Longitudinal patterns of intermittent oral corticosteroid therapy for asthma in the United Kingdom.

Background: Increasing frequency of intermittent oral corticosteroid (OCS) prescription and cumulative OCS exposure increase the risk of OCS-related adverse outcomes. Objective: We sought to describe the evolution and trajectory of intermittent OCS prescription patterns in patients with asthma and investigate risk factors independently associated with transitioning to a frequent prescription pattern. Methods: This historical cohort study included patients with active asthma managed in UK primary care and included in the Optimum Patient Care Research Database (OPCRD; opcrd.co.uk). Intermittent OCS prescription patterns were categorized as sporadic, infrequent, moderately frequent, or frequent. Prescription pattern sequences were described for those who had a frequent sequence in their final year of prescribing. We examined associations between OCS prescription pattern and the hazard of transitioning into a frequent intermittent OCS prescription pattern using multivariable Cox regression with a 10-year look-back period. Results: Of 105,229 patients with intermittent OCS prescriptions, 57.1% (n = 60,083) had a frequent OCS prescription pattern at some point. Irrespective of baseline pattern, most patients transitioned to frequent prescription during the look back. The strongest risk factors were a more frequent prescription pattern at the start of look-back period, a lower percentage peak expiratory flow rate, and higher Global Initiative for Asthma treatment step. Older age, female sex, obesity, and active smoking were also associated with a higher risk of transitioning. Conclusion: Our findings help identify those most at risk of transitioning to frequent intermittent OCS receipt and encourage earlier intervention with OCS-sparing treatments.

Underuse of ß-blockers in heart failure and chronic obstructive pulmonary disease.

OBJECTIVE: Although ß-blockers are an established therapy in heart failure (HF) guidelines, including for patients with chronic obstructive pulmonary disease (COPD), there remain concerns regarding bronchoconstriction even with cardioselective ß-blockers. We wished to assess the real-life use of ß-blockers for patients with HF and comorbid COPD. METHODS: We evaluated data from the Optimum Patient Care Research Database over a period of 1 year for co-prescribing of ß-blockers with either an ACE inhibitor (ACEI) or angiotensin-2 receptor blocker (ARB) in patients with HF alone versus HF+COPD. Association with inhaler therapy was also evaluated. RESULTS: We identified 89 861 patients with COPD, 24 237 with HF and 10 853 with both conditions. In patients with HF+COPD, the mean age was 79 years; 60% were male, and 27% had prior myocardial infarction. Of patients with HF+COPD, 22% were taking a ß-blocker in conjunction with either ACEI/ARB (n=2416) compared with 41% of patients with HF only (n=10 002) (adjusted OR 0.54, 95% CI 0.51 to 0.58, p<0.001). Among HF+COPD patients taking inhaled corticosteroid (ICS) with long-acting ß-agonist (LABA) and long-acting muscarinic antagonist, 27% of patients were taking an ACEI/ARB with ß-blockers (n=778) versus 46% taking an ACEI/ARB without ß-blockers (n=1316). Corresponding figures for those patients taking ICS/LABA were 20% (n=583) versus 48% (n=1367), respectively. CONCLUSIONS: These data indicate a substantial unmet need for patients with COPD who should be prescribed ß-blockers more often for concomitant HF.

Short-term results of endonasal dacryocystorhinostomy with a mucosal flap and a bone dissection technique.

OBJECTIVE: To determine the short-term results of endonasal dacryocystorhinostomy (DCR) with a mucosal flap and a bone dissection technique. MATERIALS AND METHODS: A retrospective study including consecutive 22 patients who underwent endonasal DCR between June 2004 and January 2006. The study was designed to look at the patients' symptoms and satisfaction following the procedure; hence, a telephone survey was undertaken. The absence or improvement of symptoms was defined as a successful outcome. RESULTS: There were 22 patients in the study cohort. The mean follow-up was 12 months. The procedure was successful in 20 patients (90.9%), with no residual epiphora. Failure was noted only in 2 patients. CONCLUSION: The short-term success rate of endonasal DCR was 90.90%. In a previous study from our unit, the success rate with endonasal laser DCR at 1 year was 83% and the 5-year success rate was only 56%, which made us stop doing the laser approach. We currently favour endonasal DCR with the mucosal flap approach in our unit.

Long-term results of endonasal laser dacryocystorhinostomy.

OBJECTIVE: To determine the long-term success rate of endonasal laser dacryocystorhinostomy (DCR) in our unit. MATERIALS AND METHODS: This was a retrospective study including all the consecutive cases of endonasal laser DCR (ELDCR) between November 1996 and December 1999. Patients who underwent revision DCR were excluded. The absence or improvement of symptoms as reported by the patients was defined as successful outcome. Conversely, recurrence of epiphora was considered as failure. The results were reviewed at 1 year in the clinic and at further 3 years and 5 years by telephone consultation. RESULTS: There were 65 patients (73 procedures) in the study cohort, with a mean follow-up period of 74 months (range, 60-97). Early failure was noted in 13 patients at 1 year. Only 28 patients (of the possible 50) were free from epiphora after 5 years postsurgery. CONCLUSION: We found that the success rate of ELDCR has gradually declined over the years to 56% (confidence interval, 38-69) in patients who had at least 5 years of postoperative data. We do not advocate the use of laser in endonasal DCR for patients with epiphora. EBM RATING: C-4.