DIAGNOSIS by liuqingyan

VIEWS: 8 PAGES: 9

									                  Tailored Search Strategies by Key Question
                        Preliminary Results for Discussion

Inclusion Criteria:
       Published: after January 1, 2004 and before January 31, 2008
       Population: Humans, no age, race or gender restrictions
       Language: English
       Location: United States, European countries, Australia, New Zealand,
       Japan
       Types of Studies: RCTs, Meta-analyses, reviews, guidelines,
       observational studies

DIAGNOSIS QUESTIONS

KQ1: In patients with asthma, does consultation or referral to a subspecialist
(pulmonologist/allergist) at the time of diagnosis, when admitted to the ER with
exacerbation, or early in treatment vs no consultation/referral improve
symptom control, patient satisfaction and increase patient knowledge? [A&P]

      Population: Adults, children, with asthma
      Time Point: at diagnosis, admitted to ER, early in treatment
      Intervention: consultation or referral to a subspecialist (pulmonologist/allergist) vs. no
            consultation/referral
      Outcome of Interest: symptom control, patient satisfaction, patient knowledge
      Search Terms used: consult, consultation, referral, subspecialist, pulmonologist,
            allergist, emergency, diagnosis
      Results: 0 Systematic Evidence Reviews, 0 Meta-analyses, 1 trials, 1 observational
            studies, many background studies that we could hand check for further references

KQ2. In patients with asthma does routine allergy testing (e.g., skin prick
testing, aeroallergens, immunotherapy) vs. no testing or testing HIGH RISK
(Severe uncontrolled Asthma, family Hx of allergies) improve outcomes in terms
of QOL through allergen avoidance or immunotherapy, patient knowledge and
adherence? [A&P]

      Population: adults, children, with high risk (severe uncontrolled, family history of
            allergies) asthma
      Time Point: after diagnosis
      Intervention: routine allergy testing vs. no testing
      Outcome of Interest: quality of life, [intermediate outcomes: allergy avoidance,
            immunotherapy, patient knowledge, adherence]
      Search Terms used: allergy testing, uncontrolled, immunotherapy, quality of life
      Results: 0 Systematic Evidence Reviews, 0 Meta-analyses, 0 trials, 0 observational
            studies; many background studies that we could hand check for further references

KQ3. In adults with exercise-related symptoms of asthma only and non-
diagnostic spirometry, is formal exercise testing with pre- and post-PFTs
compared to informal exercise testing (methacholine challenge test, broncho
provocation test) better for establishing the diagnosis of EIB or exercise induced
asthma? ([A]
      Population: adults with exercise-related symptoms of asthma and non-diagnostic
            spirometry
      Time Point: before diagnosis
      Intervention: formal exercise testing (with pre-post pulmonary function testing) vs.
            informal testing (methacholine challenge test, broncho provocation)
      Outcome of Interest: diagnosis of exercise-induced breathing or exercise-induced
            asthmaquality of life, [intermediate outcomes: allergy avoidance, immunotherapy,
            patient knowledge, adherence]
      Search Terms used: diagnosis, exercise-induced, spirometry, exercise testing,
            pulmonary function tests[ing], PFT, methocholine, challenge, provocation
      Results: 2 Systematic Evidence Reviews, 1 Meta-analyses, 4 trials, 2 observational
            studies, 6 others, plus many background studies that we could hand check for
            further references

KQ4. Does the routine use of office-based Spirometry compared to history and
physical for both asthma diagnosis and monitoring improve outcomes? (Peds

      Population: children with asthma
      Time Point: before and after diagnosis
      Intervention: spirometry vs. history and physical
      Outcome of Interest: diagnosis of asthma, (allow for any outcome)
      Search Terms used: spirometry, exclude hospital-based
      Results: 0 Systematic Evidence Reviews, 0 Meta-analyses, 0 trials, 0 observational
            studies, 2 other articles


KQ5. In adults with exercise-related symptoms asthma, is peak flow monitoring
to assess variability of airway obstruction compared to spirometry a comparable
way for diagnosing of EIB or exercise induced asthma? ([A] 30)
      Population: adults with exercise-related symptoms
      Time Point: before diagnosis
      Intervention: peak flow monitoring vs spirometry
      Outcome of Interest: diagnosis of exercise-induced breathing or exercise-induced
            asthma
      Search Terms used: peak flow, spirometry, exercise-induced
      Results: 1 Systematic Evidence Reviews, 0 Meta-analyses, 4 trials, 0 observational
            studies, 8 other articles

KQ6. Do biomarkers of inflammation (e.g., total and differential cell count and
mediator assays) in sputum, blood, urine, and exhaled air aid in the diagnosis
and assessment of asthma in the primary care setting? ([A&P]

      Population: adults and children with asthma
      Time Point: before and after diagnosis
      Intervention: biomarkers of inflammation (total and differential cell count and mediator
            assays) in sputum, blood, urine, and exhaled air vs. nonel
      Outcome of Interest: diagnosis or assessment of asthma
      Search Terms used: inflammation, biomarkers, sputum, cell count, assays, urine,
            exhaled breath, exclude hospital-based
      Results: 0 Systematic Evidence Reviews, 0 Meta-analyses, 0 trials, 0 observational
            studies
KQ7. Is a thorough history and physical, followed by a therapeutic challenge
sufficient to identify comorbid GERD compared to a diagnostic test in children
with asthma? ([P]

      Population: children with asthma and comorbid GERD
      Time Point: assessment of GERDs impact on asthma status
      Intervention: history and physical, followed by therapeutic challenge to identify
            comorbid GERD vs. diagnostic test
      Outcome of Interest: diagnosis or exclusion of comorbid GERD
      Search Terms used: GERD, reflux, challenge, test(s, ing).
      Results: 0 Systematic Evidence Reviews, 0 Meta-analyses, 2 trials, 0
            observational studies, 11 other articles and many other background articles
            we could search for references

KQ8. In pregnant women who were not previously diagnosed with asthma, but
who develop symptoms consistent with asthma, does assessing PFT compared
to a presumptive diagnosis (no PFT) improve patient outcome with no harm? (33)

      Population: pregnant women
      Time Point: before and after diagnosis of asthma [criteria revised from time of original
            question]
      Intervention: pulmonary function testing vs no testing [presumptive diagnosis]
      Outcome of Interest: asthma functioning, benefits, harms
      Search Terms used: pregnant, pulmonary function test(s, ing), PFT, adverse effects,
            harm
      Results: 3 Systematic Evidence Reviews, 1 Meta-analyses, 1 trials, 2 observational
            studies; many background studies that we could hand check for further references

PROGNOSIS

KQ9. In adults with asthma who present with an acute exacerbation, what
clinical predictors are best at predicting successful outpatient management?
([A]

      Population: adults with asthma
      Time Point: presenting with acute asthma exacerbation
      Intervention: clinical predictors
      Outcome of Interest: controlled asthma
      Search Terms used: predict(ors, ing, ion), acute, exacerbation, exclude hospital-based
      Results: 0 Systematic Evidence Reviews, 0 Meta-analyses, 7 possible trials, 0
            observational studies; many background studies that we could hand check for
            further references

KQ10. In patients with difficult to control asthma (adults & children), how
frequently does the management of coexisting sinusitis or GERD compared
to no management improve the control of asthma? ([A&P]

      Population: adults and children with difficult to control asthma
      Time Point: after diagnosis
      Intervention: management of comorbid GERD or sinusitis
      Outcome of Interest: controlled asthma
      Search Terms used: sinusitis, rhinitis, rhinosinusitis, GERD, reflux, difficult
      Results: 0 Systematic Evidence Reviews, 0 Meta-analyses, 5 trials, 4 observational
           studies; many background studies that we could hand check for further references

KQ11. In patients with asthma who are obese, does weight loss and exercise
compared to no weight loss/exercise improve the control of asthma symptoms?
([A&P]

      Population: obese adults and children with asthma
      Time Point: after diagnosis
      Intervention: weight loss and exercise vs. none
      Outcome of Interest: improved controlled asthma
      Search Terms used: obesity, weight loss, exercise
      Results: 1 Systematic Evidence Review/Meta-analyses, 1 trials, 2 observational studies;
            3 reviews; many background studies that we could hand check for further
            references



MEDICATIONS
KQ12. In children with under controlled asthma while on low dose ICS, what is
the best step up treatment / add on therapy to gain asthma control (search in
age groups 1-5, 5-12, 12-17)? (P 9)
      Population: children in age groups 1-5, 5-12, 12-17with under-controlled asthma on low
            dose ICS
      Time Point: after diagnosis
      Intervention: step up treatment or add-on therapy
      Outcome of Interest: controlled asthma
      Search Terms used: ICS, uncontrolled, step up, add-on
      Results: 0 Systematic Evidence Reviews, 0 Meta-analyses, 3 trials, 0 observational
            studies; 5 review articles; many background studies that we could hand check for
            further references


KQ13. In active duty personnel with asthma in operational environments, is one
controller compared to other controllers better apt to control asthma symptoms?
([A] 31)
      Population: adult active duty personnel with asthma in operational environments
      Time Point: after diagnosis
      Intervention: controller medication
      Outcome of Interest: controlled asthma symptoms
      Search Terms used: active duty, desert, dusty, humid, cold, high altitude
      Results: 0 Systematic Evidence Reviews, 0 Meta-analyses, 1 trials, 0 observational
            studies; 5 other possible articles


KQ14. In patients with mild persistent asthma and no evidence of allergies as
triggers (adults & children), does ICS compared to Montelukast or Tilade, Intal,
or other pulmonary antiinflammatories lead to better outcome and minimimize
harm? (9,15)
      Population: adults and children children with mild, persistent asthma and no evidence of
            allergies as triggers
      Time Point: after diagnosis
      Intervention: ICS vs montelukast or tilade or intal or other anti-inflammatories
      Outcome of Interest: controlled asthma, symptoms, harm or adverse effect or adverse
            event
      Search Terms used: mild, persistent, ICS, montelukast, Tilade, Intal, anti-inflammatory,
            harm, adverse effect, adverse event
      Results: 0 Systematic Evidence Reviews, 0 Meta-analyses, 0 trials, 0 observational
            studies


KQ15. In patients with moderate or severe uncontrolled asthma who are taking
ICS (adults & children), does increasing the dose of ICS compared to
adjunctive therapy (LABA, Singulair, Leukotriene) lead to better control of
symptoms with no harm? ([A] 17)
      Population: adults and children with moderate or severe uncontrolled asthma on ICS
      Time Point: after diagnosis
      Intervention: increased dosage of ICS vs adjunctive therapy (LABA, Singulair,
            Leukotriene)
      Outcome of Interest: controlled asthma, less symptoms, harms (adverse effect, adverse
            event)
      Search Terms used: moderate, severe, uncontrolled, ICS, LABA, Singulair,
            Leukotriene(s)
      Results: 0 Systematic Evidence Reviews, 1 Meta-analyses, 15 trials, 0 observational
            studies; many background studies that we could hand check for further references


KQ16. In adult patients with asthma, does tiotropium (Spiriva) compared to
long acting inhaled bronchodilators lead to comparable improvement in PFT,
peak flow measures, and safety? ([A])
      Population: adults with asthma
      Time Point: after diagnosis
      Intervention: tiotropium (Spiriva) vs long-acting inhaled bronchodilators
      Outcome of Interest: pulmonary function, peak flow, harm
      Search Terms used: tiotropium, spiriva, inhaled, bronchodilators, PFT, pulmonary
            function test(s, ing), peak flow, adverse effect, adverse events
      Results: 0 Systematic Evidence Reviews, 0 Meta-analyses, 10 possible trials, 1
            observational studies


KQ17. In patients with exercise-induced asthma (bronchospasm) (adults &
children), does taking a preventive medication before exercise compared to
continuous daily medication improve symptom control? (40) [A&P]
      Population: adults and children with exercise-induced asthma (bronchospasm)
      Time Point: after diagnosis
      Intervention: preventive medication before exercise vs. continuous daily medication
      Outcome of Interest: asthma symptoms
      Search Terms used: exercise-induced, treatment, medication, controller, preventive,
            daily
      Results: 0 Systematic Evidence Reviews, 0 Meta-analyses, 0 trials, 0 observational
            studies
KQ18. In patients older than 65 years with asthma, does the use of long acting
beta adrenergic drugs compared to not using the drug reduce adverse
cardiovascular events (e.g., sudden death, acute MI, arrhythmias)? ([A >65] 36)
      Population: adults >65 years of age with asthma
      Time Point: after diagnosis
      Intervention: LABA vs none
      Outcome of Interest: cardiovascular events (sudden death, acute MI, arrhythmias)
      Search Terms used: elderly, LABA, cardiovascular, MI, death, arrythmias, heart
      Results: 0 Systematic Evidence Reviews, 0 Meta-analyses, 0 trials, 1 observational
            studies; 1 other article


KQ19. In patients older than 65 years who require long term systemic
corticosteroids, does a reduced dose of corticosteroids compared to the
regular dose reduce the risk for adverse complications (osteoporosis, DM,
Vavascular necrosis of the femoral head, cataracts)? ([A >65]37)
      Population: adults >65 years of age with asthma on long-term systemic corticosteroids
      Time Point: after diagnosis
      Intervention: reduced dosage vs regular dosage
      Outcome of Interest: adverse effects, adverse events, osteoporosis, DM, vascular
            necrosis of femoral head, cataracts
      Search Terms used: elderly, systemic, corticosteroids, adverse effects, adverse events,
            osteoporosis, diabetes, DM, vascular necrosis, cataracts
      Results: 1 Systematic Evidence Reviews, 0 Meta-analyses, 3 possible trials, 0
            observational studies


KQ20. In patients with asthma how effective is aerosol delivery of asthma
medications by pMDI + VHC compared to nebulization for quick relief aerosols?
[A&P]
      Population: adults and children with asthma
      Time Point: after diagnosis
      Intervention: aerosol delivery of asthma medications by pMDI+VHC vs nebulization for
            quick relief aerosols
      Outcome of Interest: function, symptoms
      Search Terms used: pMDI, VHC, nebuliz(er, ed, ation), quick relief
      Results: 0 Systematic Evidence Reviews, 0 Meta-analyses, 0 trials, 0 observational
            studies


KQ21. Do studies show there is an effective pharmacotherapy (PRN SABA,
ICS Leukotrine) for the <5 year old child with recurrent wheeze, but no asthma
diagnosis? ([P] 4)
      Population: children under age 5 with recurrent wheeze
      Time Point: before diagnosis
      Intervention: PRN SABA, ICS, Leukotriene
      Outcome of Interest: function, symptoms
      Search Terms used: SABA, ICS, leukotriene, infant, toddler, child, recurrent wheeze
      Results: 1 Systematic Evidence Reviews, 1 Meta-analyses, 0 trials, 0 observational
            studies; many background studies that we could hand check for further references
KQ22. Do studies show an optimal systemic steroid preparation, dosage, and
duration of treatment for managing asthma in pediatrics? ([P] 6)
      Population: children with asthma
      Time Point: after diagnosis
      Intervention: varying preparation, dosage, duration of systemic steroids
      Outcome of Interest: function, symptoms
      Search Terms used: systemic, steroid, dosage
      Results: 0 Systematic Evidence Reviews, 0 Meta-analyses, 0 trials, 0 observational
            studies, many background studies that we could hand check for further references

KQ23. Do studies show that routine initiating LTC ICS children with persistent
asthma at discharge from the Emergency Department is more effective?
[NHLBI p.400] ([P]
ICS

      Population: children with persistent asthma
      Time Point: discharge from the Emergency Department
      Intervention: initiation of long-term ICS
      Outcome of Interest: function, symptoms
      Search Terms used: discharge, Emergency Department, persistent, ICS
      Results: 1 Systematic Evidence Reviews, 0 Meta-analyses, 1 trials, 0 observational
            studies; 2 other articles



KQ24. Does the use of a home peak flow meter based Asthma Action Plan
compared to a symptom based Asthma Action Plan result in better outcomes in
patients with asthma ([A&P]
Asthma Action Plan

      Population: adults and children with asthma
      Time Point: after diagnosis
      Intervention: Home peak flow meter based Asthma Action Plan vs. Symptom-based
            Asthma Action Plan
      Outcome of Interest: function, symptoms, QOL
      Search Terms used: Asthma Action Plan, plan, peak flow, symptom based
      Results: 1 Systematic Evidence Reviews, 0 Meta-analyses, 3 trials, 0 observational
            studies


Patient Education
KQ25. Which strategy in the outpatient setting leads to better outcomes in
terms of decreased frequency of exacerbations, ER visits, or hospitalization in
patients with asthma (A&P)?
             a. Implementation of comprehensive asthma care (pt. education,
                action plans and asthma educators) compared to usual care
                (27)
             b. Implementation of group visits compared to individual patients
                appointments
             c. Written action plans compared to not using a written action
                plan in usual care (28)
             d. Providing patient education in modality other than written
                (e.g., media, computer based, internet) (26)
      Population: adults and children with asthma
      Time Point: after diagnosis
      Intervention: patient education (action plans, educators, group visits)
      Outcome of Interest: exacerbations, ED visits, hospitalization
      Search Terms used: education, action plan, comprehensive, group visits, internet,
            web,computer, video, exclude in-patient setting
      Results: 2 Systematic Evidence Reviews, 0 Meta-analyses, 25 possible trials, 16
            possible observational studies

KQ26. Do comprehensive approaches to environmental control and
avoidance of allergens improve asthma outcomes?
      Population: adults and children with asthma
      Time Point: after diagnosis
      Intervention: mitigation of environmental triggers in the home setting
      Outcome of Interest: function, symptoms
      Search Terms used: comprehensive, trigger avoidance, mitigation, pest control, home
      Results: 0 Systematic Evidence Reviews, 0 Meta-analyses, 1 trials, 0 observational
            studies; many background studies that we could hand check for further references


KQ27. What evidence is there for poorer asthma outcomes for specific inhaled
irritants/pollutants such as tobacco smoke, particulate air pollution, NO2, SO2,
diesel exhaust, volatile organic compounds, formaldehyde and fumes?

      Population: adults and children with asthma
      Time Point: after diagnosis
      Intervention: removal of environmental factor
      Outcome of Interest: function, symptoms
      Search Terms used: tobacco smoke, particulate(s), NO2, SO2, diesel exhaust,
            volatile organic compounds, formaldehyde, fumes
      Results: 0 Systematic Evidence Reviews, 0 Meta-analyses, 0 trials, 0
            observational studies; many background studies that we could hand check
            for further references

KQ28. DO patient questionnaires improve reporting of asthma symptoms and
therefore improve asthma severity assessment and treatment?

      Population: adults and children with asthma
      Time Point: after diagnosis
      Intervention: questionnaires vs no questionnaires
      Outcome of Interest: reporting of asthma symptoms, assessment, severity
      Search Terms used: survey, questions, questionnaire, symptoms, severity,
            assessment
Results: 0 Systematic Evidence Reviews, 0 Meta-analyses, 0 trials, 0
    observational studies many background studies that we could hand check
    for further references

								
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