Nathir M. Obeidat

Associations between inhaler technique and asthma control among asthma patients using pressurised MDIs and DPIs.

OBJECTIVES To investigate associations between technique with pressurised metered-dose inhalers (pMDIs) and dry powder inhalers (DPIs) used as controller medication and asthma control variables measured using Asthma Control Test (ACT) scores. DESIGN In this cross-sectional study, the inhaler technique of asthma patients using pMDIs or DPIs (Turbuhaler® [TH] and Accuhaler Diskus™ [ACC]) were assessed against published inhaler technique checklists. ACT scores (maximum 25, higher score corresponding to better asthma control) were assessed. RESULTS Of the 130 subjects enrolled in the study (41 TH, 54 ACC and 35 pMDI), inhaler technique scores (out of nine for all devices) were low for TH (4.4 ± 0.9) and ACC (5.4 ± 1.0) compared with pMDI (8.1 ± 0.9) (P < 0.001, one-way analysis of variance). Older age and use of pMDI were associated with better inhaler technique. ACT scores were low, consistent with very poorly controlled asthma (mean TH 13.1 ± SD 3.9, mean ACC 13.3 ± SD 3.9 and mean pMDI 12.8 ± SD 4.2). No significant association between inhaler technique scores and ACT scores was found. More recent asthma diagnosis and a higher level of education were associated with higher ACT scores (better asthma control). CONCLUSION Asthma control was poor in this population. Lack of a significant association between the inhaler technique score and asthma control may reflect the multiple factors contributing to poor asthma control in the Jordanian population.

Frequency of genetic polymorphisms of ADAM33 and their association with allergic rhinitis among Jordanians

Allergic rhinitis is a chronic inflammatory disease that is assumed to be due to an interaction between different genetic and/or environmental factors. A disintegrin and metalloprotease domain 33 (ADAM33) has been extensively studied as a susceptibility gene in asthma and has been linked to bronchial hyper-responsiveness. In this study, we investigated the association between ADAM33 single nucleotide polymorphisms and the incidence of allergic rhinitis among the Jordanian population. We conducted a case-control association study on 120 adult individuals diagnosed with allergic rhinitis and 128 normal healthy controls. 8 single-nucleotide polymorphisms in ADAM33 were genotyped using PCR-RFLP method. No significant differences in the allelic frequencies of all SNPs tested between AR patients and the control volunteers were found, although S2 C/G SNP showed a tendency toward significance with P=0.06. On the genotype level significant association were found in the following genotypes: T1 AA, T1 AG, T2 GG, T2 AG, T+1 GG, T+1 AG, V4 CG, S2 CC, S2 CG, Q-1AA. Seven haplotypes were present only within AR patients and eight haplotypes were completely absent from the AR patients. Three haplotypes exhibited significant association with AR P ≤ 0.05, two of them were present only in AR patients. In conclusion, the polymorphisms in the ADAM33 gene are associated with susceptibility to AR in the Jordanian population. Furthermore, the haplotype of the tested SNPs were also associated with the risk of AR.

Effect of novel inhaler technique reminder labels on the retention of inhaler technique skills in asthma: a single-blind randomized controlled trial

Inhaler technique can be corrected with training, but skills drop off quickly without repeated training. The aim of our study was to explore the effect of novel inhaler technique labels on the retention of correct inhaler technique. In this single-blind randomized parallel-group active-controlled study, clinical pharmacists enrolled asthma patients using controller medication by Accuhaler [Diskus] or Turbuhaler. Inhaler technique was assessed using published checklists (score 0–9). Symptom control was assessed by asthma control test. Patients were randomized into active (ACCa; THa) and control (ACCc; THc) groups. All patients received a “Show-and-Tell” inhaler technique counseling service. Active patients also received inhaler labels highlighting their initial errors. Baseline data were available for 95 patients, 68% females, mean age 44.9 (SD 15.2) years. Mean inhaler scores were ACCa:5.3 ± 1.0; THa:4.7 ± 0.9, ACCc:5.5 ± 1.1; THc:4.2 ± 1.0. Asthma was poorly controlled (mean ACT scores ACCa:13.9 ± 4.3; THa:12.1 ± 3.9; ACCc:12.7 ± 3.3; THc:14.3 ± 3.7). After training, all patients had correct technique (score 9/9). After 3 months, there was significantly less decline in inhaler technique scores for active than control groups (mean difference: Accuhaler −1.04 (95% confidence interval −1.92, −0.16, P = 0.022); Turbuhaler −1.61 (−2.63, −0.59, P = 0.003). Symptom control improved significantly, with no significant difference between active and control patients, but active patients used less reliever medication (active 2.19 (SD 1.78) vs. control 3.42 (1.83) puffs/day, P = 0.002). After inhaler training, novel inhaler technique labels improve retention of correct inhaler technique skills with dry powder inhalers. Inhaler technique labels represent a simple, scalable intervention that has the potential to extend the benefit of inhaler training on asthma outcomes.Asthma: Reminder labels improve inhaler techniquePersonalized labels on asthma inhalers remind patients of correct technique and help improve symptoms over time. Iman Basheti at the Applied Science Private University in Jordan and co-workers trialed the approach of placing patient-specific reminder labels on dry-powder asthma inhalers to improve long-term technique. Poor asthma control is often exacerbated by patients making mistakes when using their inhalers. During the trial, 95 patients received inhaler training before being split into two groups: the control group received no further help, while the other group received individualized labels on their inhalers reminding them of their initial errors. After three months, 67% of patients with reminder labels retained correct technique compared to only 12% of controls. They also required less reliever medication and reported improved symptoms. This represents a simple, cheap way of tackling inhaler technique errors.

Role of Chlamydia pneumoniae in community-acquired pneumonia in hospitalized Jordanian adults.

INTRODUCTION This study investigated the role of Chlamydia pneumoniae in the etiology of community-acquired pneumonia (CAP) in Jordanian adults. METHODOLOGY Eighty hospitalized CAP patients and 110 healthy adults were enrolled. Overall prevalences of C. pneumoniae IgG antibodies in sera and the rate of acute infection were estimated, using the microimmunofluorescence method (MIF), at titers of 1:16 and 1:512, respectively. Moreover, a nested polymerase chain reaction (PCR) was used to detect C. pneumoniae DNA in nasopharyngeal and blood Buffy coat samples. RESULTS Overall chlamydial IgG prevalence was higher in CAP cases than controls (70% versus 61.8%). Similarly, higher rate of acute infection was found in patients than in controls (16.3% versus 5.5%). By focusing on subjects testing positive at 1:16, acute infection was detectable in 23.2% of CAP cases, compared with 8.8% of seropositive controls. Chlamydial DNA was confirmed in 8.2% and 8.8% of nasopharyngeal specimens from controls and patients, respectively. Moreover, 10.9% and 7.5% of Buffy coats from controls and cases, respectively, were PCR-positive. When performances of both assays for detection of the pathogen were assessed, the sensitivities of MIF and PCR were low and comparable. However, MIF demonstrated higher specificity, positive predictive value, and negative predictive value than PCR. CONCLUSIONS MIF-based data indicate that C. pneumoniae could be a potential causal agent of CAP in Jordan. This study may serve as a basis to elucidate the exact role C. pneumoniae and other co-infecting pathogens in the etiology of respiratory tract disease.

Allele and Genotype Frequencies of the Polymorphic Methylenetetrahydrofolate Reductase and Lung Cancer in ther Jordanian Population: a Case Control Study.

BACKGROUND Methylenetetrahydrofolate reductase (MTHFR) is involved in amino acid synthesis and DNA function. Two common polymorphisms are reported, C677T and A1298C, that are implicated in a number of human diseases, including cancer. OBJECTIVE The association between MTHFR C677T and A1298C genotype and haplotype frequencies in risk for lung cancer (LC) was investigated in the Jordanian population. MATERIALS AND METHODS A total of 98 LC cases were studied for MTHFR C677T and A1298C polymorphisms, compared to 89 controls taken from the general population, employing the PCR-RFLP technique. RESULTS The frequency of the genotypes of MTHFR C677T among Jordanians was: CC, 59.6%, CT, 33%; and TT, 7.4% among LC cases and 49.4%, 40.2% and 10.3% among controls. No significant association was detected between genetic polymorphism at this site and LC. At MTHFR A12987C, the genotype distribution was AA, 29.5%; AC, 45.3%, and CC 25.3% among LC cases and 36.8%, 50.6% and 12.6% among controls. Carriers of the CC genotype were more likely to have LC (OR=2.5; 95%CI: 1.04-6; p=0.039) as compared to AA carriers. Smokers and males with the CC genotype were 9.9 and 6.7 times more likely to have LC, respectively (ORsmokers=9.9; 95%CI: 1.2-84.5, p=0.018; ORmen=6.6; 95%CI: 1.7-26.2, p=0.005). Haplotype analysis of MTHFR polymorphism at the two loci showed differential distribution of the CC haplotype (677C-1298C) between cases and controls. The CC haplotype was associated with an increased risk for lung cancer (OR=1.6; 95% CI: 1.03-2.4, p=0.037). CONCLUSIONS The genetic polymorphism of MTHFR at 1298 and the CC haplotype (risk is apparently lower with the C allele at position 677) may modulate the risk for LC development among the Jordanian population. Risk associated with the 1298C allele is increased in smokers and in males. The results indicate that a critical gene involved in folate metabolism plays a modifying role in lung cancer risk, at least in the Jordanian population.

Association Between ADAM33 Polymorphisms and Susceptibility with Adult and Childhood Asthma Among Jordanians

Disintegrin and metalloprotease 33 (ADAM33) have been associated with childhood and adult asthma in many populations. ADAM33 mutations might predispose to altered lung function in early infancy. In this study, we investigated the association between single-nucleotide polymorphisms in ADAM33 and the incidence of adult and childhood asthma among Jordanians. One hundred seven pediatric asthmatic patients, 115 healthy pediatric patient controls, 160 adult asthmatic patients, and 110 healthy adults were enrolled in this study. ADAM33 polymorphisms were genotyped using the polymerase chain reaction/restriction fragment length polymorphism method. A strong association between the V4 genotype and incidence of childhood asthma was found. In the single-locus analyses of asthma risk, V4 C/G single nucleotide polymorphism (SNP) showed a trend toward significance with p=0.07. Interestingly, the CC homozygous mutant genotype frequency was significantly higher in asthmatic subjects (15.9%) than in control subjects (2.6%), resulting in an odds ratio of 7.05. In adult cases, S2, the F+1 and Q-1 genotype showed a significant association (p≤0.05) with the incidence of asthma. Two haplotypes also exhibited a significant association with asthma (p≤0.05). In conclusion, the findings of this study confirm the already reported association between V4 SNP and the incidence of childhood asthma as well as between S2, F+1, and Q-1 SNPs and the incidence of adult asthma in several populations.

P100 Improving paediatrics’ pressurised metered dose inhaler technique and asthma control: Inhaler verbal counselling vs. Trainhaler

Introduction Verbal counselling (VC) is commonly used to train patients on correct inhaler technique. Patients forget the good inhaler use with time. Trainhaler (TH), Clement Clarke, UK, is a novel pressurised metered dose inhaler (MDI) training tool designed with feedback mechanisms to train patients coordinate releasing the aerosol with using a slow and deep inhalation flow (IF) through their MDI. Our aim was to compare VC with TH in children with asthma. Methods Ethical approval was obtained and all children and their parents gave signed consent. At visit 1, asthmatic children, age 7–17 years, with an MDI hand-lung coordination problem including an IF >60 l/min were randomised into either the VC group that received verbal MDI training with emphasis on using a slow and deep IF; or into the TH group that were trained on- and given TH to practice at home. Children with correct MDI technique and IF ≤60 l/min formed the control group (CT). An 11-step MDI technique, peak IF through the inhaler and Asthma Control Questionnaire (ACQ) were evaluated. All subjects returned after 6 to 8 weeks (visit 2) for re-evaluation. Results Thirty children took part. Table 1 presents the study outcomes. All VC and TH had correct MDI steps and slow IF post-training at visit 1. Unlike CT, Wilcoxon test showed a significant decrease (p < 0.01) in the incorrect MDI steps between visits 1 and 2, within VC and TH. Mann-Whitney test showed a significant difference (p < 0.01) in the incorrect MDI steps between the CT and both intervention groups at visit 1, but no significant difference (p > 0.05) was found at visit 2. Paired t-test showed significant reductions (p < 0.01) in IF and ACQ within TH. In VC, the ACQ improved at visit 2, but the IF did not.Abstract P100 Table 1 Study groups and outcome measures Control(n = 12) VC (n = 9) TH (n = 9) Sex (M/F) 7/5 4/5 7/2 Mean (SD) age, years 9.0 (2.0) 9.9 (3.3) 9.9 (1.3) Mean (SD) FEV1% predicted at visit 1 84.2 (19.6) 84.1 (13.9) 91.2 (14.6) Median (quartiles) incorrect MDI steps at visit 1 2.0 (0; 4.75) 10 (6.5; 10) 6 (5; 9) Median (quartiles) incorrect MDI steps at visit 2 0.5 (0; 2.75) 1.0 (0; 2.0) 0.0 (0; 0.5) Mean (SD) peak IF pre-training at visit 1, l/min 46.7 (8.2) 99.1 (55.4) 115.8 (24.1) Mean (SD) peak IF at visit 2, l/min 75.0 (34.2) 98.9 (65.8) 66.1 (19.0) Mean (SD) ACQ at visit 1 1.14 (0.59) 2.43 (1.85) 2.39 (1.10) Mean (SD) ACQ at visit 2 0.74 (0.93) 0.82 (0.64) 0.70 (0.97) Conclusion VC and TH improved the children’s MDI technique which was reflected on better asthma control. VC children could not, however, maintain the acceptable IF through their MDI which is critical for aerosol lung deposition. An inhaler training tool available to patients at any time can be helpful.

Association Between Gasdermin A and Gasdermin B Polymorphisms and Susceptibility to Adult and Childhood Asthma Among Jordanians

INTRODUCTION Gasdermin A (GSDMA) and gasdermin B (GSDMB) have been associated with childhood, and to a lesser extent with adult, asthma in many populations. AIMS In this study, we investigated the association between GSDMA and GSDMB variants and the incidence of adult and childhood asthma among Jordanians. METHODS Subjects were divided into two groups: adults and children. Within the adult group there were 129 asthma patients and 111 healthy controls. In the pediatric group there were 98 asthma patients and 112 healthy children. Gasdermin A (GSDMA) (rs7212938, T/G) and Gasdermin B (rs7216389, T/C) polymorphisms were genotyped using the PCR-RFLP method. Three analysis models were applied to the genotype data: co-dominant, dominant and recessive. RESULTS An association between the GSDMB T/C single nucleotide polymorphism (SNP) genotype and the incidence of childhood asthma was found (< 0.05). GSDMB T/C SNP in children also showed a very high tendency toward significance with p = 0.0532 in the single locus analysis. In adults, no significant differences in the allelic frequencies of any of the SNPs analyzed were found between the case and control populations. At the haplotype level, GC haplotype was found to be associated with the risk of asthma in children while none of the tested haplotypes were found to be associated with asthma risk in adults. CONCLUSIONS The findings of this study confirm the previously reported association between the GSDMB gene and the risk of childhood asthma.

Inhaler technique education and asthma control among patients hospitalized for asthma in Jordan

Objectives To investigate the effect of inhaler technique education delivered by a clinical pharmacist to patients hospitalised for asthma, on inhaler technique scores and asthma control at three months post-discharge. Methods This pre-post interventional study in Jordan enrolled patients who had been admitted for asthma and were using controller medication by Accuhaler [Diskus] (ACC), Turbuhaler (TH) or Pressurized metered dose inhalers (pMDI). Inhaler technique was assessed using published checklists (score 0–9). Asthma symptom control was assessed by Asthma Control Test (ACT, range 5–25). Patients were assessed on admission (baseline), pre-discharge, and 3 months later. All patients received a ‘Show-and-Tell’ inhaler technique counseling service prior to discharge. Results Baseline data were available for 140 patients, 71% females, mean age 52.7 (SD 16.64) years, mean ACT score 10.0 (SD 4.8). Mean inhaler score was 7.5 (SD 1.52) with no significant difference between the inhaler groups (p = 0.174). After pre-discharge training, all patients had correct technique (score 9/9). After 3 months, mean inhaler scores were significantly higher than at baseline (8.14 (SD 0.87, p < 0.001), with mean change significantly higher for TH 1.21 (SD 2.25) and ACC 0.85 (SD 0.97) than pMDI (0.16; SD 0.72), p = 0.001. Symptom control improved significantly for all patients, with a mean increase in ACT score of 7.54 (SD 8.18), with no significant difference between the inhaler device groups (p = 0.326). Conclusions Patients hospitalized for asthma achieved correct inhaler technique after training by a pharmacist, and maintained better technique at 3 months than on admission. Significant improvements in ACT scores were documented for all inhaler groups.

Impact of home medication management review on medication adherence among Jordanian patients

This study was designed to evaluate the impact of Home Medication Management Review (HMMR) on self‐reported adherence, and to explore the effect of different patient factors on their medication adherence.