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      Identification of clusters of asthma control: A preliminary analysis of the Inspirers studies Translated title: Identificar clusters de controlo da asma: Uma análise preliminar dos estudos Inspirers

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      Revista Portuguesa de Imunoalergologia
      Sociedade Portuguesa de Alergologia e Imunologia Clínica
      Análise de clusters, asma, classificação, controlo da asma, teste de controlo da asma e rinite alérgica, Asthma, asthma control, classification, cluster analysis, control of allergic rhinitis and asthma test

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          Abstract

          Aims: To identify distinct asthma control clusters based on Control of Allergic Rhinitis and Asthma Test (CARAT) and to compare patients’ characteristics among these clusters. Methods: Adults and adolescents (≥13 years) with persistent asthma were recruited at 29 Portuguese hospital outpatient clinics, in the context of two observational studies of the INSPIRERS project. Demographic and clinical characteristics, adherence to inhaled medication, beliefs about inhaled medication, anxiety and depression, quality of life, and asthma control (CARAT, >24 good control) were collected. Hierarchical cluster analysis was performed using CARAT total score (CARAT-T). Results: 410 patients (68% adults), with a median (percentile 25-percentile 75) age of 28 (16-46) years, were analysed. Three clusters were identified [mean CARAT-T (min-max)]: cluster 1 [27(24-30)], cluster 2 [19(14-23)] and cluster 3 [10(2-13)]. Patients in cluster 1 (34%) were characterised by better asthma control, better quality of life, higher inhaler adherence and use of a single inhaler. Patients in clusters 2 (50%) and 3 (16%) had uncontrolled asthma, lower inhaler adherence, more symptoms of anxiety and depression and more than half had at least one exacerbation in the previous year. Furthermore, patients in cluster 3 were predominantly female, had more unscheduled medical visits and more anxiety symptoms, perceived a higher necessity of their prescribed inhalers but also higher levels of concern about taking these inhalers. There were no differences in age, body mass index, lung function, smoking status, hospital admissions or specialist physician follow-up time among the three clusters. Conclusion: An unsupervised method based on CARAT-T, identified 3 clusters of patients with distinct, clinically meaningful characteristics. The cluster with better asthma control had a cut-off similar to the established in the validation study of CARAT and an additional cut-off seems to distinguish more severe disease. Further research is necessary to validate the asthma control clusters identified.

          Translated abstract

          Objetivos: Identificar clusters de controlo da asma baseados no Teste de Controlo da Asma e Rinite Alérgica (CARAT) e comparar as características dos doentes nos diferentes clusters. Métodos: Adultos e adolescentes (≥13 anos) com asma persistente foram recrutados em 29 centros no contexto de 2 estudos observacionais do projeto INSPIRERS. Foram recolhidos dados relativos a características demográficas e clínicas, adesão ao inalador, crenças sobre a medicação, sintomas de ansiedade e depressão, qualidade de vida e controlo da asma (CARAT, >24 bom controlo). Foi efetuada uma análise hierárquica de clusters usando a pontuação total do CARAT (CARAT-T).Resultados: Foram analisados 410 doentes (68% adultos), com uma idade mediana (percentil 25-percentil 75) de 28 (16-46) anos. Foram identificados três clusters [média CARAT-T(min-max)]: cluster 1 [27(24-30)], cluster 2 [19(14-23)] e cluster 3 [10(2-13)]. Os doentes no cluster 1 (34%) apresentavam melhor controlo da asma, melhor qualidade de vida, maior adesão aos inaladores e usavam um único inalador. Os doentes nos clusters 2 (50%) e 3 (16%) tinham a asma não controlada, menor adesão aos inaladores, mais sintomas de ansiedade e depressão e mais de metade reportavam pelo menos uma exacerbação no último ano. Adicionalmente, os doentes no cluster 3 eram predominantemente mulheres, tinham mais consultas médicas não agendadas, apresentavam mais sintomas de ansiedade, percebiam uma maior necessidade dos inaladores, mas também uma maior preocupação associada ao seu uso. Não se verificaram diferenças na idade, índice de massa corporal, função pulmonar, hábitos tabágicos, hospitalizações ou tempo de seguimento pelo médico especialista. Conclusões: Um método não supervisionado baseado no CARAT-T, identificou 3 clusters de doentes com diferentes características clínicas. O cluster com melhor controlo apresenta um ponto de corte semelhante ao estabelecido no estudo de validação do CARAT. Este estudo sugere ainda a existência de um ponto de corte adicional para distinguir doença mais grave. Mais investigação é necessária para validar os clusters identificados

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          International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma.

          Severe or therapy-resistant asthma is increasingly recognised as a major unmet need. A Task Force, supported by the European Respiratory Society and American Thoracic Society, reviewed the definition and provided recommendations and guidelines on the evaluation and treatment of severe asthma in children and adults. A literature review was performed, followed by discussion by an expert committee according to the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach for development of specific clinical recommendations. When the diagnosis of asthma is confirmed and comorbidities addressed, severe asthma is defined as asthma that requires treatment with high dose inhaled corticosteroids plus a second controller and/or systemic corticosteroids to prevent it from becoming "uncontrolled" or that remains "uncontrolled" despite this therapy. Severe asthma is a heterogeneous condition consisting of phenotypes such as eosinophilic asthma. Specific recommendations on the use of sputum eosinophil count and exhaled nitric oxide to guide therapy, as well as treatment with anti-IgE antibody, methotrexate, macrolide antibiotics, antifungal agents and bronchial thermoplasty are provided. Coordinated research efforts for improved phenotyping will provide safe and effective biomarker-driven approaches to severe asthma therapy.
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            Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration.

            Much medical research is observational. The reporting of observational studies is often of insufficient quality. Poor reporting hampers the assessment of the strengths and weaknesses of a study and the generalisability of its results. Taking into account empirical evidence and theoretical considerations, a group of methodologists, researchers, and editors developed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations to improve the quality of reporting of observational studies. The STROBE Statement consists of a checklist of 22 items, which relate to the title, abstract, introduction, methods, results and discussion sections of articles. Eighteen items are common to cohort studies, case-control studies and cross-sectional studies and four are specific to each of the three study designs. The STROBE Statement provides guidance to authors about how to improve the reporting of observational studies and facilitates critical appraisal and interpretation of studies by reviewers, journal editors and readers. This explanatory and elaboration document is intended to enhance the use, understanding, and dissemination of the STROBE Statement. The meaning and rationale for each checklist item are presented. For each item, one or several published examples and, where possible, references to relevant empirical studies and methodological literature are provided. Examples of useful flow diagrams are also included. The STROBE Statement, this document, and the associated Web site (http://www.strobe-statement.org/) should be helpful resources to improve reporting of observational research. Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.
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              Identification of asthma phenotypes using cluster analysis in the Severe Asthma Research Program.

              The Severe Asthma Research Program cohort includes subjects with persistent asthma who have undergone detailed phenotypic characterization. Previous univariate methods compared features of mild, moderate, and severe asthma. To identify novel asthma phenotypes using an unsupervised hierarchical cluster analysis. Reduction of the initial 628 variables to 34 core variables was achieved by elimination of redundant data and transformation of categorical variables into ranked ordinal composite variables. Cluster analysis was performed on 726 subjects. Five groups were identified. Subjects in Cluster 1 (n = 110) have early onset atopic asthma with normal lung function treated with two or fewer controller medications (82%) and minimal health care utilization. Cluster 2 (n = 321) consists of subjects with early-onset atopic asthma and preserved lung function but increased medication requirements (29% on three or more medications) and health care utilization. Cluster 3 (n = 59) is a unique group of mostly older obese women with late-onset nonatopic asthma, moderate reductions in FEV(1), and frequent oral corticosteroid use to manage exacerbations. Subjects in Clusters 4 (n = 120) and 5 (n = 116) have severe airflow obstruction with bronchodilator responsiveness but differ in to their ability to attain normal lung function, age of asthma onset, atopic status, and use of oral corticosteroids. Five distinct clinical phenotypes of asthma have been identified using unsupervised hierarchical cluster analysis. All clusters contain subjects who meet the American Thoracic Society definition of severe asthma, which supports clinical heterogeneity in asthma and the need for new approaches for the classification of disease severity in asthma.
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                Author and article information

                Journal
                imu
                Revista Portuguesa de Imunoalergologia
                Rev Port Imunoalergologia
                Sociedade Portuguesa de Alergologia e Imunologia Clínica (Lisboa, , Portugal )
                0871-9721
                December 2020
                : 28
                : 4
                : 231-240
                Affiliations
                [4] orgnameJosé de Mello Saúde orgdiv1Imunoalergologia
                [26] Barreiro orgnameCentro Hospitalar Barreiro Montijo orgdiv1Hospital Nossa Senhora do Rosário orgdiv2Serviço de Pneumologia
                [25] Portimão orgnameGrupo HPA Saúde orgdiv1Imunoalergologia
                [5] Porto orgnameMedicina, Educação, Investigação, Desenvolvimento e Avaliação
                [9] orgnameUniversidade do Porto orgdiv1Faculdade de Medicina orgdiv2Imunologia Básica e Clínica
                [3] orgnameCUF Porto Instituto & Hospital orgdiv1Imunoalergologia
                [7] orgnameCentro Hospitalar e Universitário de Coimbra orgdiv1Serviço de Pneumologia
                [32] orgnameCentro Hospitalar Tondela-Viseu orgdiv1Hospital de São Teotónio orgdiv2Serviço de Pediatria
                [23] Ponta Delgada orgnameHospital do Divino Espirito Santo orgdiv1Unidade de Imunoalergologia
                [21] Porto orgnameCentro Hospitalar de São João orgdiv1Serviço de Imunoalergologia
                [20] Portimão orgnameCentro Hospitalar Universitário do Algarve orgdiv1Serviço de Imunoalergologia
                [34] Portimão orgnameCentro de Imunoalergologia do Algarve orgdiv1Imunoalergologia
                [16] Torres Novas orgnameCentro Hospitalar do Médio Tejo orgdiv1Hospital Rainha Santa Isabel orgdiv2Serviço de Imunoalergologia
                [37] orgnameUniversidade do Porto orgdiv1Faculdade de Medicina orgdiv2Departamento de Medicina da Comunidade Informação e Decisão em Saúde
                [8] orgnameHospital Pedro Hispano orgdiv1Unidade Local de Saúde de Matosinhos orgdiv2Unidade de Imunoalergologia
                [6] orgnameCentro Hospitalar Universitário do Porto orgdiv1Centro Materno Infantil do Norte orgdiv2Serviço de Pediatria
                [14] orgnameCentro Hospitalar Universitário de Lisboa Central orgdiv1Hospital de Dona Estefânia orgdiv2Serviço de Imunoalergologia
                [33] Lisboa orgnameCentro Hospitalar de Lisboa Central orgdiv1Hospital Santa Marta orgdiv2Serviço de Pneumologia
                [30] Alfena orgnameTrofa Saúde orgdiv1Hospital Privado de Alfena orgdiv2Imunoalergologia
                [13] orgnameCentro Hospitalar de Leiria orgdiv1Imunoalergologia
                [17] Loures orgnameHospital Beatriz Ângelo orgdiv1Serviço de Pneumologia
                [24] Vila Real orgnameCentro Hospitalar de Trás-os-Montes e Alto Douro orgdiv1Hospital São Pedro de Vila Real orgdiv2Serviço de Pneumologia
                [18] Guimarães orgnameHospital da Senhora da Oliveira orgdiv1Serviço de Pediatria
                [10] orgnameCentro Hospitalar Lisboa Norte orgdiv1Hospital de Santa Maria orgdiv2Serviço de Imunoalergologia
                [2] orgnamePolytechnic Institute of Porto orgdiv1Porto Health School orgdiv2Dept. of Cardiovascular and Respiratory Sciences
                [11] orgnameHospital Pedro Hispano orgdiv1Unidade Local de Saúde de Matosinhos orgdiv2Serviço de Pediatria
                [31] Almada orgnameHospital Garcia de Orta orgdiv1Serviço de Pneumologia
                [29] orgnameUniversidade de Lisboa orgdiv1Faculdade de Medicina orgdiv2Instituto de Medicina Molecular
                [1] orgnameUniversity of Porto orgdiv1Faculty of Medicine orgdiv2Center for Health Technology and Services Research
                [19] orgnameHospital Amato Lusitano orgdiv1Unidade Local de Saúde de Castelo Branco orgdiv2Serviço de Imunoalergologia
                [22] Covilhã orgnameCentro Hospitalar Universitário Cova da Beira orgdiv1Serviço de Imunoalergologia
                [35] orgnameCentro Hospitalar Vila Nova de Gaia/Espinho orgdiv1Unidade I orgdiv2Serviço de Imunoalergologia
                [36] orgnameCentro Hospitalar Vila Nova de Gaia/Espinho orgdiv1Unidade I orgdiv2Serviço de Pneumologia
                [28] orgnameHospitalar de Lisboa Norte orgdiv1Hospital de Santa Maria orgdiv2Departamento de Pediatria
                [12] orgnameCentro Hospitalar e Universitário de Coimbra orgdiv1Serviço de Imunoalergologia
                [27] Vila Nova de Famalicão orgnameCentro Hospitalar do Médio Ave orgdiv1Unidade Hospitalar de Famalicão orgdiv2Serviço de Pediatria
                [15] Lisboa orgnameFaculdade de Ciências Médicas orgdiv1NOVA Medical School orgdiv2Environmental Health research group
                Article
                S0871-97212020000400004 S0871-9721(20)02800400004
                10.32932/rpia.2020.12.046
                1c002cfc-40fc-4ddb-8cf7-151bf4946d0c

                This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

                History
                : 16 December 2019
                : 20 January 2020
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 34, Pages: 10
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                Análise de clusters,classification,control of allergic rhinitis and asthma test,asma,cluster analysis,controlo da asma,classificação,Asthma,asthma control,teste de controlo da asma e rinite alérgica

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