Alan Kaplan - Academia.edu (original) (raw)

Papers by Alan Kaplan

Allergy, Asthma & Clinical Immunology, 2018

Background: Although several aspects of asthma care have been identified as being sub-optimal in ... more Background: Although several aspects of asthma care have been identified as being sub-optimal in Canada, such as patient education, practice guideline adoption, and access to care, there remains a need to determine the extent to which these gaps remain, so as to investigate their underlying causes, and potential solutions. Methods: An ethics-approved mixed methods educational needs assessment was conducted in four Canadian provinces (Alberta, British Columbia, Ontario, and Quebec), combining a qualitative phase (45-min semi-structured interviews with community-based healthcare providers and key stakeholders) and a quantitative phase (15-min survey, healthcare providers only). Results: A total of 234 participants were included in the study, 44 in semi-structured interviews and 190 in the online survey. Five clinical areas were reported to be suboptimal by multiple categories of participants, and specific causes were identified for each. These areas included: Integration of guidelines into clinical practice, use of spirometry, individualisation of asthma devices to patient needs, emphasis on patient adherence and self-management, and clarity regarding roles and responsibilities of different members of the asthma healthcare team. Common causes for gaps in all these areas included suboptimal knowledge amongst healthcare providers, differing perceptions on the importance of certain interventions, and inadequate communication between healthcare providers. Conclusions: This study provides a better understanding of the specific causes underlying common gaps and challenges in asthma care in Canada. This information can inform future continuing medical education, and help providers in community settings obtain access to adequate materials, resources, and training to support optimal care of adult patients with asthma.

Pulmonary Therapy, 2017

Introduction: Targeting small airway inflammation could lead to improved clinical outcomes in ast... more Introduction: Targeting small airway inflammation could lead to improved clinical outcomes in asthma. Previous observational studies concluded that therapy with extrafine-particle [mass median aerodynamic diameter (MMAD)

Frontiers in Pediatrics, 2019

Asthma is a heterogeneous disease comprising of multiple phenotypes and affects patients from chi... more Asthma is a heterogeneous disease comprising of multiple phenotypes and affects patients from childhood up to old age. In this review, we summarize the current knowledge on the similarities and differences in asthma across different age-groups, with emphasis on the perspective from primary care. Despite the similar disease presentation, phenotyping studies showed that there are differences in the distribution of phenotypes of asthma presenting in childhood compared to that in adulthood. Whereas, asthma with early age of onset tends to be of the atopic phenotype, the disease shifts toward the non-atopic phenotypes at later ages. Studies within primary care patients aiming to elucidate risk factors for future asthma exacerbation have shown pediatric and elderly patients to be at higher risk for future asthma attacks compared to other adult patients. Regardless, both pediatric and adult studies demonstrated previous asthma episodes and severity, along with high blood eosinophil to predict subsequent asthma attacks. Differences in childhood and adult asthma are not limited to the underlying phenotypes but also extends to the challenges in the diagnosis, treatment, and management of the disease. Diagnosis of asthma is complicated by age-specific differential diagnoses such as infectious wheezing and nasal obstruction in children, and aging-related problems such as heart disease and obesity in the elderly. There are also age-related issues leading to decreased disease control such as non-adherence, tobacco use, difficulty in using inhalers and corticosteroid-related side effects which hinder asthma control at different patient age-groups. Several clinical guidelines are available to guide the diagnosis and drug prescription of asthma in pediatric patients. However, there are conflicting recommendations for the diagnostic tools and treatment for pediatric patients, posing additional challenges for primary care physicians in working with multiple guidelines. While tools such as spirometry and peak flow variability are often available in primary care, their usage in preschool patients is not consistently recommended. FeNO measurement may be a valuable non-invasive tool which can be adopted by primary physicians to assist asthma diagnosis in preschool-age patients.

Primary Care Respiratory Journal, 2012

npj Primary Care Respiratory Medicine, 2020

Comorbid conditions (comorbidities) can complicate the diagnosis and management of asthma. In dif... more Comorbid conditions (comorbidities) can complicate the diagnosis and management of asthma. In different age groups, comorbid conditions can present varying challenges, including diagnostic confusion due to mimicking asthma symptoms, exacerbation of asthma symptoms, therapy for comorbid conditions affecting asthma or therapy for asthma affecting these conditions. This review aims to summarise some common comorbid conditions with asthma, such as rhinitis, vocal cord dysfunction, gastro-oesophageal reflux, psychiatric disorders, obesity and obstructive sleep apnoea, and discuss their prevalence, symptoms, diagnosis and treatment, highlighting any differences in how they impact children and adults. Overall, there is a lack of data on the impact of treating comorbid conditions on asthma outcomes and further studies are needed to guide age-appropriate asthma management in the presence of these conditions.

Primary Care Respiratory Journal, 2008

Exacerbations are very important factors which affect the morbidity, mortality and progression of... more Exacerbations are very important factors which affect the morbidity, mortality and progression of COPD. In this study, the relative efficacy of the long-acting inhaled bronchodilator/antiinflammatory combination salmeterol/fluticasone propionate (SFC) 50/500 mcg twice daily was compared to the longacting bronchodilator tiotropium (Tio) 18 mcg once daily in preventing exacerbations and related outcomes in severe and very severe chronic obstructive pulmonary disease (COPD). This 2-year, double-blind, double-dummy parallel study recruited 1323 patients with COPD (mean FEV 1 of 39%). The primary endpoint was health care utilisation exacerbation rate. Other endpoints included health status measured by the St. George's Respiratory Questionnaire (SGRQ), mortality, adverse events, and study withdrawal. The study was funded by GlaxoSmithKline. Results: Exacerbation Rate: 1.28 in SFC vs 1.32 in Tio (p =0.656); SGRQ: 2.1 difference over two years; Withdrawal from study: 29% higher in Tio vs SFC (p=0.005); Mortality: SFC 3% vs Tio 6% (p=0.032); Pneumonia: More reported in the SFC group than Tio (p=0.008). Conclusion: Patients with severe COPD treated with SFC had a statistically significant improvement in quality of life and mortality, and had a significant decrease in withdrawals. The exacerbation rates were similar, but the SFC group had significantly more pneumonias.

Journal of Asthma and Allergy, 2018

Background: An inhaled corticosteroid (ICS) or leukotriene receptor antagonist (LTRA) may prevent... more Background: An inhaled corticosteroid (ICS) or leukotriene receptor antagonist (LTRA) may prevent wheezing/asthma attacks in preschoolers with recurrent wheeze when added to shortacting β-agonist (SABA). Objective: The aim of this historical matched cohort study was to assess the effectiveness of these treatments for preventing wheezing/asthma attacks. Methods: Electronic medical records from the Optimum Patient Care Research Database were used to characterize a UK preschool population (1-5 years old) with two or more episodes of wheezing during 1 baseline year before first prescription (index date) of ICS or LTRA, or repeat prescription of SABA. Children initiating ICS or LTRA on the index date were matched 1:4 to those prescribed only SABA for age, sex, year of index prescription, mean baseline SABA dose, baseline attacks, baseline antibiotic prescriptions, and eczema diagnosis. Wheezing/ asthma attacks (defined as asthma-related emergency attendance, hospital admission, or acute oral corticosteroid prescription) during 1 outcome year were compared using conditional logistic regression. Results: Matched ICS and SABA cohorts included 990 and 3,960 children, respectively (61% male; mean [SD] age 3.2 [1.3] years), and matched LTRA and SABA cohorts included 259 and 1,036 children, respectively (65% male; mean [SD] age 2.6 [1.2] years). We observed no significant difference between matched cohorts in the odds of a wheezing/asthma attack: ICS vs SABA, OR (95% CI) 1.01 (0.85-1.19) and LTRA vs SABA, OR (95% CI) 1.28 (0.96-1.72). Conclusion: We found no evidence that initiation of ICS or LTRA therapy is associated with fewer attacks during 1 outcome year than SABA alone for a heterogeneous group of preschool children with recurrent wheeze in the real-life clinical setting.

Canadian Journal of Respiratory, Critical Care, and Sleep Medicine, 2017

Revue canadienne des soins respiratoires et critiques et de la médecine du sommeil

Canadian respiratory journal, 2018

Poor inhaler technique and nonadherence impair the efficacy of medications for asthma and chronic... more Poor inhaler technique and nonadherence impair the efficacy of medications for asthma and chronic obstructive pulmonary disease (COPD). A range of factors, including age, dexterity, inspiratory capacity, cognitive ability, health literacy, and ethnicity, can impact a patient's ability and intention to use their device. Treatment success can also be influenced by patient preferences and perceptions. Therefore, it is important that healthcare professionals effectively match inhaler devices to individual patients' needs and abilities and empower patients by including them in treatment decisions. Physicians must, therefore, fully understand the characteristics of each device, as well as their patients' demographic characteristics and comorbidities. Following device selection, patient training and education, including a physical demonstration of the device, are key to eliminate any critical errors that may impact on health outcomes. Inhaler technique should be frequently rech...

European respiratory review : an official journal of the European Respiratory Society, 2017

Chronic obstructive pulmonary disease (COPD) is a common disease leading to further morbidity and... more Chronic obstructive pulmonary disease (COPD) is a common disease leading to further morbidity and significant mortality. The first step for any condition is to make the appropriate diagnosis, and spirometry barriers abound in practice around the world. It is tempting to undertake mass screening on all smokers to detect COPD. While this would pick up cases of COPD, results of studies of its effect on COPD end-points such as exacerbations, hospitalisations and mortality are disappointing. As such, aggressive case finding of COPD by screening for symptoms that patients may not themselves perceive is very important in primary care, with subsequent spirometry defining the diagnosis.We also have to separate out population screening from individual patient interactions. Performing spirometry, even on a truly asymptomatic patient, may allow earlier diagnosis and modification of risk factors such as smoking (mostly) and exacerbation risk. It also recognises patients with early disease who ar...

Canadian Journal of Gastroenterology, 2005

As an update to previously published recommendations for the management of Helicobacter pylori in... more As an update to previously published recommendations for the management of Helicobacter pylori infection, an evidence-based appraisal of 14 topics was undertaken in a consensus conference sponsored by the Canadian Helicobacter Study Group. The goal was to update guidelines based on the best available evidence using an established and uniform methodology to address and formulate recommendations for each topic. The degree of consensus for each recommendation is also presented. The clinical issues addressed and recommendations made were: population-based screening for H pylori in asymptomatic children to prevent gastric cancer is not warranted; testing for H pylori in children should be considered if there is a family history of gastric cancer; the goal of diagnostic interventions should be to determine the cause of presenting gastrointestinal symptoms and not the presence of H pylori infection; recurrent abdominal pain of childhood is not an indication to test for H pylori infection; ...

Primary Care Respiratory Journal, 2008

Allergic rhinitis is presently the most common chronic disorder in the pediatric population. It c... more Allergic rhinitis is presently the most common chronic disorder in the pediatric population. It can affect sleep at night and cause daytime sleepiness, with school absenteeism, "presenteeism" or inattention, mood disturbances and psychosocial problems. All this in turn can contribute to reduce school performance. The correct treatment of allergic rhinitis can improve school performance, though the fi rst generation antihistamines have unacceptable central and anticholinergic effects that can actually worsen the situation. The second generation antihistamines constitute the drug treatment of choice for allergic rhinitis in children. Vasoconstrictors should not be used in pediatric patients, due to their unpredictable pharmacokinetics and very narrow therapeutic margin. Intranasal corticoids could improve school performance in some patients, by reducing nose block or congestion, the nocturnal sleep disturbances, and daytime sleepiness. Concrete studies of the impact of chromones, anticholinergic agents, antileukotrienes and immunotherapy upon school performance are lacking.

Canadian respiratory journal : journal of the Canadian Thoracic Society

To evaluate the effectiveness of montelukast as monotherapy for patients with mild asthma who rem... more To evaluate the effectiveness of montelukast as monotherapy for patients with mild asthma who remain uncontrolled or unsatisfied while on inhaled corticosteroid (ICS) monotherapy. A multicentre, open-label study. Patients (six years of age or older) had ICS therapy discontinued and were treated with orally administered montelukast once daily for six weeks. The primary outcome measure was the rate at which asthma symptom control was achieved or maintained after six weeks of treatment. The secondary outcome measures were to compare compliance and physician satisfaction, and to further assess the safety and tolerability of montelukast. Of the 534 patients enrolled, 481 (90.1%) completed the study. Mean (+/- SD) age was 27.8+/-19.0 years. The number of patients with uncontrolled symptoms decreased from 455 (85.2%) at baseline to 143 (26.8%) at week 6 (P<0.001), and mean Asthma Control Questionnaire score decreased from 1.4+/-0.8 to 0.6+/-0.6 (P<0.001), representing a clinically si...

Canadian respiratory journal : journal of the Canadian Thoracic Society, 2006

The present supplement summarizes the proceedings of the symposium "Implementing practice gu... more The present supplement summarizes the proceedings of the symposium "Implementing practice guidelines: A workshop on guidelines dissemination and implementation with a focus on asthma and…

New England Journal of Medicine, 2007

There are several treatment options available for patients who have mild persistent asthma. After... more There are several treatment options available for patients who have mild persistent asthma. After being shown a typical case study and three possible treatment options, three respiratory specialists each selected a different option. The options were: using a combination beclometasone/albuterol inhaler on an as-needed basis; daily treatment with an oral leukotriene receptor antagonist together with asneeded use of a short-acting beta2-agonist (SABA) inhaler; and using a combination inhaled corticosteroid/long-acting beta2-agonist inhaler once-daily together with as-needed SABA. The evidence for each option is reviewed in the light of recent research.

Canadian Medical Association Journal, 2008

Canadian Medical Association Journal, 2009

Canadian Medical Association Journal, 2009

• A clinical diagnosis of asthma should be prompted by intermittent symptoms of breathlessness, w... more • A clinical diagnosis of asthma should be prompted by intermittent symptoms of breathlessness, wheezing, cough, sputum or chest tightness. • Measurements of lung function by spirometry, before and after administration of a β 2-agonist, should be used to confirm the clinical diagnosis of asthma. • Occupational asthma should be considered in all cases of new-onset asthma in adults. • Challenge testing is most useful to exclude a diagnosis of asthma.

Pulmonary Therapy

Asthma is a chronic inflammatory disease involving multiple mediators and cytokines. While our cu... more Asthma is a chronic inflammatory disease involving multiple mediators and cytokines. While our current treatments have shown significant therapeutic benefits, there still appear to be some patients who, despite aggressive therapy, good adherence, and inhaler technique, continue to have exacerbations. Exacerbations lead to loss of lung function, exposure to systemic corticosteroids, effects on quality of life, and even mortality. There is a large number of glucagon-like peptide-1 (GLP-1) receptors in the lung even compared with other organs, and studies have shown evidence of reduced exacerbations in asthmatics treated with GLP-1 receptor agonists (GLP-1 RA). While weight loss may affect lung mechanics, evidence of inflammatory changes has been revealed that could explain this relationship. This article will review the data behind these conjectures and outline potential clinical utility and the need for future studies to truly understand the role of GLP-1 receptors in the lung.

Respiratory Research, 2020

Diagnosing and treating asthma in paediatric patients remains challenging, with many children and... more Diagnosing and treating asthma in paediatric patients remains challenging, with many children and adolescents remaining uncontrolled despite treatment. Selecting the most appropriate pharmacological treatment to add onto inhaled corticosteroids (ICS) in children and adolescents with asthma who remain symptomatic despite ICS can be difficult. This literature review compares the efficacy and safety of long-acting β2-agonists (LABAs), leukotriene receptor antagonists (LTRAs) and long-acting muscarinic antagonists (LAMAs) as add-on treatment to ICS in children and adolescents aged 4–17 years.A literature search identified a total of 29 studies that met the inclusion criteria, including 21 randomised controlled trials (RCTs) of LABAs versus placebo, two RCTs of LAMAs (tiotropium) versus placebo, and four RCTs of LTRA (montelukast), all as add-on to ICS. In these studies, tiotropium and LABAs provided greater improvements in lung function than LTRAs, when compared with placebo as add-on t...

Allergy, Asthma & Clinical Immunology, 2018

Background: Although several aspects of asthma care have been identified as being sub-optimal in ... more Background: Although several aspects of asthma care have been identified as being sub-optimal in Canada, such as patient education, practice guideline adoption, and access to care, there remains a need to determine the extent to which these gaps remain, so as to investigate their underlying causes, and potential solutions. Methods: An ethics-approved mixed methods educational needs assessment was conducted in four Canadian provinces (Alberta, British Columbia, Ontario, and Quebec), combining a qualitative phase (45-min semi-structured interviews with community-based healthcare providers and key stakeholders) and a quantitative phase (15-min survey, healthcare providers only). Results: A total of 234 participants were included in the study, 44 in semi-structured interviews and 190 in the online survey. Five clinical areas were reported to be suboptimal by multiple categories of participants, and specific causes were identified for each. These areas included: Integration of guidelines into clinical practice, use of spirometry, individualisation of asthma devices to patient needs, emphasis on patient adherence and self-management, and clarity regarding roles and responsibilities of different members of the asthma healthcare team. Common causes for gaps in all these areas included suboptimal knowledge amongst healthcare providers, differing perceptions on the importance of certain interventions, and inadequate communication between healthcare providers. Conclusions: This study provides a better understanding of the specific causes underlying common gaps and challenges in asthma care in Canada. This information can inform future continuing medical education, and help providers in community settings obtain access to adequate materials, resources, and training to support optimal care of adult patients with asthma.

Pulmonary Therapy, 2017

Introduction: Targeting small airway inflammation could lead to improved clinical outcomes in ast... more Introduction: Targeting small airway inflammation could lead to improved clinical outcomes in asthma. Previous observational studies concluded that therapy with extrafine-particle [mass median aerodynamic diameter (MMAD)

Frontiers in Pediatrics, 2019

Asthma is a heterogeneous disease comprising of multiple phenotypes and affects patients from chi... more Asthma is a heterogeneous disease comprising of multiple phenotypes and affects patients from childhood up to old age. In this review, we summarize the current knowledge on the similarities and differences in asthma across different age-groups, with emphasis on the perspective from primary care. Despite the similar disease presentation, phenotyping studies showed that there are differences in the distribution of phenotypes of asthma presenting in childhood compared to that in adulthood. Whereas, asthma with early age of onset tends to be of the atopic phenotype, the disease shifts toward the non-atopic phenotypes at later ages. Studies within primary care patients aiming to elucidate risk factors for future asthma exacerbation have shown pediatric and elderly patients to be at higher risk for future asthma attacks compared to other adult patients. Regardless, both pediatric and adult studies demonstrated previous asthma episodes and severity, along with high blood eosinophil to predict subsequent asthma attacks. Differences in childhood and adult asthma are not limited to the underlying phenotypes but also extends to the challenges in the diagnosis, treatment, and management of the disease. Diagnosis of asthma is complicated by age-specific differential diagnoses such as infectious wheezing and nasal obstruction in children, and aging-related problems such as heart disease and obesity in the elderly. There are also age-related issues leading to decreased disease control such as non-adherence, tobacco use, difficulty in using inhalers and corticosteroid-related side effects which hinder asthma control at different patient age-groups. Several clinical guidelines are available to guide the diagnosis and drug prescription of asthma in pediatric patients. However, there are conflicting recommendations for the diagnostic tools and treatment for pediatric patients, posing additional challenges for primary care physicians in working with multiple guidelines. While tools such as spirometry and peak flow variability are often available in primary care, their usage in preschool patients is not consistently recommended. FeNO measurement may be a valuable non-invasive tool which can be adopted by primary physicians to assist asthma diagnosis in preschool-age patients.

Primary Care Respiratory Journal, 2012

npj Primary Care Respiratory Medicine, 2020

Comorbid conditions (comorbidities) can complicate the diagnosis and management of asthma. In dif... more Comorbid conditions (comorbidities) can complicate the diagnosis and management of asthma. In different age groups, comorbid conditions can present varying challenges, including diagnostic confusion due to mimicking asthma symptoms, exacerbation of asthma symptoms, therapy for comorbid conditions affecting asthma or therapy for asthma affecting these conditions. This review aims to summarise some common comorbid conditions with asthma, such as rhinitis, vocal cord dysfunction, gastro-oesophageal reflux, psychiatric disorders, obesity and obstructive sleep apnoea, and discuss their prevalence, symptoms, diagnosis and treatment, highlighting any differences in how they impact children and adults. Overall, there is a lack of data on the impact of treating comorbid conditions on asthma outcomes and further studies are needed to guide age-appropriate asthma management in the presence of these conditions.

Primary Care Respiratory Journal, 2008

Exacerbations are very important factors which affect the morbidity, mortality and progression of... more Exacerbations are very important factors which affect the morbidity, mortality and progression of COPD. In this study, the relative efficacy of the long-acting inhaled bronchodilator/antiinflammatory combination salmeterol/fluticasone propionate (SFC) 50/500 mcg twice daily was compared to the longacting bronchodilator tiotropium (Tio) 18 mcg once daily in preventing exacerbations and related outcomes in severe and very severe chronic obstructive pulmonary disease (COPD). This 2-year, double-blind, double-dummy parallel study recruited 1323 patients with COPD (mean FEV 1 of 39%). The primary endpoint was health care utilisation exacerbation rate. Other endpoints included health status measured by the St. George's Respiratory Questionnaire (SGRQ), mortality, adverse events, and study withdrawal. The study was funded by GlaxoSmithKline. Results: Exacerbation Rate: 1.28 in SFC vs 1.32 in Tio (p =0.656); SGRQ: 2.1 difference over two years; Withdrawal from study: 29% higher in Tio vs SFC (p=0.005); Mortality: SFC 3% vs Tio 6% (p=0.032); Pneumonia: More reported in the SFC group than Tio (p=0.008). Conclusion: Patients with severe COPD treated with SFC had a statistically significant improvement in quality of life and mortality, and had a significant decrease in withdrawals. The exacerbation rates were similar, but the SFC group had significantly more pneumonias.

Journal of Asthma and Allergy, 2018

Background: An inhaled corticosteroid (ICS) or leukotriene receptor antagonist (LTRA) may prevent... more Background: An inhaled corticosteroid (ICS) or leukotriene receptor antagonist (LTRA) may prevent wheezing/asthma attacks in preschoolers with recurrent wheeze when added to shortacting β-agonist (SABA). Objective: The aim of this historical matched cohort study was to assess the effectiveness of these treatments for preventing wheezing/asthma attacks. Methods: Electronic medical records from the Optimum Patient Care Research Database were used to characterize a UK preschool population (1-5 years old) with two or more episodes of wheezing during 1 baseline year before first prescription (index date) of ICS or LTRA, or repeat prescription of SABA. Children initiating ICS or LTRA on the index date were matched 1:4 to those prescribed only SABA for age, sex, year of index prescription, mean baseline SABA dose, baseline attacks, baseline antibiotic prescriptions, and eczema diagnosis. Wheezing/ asthma attacks (defined as asthma-related emergency attendance, hospital admission, or acute oral corticosteroid prescription) during 1 outcome year were compared using conditional logistic regression. Results: Matched ICS and SABA cohorts included 990 and 3,960 children, respectively (61% male; mean [SD] age 3.2 [1.3] years), and matched LTRA and SABA cohorts included 259 and 1,036 children, respectively (65% male; mean [SD] age 2.6 [1.2] years). We observed no significant difference between matched cohorts in the odds of a wheezing/asthma attack: ICS vs SABA, OR (95% CI) 1.01 (0.85-1.19) and LTRA vs SABA, OR (95% CI) 1.28 (0.96-1.72). Conclusion: We found no evidence that initiation of ICS or LTRA therapy is associated with fewer attacks during 1 outcome year than SABA alone for a heterogeneous group of preschool children with recurrent wheeze in the real-life clinical setting.

Canadian Journal of Respiratory, Critical Care, and Sleep Medicine, 2017

Revue canadienne des soins respiratoires et critiques et de la médecine du sommeil

Canadian respiratory journal, 2018

Poor inhaler technique and nonadherence impair the efficacy of medications for asthma and chronic... more Poor inhaler technique and nonadherence impair the efficacy of medications for asthma and chronic obstructive pulmonary disease (COPD). A range of factors, including age, dexterity, inspiratory capacity, cognitive ability, health literacy, and ethnicity, can impact a patient's ability and intention to use their device. Treatment success can also be influenced by patient preferences and perceptions. Therefore, it is important that healthcare professionals effectively match inhaler devices to individual patients' needs and abilities and empower patients by including them in treatment decisions. Physicians must, therefore, fully understand the characteristics of each device, as well as their patients' demographic characteristics and comorbidities. Following device selection, patient training and education, including a physical demonstration of the device, are key to eliminate any critical errors that may impact on health outcomes. Inhaler technique should be frequently rech...

European respiratory review : an official journal of the European Respiratory Society, 2017

Chronic obstructive pulmonary disease (COPD) is a common disease leading to further morbidity and... more Chronic obstructive pulmonary disease (COPD) is a common disease leading to further morbidity and significant mortality. The first step for any condition is to make the appropriate diagnosis, and spirometry barriers abound in practice around the world. It is tempting to undertake mass screening on all smokers to detect COPD. While this would pick up cases of COPD, results of studies of its effect on COPD end-points such as exacerbations, hospitalisations and mortality are disappointing. As such, aggressive case finding of COPD by screening for symptoms that patients may not themselves perceive is very important in primary care, with subsequent spirometry defining the diagnosis.We also have to separate out population screening from individual patient interactions. Performing spirometry, even on a truly asymptomatic patient, may allow earlier diagnosis and modification of risk factors such as smoking (mostly) and exacerbation risk. It also recognises patients with early disease who ar...

Canadian Journal of Gastroenterology, 2005

As an update to previously published recommendations for the management of Helicobacter pylori in... more As an update to previously published recommendations for the management of Helicobacter pylori infection, an evidence-based appraisal of 14 topics was undertaken in a consensus conference sponsored by the Canadian Helicobacter Study Group. The goal was to update guidelines based on the best available evidence using an established and uniform methodology to address and formulate recommendations for each topic. The degree of consensus for each recommendation is also presented. The clinical issues addressed and recommendations made were: population-based screening for H pylori in asymptomatic children to prevent gastric cancer is not warranted; testing for H pylori in children should be considered if there is a family history of gastric cancer; the goal of diagnostic interventions should be to determine the cause of presenting gastrointestinal symptoms and not the presence of H pylori infection; recurrent abdominal pain of childhood is not an indication to test for H pylori infection; ...

Primary Care Respiratory Journal, 2008

Allergic rhinitis is presently the most common chronic disorder in the pediatric population. It c... more Allergic rhinitis is presently the most common chronic disorder in the pediatric population. It can affect sleep at night and cause daytime sleepiness, with school absenteeism, "presenteeism" or inattention, mood disturbances and psychosocial problems. All this in turn can contribute to reduce school performance. The correct treatment of allergic rhinitis can improve school performance, though the fi rst generation antihistamines have unacceptable central and anticholinergic effects that can actually worsen the situation. The second generation antihistamines constitute the drug treatment of choice for allergic rhinitis in children. Vasoconstrictors should not be used in pediatric patients, due to their unpredictable pharmacokinetics and very narrow therapeutic margin. Intranasal corticoids could improve school performance in some patients, by reducing nose block or congestion, the nocturnal sleep disturbances, and daytime sleepiness. Concrete studies of the impact of chromones, anticholinergic agents, antileukotrienes and immunotherapy upon school performance are lacking.

Canadian respiratory journal : journal of the Canadian Thoracic Society

To evaluate the effectiveness of montelukast as monotherapy for patients with mild asthma who rem... more To evaluate the effectiveness of montelukast as monotherapy for patients with mild asthma who remain uncontrolled or unsatisfied while on inhaled corticosteroid (ICS) monotherapy. A multicentre, open-label study. Patients (six years of age or older) had ICS therapy discontinued and were treated with orally administered montelukast once daily for six weeks. The primary outcome measure was the rate at which asthma symptom control was achieved or maintained after six weeks of treatment. The secondary outcome measures were to compare compliance and physician satisfaction, and to further assess the safety and tolerability of montelukast. Of the 534 patients enrolled, 481 (90.1%) completed the study. Mean (+/- SD) age was 27.8+/-19.0 years. The number of patients with uncontrolled symptoms decreased from 455 (85.2%) at baseline to 143 (26.8%) at week 6 (P<0.001), and mean Asthma Control Questionnaire score decreased from 1.4+/-0.8 to 0.6+/-0.6 (P<0.001), representing a clinically si...

Canadian respiratory journal : journal of the Canadian Thoracic Society, 2006

The present supplement summarizes the proceedings of the symposium "Implementing practice gu... more The present supplement summarizes the proceedings of the symposium "Implementing practice guidelines: A workshop on guidelines dissemination and implementation with a focus on asthma and…

New England Journal of Medicine, 2007

There are several treatment options available for patients who have mild persistent asthma. After... more There are several treatment options available for patients who have mild persistent asthma. After being shown a typical case study and three possible treatment options, three respiratory specialists each selected a different option. The options were: using a combination beclometasone/albuterol inhaler on an as-needed basis; daily treatment with an oral leukotriene receptor antagonist together with asneeded use of a short-acting beta2-agonist (SABA) inhaler; and using a combination inhaled corticosteroid/long-acting beta2-agonist inhaler once-daily together with as-needed SABA. The evidence for each option is reviewed in the light of recent research.

Canadian Medical Association Journal, 2008

Canadian Medical Association Journal, 2009

Canadian Medical Association Journal, 2009

• A clinical diagnosis of asthma should be prompted by intermittent symptoms of breathlessness, w... more • A clinical diagnosis of asthma should be prompted by intermittent symptoms of breathlessness, wheezing, cough, sputum or chest tightness. • Measurements of lung function by spirometry, before and after administration of a β 2-agonist, should be used to confirm the clinical diagnosis of asthma. • Occupational asthma should be considered in all cases of new-onset asthma in adults. • Challenge testing is most useful to exclude a diagnosis of asthma.

Pulmonary Therapy

Asthma is a chronic inflammatory disease involving multiple mediators and cytokines. While our cu... more Asthma is a chronic inflammatory disease involving multiple mediators and cytokines. While our current treatments have shown significant therapeutic benefits, there still appear to be some patients who, despite aggressive therapy, good adherence, and inhaler technique, continue to have exacerbations. Exacerbations lead to loss of lung function, exposure to systemic corticosteroids, effects on quality of life, and even mortality. There is a large number of glucagon-like peptide-1 (GLP-1) receptors in the lung even compared with other organs, and studies have shown evidence of reduced exacerbations in asthmatics treated with GLP-1 receptor agonists (GLP-1 RA). While weight loss may affect lung mechanics, evidence of inflammatory changes has been revealed that could explain this relationship. This article will review the data behind these conjectures and outline potential clinical utility and the need for future studies to truly understand the role of GLP-1 receptors in the lung.

Respiratory Research, 2020

Diagnosing and treating asthma in paediatric patients remains challenging, with many children and... more Diagnosing and treating asthma in paediatric patients remains challenging, with many children and adolescents remaining uncontrolled despite treatment. Selecting the most appropriate pharmacological treatment to add onto inhaled corticosteroids (ICS) in children and adolescents with asthma who remain symptomatic despite ICS can be difficult. This literature review compares the efficacy and safety of long-acting β2-agonists (LABAs), leukotriene receptor antagonists (LTRAs) and long-acting muscarinic antagonists (LAMAs) as add-on treatment to ICS in children and adolescents aged 4–17 years.A literature search identified a total of 29 studies that met the inclusion criteria, including 21 randomised controlled trials (RCTs) of LABAs versus placebo, two RCTs of LAMAs (tiotropium) versus placebo, and four RCTs of LTRA (montelukast), all as add-on to ICS. In these studies, tiotropium and LABAs provided greater improvements in lung function than LTRAs, when compared with placebo as add-on t...