Effects of Vitamin D Serum Level on Morbidity and Mortality in Patients with COVID-19: A Systematic Review and Meta-Analysis.

PURPOSE: It has been shown that low Vitamin D serum concentration is associated with increased pneumonia and viral respiratory infections. Vitamin D is readily available, inexpensive, and easy to administer to subjects infected with COVID-19. If effective in reducing the severity of COVID-19, it could be an important and feasible therapeutic intervention. METHODS: We performed a systematic review and meta-analysis of the literature to determine the effects of Vitamin D serum concentration on mortality and morbidity in COVID-19 patients. The primary objectives were to determine if Vitamin D serum concentration decrease mortality, ICU admissions, ventilator support, and length of hospital stay in COVID-19 patients. RESULTS: A total of 3572 publications were identified. Ultimately, 20 studies are included. A total of 12,806 patients aged between 42 to 81 years old were analyzed. The pooled estimated RR for mortality, ICU admission, ventilator support and length of hospital stay were 1.49 (95% CI: 1.34, 1.65), 0.87 (95% CI: 0.67, 1.14), 1.29 (95% CI: 0.79, 1.84), and 0.84 (95% CI -0.45, 2.13). CONCLUSION: There is no statistical difference in mortality, ICU admission rate, ventilator support requirement, and length of hospital stay in COVID-19 patients with low and high Vitamin D serum concentration.

Angiotensin-Converting Enzyme Inhibitor Induced Cough in Chinese Patients: a Systematic Review and Meta-analysis.

PURPOSE: To determine the risk of angiotensin converting enzyme inhibitor (ACEI)-induced cough compared to non-ACEI cough among Chinese patients. METHODS: A comprehensive search was conducted including randomized controlled trials, case-control studies and observational studies that compared ACEI treatment with control treatment in MEDLINE, EMBASE, CINAHL, Scopus, Google Scholar and ProQuest Dissertations & Theses Global. The studies which contained: Chinese population, ACEI, non-ACEI, and indications for the treatment of ACEI were included. The pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated to compare the relative risk of cough between ACEIs and non-ACEI drugs based on the events of reported cough in each study. RESULTS: Eleven randomized controlled trials were included with a total of 1815 patients. The total number of cough events in ACEI treatment was 101 in 930 patients (11%) and 20 in 885 patients (2%) in the Non-ACEI treatment. The pooled RR was 5.16 (95% CI: 3.39-7.85) under fixed model. The discontinuation number of single ACEI treatment due to coughing side effect was 21 and the withdrawal rate was 4.13%. Only two patients discontinued non-ACEIs treatment due to the intolerable cough and the withdrawal rate was 0.34%. The overall RR of withdrawal related to cough was 7.06 (95% CI: 2.49-20.04). CONCLUSIONS: The pooled risk of the incidence of ACEI-induced cough was about five times higher than that of non-ACEI-induced cough in Chinese population. The risk of withdrawal events related to cough in the single ACEI treatment was seven times of that in the non-ACEI treatment.

Sex differences in outcomes after discharge from Alberta emergency departments for asthma: A large population-based study.

OBJECTIVE: Asthma exacerbations frequently result in emergency department (ED) visits. While sex differences have been identified in some asthma studies, there is a paucity of literature on sex differences in the ED setting, especially population-based ones. This study examines sex differences in important outcomes of patients discharged from EDs for acute asthma in Alberta, Canada. METHODS: Alberta residents aged from 2 to 55 years discharged from EDs with a primary diagnosis of asthma during 1999-2011 were identified from administrative databases from a single-payer health care system for the entire geographic region of Alberta. Multivariable Cox regression models analyzed time to first follow-up physician or specialist visit, and logistic regression models analyzed the binary outcome of ED return within 30 days for asthma. RESULTS: There were 115,853 discharged patients analyzed (40.4% and 59.1% female in pediatric and adult groups, respectively). Approximately 26% of patients revisited the ED during 1999-2011 and 5.1% did so within 30 days. Women had higher odds of a 30-day ED return after ED discharge than men (unadjusted odds ratio [uOR] = 1.26; 95% confidence interval [CI] 1.17-1.36). Time to first non-ED physician follow-up was shorter for girls (unadjusted hazard ratio [uHR] = 1.05; 95%CI 1.03-1.07) and women (uHR = 1.62; 95%CI 1.59-1.64) than for boys and men, respectively. Significant interactions between sex and age, socio-economic status, area of residence, and comorbidities were identified and changed the effect of sex on outcomes. CONCLUSIONS: In conclusion, women return to EDs within 30 days of discharge for acute asthma more often than men. Time to first non-ED physician follow-up for children and adults differed by sex. Multiple factors likely contribute to these differences; however, identifying these differences is critical to understand the influence of sex on health behaviors and outcomes.

Using the theoretical domains framework to identify barriers and enablers to pediatric asthma management in primary care settings.

OBJECTIVES: This study aimed to apply a theory-based approach to identify barriers and enablers to implementing the Alberta Primary Care Asthma Pediatric Pathway (PCAPP) into clinical practice. Phase 1 included an assessment of assumptions underlying the intervention from the perspectives of the developers. Phase 2 determined the perceived barriers and enablers for: 1) primary care physicians' prescribing practices, 2) allied health care professionals' provision of asthma education to parents, and 3) children and parents' adherence to their treatment plans. METHODS: Interviews were conducted with 35 individuals who reside in Alberta, Canada. Phase 1 included three developers. Phase 2 included 11 primary care physicians, 10 allied health care professionals, and 11 parents of children with asthma. Phase 2 interviews were based on the 14 domains of the Theoretical Domains Framework (TDF). Transcribed interviews were analyzed using a directed content analysis. Key assumptions by the developers about the intervention, and beliefs by others about the barriers and enablers of the targeted behaviors were identified. RESULTS: Eight TDF domains mapped onto the assumptions of the pathway as described by the intervention developers. Interviews with health care professionals and parents identified nine TDF domains that influenced the targeted behaviors: knowledge, skills, beliefs about capabilities, social/professional role and identity, beliefs about consequences, environmental context and resources, behavioral regulation, social influences, and emotions. CONCLUSIONS: Barriers and enablers perceived by health care professionals and parents that influenced asthma management will inform the optimization of the PCAPP prior to its evaluation.

Diclofenac--Acetaminophen Combination Induced Acute Kidney Injury In Postoperative Pain Relief.

PURPOSE: The objective of this study was to determine: 1) the incidence and the risk factors of diclofenac/acetaminophen combination as a single agent induced Acute Kidney Injury (AKI) in postoperative pain relief 2) the average cost and length of hospital stay for patients in AKI group and non-AKI group. METHODS: All patients with no prior history of chronic kidney disease (CKD) and normal serum creatinine [44~130 µmol /l] who received diclofenac and acetaminophen combination as a single agent intramuscularly (IM) between January and December 2015 in The Second Xiangya Hospital, Changsha, Hunan, China were included in this retrospective own-control study. Baseline serum creatinine (SCr) and SCr during NSAID use were collected. AKI is defined as an increased of Scr over 1.5 times the baseline. Multivariate analyses were performed with a logistic regression model to assess the significant risk factors of AKI. RESULTS: A total of 821 patients were included in the study with 63 [7.7%] patients had diclofenac/acetaminophen combination single agent induced AKI. Multivariate analysis confirmed that using diclofenac/acetaminophen combination after surgeries within 24 h were significantly associated with AKI [odds ratio, OR, 2.173; 95% CI, 1.113-4.243; P=0.023]. The average cost and length of hospitalization in AKI group was 1.87 times [p=0.000] and 1.2 times [p=0.043] comparison than non-AKI group, respectively. CONCLUSIONS: The incidence of diclofenac/acetaminophen combination single agent induced AKI in postoperative pain relief was 7.7%. Patients with hypertension or liver cirrhosis was more likely to develop AKI and using diclofenac/acetaminophen combination after surgeries within 24 h was significant risk factors for AKI. AKI prolonged the cost and length of hospitalization. This article is open to POST-PUBLICATION REVIEW. Registered readers (see "For Readers") may comment by clicking on ABSTRACT on the issue's contents page.

The Development and Refinement of an e-Health Screening, Brief Intervention, and Referral to Treatment for Parents to Prevent Childhood Obesity in Primary Care.

BACKGROUND: Nearly one-third of Canadian children can be categorized as overweight or obese. There is a growing interest in applying e-health approaches to prevent unhealthy weight gain in children, especially in settings that families access regularly. Our objective was to develop and refine an e-health screening, brief intervention, and referral to treatment (SBIRT) for parents to help prevent childhood obesity in primary care. MATERIALS AND METHODS: Our SBIRT, titled the Resource Information Program for Parents on Lifestyle and Education (RIPPLE), was developed by our research team and an e-health intervention development company. RIPPLE was based on existing SBIRT models and contemporary literature on children's lifestyle behaviors. Refinements to RIPPLE were guided by feedback from five focus groups (6-10 participants per group) that documented perceptions of the SBIRT by participants (healthcare professionals [n = 20], parents [n = 10], and researchers and graduate trainees [n = 8]). Focus group commentaries were transcribed in real time using a court reporter. Data were analyzed thematically. RESULTS: Participants viewed RIPPLE as a practical, well-designed, and novel tool to facilitate the prevention of childhood obesity in primary care. However, they also perceived that RIPPLE may elicit negative reactions from some parents and suggested improvements to specific elements (e.g., weight-related terms). CONCLUSIONS: RIPPLE may enhance parents' awareness of children's weight status and motivation to change their children's lifestyle behaviors but should be improved prior to implementation. Findings from this research directly informed revisions to our SBIRT, which will undergo preliminary testing in a randomized controlled trial.

Administration Technique and Acceptance of Inhaler Devices in Patients With Asthma or COPD.

BACKGROUND: Correct technique and patient acceptance of inhalation devices for lung disease influence successful long-term management. Patient ability to use the proper technique may differ depending on the device as well as patient factors. OBJECTIVES: The objectives of our study are to measure self-reported level of acceptability of inhaler devices in community settings and compare correct use of inhaler devices using a novel scale for measuring appropriate inhaler technique. METHODS: This prospective observational study enrolled patients from 3 different practice sites with asthma and/or chronic obstructive pulmonary disease (COPD) who were using an inhaler device. In addition to describing the samples' overall acceptability and correct use scores for the different inhalers, acceptability and correct use scores were compared based on patient characteristics. RESULTS: A total of 161 patients completed the study. The results show that acceptability was lowest for the pressurized metered dose inhaler (pMDI) with a spacer (S); effective use was best demonstrated with pMDI and poorest with pMDI-S. Older patients were found to be more accepting of the HandiHaler device than younger patients. Patients reporting taking more inhaled drugs were found to be more accepting of the pMDI-S than those taking fewer drugs. Finally, patients reporting taking more inhaled drugs demonstrated less-effective use of the HandiHaler device than patients taking fewer drugs. CONCLUSION: Pulmonary disease duration does not ensure improved use for all inhalers; patients taking more drugs demonstrate less-effective use for some devices. Assessment of patient acceptance and factors that predict the ability to use a device should be considered to individualize therapy.

Finding a BETTER way: a qualitative study exploring the prevention practitioner intervention to improve chronic disease prevention and screening in family practice.

BACKGROUND: Our randomized controlled trial (The BETTER Trial) found that training a clinician to become a Prevention Practitioner (PP) in family practices improved chronic disease prevention and screening (CDPS). PPs were trained on CDPS and provided prevention prescriptions tailored to participating patients. For this embedded qualitative study, we explored perceptions of this new role to understand the PP intervention. METHODS: We used grounded theory methodology and purposefully sampled participants involved in any capacity with the BETTER Trial. Two physicians and one coordinator in each of two cities (Toronto, Ontario and Edmonton, Alberta) conducted eight individual semi-structured interviews and seven focus groups. We used an interview guide and documented research activities through an audit trail, journals, field notes and memos. We analyzed the data using the constant comparative method throughout open coding followed by theoretical coding. RESULTS: A framework and process involving external and internal practice facilitation using the new role of PP was thought to impact CDPS. The PP facilitated CDPS through on-going relationships with patients and practice team members. Key components included: 1) approaching CDPS in a comprehensive manner, 2) an individualized and personalized approach at multiple levels, 3) integrated continuity that included linking the patients and practices to CPDS resources, and 4) adaptability to different practices and settings. CONCLUSIONS: The BETTER framework and key components are described as impacting CDPS through a process that involved a new role, the PP. The introduction of a novel role of a clinician within the primary care practice with skills in CDPS could appropriately address gaps in prevention and screening.

Plasma essential fatty acid on hospital admission is a marker of COVID-19 disease severity.

It is important for allocation of resources to predict those COVID patients at high risk of dying or organ failure. Early signals to initiate cellular events of host immunity can be derived from essential fatty acid metabolites preceding the cascade of proinflammatory signals. Much research has focused on understanding later proinflammatory responses. We assessed if remodelling of plasma phospholipid content of essential fatty acids by the COVID-19 virus provides early markers for potential death and disease severity. Here we show that, at hospital admission, COVID-19 infected subjects who survive exhibit higher proportions of C20:4n-6 in plasma phospholipids concurrent with marked proinflammatory cytokine elevation in plasma compared to healthy subjects. In contrast, more than half of subjects who die of this virus exhibit very low C18:2n-6 and C20:4n-6 content in plasma phospholipids on hospital admission compared with healthy control subjects. Moreover, in these subjects who die, the low level of primary inflammatory signals indicates limited or aberrant stimulation of host immunity. We conclude that COVID-19 infection results in early fundamental remodelling of essential fatty acid metabolism. In subjects with high mortality, it appears that plasma n-6 fatty acid content is too low to stimulate cellular events of host immunity.

Facilitators and barriers to the implementation of the Primary Care Asthma Paediatric Pathway: a qualitative analysis.

OBJECTIVE: The aim of this qualitative study was to use a theory-based approach to understand the facilitators and barriers that impacted the implementation of the Primary Care Asthma Paediatric Pathway. DESIGN: Qualitative semistructured focus groups following a randomised cluster-controlled design. SETTING: 22 primary care practices in Alberta, Canada. PARTICIPANTS: 37 healthcare providers participated in four focus groups to discuss the barriers and facilitators of pathway implementation. INTERVENTION: An electronic medical record (EMR) based paediatric asthma pathway, online learning modules, in-person training for allied health teams in asthma education, and a clinical dashboard for patient management. MAIN OUTCOME MEASURES: Our qualitative findings are organised into three themes using the core constructs of the normalisation process theory: (1) Facilitators of implementation, (2) Barriers to implementation, and (3) Proposed mitigation strategies. RESULTS: Participants were positive about the pathway, and felt it served as a reminder of paediatric guideline-based asthma management, and an EMR-based targeted collection of tools and resources. Barriers included a low priority of paediatric asthma due to few children with asthma in their practices. The pathway was not integrated into clinic flow and there was not a specific process to ensure the pathway was used. Sites without project champions also struggled more with implementation. Despite these barriers, clinicians identified mitigation strategies to improve uptake including developing a reminder system within the EMR and creating a workflow that incorporated the pathway. CONCLUSION: This study demonstrated the barriers and facilitators shaping the asthma pathway implementation. Our findings highlighted that if team support of enrolment (establishing buy-in), legitimisation (ensuring teams see their role in the pathway) and activation (an ongoing plan for sustainability) there may have been greater uptake of the pathway. TRIAL REGISTRATION NUMBER: This study was registered at clinicaltrials.gov on 25 June 2015; the registration number is: NCT02481037, https://clinicaltrials.gov/ct2/show/NCT02481037?term=andrew+cave&cond=Asthma+in+Children&cntry=CA&city=Edmonton&draw=2&rank=1.

Comparative peripheral edema for dihydropyridines calcium channel blockers treatment: A systematic review and network meta-analysis.

Dihydropyridine calcium channel blockers (DHPCCBs) are widely used to treat hypertension and chronic coronary artery disease. One common adverse effect of DHPCCBs is peripheral edema, particularly of the lower limbs. The side effect could lead to dose reduction or discontinuation of the medication. The combination of DHPCCBs and renin-angiotensin system blockers has shown to reduce the risk of DHPCCBs-associated peripheral edema compared with DHPCCBs monotherapy. We performed the current systematic review and network meta-analysis of randomized controlled trials (RCTs) to estimate the rate of peripheral edema with DHPCCBs as a class and with individual DHPCCBs and the ranking of the reduction of peripheral edema. The effects of renin-angiotensin system blockers on DHPCCBs network meta-analysis were created to analyze the ranking of the reduction of peripheral edema. A total of 3312 publications were identified and 71 studies with 56,283 patients were included. Nifedipine ranked highest in inducing peripheral edema (SUCRA 81.8%) and lacidipine (SUCRA 12.8%) ranked the least. All DHPCCBs except lacidipine resulted in higher relative risk (RR) of peripheral edema compared with placebo. Nifedipine plus angiotensin receptor blocker (SUCRA: 92.3%) did not mitigate peripheral edema and amlodipine plus angiotensin-converting enzyme inhibitors (SUCRA: 16%) reduced peripheral edema the most. Nifedipine ranked the highest and lacidipine ranked the lowest amongst DHPCCBs for developing peripheral edema when used for cardiovascular indications. The second or higher generation of DHPCCBs combination with ACEIs or ARBs or diuretics lowered the chance of peripheral edema development compared to single DHPCCB treatment.

A De Novo Pharmacist-Family Physician Collaboration Model in a Family Medicine Clinic in Alberta, Canada.

Collaborative practice in health-care has proven to be an effective and efficient method for the management of chronic diseases. This study describes a de novo collaborative practice between a pharmacist and a family physician. The primary objective of the study is to describe the collaboration model between a pharmacist and family physician. The secondary objective is to describe the pharmacist workload. A list of patients who had at least one interaction with the pharmacist was generated and printed from the electronic medical record. There were 389 patients on the patient panel. The pharmacist had at least one encounter with 159 patients. There were 83 females. The most common medical condition seen by the pharmacist was hypertension. A total of 583 patient consultations were made by the pharmacist and 219 of those were independent visits. The pharmacist wrote 1361 prescriptions. The expanded scope of practice for pharmacists in Alberta includes additional prescribing authority. The pharmacists' education and clinical experience gained trust from the family physician. These, coupled with the family physician's previous positive experience working with pharmacists made the collaboration achievable.

Chronic obstructive pulmonary disease as a risk factor in primary care: a Canadian retrospective cohort study.

Chronic obstructive pulmonary disease (COPD) is a complex disease that is predicted to be the third most common cause of death by 2030. In Canada, the care and management of chronic conditions is largely provided by primary care providers. Although there is emerging research and initiatives that describe the prevalence of COPD in Canadian primary care settings, to our knowledge, there have been no efforts to use a large pan-Canadian database to analyze COPD as a risk factor for other common chronic conditions managed in primary care. We report the risk of developing comorbidities after the onset of COPD, that is, the extent to which COPD is a risk factor for developing common chronic conditions (heart failure, depression, anxiety, coronary artery disease, diabetes, anemia, hypertension, ischemic heart disease, underweight, and osteoporosis). After adjusting for age, sex, urban vs rural residence, and smoking status, the relative risks for patients with COPD at baseline were significantly higher for subsequent incidence of anemia, anxiety, diabetes, depression, heart failure, ischemic heart disease, lung cancer, osteoporosis, sleep apnea, underweight, and hypertension than patients without COPD. Using a cut-point of a 200% increase in relative risk as indicative of particular clinical relevance, COPD has a statistically and clinically significant association with developing lung cancer, becoming underweight, and developing heart failure.

Pulse Oximetry Screening and Critical Congenital Heart Disease in the State of Oregon.

Late diagnosis of critical congenital heart disease (CCHD) is associated with higher levels of morbidity and mortality in neonates. Nearly all states have passed laws mandating universal pulse oximetry screening (POxS) of newborns to improve early detection rates of CCHD. We performed a retrospective chart review of all transthoracic echocardiograms (TTEs) interpreted by our institution on patients between 0 and 30 days of life in the years 2010 (prior to POxS) and 2015 (after POxS). Between 2010 and 2015, the number of neonatal TTEs interpreted by our institution decreased by 18.2%. In 2015, there were 46 neonates diagnosed with CCHD with a 78% prenatal detection rate. There was only one case of a true-positive POxS. Our study demonstrated that the initiation of POxS coincided with a significant decrease in neonatal TTEs, suggesting universal POxS may impart reassurance to primary providers leading to a decrease in TTE utilization.

Determination of efficacy and toxicity of diclofenac microemulsion formulation for musculoskeletal pain: an observational study.

OBJECTIVE: Musculoskeletal pain is often caused by injury to the bones, muscles, tendons, ligaments or nerves. Symptoms can be localized or generalized. Mild-moderate symptoms are treated with topical/oral over the counter drugs. Microemulsion delivery formulations are thermodynamically stable, have superior bioavailability and better penetration of lipophilic and hydrophilic drug into the dermis. A prospective observational study in patients: 18 years or older, with mild-moderate musculoskeletal pain; with severe pain without adequate pain control; with severe pain and could not tolerate oral agents; with renal impairment were invited to try diclofenac 2% in microemulsion foam. They were followed up at 2 and 4 weeks. A 50% reduction on a visual analog pain scale was considered success. Adverse events were defined as irritation, gastrointestinal upset/bleed, rectal bleed, and hematemesis. The objective was to determine the efficacy and toxicity of diclofenac 2% in microemulsion foam. RESULTS: Thirteen consecutive patients with musculoskeletal pain consented to participate. Two patients were lost to follow up. Two of the 11 patients reported minimal improvement, while nine patients reported minimum 50% reduction. No adverse effects were reported. Diclofenac 2% in microemulsion foam is effective in the treatment of mild to moderate musculoskeletal pain and well tolerated.

Understanding Patient Perspectives on Medication Adherence in Asthma: A Targeted Review of Qualitative Studies.

Adherence to asthma medications is generally poor and undermines clinical outcomes. Poor adherence is characterized by underuse of inhaled corticosteroids (ICS), often accompanied by over-reliance on short-acting ß2-agonists for symptom relief. To identify drivers of poor medication adherence, a targeted literature search was performed in MEDLINE and EMBASE for articles presenting qualitative data evaluating medication adherence in asthma patients (≥12 years old), published from January 1, 2012 to February 26, 2018. A thematic analysis of 21 relevant articles revealed several key themes driving poor medication adherence, including asthma-specific drivers and more general drivers common to chronic diseases. Due to the episodic nature of asthma, many patients felt that their daily life was not substantially impacted; consequently, many harbored doubts about the accuracy of their diagnosis or were in denial about the impact of the disease and, in turn, the need for long-term treatment. This was further compounded by poor patient-physician communication, which contributed to suboptimal knowledge about asthma medications, including lack of understanding of the distinction between maintenance and reliever inhalers, suboptimal inhaler technique, and concerns about ICS side effects. Other drivers of poor medication adherence included the high cost of asthma medication, general forgetfulness, and embarrassment over inhaler use in public. Overall, patients' perceived lack of need for asthma medications and medication concerns, in part due to suboptimal knowledge and poor patient-physician communication, emerged as key drivers of poor medication adherence. Optimal asthma care and management should therefore target these barriers through effective patient- and physician-centered strategies.

Usage Patterns of Short-Acting ß2-Agonists and Inhaled Corticosteroids in Asthma: A Targeted Literature Review.

Despite the availability of effective asthma treatments, some patients are poorly controlled because of overreliance on short-acting ß2-agonists (SABAs) and underuse of inhaled corticosteroids (ICSs). To identify patient characteristics and outcomes associated with SABA overreliance and ICS underuse, we conducted a targeted literature review of the quantitative evidence on asthma medication use. Articles evaluating SABA and/or ICS use in patients with asthma (aged ≥12 years), published between January 2012 and March 2018, were identified using MEDLINE and EMBASE. We observed that studies classified SABA usage as "overuse," "high use," "excess use," "extreme overuse," "suboptimal use," and "inappropriate use." Multiple thresholds were used to define overuse of SABA (≥3 to ≥12 canisters/y). SABA overreliance was prevalent, with approximately 20% of adults using 3 or more canisters per year (≥12 inhalations/wk). Similarly, inappropriate ICS use, classified as "suboptimal," "high use," "underuse," and "unlicensed use," was defined by varying thresholds. Specific patient populations, such as older adults, smokers, and patients with low income, were more susceptible to SABA overreliance and ICS underuse. Overreliance on SABAs was associated with increased risk of severe exacerbations, asthma-related hospitalizations, emergency department visits, and asthma-related costs. These findings emphasize the prevalence and related burden of SABA overreliance at the potential expense of appropriate ICS use.

Effective Asthma Management: Is It Time to Let the AIR out of SABA?

For years, standard asthma treatment has included short acting beta agonists (SABA), including as monotherapy in patients with mild asthma symptoms. In the Global Initiative for Asthma 2019 strategy for the management of asthma, the authors recommended a significant departure from the traditional treatments. Short acting beta agonists (SABAs) are no longer recommended as the preferred reliever for patients when they are symptomatic and should not be used at all as monotherapy because of significant safety concerns and poor outcomes. Instead, the more appropriate course is the use of a combined inhaled corticosteroid-fast acting beta agonist as a reliever. This paper discusses the issues associated with the use of SABA, the reasons that patients over-use SABA, difficulties that can be expected in overcoming SABA over-reliance in patients, and our evolving understanding of the use of "anti-inflammatory relievers" in our patients with asthma.