INTRODUÇÃO À MEDICINA II

What is the relation between the results of the CARAT (Control of Alergic Rhinitis and Asthma Test) and the ones of lung function tests?

BACKGROUND

BackgroundJustification

Aims2

1- Ito Y, Adachi Y, Itazawa T, Okabe Y, Adachi YS, Higuchi O, Katsunuma T, Miyawaki T. “Association between the Results of the Childhood Asthma Control Test and Objective Parameters in Asthmatic Children” J Asthma. 2011 Nov 2. [Epub ahead of print]

Participants/MethodsResultsDiscussion

BACKGROUND

BackgroundJustification

Aims3

12 – E Bateman, L Boulet, A Cru, M FitzGerald, T Haahtela, M Levy, P O’Byrne, K Ohta, P, Paggiaro, S Pedersen, M Soto-Quiro, G Wong, N Barnes, P Barnes, A Becker, J Drazen, R Lemanske, E Pizichini, H Reddel, S Sullivan, S Wenzel – Global Strategy fot Asthma Management and Prevention http://www.ginasthma.org/pdf/GINA_Report_2010.pdf

Participants/MethodsResults

1-

BACKGROUND

BackgroundJustification

Aims

4 Participants/MethodsResults

11- M Masoli, D Fabian, S Holt, R Beasley – Global Burden of Asthma http://www.ginasthma.org/pdf/GINABurdenReport.pdf27- António Bugalho de Almeira, João A. Fonseca, Mário de Almeida, Ana Todo-Bom ETAL, Inquérito Nacional sobre a Asma (INASma), Dezembro 2010

Discussion

BACKGROUND

BackgroundJustification

Aims5

11- M Masoli, D Fabian, S Holt, R Beasley – Global Burden of Asthma http://www.ginasthma.org/pdf/GINABurdenReport.pdf

Participants/MethodsResultsDiscussion

Figure 2 – Asthma prevalence on a worldwide basis

BACKGROUND

BackgroundJustification

Aims6

ASTHMA AND LIFE QUALITY

“Psychological distress was more frequent in those with asthma (17.9% v 12.2%, p<0.01) and a higher proportion with asthma were at higher risk for anxiety or depression

(40.5% v 31.2%, p<0.01)”

“The burden of asthma on individuals and on society includes a substantial impact on quality of life. There is a widely held view

that monitoring the impact of asthma should include measures of its impact on quality of life. However, there is no generally agreed

approach to population-based monitoring of quality of life in relation to specific chronic diseases, such as asthma.”

2- Adams, R. J., D. H. Wilson, et al. (2004). "Psychological factors and asthma quality of life: a population based study." Thorax 59(11): 930-935.

Participants/MethodsResultsDiscussion

BACKGROUND

BackgroundJustification

Aims

7 Participants/MethodsResults

26- Miguel Domingues, Control of Allergic Rhinitis and Asthma Test (CARAT): its applicability in assessment of asthma control in adult subjects without rhinitis, ECS Universidade do Minho 2011

Discussion

JUSTIFICATION

Background

Justification

Aims8

CARAT Questionnaire(Control of Allergic Rhinitis and

Asthma Test)

- Zero costs;- Available on the Internet;

- No need for medical intervention;

Lung Function Test (LFT)

- Costs 11€;- Available only in some health

care institutions;- Requires medical

intervention;

3 - Ruiz Aguirre J, Vilert Garrofa E, Solanas Saura P, Morera Jordán C, Mallorquí Beltrán C, Mas Marqués M. “Costs of spirometry as a screening test for chronic obstructive pulmonary disease in primary care” Aten Primaria. 2005 Oct 31;36(7):373-7.

Participants/MethodsResultsDiscussion

JUSTIFICATION

BackgroundJustification

Aims9

“…in the new GINA guidelines, revised in 2006, emphasis is placed on the concept that the goal of

asthma treatment is to achieve and maintain clinical control. GINA 2006 recommends the classification of

asthma by the level of control: controlled, partly controlled, or uncontrolled.”

• There’s a need to reinforce the use of a wider set of control measures of asthma

13 - Toshiro Shirai, Kazuki Furuhashi, Takafumi Soda, Kingo Shida, “Relatioship of the Asthma Control Test with pulmonary function and exhaled nitric oxide,”Annals of Allergy, Asthma and Immunology”, vol 101 December 2008

Participants/MethodsResultsDiscussion

JUSTIFICATION

Background

Justification

Aims10

• Use of the CARAT questionnaire allows a closer and more frequent approach, since symptoms involving asthma can change

15. Toshiro Shirai, Kazuki Furuhashi, Takafumi Soda, Kingo Shida, “Relatioship of the Asthma Control Test with pulmonary function and exhaled nitric oxide,”Annals of Allergy, Asthma and Immunology”, vol 101 December 2008

“…asthma severity involves both the severity of the underlyingdisease and its responsiveness to treatment and may change

over months or years.”

Participants/MethodsResultsDiscussion

JUSTIFICATION

Background

Justification

Aims11

• A greater use of the CARAT questionnaire combined with other tests could decrease medical costs and increase life quality

Participants/MethodsResultsDiscussion

AIMS

Background

Justification

Aims12

• Evaluate the correlation between CARAT questionnaire and lung function test results in adults suffering from both asthma and rhinitis,

and who have done both tests;-Speculate about possible reasons for disparities

between CARAT and LFT results;• Assess whether a specific lung function test

variable (%PredFEV1) is directly related to CARAT results;

-Explain the reasoning behind possible findings.

Participants/MethodsResultsDiscussion

PARTICIPANTS/METHODS

Background

Justification

Aims13 Participants/MethodsResults

1. PARTICIPANTS:1.1 CHARACTERISTICS:

• Asthma and Rhinitis (or Asthma) patients from “Centro Hospital do Porto”;

- Male and Female;- Over 18 years;- Able to read and fill in the questionnaire;- Had undertaken the Spirometry Test

around the same time they had answered the CARAT questionnaire.

Discussion

PARTICIPANTS/METHODS

Background

Justification

Aims14 Participants/MethodsResults

2. METHODS:

Observational Cross Sectional

THIS STUDY IS:

Discussion

PARTICIPANTS/METHODS

Background

Justification

Aims

15 Participants/MethodsResults

2.1 DATA COLLECTING:

• Data retrieved from the Immunoallergology service’s Doctor’s Suport System (SAM) of the São João Hospital during the period of February- July 2011. Diseases shown were diagnosed in person by the physician. Both plain text medical history files and ICD-9-coded diagnoses were used. In some cases, information was missing;

• We had access to variables such as: age, gender, weight, height, diagnosis (asthma and/or rhinitis), atopy and also the scores obtained in the CARAT and Lung Function Tests.

Discussion

PARTICIPANTS/METHODS

Background

Justification

Aims

16 Participants/MethodsResults

2.1.1 Variables:

Discussion

PARTICIPANTS/METHODS

Background

Justification

Aims

17 Participants/MethodsResults

2.2 SELECTED DATA:

2.2.1 Statistic Studies

• Patients were excluded according to the flowchart;

• The selected data underwent statistic treatment using IBM SPSS 20:

- Statistical analysis included Pearson correlations between different values;- Correlations were assessed for statistical significance

(p<0,05);- Results were represented in graphs and charts.

Discussion

18 Flowchart 1 – Inclusion/exclusion criteria

RESULTS

Background

Justification

Aims19 Participants/MethodsResults Discussion

Table 1: Demographic data from the population in our study

PARTICIPANTS/METHODS

Background

Justification

Aims

20 Participants/MethodsResults

2.2.3 Correlations:

• CARAT lower airway and %Pred FEV1;• Global score CARAT and %Pred FEV1;• CARAT upper airway score and % Pred FEV1;

Discussion

RESULTS

Background

Justification

Aims21 Participants/MethodsResults

Graph 1: Correlation between CARAT lower airway score and %Pred FEV1

*N=319

Pearson’s correlation coefficient:0,205

Significance:P<0,001

Discussion

RESULTS

Background

Justification

Aims22 Participants/MethodsResults

Graph 2: Correlation between Global CARAT score and %Pred FEV1

*N=319

Pearson’s correlation coefficient:0,078

Significance:P=0,164

Discussion

RESULTS

Background

Justification

Aims23 Participants/MethodsResults

Graph 3: Correlation between CARAT upper airway score and %Pred FEV1

*N=319

Pearson’s correlation coefficient:-0,138

Significance:P=0,013

Discussion

DISCUSSION

Background

Justification

Aims24 Participants/MethodsResultsDiscussion

1. GLOBAL CARAT SCORE AND %PRED FEV1:

• Non-significant;• Patients with controlled asthma and rhinitis

didn’t have a better result in their %Pred FEV1 value;

As expected, the results of the correlation between the Global CARAT Scores (concerning rhinitis) and the

spirometry results were not significant.

DISCUSSION

Background

Justification

Aims25 Participants/MethodsResultsDiscussion

2. CARAT UPPER AIRWAY SCORES AND%PRED FEV1:

• Significant (p=0.013);• Negative correlation coefficient(-0.138);

• Unexpected result. Correlation was done with the intent of displaying an absence of relationship between the two variables;

• Suggests that a higher control score regarding rinitis would imply a lower spirometry result;

DISCUSSION

Background

Justification

Aims26 Participants/MethodsResultsDiscussion

2. CARAT UPPER AIRWAY SCORES AND%PRED FEV1:

• Relation was opposite to what would be expected, even in case of improper separation of the questionaire scores, which we thought would lead to a positive correlation between upper airway scores and LFT results, suggesting that asthma and rhinitis could not be separated);

• May be due to an unaccounted for confounding parameter.

DISCUSSION

Background

Justification

Aims27 Participants/MethodsResultsDiscussion

2. CARAT LOWER AIRWAY SCORES AND%PRED FEV1:

• Significant (p≺0,001);• Correlation coefficient was quite low;• The degree to which the variation in CARAT's

scores explains the variation in %PredFEVI is only 4%;

• The fact that asthma control may be influenced by many factors, such as stress, allergies, could

explain these low values

DISCUSSION28 Backgrou

nd

Justification

Aims28 Participants/MethodsResultsDiscussion

• We have strong evidence to suggest that CARAT scores are properly separated, although there are no studies that prove so, since the Lower Airway Score has a much stronger and much more significant correlation (p<0,001) with lung function test results than the global CARAT scores, which had a near null coefficient, and a non-significant p value(P=0,164).

• This is further supported by the fact that lower airway scores behaved similarly to past attempts at similar approaches, such as the ACT (Asthma Control Test).

DISCUSSION

Background

Justification

Aims29 Participants/MethodsResultsDiscussion

• For future studies, a more detailed research about the negative correlation found between the results of the upper airway CARAT scores and %PredFEV1 could be done with the intent of finding if there is actually an unexpected correlation, or if it was just due to the complications of this study;

• Concerning future research into the correlation between CARAT Scores and %PredFEV1, we believe that, in future studies, an increased number of participants may attenuate the confounding parameters mentioned (stress, allergies…).

References 30

1. Ito Y, Adachi Y, Itazawa T, Okabe Y, Adachi YS, Higuchi O, Katsunuma T, Miyawaki T. “Association between the Results of the Childhood Asthma Control Test and Objective Parameters in Asthmatic Children” J Asthma. 2011 Nov 2. [Epub ahead of print]

2. Adams, R. J., D. H. Wilson, et al. (2004). "Psychological factors and asthma quality of life: a population based study." Thorax 59(11): 930-935

3. Ruiz Aguirre J, Vilert Garrofa E, Solanas Saura P, Morera Jordán C, Mallorquí Beltrán C, Mas Marqués M. “Costs of spirometry as a screening test for chronic obstructive pulmonary disease in primary care” Aten Primaria. 2005 Oct 31;36(7):373-7

4. J. A. Fonseca, L. Nogueira-Silva, M. Morais-Almeida, L. Azevedo, A. Sa-Sousa, M. Branco-Ferreira, L. Fernandes, J. Bousquet “Validation of a questionnaire (CARAT10) to assess rhinitis and asthma in patients with asthma” Allergy 2010; 65: 1042–1048

5. Hoeksema LJ, Bazzy-Asaad A, Lomotan EA, Edmonds DE, Ramírez-Garnica G, Shiffman RN, Horwitz LI. “Accuracy of a computerized clinical decision-support system for asthma assessment and management” J Am Med Inform Assoc. 2011 May 1;18(3):243-50

6. Sekiya K, Taniguchi M, Fukutomi Y, Tsuburai T, Mitsui C, Tanimoto H, Oshikata C, Tsurikisawa N, Hasegawa M, Akiyama, K. Actual control state of intermittent asthma classified on the basis of subjective symptoms. Intern Med. 2011;50(15):1545-51. Epub 2011 Aug 1

7. Hoskins G, Williams B, Jackson C, Norman PD, Donnan PT. “Assessing Asthma control in UK primary care: Use of routinely collected prospective observational consultation data to determine appropriateness of a variety of control assessment models.” BMC Fam Pract. 2011 Sep 29;12:105

8. Shiota N, Yokoyama A, Haruta Y, Hattori N, Kohno N. “Association of airway inflammation with asthma control level evaluated by the asthma control test” J Asthma. 2011 Nov;48(9):907-13. Epub 2011 Sep 26

31

References

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10. Barbaro MP, Lacedonia D, Palladino GP, Bergantino L, Ruggeri C, Martinelli D, Carpagnano GE. “Dyspnea perception in asthma: role of airways inflammation, age and emotional status” Respir Med. 2011 Feb;105(2):195-203. Epub 2010 Oct 20

11. M Masoli, D Fabian, S Holt, R Beasley – Global Burden of Asthma http://www.ginasthma.org/pdf GINABurdenReport.pdf

12. E Bateman, L Boulet, A Cru, M FitzGerald, T Haahtela, M Levy, P O’Byrne, K Ohta, P, Paggiaro, S Pedersen, M Soto-Quiro, G Wong, N Barnes, P Barnes, A Becker, J Drazen, R Lemanske, E Pizichini, H Reddel, S Sullivan, S Wenzel – Global Strategy fot Asthma Management and Prevention

13. Toshiro Shirai, Kazuki Furuhashi, Takafumi Soda, Kingo Shida, “Relatioship of the Asthma Control Test with pulmonary function and exhaled nitric oxide,”Annals of Allergy, Asthma and Immunology”, vol 101 December 2008

14. Malinovschi A, Pizzimenti S, Sciascia S, Heffler E, Badiu I, Rolla G. Exhaled breath condensate nitrates, but not nitrites or FENO, relate to asthma control, Respiratory Medicine,105(7),1007-13, Jul 2011

15. Kostikas K, Papaioannou AI, Tanou K, Giouleka P, Koutsokera A, Minas M, Papiris S, Gourgoulianis KI, Taylor DR, Loukides S. Exhaled NO and exhaled breath condensate pH in the evaluation of asthma control. Respiratory Medicine,105(4),526-32, Apr2011

16. Xu F, Zou Z, Yan S, Li F, Kan H, Norback D, Wieslander G, Xu J, Zhao Z ,Fractional exhaled nitric oxide in relation to asthma, allergic rhinitis, and atopic dermatitis in chinese children. J Asthma., , 48(10),1001-6, 2011 Dec

17. Sastre J, Olaguíbel JM, López Viña A, Vega JM, del Pozo V, Picado C. Increased body mass index does not lead to a worsening of asthma control in a large adult asthmatic population in Spain,Journal of Investigation and Allergology and Clinical Immunology.,20(7):551-5,2010.

32

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18. Youkou A, Hasegawa T, Suzuki K, Koya T, Sakagami T, Toyabe S, Arakawa M, Gejyo F, Narita I, Suzuki E. Influence of obesity on control in asthmatic Japanese patients defined by the Japanese definition of obesity, Internal Medicine.,50(18):1911-6,2011

19. Smith LA, Bokhour B, Hohman KH, Miroshnik I, Kleinman KP, Cohn E, Cortés DE, Galbraith A, Rand C, Lieu TA. Modifiable risk factors for suboptimal control and controller medication underuse among children with asthma. Pediatrics,122(4),760-9 Oct2008

20. Carroll WD, Wildhaber J, Brand PL. Parent misperception of control in childhood/adolescent asthma. The room to breathe survey, The European Respiratory Journal,Jun 2011

21. Papakosta D, Latsios D, Manika K, Porpodis K, Kontakioti E, Gioulekas D., Asthma Control Test Is Correlated to FEV(1) and Nitric Oxide in GreekAsthmatic Patients: Influence of Treatment, J Asthma, v 48, n 9,p 901-6, Sep 2011

22. Kilic H, Oguzulgen IK, Bakir F, Turktas H. Asthma in obese women:outcomesand factors involved, J Investig Allergol Clin Immunol, v 21, n 4, p 290-6, 2011

23. Yu HR, Niu CK, Kuo HC, Tsui KY, Wu CC, Ko CH, Sheen JM, Huang EY, Comparison of the Global Initiative for Asthma guideline-based Asthma Control Measure and the Childhood Asthma Control Test in evaluating asthma control in children, YangKD Pediatr Neonatology, v 51, n 5, p 273-8, Oct 2010

24. Shenolikar R, Song X, Anderson JA, Chu BC, Cantrell CR. Costs of asthma among US working adults, Am J Manag Care, v 17, n 6, p 409-16, Jun 2011

25. Prabhakaran L, Arul E, Abisheganaden J, Chee J., Difference in Asthma Control Test™ (ACT) scores in three different clinical practice settings, Ann Acad Med Singapore, v 39, n 10, p 783-9, 2010

26. Miguel Domingues, Control of Allergic Rhinitis and Asthma Test (CARAT): its applicability in assessment of asthma control in adult subjects without rhinitis,ECS Universidade do Minho 2011

27. António Bugalho de Almeira, João A. Fonseca, Mário de Almeida, Ana Todo-Bom ETAL, Inquérito Nacional sobre a Asma (INASma), Dezembro 2010

Alexandra Azevedo

Ana Mafalda Neves

Bárbara Oliveira

Caroline Lopes

Joana Ribeiro

José Pedro Barbosa

Maria Beatriz Sampaio

Maria Luísa Vieira

Paulo Santos

Regina Silva

Rodrigo Andrade

Rui Ananias Gonçalves

33Faculdade de Medicina da Universidade do Porto Turma 19

25 de Maio de 2012

We would like to thank

Prof. Dr. João Fonseca,

Prof. Dr. Altamiro da Costa Pereira,

Ana Margarida Pereira,

Daniela Linhares

for the help given and time expended in our study.

34

ACKNOWLEDGEMENTS

25 de Maio de 2012