Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Transmission (medicine) wikipedia , lookup
Public health genomics wikipedia , lookup
Race and health wikipedia , lookup
Epidemiology of metabolic syndrome wikipedia , lookup
Epidemiology wikipedia , lookup
Preventive healthcare wikipedia , lookup
Diseases of poverty wikipedia , lookup
Grazie per aver scelto di utilizzare a scopo didattico questo materiale delle Guidelines 2011 libra. Le ricordiamo che questo materiale è di proprietà dell’autore e fornito come supporto didattico per uso personale. Is a uniform definition of severity, control and risk possible in chronic diseases ? 1- A novel concept of chronic diseases 2- The example of asthma 3- Tentative uniform definition 4- Needs for a uniform definition Is a uniform definition of severity, control and risk possible in chronic diseases ? 1- A novel concept of chronic diseases 2- The example of asthma 3- Tentative uniform definition 4- Needs for a uniform definition Socio-economic determinants Life style - environment Risk and protective factors Tobacco smoking, Pollutants Allergens, Nutrition, Infections Physical exercise, Others Socio-economic determinants Life style - environment Risk and protective factors Tobacco smoking, Pollutants Allergens, Nutrition, Infections Physical exercise, Others Genes Socio-economic determinants Life style - environment Risk and protective factors Tobacco smoking, Pollutants Allergens, Nutrition, Infections Physical exercise, Others Genes Biological expression of chronic diseases Transcripts, proteins, metabolites Target organ local inflammation Systemic inflammation Cell and tissue remodelling Clinical expression of chronic diseases Co-morbidities Severity of co-morbidities Persistence, remission Long-term morbidity Responsiveness - side effects to treatment Socio-economic determinants Life style - environment Risk and protective factors Tobacco smoking, Pollutants Allergens, Nutrition, Infections Physical exercise, Others Genes Biological expression of chronic diseases Transcripts, proteins, metabolites Target organ local inflammation Systemic inflammation Cell and tissue remodelling Ageing Clinical expression of chronic diseases Co-morbidities Severity of co-morbidities Persistence, remission Long-term morbidity Responsiveness - side effects to treatment Socio-economic determinants Life style - environment Risk and protective factors Tobacco smoking, Pollutants Allergens, Nutrition, Infections Physical exercise, Others Genes Biological expression of chronic diseases Transcripts, proteins, metabolites Target organ local inflammation Systemic inflammation Cell and tissue remodelling Ageing Clinical expression of chronic diseases Co-morbidities Severity of co-morbidities Persistence, remission Long-term morbidity Responsiveness - side effects to treatment Systems biology on precise phenotypes Socio-economic determinants Life style - environment Risk and protective factors Tobacco smoking, Pollutants Allergens, Nutrition, Infections Physical exercise, Others Genes Health promotion Primary prevention Systems biology on precise phenotypes Biological expression of chronic diseases Transcripts, proteins, metabolites Target organ local inflammation Systemic inflammation Cell and tissue remodelling Ageing Clinical expression of chronic diseases Co-morbidities Severity of co-morbidities Persistence, remission Long-term morbidity Responsiveness - side effects to treatment Personalized medicine - Primary prevention - Secondary prevention - Tertiary prevention - Treatment Classical phenotypes Novel phenotypes Hypothesis-driven Discovery driven Patient with chronic disease CVD COPD Diabetes Co-morbidities (standardized assessment) Assessment of co-morbities and severity Severity of co-morbidities (standardized assessment) Classical phenotypes in patients with severe defined diseases and co-morbidities Novel phenotypes in individual patients with severe co-morbidities of chronic diseases Responsiveness to treatment Follow up Responsiveness to treatment Follow up Classical phenotypes Novel phenotypes Hypothesis-driven Discovery driven Patient with chronic disease CVD COPD Diabetes Co-morbidities (standardized assessment) Assessment of co-morbities and severity Severity of co-morbidities (standardized assessment) Classical phenotypes in patients with severe defined diseases and co-morbidities Novel phenotypes in individual patients with severe co-morbidities of chronic diseases Responsiveness to treatment Follow up Responsiveness to treatment Follow up Classical phenotypes Novel phenotypes Hypothesis-driven Discovery driven Patient with chronic disease CVD COPD Diabetes Co-morbidities (standardized assessment) Assessment of co-morbities and severity Severity of co-morbidities (standardized assessment) Classical phenotypes in patients with severe defined diseases and co-morbidities Novel phenotypes in individual patients with severe co-morbidities of chronic diseases Responsiveness to treatment Follow up Responsiveness to treatment Follow up Is a uniform definition of severity, control and risk possible in chronic diseases ? 1- A novel concept of chronic diseases 2- The example of asthma Asthma severity - GINA 2002 Asthma severity Control • Symptoms • Functional limitation over 2-4 weeks • Exacerbations over 6-12 mo Classification of asthma: GINA 1998 Current treatment step Step 1 Step 2 Step 3 Step 4 No controller <500 BDP 200–1000 BDP + LABA >1000 BDP + LABA + other Step 1 Symptoms <1 x week Nocturnal symptoms ≤2x month Lung function normal between episodes Intermittent Mild persistent Moderate persistent Severe persistent Step 2 Symptoms >1 x week Nocturnal symptoms <1 x week Lung function normal between episodes Mild persistent Moderate persistent Severe persistent Severe persistent Step 3 Symptoms daily Nocturnal symptoms ≥1 x week FEV1 60–80% predicted Moderate persistent Severe persistent Severe persistent Severe persistent Step 4 Symptoms daily Frequent nocturnal symptoms FEV1 <60% predicted Severe persistent Severe persistent Severe persistent Severe persistent Clinical features Asthma control - GINA 2006 Asthma control Control • Symptoms • Functional limitation over 2-4 weeks • Exacerbations over 6-12 mo GINA 2002 (severity)- 2006 (control) Control of asthma: GINA 2006 characteristics controlled Partially controlled uncontrolled Day time symptoms none > 2 / week 3 or more features Limitations of activities none any of uncontrollled asthma Nocturnal symptoms none any present in any week Need for reliever rescue medication none > 2 / week Lung function (FEV1 or PEFR) Normal or near normal >80% predicted or personal best Exacerbations none ≥ 1 / yr One in any week Asthma severity- NAEPP3 (NHLBI) Asthma severity Control • Symptoms • Functional limitation over 2-4 weeks • Exacerbations over 6-12 mo Responsiveness to treatment Future risks • Asthma exacerbations • Lung function loss • Lung growth in children • Adverse reactions from medications) GINA 2002 - 2010 Definition of severe asthma (Geneva, 6-7 April 2009) Asthma severity WHO definition Bousquet J et al, J Allergy Clin Immunol 2010 Asthma severity Control • Symptoms • Functional limitation over 2-4 weeks • Exacerbations over 6-12 mo • Level of treatment • Inhalation technique • Compliance Responsiveness to treatment Future risks • Asthma exacerbations • Lung function loss • Lung growth in children • Adverse reactions from medications) Is a uniform definition of severity, control and risk possible in chronic diseases ? 1- A novel concept of chronic diseases 2- The example of asthma 3- Tentative definition WP 6 Epigenetics and targeted proteomics Uniform severity of chronic diseases Assess and regularly review CONTROL Diagnosis of chronic disease Underdiagnosis Short-term (eg exacerbation) Long-term (eg remodelling) RISK Risks due to co-morbidities Side effects from treatment Uniform severity of chronic diseases Asthma Diabetes Underdiagnosis Risk of acute exacerbation Risk of coma and death Effective treatment ICS -ß2 agonists Insulin, oral drugs No treatment available/affordable Risk of acute exacerbation Risk of coma and death Incorrect diagnosis (example) COPD (adults) CF (children) Other coma Difficult-to-treat disease Compliance Inhaler misuse Risk factors (tobacco, allergen) Compliance Complications Risk factors (diet, tobacco) Controlled treatment dependent disease Risk of exacerbation when treatment stopped Risk of death when treatment stopped Uncontrolled treatment resistant disease Risk of severe exacerbation Insulin-resistant diabetes Uniform severity of chronic diseases Diagnosis of chronic disease Underdiagnosis Assess and regularly review CONTROL Patient with uncontrolled chronic disease Is treatment/prevention effective ? NO Short-term (eg exacerbation) Long-term (eg remodelling) RISK Risks due to co-morbidities Side effects from treatment Uniform severity of chronic diseases Asthma Diabetes Underdiagnosis Risk of acute exacerbation Risk of coma and death Effective treatment ICS -ß2 agonists Insulin, oral drugs No treatment available/affordable Risk of acute exacerbation Risk of coma and death Incorrect diagnosis (example) COPD (adults) CF (children) Other coma Difficult-to-treat disease Compliance Inhaler misuse Risk factors (tobacco, allergen) Compliance Complications Risk factors (diet, tobacco) Controlled treatment dependent disease Risk of exacerbation when treatment stopped Risk of death when treatment stopped Uncontrolled treatment resistant disease Risk of severe exacerbation Insulin-resistant diabetes Uniform severity of chronic diseases Diagnosis of chronic disease Underdiagnosis Assess and regularly review CONTROL Patient with uncontrolled chronic disease Is treatment/prevention effective ? Is treatment available and affordable ? NO Short-term (eg exacerbation) Untreated severe disease Long-term (eg remodelling) RISK Risks due to co-morbidities Side effects from treatment Uniform severity of chronic diseases Asthma Diabetes Underdiagnosis Risk of acute exacerbation Risk of coma and death Effective treatment ICS -ß2 agonists Insulin, oral drugs No treatment available/affordable Risk of acute exacerbation Risk of coma and death Incorrect diagnosis (example) COPD (adults) CF (children) Other coma Difficult-to-treat disease Compliance Inhaler misuse Risk factors (tobacco, allergen) Compliance Complications Risk factors (diet, tobacco) Controlled treatment dependent disease Risk of exacerbation when treatment stopped Risk of death when treatment stopped Uncontrolled treatment resistant disease Risk of severe exacerbation Insulin-resistant diabetes Uniform severity of chronic diseases Diagnosis of chronic disease Underdiagnosis Assess and regularly review CONTROL Patient with uncontrolled chronic disease Is treatment/prevention effective ? Is treatment available and affordable ? NO Short-term (eg exacerbation) Untreated severe disease Long-term (eg remodelling) Treat according to guidelines Check if diagnosis is correct OR if there are other associated diseases Possible risk due to other disease RISK Risks due to co-morbidities Side effects from treatment No asthma Re-check asthma diagnosis Diagnosis Severe asthma due to occupational expoure to isocyanates OR NO Asthma PLUS another condition causing current symptoms No asthma Re-check asthma diagnosis OR NO Asthma PLUS another condition causing current symptoms Visit for coarse voice due to high dose ICS (and dyspnea) in a severe asthmatic FEV1: 1.78 l (72%), post-ß2: 1.92 (+5%), FEV1/FVC: 66% Uniform severity of chronic diseases Asthma Diabetes Underdiagnosis Risk of acute exacerbation Risk of coma and death Effective treatment ICS -ß2 agonists Insulin, oral drugs No treatment available/affordable Risk of acute exacerbation Risk of coma and death Incorrect diagnosis (example) COPD (adults) CF (children) Other coma Difficult-to-treat disease Compliance Inhaler misuse Risk factors (tobacco, allergen) Compliance Complications Risk factors (diet, tobacco) Controlled treatment dependent disease Risk of exacerbation when treatment stopped Risk of death when treatment stopped Uncontrolled treatment resistant disease Risk of severe exacerbation Insulin-resistant diabetes Uniform severity of chronic diseases Diagnosis of chronic disease Underdiagnosis Assess and regularly review CONTROL Patient with uncontrolled chronic disease Is treatment/prevention effective ? Is treatment available and affordable ? NO Short-term (eg exacerbation) Untreated severe disease Long-term (eg remodelling) Treat according to guidelines Check if diagnosis is correct OR if there are other associated diseases Possible risk due to other disease Check co-morbidies, risk factors compliance and/or treatment administration Difficult-to-treat disease RISK Risks due to co-morbidities Side effects from treatment Uniform severity of chronic diseases Asthma Diabetes Underdiagnosis Risk of acute exacerbation Risk of coma and death Effective treatment ICS -ß2 agonists Insulin, oral drugs No treatment available/affordable Risk of acute exacerbation Risk of coma and death Incorrect diagnosis (example) COPD (adults) CF (children) Other coma Difficult-to-treat disease Compliance Inhaler misuse Risk factors (tobacco, allergen) Compliance Complications Risk factors (diet, tobacco) Controlled treatment dependent disease Risk of exacerbation when treatment stopped Risk of death when treatment stopped Uncontrolled treatment resistant disease Risk of severe exacerbation Insulin-resistant diabetes Uniform severity of chronic diseases Diagnosis of chronic disease Underdiagnosis Assess and regularly review CONTROL Patient with uncontrolled chronic disease NO Is treatment/prevention effective ? Short-term (eg exacerbation) Untreated severe disease Is treatment available and affordable ? Long-term (eg remodelling) Treat according to guidelines Check if diagnosis is correct OR if there are other associated diseases Possible risk due to other disease Check co-morbidies, risk factors compliance and/or treatment administration Difficult-to-treat disease Treat to the highest recommended dose Severe disease controlled with optimal treatment RISK Risks due to co-morbidities Side effects from treatment Uniform severity of chronic diseases Asthma Diabetes Underdiagnosis Risk of acute exacerbation Risk of coma and death Effective treatment ICS -ß2 agonists Insulin, oral drugs No treatment available/affordable Risk of acute exacerbation Risk of coma and death Incorrect diagnosis (example) COPD (adults) CF (children) Other coma Difficult-to-treat disease Compliance Inhaler misuse Risk factors (tobacco, allergen) Compliance Complications Risk factors (diet, tobacco) Controlled treatment dependent disease Risk of exacerbation when treatment stopped Risk of death when treatment stopped Uncontrolled treatment resistant disease Risk of severe exacerbation Insulin-resistant diabetes Uniform severity of chronic diseases Diagnosis of chronic disease Underdiagnosis Assess and regularly review CONTROL Patient with uncontrolled chronic disease NO Is treatment/prevention effective ? Short-term (eg exacerbation) Untreated severe disease Is treatment available and affordable ? Long-term (eg remodelling) Treat according to guidelines Check if diagnosis is correct OR if there are other associated diseases Possible risk due to other disease Check co-morbidies, risk factors compliance and/or treatment administration Difficult-to-treat disease Treat to the highest recommended dose Severe disease uncontrolled despite optimal treatment Severe disease controlled with optimal treatment RISK Risks due to co-morbidities Side effects from treatment Uniform severity of chronic diseases Asthma Diabetes Underdiagnosis Risk of acute exacerbation Risk of coma and death Effective treatment ICS -ß2 agonists Insulin, oral drugs No treatment available/affordable Risk of acute exacerbation Risk of coma and death Incorrect diagnosis (example) COPD (adults) CF (children) Other coma Difficult-to-treat disease Compliance Inhaler misuse Risk factors (tobacco, allergen) Compliance Complications Risk factors (diet, tobacco) Controlled treatment dependent disease Risk of exacerbation when treatment stopped Risk of death when treatment stopped Uncontrolled treatment resistant disease Risk of severe exacerbation Insulin-resistant diabetes Is a uniform definition of severity, control and risk possible in chronic diseases ? 1- A novel concept of chronic diseases 2- The example of asthma 3- Tentative uniform definition 4- Needs for a uniform definition Applicability of the definition • Public health: to improve the quality of allergy care, but also to optimize health care planning and policies. • Clinical practice: simplicity for physicians • Clinical trials • Research: Well characterized approved phenotypes • Epidemiologic studies: Well characterized approved phenotypes • Drug development • Applicable to developed and developing countries • Registries One step in the phenotype complexity By courtesy from J Kiley One step in the phenotype complexity By courtesy from J Kiley