracted data; if required, we contacted authors for additional data. We performed meta‐analyses using random‐effects modeling. We carried out sensitivity analysis for allocation concealment, blinding of outcome assessment, study design and intention‐to‐treat analysis.
Main results
A total of 26 trials involving 2997 people were included, with a follow‐up ranging from 3 to 24 months. Studies were conducted in 11 different countries. The mean age of the included participants was 68 years, 68% were male and the mean forced expiratory volume in one second (FEV1)% predicted value was 44.3% (range 28% to 66%). Participants were treated in all types of healthcare settings: primary (n = 8), secondary (n = 12), tertiary care (n = 1), and in both primary and secondary care (n = 5). Overall, the studies were of high to moderate methodological quality.
Compared with controls, IDM showed a statistically and clinically significant improvement in disease‐specific QoL on all domains of the Chronic Respiratory Questionnaire after 12 months: dyspnea (mean difference (MD) 1.02; 95% confidence interval (CI) 0.67 to 1.36); fatigue (MD 0.82; 95% CI 0.46 to 1.17); emotional (MD 0.61; 95% CI 0.26 to 0.95) and mastery (MD 0.75; 95% CI 0.38 to 1.12). The St. George's Respiratory Questionnaire (SGRQ) for QoL reached the clinically relevant difference of four units only for the impact domain (MD ‐4.04; 95% CI ‐5.96 to ‐2.11, P < 0.0001). IDM showed a significantly improved disease‐specific QoL on the activity domain of the SGRQ: MD ‐2.70 (95% CI ‐4.84 to ‐0.55, P = 0.01). There was no significant difference on the symptom domain of the SGRQ: MD ‐2.39 (95% CI ‐5.31 to 0.53, P = 0.11). According to the GRADE approach, quality of evidence on the SGRQ was scored as high quality, and on the CRQ as moderate quality evidence. Participants treated with an IDM program had a clinically relevant improvement in six‐minute walking distance of 43.86 meters compared with controls after 12 months (95% CI 21.83 to 65.89; P < 0.001, moderate quality). There was a reduction in the number of participants with one or more hospital admissions over three to 12 months from 27 per 100 participants in the control group to 20 (95% CI 15 to 27) per 100 participants in the IDM group (OR 0.68; 95% CI 0.47 to 0.99, P = 0.04; number needed to treat = 15). Hospitalization days were significantly lower in the IDM group compared with controls after 12 months (MD ‐3.78 days; 95% CI ‐5.90 to ‐1.67, P < 0.001). Admissions and hospital days were graded as high quality evidence. No adverse effects were reported in the intervention group. No difference between groups was found on mortality (OR 0.96; 95%CI 0.52 to 1.74). There was insufficient evidence to refute or confirm the long term effectiveness of IDM.
Authors' conclusions
In these COPD participants, IDM not only improved disease‐specific QoL and exercise capacity, but also reduced hospital admissions and hospital days per person.
The Internet may support patient self-management of chronic conditions, such as asthma.
To evaluate the effectiveness of Internet-based asthma self-management.
Randomized, controlled trial.
37 ...general practices and 1 academic outpatient department in the Netherlands.
200 adults with asthma who were treated with inhaled corticosteroids for 3 months or more during the previous year and had access to the Internet.
Asthma-related quality of life at 12 months (minimal clinically significant difference of 0.5 on the 7-point scale), asthma control, symptom-free days, lung function, and exacerbations.
Participants were randomly assigned by using a computer-generated permuted block scheme to Internet-based self-management (n = 101) or usual care (n = 99). The Internet-based self-management program included weekly asthma control monitoring and treatment advice, online and group education, and remote Web communications.
Asthma-related quality of life improved by 0.56 and 0.18 points in the Internet and usual care groups, respectively (adjusted between-group difference, 0.38 95% CI, 0.20 to 0.56). An improvement of 0.5 point or more occurred in 54% and 27% of Internet and usual care patients, respectively (adjusted relative risk, 2.00 CI, 1.38 to 3.04). Asthma control improved more in the Internet group than in the usual care group (adjusted difference, -0.47 CI, -0.64 to -0.30). At 12 months, 63% of Internet patients and 52% of usual care patients reported symptom-free days in the previous 2 weeks (adjusted absolute difference, 10.9% CI, 0.05% to 21.3%). Prebronchodilator FEV1 changed with 0.24 L and -0.01 L for Internet and usual care patients, respectively (adjusted difference, 0.25 L CI, 0.03 to 0.46 L). Exacerbations did not differ between groups.
The study was unblinded and lasted only 12 months.
Internet-based self-management resulted in improvements in asthma control and lung function but did not reduce exacerbations, and improvement in asthma-related quality of life was slightly less than clinically significant.
Netherlands Organization for Health Research and Development, ZonMw, and Netherlands Asthma Foundation.
The outcome measures most frequently used in studies on the effectiveness of migraine treatment are whether the patient is free of pain, nausea, and free of photophobia/phonophobia within two hours. ...However, no patient-centred outcome measures are available. Therefore, we performed an online Delphi procedure to compile a list of outcome measures deemed most important to migraine patients.
From a large database of migraine patients, we randomly selected 150 males and 150 females patients. We asked the open-ended question: 'If a new medicine was developed for migraine attacks, what would you wish the effect of this medication to be?' In the second and third rounds, we presented the answers of the first round and asked the patients to rate the importance of each item.
The initial response rate was 56% (n = 169). In the subsequent rounds the response rates were 90% (n = 152), and 97% (n = 147), respectively. Patients wanted their attack medication to treat the headache within 30 min, to prevent the attack from getting worse, to ensure they could function properly within 1 h, and prevent the recurrence of symptoms during the same day.
The currently used outcome measures in migraine research do not sufficiently reflect the wishes of patients. Patients want the medication to work faster, to take away pain at an earlier stage, to make them able to function properly quickly, and to prevent recurrence. These aspects should be considered in future evaluation of new attack medication for migraine.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
AbstractObjectiveTo assess the benefits and harms of spinal manipulative therapy (SMT) for the treatment of chronic low back pain.DesignSystematic review and meta-analysis of randomised controlled ...trials.Data sourcesMedline, PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, and trial registries up to 4 May 2018, including reference lists of eligible trials and related reviews.Eligibility criteria for selecting studiesRandomised controlled trials examining the effect of spinal manipulation or mobilisation in adults (≥18 years) with chronic low back pain with or without referred pain. Studies that exclusively examined sciatica were excluded, as was grey literature. No restrictions were applied to language or setting.Review methodsTwo reviewers independently selected studies, extracted data, and assessed risk of bias and quality of the evidence. The effect of SMT was compared with recommended therapies, non-recommended therapies, sham (placebo) SMT, and SMT as an adjuvant therapy. Main outcomes were pain and back specific functional status, examined as mean differences and standardised mean differences (SMD), respectively. Outcomes were examined at 1, 6, and 12 months. Quality of evidence was assessed using GRADE. A random effects model was used and statistical heterogeneity explored.Results47 randomised controlled trials including a total of 9211 participants were identified, who were on average middle aged (35-60 years). Most trials compared SMT with recommended therapies. Moderate quality evidence suggested that SMT has similar effects to other recommended therapies for short term pain relief (mean difference −3.17, 95% confidence interval −7.85 to 1.51) and a small, clinically better improvement in function (SMD −0.25, 95% confidence interval −0.41 to −0.09). High quality evidence suggested that compared with non-recommended therapies SMT results in small, not clinically better effects for short term pain relief (mean difference −7.48, −11.50 to −3.47) and small to moderate clinically better improvement in function (SMD −0.41, −0.67 to −0.15). In general, these results were similar for the intermediate and long term outcomes as were the effects of SMT as an adjuvant therapy. Evidence for sham SMT was low to very low quality; therefore these effects should be considered uncertain. Statistical heterogeneity could not be explained. About half of the studies examined adverse and serious adverse events, but in most of these it was unclear how and whether these events were registered systematically. Most of the observed adverse events were musculoskeletal related, transient in nature, and of mild to moderate severity. One study with a low risk of selection bias and powered to examine risk (n=183) found no increased risk of an adverse event (relative risk 1.24, 95% confidence interval 0.85 to 1.81) or duration of the event (1.13, 0.59 to 2.18) compared with sham SMT. In one study, the Data Safety Monitoring Board judged one serious adverse event to be possibly related to SMT.ConclusionSMT produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvement in function in the short term. Clinicians should inform their patients of the potential risks of adverse events associated with SMT.
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