Difficult to Treat and Severe Asthma: Management Strategies.

Asthma is a common chronic inflammatory disease in the United States. Up to 17% of asthma cases are classified as difficult to treat, and 3.7% of these are considered severe. Uncontrolled asthma is characterized by poor symptom control or frequent exacerbations. In difficult-to-treat asthma, the asthma is uncontrolled despite adherence to inhaled corticosteroid therapy in combination with a second controller, an oral corticosteroid is needed to achieve control, or it is uncontrolled despite oral corticosteroid therapy. Severe asthma is a subset of difficult-to-treat asthma in which the disease is uncontrolled despite adherence to optimal management or it worsens when high-intensity therapy is decreased. The diagnosis of asthma should be confirmed and modifiable factors and comorbidities addressed in patients with difficult-to-treat asthma. An adequate trial of an inhaled corticosteroid and long-acting beta agonist should be implemented with nonbiologic add-on therapies, such as a long-acting muscarinic agent or leukotriene receptor antagonist. Evaluation of severe asthma involves assessment of asthma phenotype. Evidence of type 2 inflammation indicates that the patient may benefit from newer biologic agents. Breathing exercises may improve quality of life, asthma symptoms, lung function, and number of exacerbations. Vitamin D and soy supplementation are ineffective. Bronchial thermoplasty is a procedural option that may be considered if there is inadequate response to other therapies.

Place of birth, cancer beliefs and being current with colon cancer screening among US adults.

BACKGROUND: Historically, studies suggested that immigrants acquire the risk of colorectal cancer (CRC) as US-born persons within the same generation. CRC risk of immigrants is largely unknown in this era of cancer screening and widespread immigration. We investigated the association of place of birth and cancer beliefs with uptake of CRC screening. METHODS: The 2007 Health Information National Trends Survey was used and 4,299 respondents (weighted population size=81,896,392) who were 50 years and older (3,960 US-born and 339 foreign-born) were identified. We defined being current with CRC screening guidelines as the use of fecal occult blood test within 1 year, sigmoidoscopy within 5 years, or colonoscopy within 10 years. We compared being up-to-date with CRC screening among foreign-born versus US-born respondents. Logistic regression models were used to calculate odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Overall, 2,594 (63.3%) US-born and 208 (52.8%) foreign-born respondents were current with CRC screening. Foreign-born respondents were less current in unadjusted model (OR 0.65; 95% CI: 0.50-0.85) but became non-statistically significant after adjustment (OR 0.79; 95% CI: 0.51-1.24). Respondents who believed that screening finds cancer when it is easy to treat (OR 2.85; 95% CI: 1.44-3.61), those who believed that cancer can be cured when detected early (OR 1.56; 95% CI: 1.20-2.00), and those who worry about getting cancer (OR 1.34; 95% CI: 1.10-1.61) were likely to be current with CRC screening. However, respondents with fatalistic beliefs were borderline less likely to be current (OR 0.82; 95% CI: 0.65-1.04). CONCLUSION: There is a need to improve education on CRC screening, particularly among foreign-born adults.

Translating epoetin research into practice: the role of government and the use of scientific evidence.

Spending for epoetin is Medicare's single largest drug expenditure. We chronicle the evolution of epoetin policy based on a lack of well-designed post-Food and Drug Administration approval studies demonstrating clinical benefit; congressional/federal agency reliance on clinical practice guidelines that might have misinterpreted evidence supporting causality; and the premature translation of research into practice and policy. Were the right choices made? Epoetin showcases the risk and benefit conundrum created when evidentiary standards are relaxed. Our review concludes with broad-based policy recommendations for the newly implemented Medicare Part D program.