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      Asthma care practicing among general practitioners in Lebanon: a cross-sectional study


      , MD, FCCP, FACP 1 , , MPH 2 , , DM 3 , , DMD, MPH , 2

      The Journal of Asthma

      Informa Healthcare USA, Inc.

      Control/management, education, epidemiology, pharmacotherapy

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          The aim of this study was to characterize the current practice of asthma among general practitioners (GPs) in Lebanon.


          Out of 2450 Lebanese registered GPs, a representative sample of 330 were stratified by region to fill out the questionnaire constructed on the basis of surveys developed mainly by the Chicago Asthma Surveillance Initiative Report Team in newly moderate persistent asthma patients aged 5 years and above. The questionnaire included information about ascertaining diagnostic techniques, pharmacotherapeutic approaches, formal patient education program; asthma related continuing medical education and asthma practice guidelines.


          Totally, 302 completed the questionnaire achieving a response rate of 91.5%. Chest radiography was the most commonly used diagnostic test (98%), while stain for eosinophilia was the less commonly used (7.9%). For clinical monitoring, cough and wheezing (98.7%) were mostly assessed. Short acting inhaled β 2-agonists were often the most prescribed (94.3%) followed by inhaled corticosteroids (87.4%) then by long acting β-agonist (LABA) and theophylline (27.5% and 20.9%, respectively). Moreover, 10% of GPs provided formal asthma education program, 72.2% attended professional education and 65% adopted guidelines.


          Based on current international guidelines, the overall Lebanese GPs practice of asthma management is not at an acceptable standard. Therefore, it is recommended to improve monitoring parameters, implement the asthma guidelines nationally and improve patient education.

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          Most cited references 27

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          Asthma exacerbations and sputum eosinophil counts: a randomised controlled trial.

          Treatment decisions in asthma are based on assessments of symptoms and simple measures of lung function, which do not relate closely to underlying eosinophilic airway inflammation. We aimed to assess whether a management strategy that minimises eosinophilic inflammation reduces asthma exacerbations compared with a standard management strategy. We recruited 74 patients with moderate to severe asthma from hospital clinics and randomly allocated them to management either by standard British Thoracic Society asthma guidelines (BTS management group) or by normalisation of the induced sputum eosinophil count and reduction of symptoms (sputum management group). We assessed patients nine times over 12 months. The results were used to manage those in the sputum management group, but were not disclosed in the BTS group. The primary outcomes were the number of severe exacerbations and control of eosinophilic inflammation, measured by induced sputum eosinophil count. Analyses were by intention to treat. The sputum eosinophil count was 63% (95% CI 24-100) lower over 12 months in the sputum management group than in the BTS management group (p=0.002). Patients in the sputum management group had significantly fewer severe asthma exacerbations than did patients in the BTS management group (35 vs 109; p=0.01) and significantly fewer patients were admitted to hospital with asthma (one vs six, p=0.047). The average daily dose of inhaled or oral corticosteroids did not differ between the two groups. A treatment strategy directed at normalisation of the induced sputum eosinophil count reduces asthma exacerbations and admissions without the need for additional anti-inflammatory treatment.
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            Can guideline-defined asthma control be achieved? The Gaining Optimal Asthma ControL study.

            For most patients, asthma is not controlled as defined by guidelines; whether this is achievable has not been prospectively studied. A 1-year, randomized, stratified, double-blind, parallel-group study of 3,421 patients with uncontrolled asthma compared fluticasone propionate and salmeterol/fluticasone in achieving two rigorous, composite, guideline-based measures of control: totally and well-controlled asthma. Treatment was stepped-up until total control was achieved (or maximum 500 microg corticosteroid twice a day). Significantly more patients in each stratum (previously corticosteroid-free, low- and moderate-dose corticosteroid users) achieved control with salmeterol/fluticasone than fluticasone. Total control was achieved across all strata: 520 (31%) versus 326 (19%) patients after dose escalation (p < 0.001) and 690 (41%) versus 468 (28%) at 1 year for salmeterol/fluticasone and fluticasone, respectively. Asthma became well controlled in 1,071 (63%) versus 846 (50%) after dose escalation (p < 0.001) and 1,204 (71%) versus 988 (59%) at 1 year. Control was achieved more rapidly and at a lower corticosteroid dose with salmeterol/fluticasone versus fluticasone. Across all strata, 68% and 76% of the patients receiving salmeterol/fluticasone and fluticasone, respectively, were on the highest dose at the end of treatment. Exacerbation rates (0.07-0.27 per patient per year) and improvement in health status were significantly better with salmeterol/fluticasone. This study confirms that the goal of guideline-derived asthma control was achieved in a majority of the patients.
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              Worldwide variations in the prevalence of asthma symptoms: the International Study of Asthma and Allergies in Childhood (ISAAC)

              The International Study of Asthma and Allergies in Childhood (ISAAC) was designed to allow comparisons between populations in different countries. ISAAC Phase One, reported here, used standardized simple surveys which were conducted among representative samples of school children from centres in most regions of the world. Two age groups (13-14 and 6-7 yrs) with approximately 3,000 children in each group were studied in each centre. The 13-14 yr olds (n=463,801) were studied in 155 centres (56 countries) and the 6-7 yr olds (n=257,800) were studied in 91 centres (38 countries). There were marked variations in the prevalence of asthma symptoms with up to 15-fold differences between countries. The prevalence of wheeze in the last 12 months ranged from 2.1-32.2% in the older age group and 4.1-32.1% in the younger age group and was particularly high in English speaking countries and Latin America. A video questionnaire completed in the older age group in 99 centres (42 countries) showed a similar pattern. The major differences between populations found in the International Study of Asthma and Allergies in Childhood Phase One are likely to be due to environmental factors. The results provide a framework for studies between populations in contrasting environments which are likely to yield new clues about the aetiology of asthma.

                Author and article information

                J Asthma
                J Asthma
                The Journal of Asthma
                Informa Healthcare USA, Inc.
                February 2014
                08 October 2013
                : 51
                : 1
                : 51-57
                1Pulmonary & Critical Care Department, King Fahad Medical City Hospital RiyadhSaudi Arabia
                2Research and Scientific Publication Center, King Fahad Medical City Hospital RiyadhSaudi Arabia
                3Medical School, Lebanese University BeirutLebanon
                Author notes
                Correspondence: Dr. Mohamad Al-TannirClinical and Translational Research Department, Research and Scientific Publication Center King Fahad Medical City, P. O. Box 59046, Riyadh 11525Saudi Arabia. Tel: +00966-1-288-9999 ext. 8391. E-mail: maltannir@ 123456kfmc.med.sa
                © 2014 Informa Healthcare USA, Inc. All rights reserved: reproduction in whole or part not permitted

                This is an open-access article distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the source is credited.

                Asthma in the Primary Care Setting


                control/management, epidemiology, education, pharmacotherapy


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