Clinical standards for the diagnosis and management of asthma in low- and middle-income countries

BACKGROUND: The aim of these clinical standards is to aid the diagnosis and management of asthma in low-resource settings in low- and middle-income countries (LMICs).METHODS: A panel of 52 experts in the field of asthma in LMICs participated in a two-stage Delphi process to establish and reach a consensus on the clinical standards.RESULTS: Eighteen clinical standards were defined: Standard 1, Every individual with symptoms and signs compatible with asthma should undergo a clinical assessment; Standard 2, In individuals (>6 years) with a clinical assessment supportive of a diagnosis of asthma, a hand-held spirometry measurement should be used to confirm variable expiratory airflow limitation by demonstrating an acute response to a bronchodilator; Standard 3, Pre- and post-bronchodilator spirometry should be performed in individuals (>6 years) to support diagnosis before treatment is commenced if there is diagnostic uncertainty; Standard 4, Individuals with an acute exacerbation of asthma and clinical signs of hypoxaemia or increased work of breathing should be given supplementary oxygen to maintain saturation at 94-98%; Standard 5, Inhaled short-acting beta-2 agonists (SABAs) should be used as an emergency reliever in individuals with asthma via an appropriate spacer device for metered-dose inhalers; Standard 6, Short-course oral corticosteroids should be administered in appropriate doses to individuals having moderate to severe acute asthma exacerbations (minimum 3-5 days); Standard 7, Individuals having a severe asthma exacerbation should receive emergency care, including oxygen therapy, systemic corticosteroids, inhaled bronchodilators (e.g., salbutamol with or without ipratropium bromide) and a single dose of intravenous magnesium sulphate should be considered; Standard 8, All individuals with asthma should receive education about asthma and a personalised action plan; Standard 9, Inhaled medications (excluding dry-powder devices) should be administered via an appropriate spacer device in both adults and children. Children aged 0-3 years will require the spacer to be coupled to a face mask; Standard 10, Children aged <5 years with asthma should receive a SABA as-needed at step 1 and an inhaled corticosteroid (ICS) to cover periods of wheezing due to respiratory viral infections, and SABA as-needed and daily ICS from step 2 upwards; Standard 11, Children aged 6-11 years with asthma should receive an ICS taken whenever an inhaled SABA is used; Standard 12, All adolescents aged 12-18 years and adults with asthma should receive a combination inhaler (ICS and rapid onset of action long-acting beta-agonist [LABA] such as budesonide-formoterol), where available, to be used either as-needed (for mild asthma) or as both maintenance and reliever therapy, for moderate to severe asthma; Standard 13, Inhaled SABA alone for the management of patients aged >12 years is not recommended as it is associated with increased risk of morbidity and mortality. It should only be used where there is no access to ICS.The following standards (14-18) are for settings where there is no access to inhaled medicines. Standard 14, Patients without access to corticosteroids should be provided with a single short course of emergency oral prednisolone; Standard 15, Oral SABA for symptomatic relief should be used only if no inhaled SABA is available. Adjust to the individual's lowest beneficial dose to minimise adverse effects; Standard 16, Oral leukotriene receptor antagonists (LTRA) can be used as a preventive medication and is preferable to the use of long-term oral systemic corticosteroids; Standard 17, In exceptional circumstances, when there is a high risk of mortality from exacerbations, low-dose oral prednisolone daily or on alternate days may be considered on a case-by-case basis; Standard 18. Oral theophylline should be restricted for use in situations where it is the only bronchodilator treatment option available.CONCLUSION: These first consensus-based clinical standards for asthma management in LMICs are intended to help clinicians provide the most effective care for people in resource-limited settings.

An expert system for water quality modelling

The RAISON-micro (Regional Analysis by Intelligent System ON a micro-computer) expert system is being used to predict the effects of mine effluents on receiving waters in Ontario. The potential of this system to assist regulatory agencies and mining industries to define more acceptable effluent limits was shown in an initial study. This system has been further developed so that the expert system helps the model user choose the most appropriate model for a particular application from a hierarchy of models. The system currently contains seven models which range from steady state to time dependent models, for both conservative and nonconservative substances in rivers and lakes. The menu driven expert system prompts the model user for information such as the nature of the receiving water system, the type of effluent being considered, and the range of background data available for use as input to the models. The system can also be used to determine the nature of the environmental conditions at the site which are not available in the textual information database, such as the components of river flow. Applications of the water quality expert system are presented for representative mine sites in the Timmins area of Ontario.

An expert system for assessing safety and security of heterogeneous public water sources

We have implemented a diagnostic system designed to advise on the likely causes of sanitary problems with public water sources. The approach to the problem makes extensive use of rule based expert systems and multi media information (maps, data, text, expert knowledge). The rules were based on actual water survey data, with a weighting scheme designed to highlight causes of health risks approximately in reverse order of importance (where such order may be presumed to exist). Out put is a vailable in one of several languages.

Evaluation of the effects of acid precipitation in eastern Canada using the raison system

Evaluations have been made of the key chemical factors in the aquatic effects upon surface waters due to acidic precipitation in eastern Canada. The region of Canada east of the Manitoba/Ontario border was divided into 22 aggregates and assessments of inorganic and organic ion chemistry appraised relative to sulphate deposition rates and distributions. Aquatic sensitivity is largely dominated by the concentration, distribution and magnitude of SO inf4 (sup2-) (sulphate) deposition and by the prevalent geology and derived soils found in each aggregate. The RAISON system provided an adaptable and highly flexible platform to evaluate interactively, multiple data sets of divergent characteristics. Attributes usually associated with geographical information systems are significantly augmented by quantitative numerical and stochastic capabilities that were used extensively in this study.

The predicted effect of SO2 emission controls on the water quality of eastern Canadian lakes

Changes in SO inf4 (sup2-) deposition predicted to occur in response to implementation of announced SO2 emission control programs in Canada and the U.S.A. have been used as input to water chemistry models thereby giving an estimate of the changes in lake acid neutralizing capacity (ANC) and pH that can be expected from these programs. Eastern Canada has been divided into 22 subregions for the purpose of this analysis. Relative to the current level (1982-86) of SO inf4 (sup2-) deposition (Scenario 1), the effect of the Canadian SO2 emission control program alone (Scenario 2) is compared to that obtained when controls are implemented throughout North America (Scenarios 3 and 4). SO2 emission reduction will effect a shrinkage of the high wet SO inf4 (sup2-) deposition field in NE North America such that under Scenario 4 conditions, almost no area will remain in Canada that receives >20 kg ha(-1) yr(-1). The greatest decrease in deposition and resulting change in lake chemistry occurs in southern Ontario and southwestern Quebec. ANC distributions shift to higher concentrations and the percentage of lakes having pH<6 decreases in these areas. The Atlantic Provinces will obtain only a minor benefit from the control programs, i.e. experiencing only a small decrease in deposition and improvement in water quality. High sensitivity of the terrain in many parts of Atlantic Canada means that large numbers of lakes will remain acidic (i.e. ANC<0) and/or have pH<6 (an important biological threshold) even after full implementation of the current plans for SO2 control in Canada and the U.S.

A knowledge-based approach to regional acidification modelling

Data from over 2000 stations and knowledge from experts on atmospheric transport, soil geochemistry, lake chemistry, wetland processes and acidification modelling were assembled in an expert system. The data were grouped by aggregates of tertiary watersheds based on water chemistry knowledge. A set of expert rules was used to determine which of six existing models was most appropriate for a given set of data. Comparison of computed and observed alkalinity indicated median relative errors from 11.3-17.9%, with regression slopes ranging from 0.91-1.18 and regression coefficients between 0.82 and 0.99. The expert model performance was further confirmed with paleolimnological data and other independent sets of data. The sensitivity of the predicted alkalinity was illustrated by changing some of the rules. Given that the rules were acceptable by experts and produced reasonable agreement with observations, the knowledge-based system seemed a viable approach to the impact assessment of acidic deposition.

Application of four watershed acidification models to Batchawana Watershed, Canada

Four watershed acidification models (TMWAM, ETD, ILWAS, and RAINS) are reviewed and a comparison of model performance is presented for a common watershed. The models have been used to simulate the dynamics of water quantity and quality at Batchawana Watershed, Canada, a sub-basin of the Turkey Lakes Watershed. The computed results are compared with observed data for a four-year period (Jan. 1981-Dec. 1984). The models exhibit a significant range in the ability to simulate the daily, monthly and seasonal changes present in the observed data. Monthly watershed outflows and lake chemistry predictions are compared to observed data. pH and ANC are the only two chemical parameters common to all four models. Coefficient of efficiency (E), linear (r) and rank (R) correlation coefficients, and regression slope (s) are used to compare the goodness of fit of the simulated with the observed data. The ILWAS, TMWAM and RAINS models performed very well in predicting the monthly flows, with values of r and R of approximately 0.98. The ETD model also showed strong correlations with linear (r) and rank (R) correlation coefficients of 0.896 and 0.892, respectively. The results of the analyses showed that TMWAM provided the best simulation of pH (E=0.264, r=0.648), which is slightly better than ETD (E=0.240, r=0.549), and much better than ILWAS (E=-2.965, r=0.293), and RAINS (E=-4.004, r=0.473). ETD was found to be superior in predicting ANC (E=0.608, r=0.781) as compared to TMWAM (E=0.340, r=0.598), ILWAS (E=0.275, r=0.442), and RAINS (E=-1.048, r=0.356). The TMWAM model adequately simulated SO4 over the four-year period (E=0.423, r=0.682) but the ETD (E=-0.904, r=0.274), ILWAS (E=-4.314, r=0.488), and RAINS (E=-6.479, r=0.126) models all performed poorer than the benchmark model (mean observed value).

Coeliac disease and pernicious anaemia

Despite the often reported autoimmune basis for coeliac disease and pernicious anaemia, there have been only occasional reports of the two conditions occurring together. We wish to report of such an association occurring in a 61 year old patient and comment on the diagnostic and prognostic implications.

Transcriptional and translational control of nafenopin-induced ornithine decarboxylase activity in rat liver

The induction of liver ornithine decarboxylase activity by nafenopin was studied in rats. The alpha-adrenergic antagonist, phentolamine, injected 0.5 hr before nafenopin, greatly potentiated the response. Actinomycin D, injected before nafenopin, did not affect nafenopin-induced ornithine decarboxylase activity whereas the potentiating effect of phentolamine was inhibited. In contrast, administration of actinomycin D 5.0 hr after nafenopin markedly enhanced nafenopin-induced activity. The induction of ornithine decarboxylase activity by nafenopin, as well as the potentiating effect of phentolamine was inhibited by 1,3-diaminopropane and cycloheximide, implying a requirement for synthesis of new enzyme protein for both effects. These results suggest that nafenopin induced ODC through a posttranscriptional mechanism whereas the potentiating effect of phentolamine requires transcription of new messenger RNA.