Baseline management of asthma control | Allergologia et Immunopathologia

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Cruz Niesvaara, J.A. Cumplido Bonny, H.R. Hernández Suárez, L. Almeida Quintana, T. Carrillo Díaz" "autores" => array:5 [ 0 => array:2 [ "nombre" => "D." "apellidos" => "Cruz Niesvaara" ] 1 => array:2 [ "nombre" => "J.A." "apellidos" => "Cumplido Bonny" ] 2 => array:2 [ "nombre" => "H.R." "apellidos" => "Hernández Suárez" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Almeida Quintana" ] 4 => array:2 [ "nombre" => "T." 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"apellidos" => "Exeter" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0301054613001092?idApp=UINPBA00004N" "url" => "/03010546/0000004200000002/v1_201403270032/S0301054613001092/v1_201403270032/en/main.assets" ] "en" => array:17 [ "idiomaDefecto" => true "cabecera" => "Review" "titulo" => "Baseline management of asthma control" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "162" "paginaFinal" => "168" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "O. Cavkaytar, B.E. Sekerel" "autores" => array:2 [ 0 => array:2 [ "nombre" => "O." "apellidos" => "Cavkaytar" ] 1 => array:4 [ "nombre" => "B.E." "apellidos" => "Sekerel" "email" => array:1 [ 0 => "b_sekerel@yahoo.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Hacettepe University, Faculty of Medicine, Pediatric Allergy and Asthma Unit, Ankara, Turkey" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "textoCompleto" => "IntroductionAsthma is a complex, chronic inflammatory disease of the lower airways characterised by variable airflow obstruction and airway hyper-responsiveness. Asthma occurs as a consequence of both patient-related and environmental factors and affects people of all ages.Prevalence, incidence, mortality, and morbidityApproximately 300 million individuals are currently suffering from asthma worldwide.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> The prevalence of asthma is estimated to range from 3% to 38% among children and from 2% to 12% among adults.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> The International Study of Asthma and Allergies (ISAAC) Phase 1 and Phase 3 provided a huge amount of data on the prevalence of asthma and the changes in asthma prevalence during five to ten year periods among children worldwide.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> In the phase 1 study, the 12-month prevalence of asthma symptoms was highest in medical centres in the United Kingdom, Australia, New Zealand, and the Republic of Ireland, followed by some centres in North, Central and South America. In the phase 3 study, the prevalence of asthma in 6–7-year-old children increased in centres in Asia-Pacific, India, North America, the eastern Mediterranean, and Western Europe. An increase was also observed among 13–14-year-old children primarily in centres in Africa, Latin America, and northern and eastern Europe, as well as Asia-Pacific and India. Asthma symptom prevalence decreased significantly in English language countries which were previously found to have high prevalences.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Although variation exists among countries, all countries reported that the lifetime asthma prevalence had increased,<a class="elsevierStyleCrossRef" href="#bib0020">4</a> and worldwide data also showed an overall rise in asthma prevalence.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>Additionally, the asthma incidence rate has been increasing for both male and female adults over time, with higher estimates for women.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> A review of studies published between 1974 and 2004 estimated the incidence of asthma in adults as 3.6 and 4.6 asthma cases per 1000 person-years for men and women, respectively.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> There is now evidence of a plateau in asthma incidence among children. The Centres for Disease Control and Prevention collected data on the status of childhood asthma in the U.S.A. between 1980 and 2007. They determined that, although asthma prevalence increased from 3.6% in 1980 to 7.5% in 1997, the lifetime, current symptom, and asthma attack prevalences remained stable between 1997 and 2007, revealing a plateau.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Most recent studies have demonstrated similar results for adults<a class="elsevierStyleCrossRef" href="#bib0035">7</a> and for children<a class="elsevierStyleCrossRef" href="#bib0040">8</a> from different parts of Europe.The annual death rate due to asthma is estimated to be 250,000,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> and the majority of deaths occur in low and middle income countries. The World Health Organisation estimates that 15 million disability-adjusted life years are lost annually due to asthma; asthma, therefore, represents 1% of the total global disease burden.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Patients from low- and middle-income countries have more severe symptoms than those in high-income countries, possibly due to incorrect diagnoses, poor access to health care, the unaffordability of therapy, exposure to environmental irritants, and genetic susceptibility to more severe disease.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>Asthma gives rise to lost work and school days, significant economic burden due to exacerbations, lung function impairment, limitations in daily activities, and sleep disturbances, resulting in decreased quality of life unless the disease is carefully controlled. For example, a nationwide multicentre cross-sectional study from Turkey determined the following: 44.2% of patients who had been followed for at least one year by tertiary allergy clinics had required at least one unscheduled visit; 29.9% had required emergency admission; and 13.6% had required hospitalisation during the previous year. Furthermore, 74.6% missed at least one day of school due to asthma, and 51.3% missed work days.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> The annual cost per patient was approximately 1500 US dollars,<a class="elsevierStyleCrossRef" href="#bib0060">12</a> a cost comparable to that of patients in developed countries. As demonstrated by these two studies, the level of asthma control must be improved to lower the economic burden, morbidity and mortality.What does “control” mean in asthma?While previously disease management was based on a severity index, the Global Initiative for Asthma (GINA) changed the aim of asthma treatment to achieving asthma control and maintaining control for long periods. The GINA has adopted a five-step approach to asthma control in which each step represents a different treatment option with increasing efficacy.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> The five-step approach is designed to maintain control with the least amount of medication.The term “control” involves the assessment of both clinical manifestations and future risk to the patient.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> Clinical manifestations include the frequency of current daytime and nocturnal symptoms, sleep disturbances, and limitations in daily activities. Additionally, the frequency at which a reliever/rescue treatment was required in the last four weeks, together with spirometric evaluation (peak expiratory flow (PEF) or forced expiratory volume in the first second (FEV1)), determine the ‘impairment’ domain. The assessment of future risk is based on the frequency of exacerbations which required systemic steroids in the last year, as well as any rapid decline in lung function or side effects of treatment.<a class="elsevierStyleCrossRefs" href="#bib0005">1,14</a> The GINA guidelines classify patients into three categories according to the level of control (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) in a manner similar to the NAEPP guidelines. Asthma guidelines focus on achieving and maintaining asthma control while balancing the risks associated with medications. The guidelines also recommend that, if the asthma is currently uncontrolled, treatment must be stepped up until control is achieved. An increase in therapy can also be considered if the asthma is partly controlled. In other words, treatment must be continued until complete control is achieved; control of one or a few individual outcomes is not sufficient.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> After control has been established, treatment should be maintained for at least three months.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Until recently, the term ‘severity’ was used extensively in the assessment of the treatment needs of asthmatic patients and was considered interchangeable with the term ‘control’. However, these two terms describe distinct concepts.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> Nowadays, severity is defined as the intensity of treatment needed to achieve and maintain good control. For example, severe asthma is defined by the requirement for high intensity treatment. Patients with severe asthma include both those with poor control and frequent exacerbations despite high intensity treatment and those who can only maintain good control while receiving high intensity treatment. However, in daily clinical practice, to specify the control level of the patient and to increase therapy when necessary is less complex.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Furthermore, cross-sectional studies worldwide have shown that the use of inhaled corticosteroids (ICS) and reliever medication is independent of patients’ asthma severity gradings.<a class="elsevierStyleCrossRefs" href="#bib0085">17,18</a>Global control levelsThe Asthma Insights and Reality (AIR) surveys were conducted globally to determine the level of control, as defined by the GINA guidelines, in different parts of the world. The AIR surveys started in the United States in 1998, followed by surveys in Europe (AIRE) in 1999, in Japan in 2000, and in central and eastern Europe in 2001. When all the data were analysed together, the majority of patients (51–74%) had daytime symptoms; 41–59% experienced sleep disturbances; 33–59% had exercise-induced symptoms; and the rate of limitations in daily activities ranged from 17% in Japan to 68% in central and eastern Europe.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> Of the patients who completed the AIRE survey, only 5.3% met all the criteria for asthma control; 30.5% of adults and 28% of children reported sleep disturbances at least once a week; 19.1% of children and 37.9% of adults reported limitations in normal physical activity due to asthma; and 42.7% of children and 17.1% of adults reported school/work absences due to asthma.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> The AIR survey in Turkey (AIRET) revealed a huge discrepancy between guideline-based control level classifications of the patients and their own perceptions. Only 1.3% of all participants achieved guideline-based asthma control. However, 45% of participants believed that their asthma was either completely or well-controlled.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> In the CAPTURE study, patients’ perceptions of their childhood asthma were analysed using a questionnaire. At least 40% of the children continued to experience coughing, dyspnoea and wheezing; 60% experienced exercise-induced symptoms more than once a week; 40% of adolescents experienced sleep disturbances; and 25% had wheezing and exercise-induced symptoms more than once a week.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> In a more recent study conducted in six different countries, only 4% of the children and adolescents described their asthma as being “very bad”, while more than half reported that they woke up during the night due to their asthma. These results reveal underestimation of the severity of asthma and overestimation of its control by paediatric asthmatics.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> In the second part of the study, parental perceptions related to the control and severity levels of asthma in their children were found to be similarly inaccurate, unfortunately.<a class="elsevierStyleCrossRef" href="#bib0115">23</a>The underlying reasons for low levels of controlThere are many possible reasons for low asthma control levels worldwide (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). In a review of asthma programmes and projects around the world, the rates of exposure to and application of national and international asthma guidelines were found to be low in diverse regions. The absence of medical education programmes and training for health care providers, and insufficient access to drugs for patients were found to contribute to the low levels of control.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> Physicians often do not ask enough questions to accurately determine and document whether asthma is under control.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> To establish widespread successful control, governments, health care organisations, medical professionals, and the pharmaceutical industry must first agree on management programme policies. National and regional epidemiological data on the burden of asthma, asthma risk factors, and methods to reduce risk must then be determined and disseminated to all health care providers. Regular training programmes covering new issues in management of control must be provided to health care professionals, especially those in primary care centres. Patients must have easy access to health care centres in which lung function can be measured. Patients must also be educated on the use of different types of inhaled medication. A partnership with the patient and the family must be built, and the goals of treatment and asthma care should be explained.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> Patients must be monitored on a regular basis and trained on when and how to manage their asthma.<a class="elsevierStyleCrossRef" href="#bib0050">10</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Poor control: is it a conviction?Inhaled corticosteroids (ICS) are the cornerstone of asthma treatment for all age groups, and guidelines from all countries advocate the use of ICS for the treatment of persistent disease. Treatment with ICS decreases asthma mortality and morbidity, reduces symptoms, improves lung function, reduces bronchial hyper-responsiveness, and reduces the number of exacerbations.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> Moreover, ICS are generally well-tolerated by both children and adults and adverse events tend to be minimal if a low to medium dose is used.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> However, concerns about adverse effects remain and are particularly associated with sustained high doses.The presence of a considerable amount of uncontrolled asthma patients with respect to guidelines brought to mind that there were limitations or problems in treatment strategies. To clarify this point, the Gaining of Asthma Control (GOAL) study was conducted on patients with uncontrolled asthma. In this study, asthma treatments were analysed to determine whether they were able to achieve and maintain the desired control levels, defined in the guidelines.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> The aim of the study was to compare the efficacy of two recommended controller medications (ICS alone versus long-acting beta2 agonist (LABA) plus ICS) in achieving good or total asthma control as defined by the GINA and NIH guidelines<a class="elsevierStyleCrossRef" href="#bib0130">26</a> (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Well-controlled or completely-controlled asthma was achieved in 71% and 42% of patients in the LABA plus ICS group and the ICS group, respectively, proving that much higher levels of asthma control can be achieved using current treatments than those found in the AIR surveys. Patients who achieved control experienced a very low number of exacerbations and recorded near maximal health status scores.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> These data suggest that the asthma control level determines the risk of having an exacerbation. Additionally, for patients with the same level of control, the risk of having an exacerbation was independent of the medication used. The next phase of the study was about maintenance of control. Control was maintained for a median of almost three months in totally-controlled patients and six months in well-controlled patients respectively, showing that the control level is important for its maintenance.<a class="elsevierStyleCrossRef" href="#bib0135">27</a>Besides the GOAL study, other studies have analysed the effects of treatment strategies on asthma control using different items of control. In patients with mild persistent asthma, early intervention with budesonide was associated with a lower risk of hospitalisation, emergency admission and death from asthma and less need of additional medication, such as extra doses of ICS or LABA.<a class="elsevierStyleCrossRef" href="#bib0140">28</a>In the CAMP study, 1041 children with mild to moderate asthma were treated with budesonide, nedocromil or a placebo for four to six years. During this period, budesonide treatment significantly reduced the symptom score, the number of sleep disturbances/month, and the use of albuterol (from 10 to three puffs/week), and increased the number of episode-free days.<a class="elsevierStyleCrossRef" href="#bib0145">29</a>Measuring control levelsPhysicians in daily clinical practice need practical tools for determining patients’ control levels and for quantifying each patient's improvement during the course of the disease. Tools are also needed to aid physicians in deciding whether to increase therapy doses. Several different instruments are available which vary in applicability in daily practice.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> Five validated tests have been identified, and features of each were previously presented, in accordance with GINA guidelines, in a review<a class="elsevierStyleCrossRef" href="#bib0150">30</a> (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>The asthma control questionnaire (ACQ) has been widely used. The ACQ is the only tool of the five which has been validated in persons 17 years of age or older, and a paediatric version has also been recently tested.<a class="elsevierStyleCrossRef" href="#bib0155">31</a> The ACQ includes six clinical questions, two related to shortness of breath and wheezing and four GINA questions along with measurement of FEV1. Each question is scored between 0 and 6 (0: no impairment, 6: maximum impairment). The ACQ results are determined by taking the mean of all seven items. Seven-, six- and five-item versions have been validated for measuring asthma control based on GINA and NIH guidelines<a class="elsevierStyleCrossRef" href="#bib0160">32</a> and the control parameters determined in the GOAL study.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> A score of 1.5 was defined as the cut-off point for poorly-controlled asthma, and a score of 0.75 was defined as the cut-off point for well-controlled asthma.The asthma control scoring system (ACSS) assesses clinical, physiological (PEF, FEV1 and ΔPEF) and inflammatory parameters (sputum eosinophilia) and is composed of eight items in total. The ACSS defines control as the mean percentage in which 100% represents the best control. The ACSS has demonstrated good test-retest reliability, good internal consistency and moderate correlations with the mini-asthma quality of life questionnaire and the ACQ.<a class="elsevierStyleCrossRef" href="#bib0170">34</a>The Asthma Control Test (ACT) is based on the patient's own perception of asthma control. The sum of the scores ranges from 5 (poor control) to 25 (complete control). A patient with a score of 15 or lower is classified as having poor control. The ACT is easy to apply and is the most widely-used tool in daily clinical practice. The ACT has been shown to be reliable, valid and capable of identifying patients with poor asthma control among patients older than 12 years (the five-item version)<a class="elsevierStyleCrossRef" href="#bib0175">35</a> and between the ages of four and 11 years (seven-item version).<a class="elsevierStyleCrossRef" href="#bib0180">36</a> The ACT and childhood ACT have been translated into various languages and have also been determined reliable, valid and capable of reflecting changes in control over time.<a class="elsevierStyleCrossRefs" href="#bib0185">37–39</a>The asthma therapy assessment questionnaire (ATAQ) has been validated and assesses control by evaluating seven parameters, including missed work, school, and normal daily activities; night-time sleep disturbances due to asthma symptoms; and the use of relief medications based on self-perception.<a class="elsevierStyleCrossRef" href="#bib0150">30</a>All of these tests were found to have test-retest reliability and internal consistency, validity, responsiveness, and interpretability.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> All are relatively short, easy to interpret, and applicable to patients with different levels of disease severity and control.ConclusionsThe desired level of asthma control has not been achieved in a considerable number of regions throughout the world. The lack of asthma control results from the disease process itself, overestimation of disease control by patients and physicians, and some social and economic factors. Low control levels increase morbidity and mortality, especially in developing countries. Providing education to physicians, especially in primary care, and to patients on what constitutes good asthma control according to the guidelines is the first step to improvement. The revised guidelines underline the significance of assessment, achievement and maintenance of control through ongoing, regular monitorisation.Here we report that we have no potential conflicts of interest, and no financial support was received for this review.Ethical disclosuresProtection of human and animal subjectsThe authors declare that no experiments were performed on humans or animals for this investigation.Confidentiality of dataThe authors declare that no patient data appears in this articleRight to privacy and informed consentThe authors declare that no patient data appears in this article.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "xres325677" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec307255" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Prevalence, incidence, mortality, and morbidity" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "What does “control” mean in asthma?" ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Global control levels" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "The underlying reasons for low levels of control" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Poor control: is it a conviction?" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Measuring control levels" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusions" ] 10 => array:3 [ "identificador" => "sec0045" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec1045" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Right to privacy and informed consent" ] ] ] 11 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflicts of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-09-19" "fechaAceptado" => "2012-10-26" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec307255" "palabras" => array:5 [ 0 => "Asthma prevalence" 1 => "Asthma mortality" 2 => "Asthma control" 3 => "Global Initiative for Asthma" 4 => "Asthma Control Test" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Asthma is a complex, chronic inflammatory disease of the lower airways affecting people of all ages. Approximately 300 million individuals are currently suffering from asthma worldwide. The prevalence of asthma is estimated to range from 3% to 38% in children and from 2% to 12% in adults. The disease causes lost school and work days, limitations in daily activities, and sleep disturbances. Lung function impairment also occurs, resulting in decreased quality of life unless disease control is achieved and a high annual financial burden is incurred. Achievement and maintenance of control through assessment of clinical manifestations and future risk has become the aim of treatment over the years. Unfortunately, the desired level of asthma control has not been achieved in a considerable number of regions throughout the world, and the level of control is overestimated by both patients and their parents. This review examines the mortality and morbidity rates for asthma, emphasizes the challenges inherent to control management, and provides data on the tools used to measure control level." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "PEF: peak expiratory flow; FEV1: forced expiratory volume in 1s." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Characteristics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Controlled (all of the following) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Partly controlled (any measure present in any week) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Uncontrolled \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Daytime symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None (twice or less/week) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">More than twice per week \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Three or more features of “partly controlled” asthma present in any week</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Limitations of activities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Any \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nocturnal symptoms/awakening \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Any \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Need for reliever/rescue treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None (twice or less per week) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">More than twice per week \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lung function PEF or FEV1<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><80% predicted or personal best (if known) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Exacerbations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">One or more per year<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">One in any week<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab474694.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Not a reliable test for children aged ≤5 years." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "Any week with an exacerbation is an uncontrolled asthma week." ] ] ] "descripcion" => array:1 [ "en" => "Global Initiative for Asthma (GINA) definitions of asthma control." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Factors related to the guidelines \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Production of complex guidelines that are not easily implemented \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Problems with the publication and distribution of guidelines \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complicated classification of severity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Absence of case presentations from daily clinical practice \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Factors related to health care providers \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Restricted time allocated for each patient \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abundance of guidelines \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Problems communicating with patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Absence of a gold standard test for measuring control \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Insufficient use of spirometers, PEF metres and questionnaires for measuring asthma control \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Failure to get up-to-date on new data about asthma management \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Overestimation of asthma control \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Factors related to the patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient denial \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Underestimation of symptom severity and overestimation of disease control \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Drug intake non-compliance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Related psychiatric disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Trust in alternative therapy rather than in medication \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Absence of health insurance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Social, economic, and scientific factors \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Insufficient supply of current drugs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High cost of new drug production \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low access to drugs among health care facilities \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Difficulty in determining aetiology \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab474696.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Challenges in the management of asthma control." ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "GINA=Global Initiative for Asthma; NIH=National Institutes of Health; PEF=Peak expiratory flowCompletely- and well-controlled asthma were defined by achievement of all of the specified criteria for a given week. Completely-controlled asthma was achieved if the patient recorded seven totally controlled weeks and had no exacerbations, emergency room visits, or medication-related adverse events during the eight consecutive assessment weeks. Well-controlled asthma was similarly assessed over the eight weeks. All assessments were performed over eight weeks during the double-blind treatment period. Baseline control and control during the open-label phase were assessed over a four-week period." "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Characteristics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Goals of GINA/NIH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Completely controlled (each week, all of the following) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Well-controlled (each week, two or more of the following) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Daytime symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Minimal (ideally none) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤2 days with symptom score > 1‡ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rescue β2-agonist use \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Minimal (ideally none) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use on ≤ 2 days and ≤ 4 occasions/week \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Morning PEF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Near normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥80% predicted<a class="elsevierStyleCrossRef" href="#tblfn0025">b</a> every day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥80% predicted<a class="elsevierStyleCrossRef" href="#tblfn0025">b</a> every day \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab474697.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Characteristics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Goals of GINA/NIH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Completely controlled (each week, all of the following) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Well-controlled (all of the following) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Night-time sleep disturbances \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Minimal (ideally none) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Exacerbations<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Minimal (infrequent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Emergency visits \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab474698.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "a" "nota" => "Exacerbation was defined as deterioration in asthma requiring treatment with an oral corticosteroid, an emergency department visit or hospitalisation." ] 1 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "b" "nota" => "The predicted PEF was calculated based on the European Community for Steel and Coal standards for patients 18 years and older and based on the Polgar standards for patients 12–17 years old." ] ] ] "descripcion" => array:1 [ "en" => "Definitions of well-controlled and completely-controlled asthma based on the Global Initiative for Asthma/National Institutes of Health guidelines.<a class="elsevierStyleCrossRef" href="#bib0130">26</a>" ] ] 3 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "ACQ: Asthma Control Questionnaire; ACSS: Asthma Control Scoring System; ACT: Asthma Control Test; ATAQ: Asthma Assessment Questionnaire; LASS: Lara Asthma Symptom Scale; GINA: Global Initiative for Asthma." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">GINA characteristics of asthma control \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">ACQ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">ACSS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">ACT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">ATAQ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">LASS \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Daytime symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Limitation in activities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nocturnal symptoms/sleep disturbances \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Need for reliever/rescue treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lung Function (PEF or FEV1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Exacerbations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab474695.png" ] ] ] ] "descripcion" => array:1 [ "en" => "The ability of asthma control instruments to assess the control characteristics outlined in the GINA guidelines.<a class="elsevierStyleCrossRef" href="#bib0150">30</a>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:39 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. Updated 2011. <a class="elsevierStyleInterRef" href="http://www.ginasthma.org/uploads/users/files/GINA_Report_2011.pdf">www.ginasthma.org/uploads/users/files/GINA_Report_2011.pdf</a>." ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology of asthma and allergic diseases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E.A. Tang" 1 => "E. Matsui" 2 => "D.G. Wiesch" 3 => "J.M. Samet" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:5 [ "titulo" => "Middleton's allergy principles & practice" "paginaInicial" => "715" "paginaFinal" => "768" "edicion" => "7th edition" "serieFecha" => "2008" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Worldwide time trends in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC phases one and three repeat multicountry cross-sectional surveys" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.I. Asher" 1 => "S. Montefort" 2 => "B. Bjorksten" 3 => "C.K. Lai" 4 => "D.P. Strachan" 5 => "S.K. 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Baseline management of asthma control

O. Cavkaytar, B.E. Sekerel

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b_sekerel@yahoo.com

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Hacettepe University, Faculty of Medicine, Pediatric Allergy and Asthma Unit, Ankara, Turkey

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among children and from 2&#37; to 12&#37; among adults&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The International Study of Asthma and Allergies &#40;ISAAC&#41; Phase 1 and Phase 3 provided a huge amount of data on the prevalence of asthma and the changes in asthma prevalence during five to ten year periods among children worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In the phase 1 study&#44; the 12-month prevalence of asthma symptoms was highest in medical centres in the United Kingdom&#44; Australia&#44; New Zealand&#44; and the Republic of Ireland&#44; followed by some centres in North&#44; Central and South America&#46; In the phase 3 study&#44; the prevalence of asthma in 6&#8211;7-year-old children increased in centres in Asia-Pacific&#44; India&#44; North America&#44; the eastern Mediterranean&#44; and Western Europe&#46; An increase was also observed among 13&#8211;14-year-old children primarily in centres in Africa&#44; Latin America&#44; and northern and eastern Europe&#44; as well as Asia-Pacific and India&#46; Asthma symptom prevalence decreased significantly in English language countries which were previously found to have high prevalences&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Although variation exists among countries&#44; all countries reported that the lifetime asthma prevalence had increased&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and worldwide data also showed an overall rise in asthma prevalence&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Additionally&#44; the asthma incidence rate has been increasing for both male and female adults over time&#44; with higher estimates for women&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> A review of studies published between 1974 and 2004 estimated the incidence of asthma in adults as 3&#46;6 and 4&#46;6 asthma cases per 1000 person-years for men and women&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> There is now evidence of a plateau in asthma incidence among children&#46; The Centres for Disease Control and Prevention collected data on the status of childhood asthma in the U&#46;S&#46;A&#46; between 1980 and 2007&#46; They determined that&#44; although asthma prevalence increased from 3&#46;6&#37; in 1980 to 7&#46;5&#37; in 1997&#44; the lifetime&#44; current symptom&#44; and asthma attack prevalences remained stable between 1997 and 2007&#44; revealing a plateau&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Most recent studies have demonstrated similar results for adults<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and for children<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> from different parts of Europe&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The annual death rate due to asthma is estimated to be 250&#44;000&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and the majority of deaths occur in low and middle income countries&#46; The World Health Organisation estimates that 15 million disability-adjusted life years are lost annually due to asthma&#59; asthma&#44; therefore&#44; represents 1&#37; of the total global disease burden&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Patients from low- and middle-income countries have more severe symptoms than those in high-income countries&#44; possibly due to incorrect diagnoses&#44; poor access to health care&#44; the unaffordability of therapy&#44; exposure to environmental irritants&#44; and genetic susceptibility to more severe disease&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Asthma gives rise to lost work and school days&#44; significant economic burden due to exacerbations&#44; lung function impairment&#44; limitations in daily activities&#44; and sleep disturbances&#44; resulting in decreased quality of life unless the disease is carefully controlled&#46; For example&#44; a nationwide multicentre cross-sectional study from Turkey determined the following&#58; 44&#46;2&#37; of patients who had been followed for at least one year by tertiary allergy clinics had required at least one unscheduled visit&#59; 29&#46;9&#37; had required emergency admission&#59; and 13&#46;6&#37; had required hospitalisation during the previous year&#46; Furthermore&#44; 74&#46;6&#37; missed at least one day of school due to asthma&#44; and 51&#46;3&#37; missed work days&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The annual cost per patient was approximately 1500 US dollars&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> a cost comparable to that of patients in developed countries&#46; As demonstrated by these two studies&#44; the level of asthma control must be improved to lower the economic burden&#44; morbidity and mortality&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">What does &#8220;control&#8221; mean in asthma&#63;</span><p id="par0030" class="elsevierStylePara elsevierViewall">While previously disease management was based on a severity index&#44; the Global Initiative for Asthma &#40;GINA&#41; changed the aim of asthma treatment to achieving asthma control and maintaining control for long periods&#46; The GINA has adopted a five-step approach to asthma control in which each step represents a different treatment option with increasing efficacy&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The five-step approach is designed to maintain control with the least amount of medication&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The term &#8220;control&#8221; involves the assessment of both clinical manifestations and future risk to the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Clinical manifestations include the frequency of current daytime and nocturnal symptoms&#44; sleep disturbances&#44; and limitations in daily activities&#46; Additionally&#44; the frequency at which a reliever&#47;rescue treatment was required in the last four weeks&#44; together with spirometric evaluation &#40;peak expiratory flow &#40;PEF&#41; or forced expiratory volume in the first second &#40;FEV<span class="elsevierStyleInf">1</span>&#41;&#41;&#44; determine the &#8216;impairment&#8217; domain&#46; The assessment of future risk is based on the frequency of exacerbations which required systemic steroids in the last year&#44; as well as any rapid decline in lung function or side effects of treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;14</span></a> The GINA guidelines classify patients into three categories according to the level of control &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; in a manner similar to the NAEPP guidelines&#46; Asthma guidelines focus on achieving and maintaining asthma control while balancing the risks associated with medications&#46; The guidelines also recommend that&#44; if the asthma is currently uncontrolled&#44; treatment must be stepped up until control is achieved&#46; An increase in therapy can also be considered if the asthma is partly controlled&#46; In other words&#44; treatment must be continued until complete control is achieved&#59; control of one or a few individual outcomes is not sufficient&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> After control has been established&#44; treatment should be maintained for at least three months&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Until recently&#44; the term &#8216;severity&#8217; was used extensively in the assessment of the treatment needs of asthmatic patients and was considered interchangeable with the term &#8216;control&#8217;&#46; However&#44; these two terms describe distinct concepts&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Nowadays&#44; severity is defined as the intensity of treatment needed to achieve and maintain good control&#46; For example&#44; severe asthma is defined by the requirement for high intensity treatment&#46; Patients with severe asthma include both those with poor control and frequent exacerbations despite high intensity treatment and those who can only maintain good control while receiving high intensity treatment&#46; However&#44; in daily clinical practice&#44; to specify the control level of the patient and to increase therapy when necessary is less complex&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Furthermore&#44; cross-sectional studies worldwide have shown that the use of inhaled corticosteroids &#40;ICS&#41; and reliever medication is independent of patients&#8217; asthma severity gradings&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Global control levels</span><p id="par0045" class="elsevierStylePara elsevierViewall">The Asthma Insights and Reality &#40;AIR&#41; surveys were conducted globally to determine the level of control&#44; as defined by the GINA guidelines&#44; in different parts of the world&#46; The AIR surveys started in the United States in 1998&#44; followed by surveys in Europe &#40;AIRE&#41; in 1999&#44; in Japan in 2000&#44; and in central and eastern Europe in 2001&#46; When all the data were analysed together&#44; the majority of patients &#40;51&#8211;74&#37;&#41; had daytime symptoms&#59; 41&#8211;59&#37; experienced sleep disturbances&#59; 33&#8211;59&#37; had exercise-induced symptoms&#59; and the rate of limitations in daily activities ranged from 17&#37; in Japan to 68&#37; in central and eastern Europe&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Of the patients who completed the AIRE survey&#44; only 5&#46;3&#37; met all the criteria for asthma control&#59; 30&#46;5&#37; of adults and 28&#37; of children reported sleep disturbances at least once a week&#59; 19&#46;1&#37; of children and 37&#46;9&#37; of adults reported limitations in normal physical activity due to asthma&#59; and 42&#46;7&#37; of children and 17&#46;1&#37; of adults reported school&#47;work absences due to asthma&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The AIR survey in Turkey &#40;AIRET&#41; revealed a huge discrepancy between guideline-based control level classifications of the patients and their own perceptions&#46; Only 1&#46;3&#37; of all participants achieved guideline-based asthma control&#46; However&#44; 45&#37; of participants believed that their asthma was either completely or well-controlled&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> In the CAPTURE study&#44; patients&#8217; perceptions of their childhood asthma were analysed using a questionnaire&#46; At least 40&#37; of the children continued to experience coughing&#44; dyspnoea and wheezing&#59; 60&#37; experienced exercise-induced symptoms more than once a week&#59; 40&#37; of adolescents experienced sleep disturbances&#59; and 25&#37; had wheezing and exercise-induced symptoms more than once a week&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> In a more recent study conducted in six different countries&#44; only 4&#37; of the children and adolescents described their asthma as being &#8220;very bad&#8221;&#44; while more than half reported that they woke up during the night due to their asthma&#46; These results reveal underestimation of the severity of asthma and overestimation of its control by paediatric asthmatics&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> In the second part of the study&#44; parental perceptions related to the control and severity levels of asthma in their children were found to be similarly inaccurate&#44; unfortunately&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The underlying reasons for low levels of control</span><p id="par0050" class="elsevierStylePara elsevierViewall">There are many possible reasons for low asthma control levels worldwide &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; In a review of asthma programmes and projects around the world&#44; the rates of exposure to and application of national and international asthma guidelines were found to be low in diverse regions&#46; The absence of medical education programmes and training for health care providers&#44; and insufficient access to drugs for patients were found to contribute to the low levels of control&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Physicians often do not ask enough questions to accurately determine and document whether asthma is under control&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> To establish widespread successful control&#44; governments&#44; health care organisations&#44; medical professionals&#44; and the pharmaceutical industry must first agree on management programme policies&#46; National and regional epidemiological data on the burden of asthma&#44; asthma risk factors&#44; and methods to reduce risk must then be determined and disseminated to all health care providers&#46; Regular training programmes covering new issues in management of control must be provided to health care professionals&#44; especially those in primary care centres&#46; Patients must have easy access to health care centres in which lung function can be measured&#46; Patients must also be educated on the use of different types of inhaled medication&#46; A partnership with the patient and the family must be built&#44; and the goals of treatment and asthma care should be explained&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Patients must be monitored on a regular basis and trained on when and how to manage their asthma&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Poor control&#58; is it a conviction&#63;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Inhaled corticosteroids &#40;ICS&#41; are the cornerstone of asthma treatment for all age groups&#44; and guidelines from all countries advocate the use of ICS for the treatment of persistent disease&#46; Treatment with ICS decreases asthma mortality and morbidity&#44; reduces symptoms&#44; improves lung function&#44; reduces bronchial hyper-responsiveness&#44; and reduces the number of exacerbations&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Moreover&#44; ICS are generally well-tolerated by both children and adults and adverse events tend to be minimal if a low to medium dose is used&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> However&#44; concerns about adverse effects remain and are particularly associated with sustained high doses&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The presence of a considerable amount of uncontrolled asthma patients with respect to guidelines brought to mind that there were limitations or problems in treatment strategies&#46; To clarify this point&#44; the Gaining of Asthma Control &#40;GOAL&#41; study was conducted on patients with uncontrolled asthma&#46; In this study&#44; asthma treatments were analysed to determine whether they were able to achieve and maintain the desired control levels&#44; defined in the guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> The aim of the study was to compare the efficacy of two recommended controller medications &#40;ICS alone versus long-acting beta<span class="elsevierStyleInf">2</span> agonist &#40;LABA&#41; plus ICS&#41; in achieving good or total asthma control as defined by the GINA and NIH guidelines<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Well-controlled or completely-controlled asthma was achieved in 71&#37; and 42&#37; of patients in the LABA plus ICS group and the ICS group&#44; respectively&#44; proving that much higher levels of asthma control can be achieved using current treatments than those found in the AIR surveys&#46; Patients who achieved control experienced a very low number of exacerbations and recorded near maximal health status scores&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> These data suggest that the asthma control level determines the risk of having an exacerbation&#46; Additionally&#44; for patients with the same level of control&#44; the risk of having an exacerbation was independent of the medication used&#46; The next phase of the study was about maintenance of control&#46; Control was maintained for a median of almost three months in totally-controlled patients and six months in well-controlled patients respectively&#44; showing that the control level is important for its maintenance&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Besides the GOAL study&#44; other studies have analysed the effects of treatment strategies on asthma control using different items of control&#46; In patients with mild persistent asthma&#44; early intervention with budesonide was associated with a lower risk of hospitalisation&#44; emergency admission and death from asthma and less need of additional medication&#44; such as extra doses of ICS or LABA&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In the CAMP study&#44; 1041 children with mild to moderate asthma were treated with budesonide&#44; nedocromil or a placebo for four to six years&#46; During this period&#44; budesonide treatment significantly reduced the symptom score&#44; the number of sleep disturbances&#47;month&#44; and the use of albuterol &#40;from 10 to three puffs&#47;week&#41;&#44; and increased the number of episode-free days&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Measuring control levels</span><p id="par0080" class="elsevierStylePara elsevierViewall">Physicians in daily clinical practice need practical tools for determining patients&#8217; control levels and for quantifying each patient&#39;s improvement during the course of the disease&#46; Tools are also needed to aid physicians in deciding whether to increase therapy doses&#46; Several different instruments are available which vary in applicability in daily practice&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Five validated tests have been identified&#44; and features of each were previously presented&#44; in accordance with GINA guidelines&#44; in a review<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The asthma control questionnaire &#40;ACQ&#41; has been widely used&#46; The ACQ is the only tool of the five which has been validated in persons 17 years of age or older&#44; and a paediatric version has also been recently tested&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> The ACQ includes six clinical questions&#44; two related to shortness of breath and wheezing and four GINA questions along with measurement of FEV<span class="elsevierStyleInf">1</span>&#46; Each question is scored between 0 and 6 &#40;0&#58; no impairment&#44; 6&#58; maximum impairment&#41;&#46; The ACQ results are determined by taking the mean of all seven items&#46; Seven-&#44; six- and five-item versions have been validated for measuring asthma control based on GINA and NIH guidelines<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> and the control parameters determined in the GOAL study&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> A score of 1&#46;5 was defined as the cut-off point for poorly-controlled asthma&#44; and a score of 0&#46;75 was defined as the cut-off point for well-controlled asthma&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The asthma control scoring system &#40;ACSS&#41; assesses clinical&#44; physiological &#40;PEF&#44; FEV<span class="elsevierStyleInf">1</span> and &#916;PEF&#41; and inflammatory parameters &#40;sputum eosinophilia&#41; and is composed of eight items in total&#46; The ACSS defines control as the mean percentage in which 100&#37; represents the best control&#46; The ACSS has demonstrated good test-retest reliability&#44; good internal consistency and moderate correlations with the mini-asthma quality of life questionnaire and the ACQ&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The Asthma Control Test &#40;ACT&#41; is based on the patient&#39;s own perception of asthma control&#46; The sum of the scores ranges from 5 &#40;poor control&#41; to 25 &#40;complete control&#41;&#46; A patient with a score of 15 or lower is classified as having poor control&#46; The ACT is easy to apply and is the most widely-used tool in daily clinical practice&#46; The ACT has been shown to be reliable&#44; valid and capable of identifying patients with poor asthma control among patients older than 12 years &#40;the five-item version&#41;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> and between the ages of four and 11 years &#40;seven-item version&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> The ACT and childhood ACT have been translated into various languages and have also been determined reliable&#44; valid and capable of reflecting changes in control over time&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37&#8211;39</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The asthma therapy assessment questionnaire &#40;ATAQ&#41; has been validated and assesses control by evaluating seven parameters&#44; including missed work&#44; school&#44; and normal daily activities&#59; night-time sleep disturbances due to asthma symptoms&#59; and the use of relief medications based on self-perception&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">All of these tests were found to have test-retest reliability and internal consistency&#44; validity&#44; responsiveness&#44; and interpretability&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> All are relatively short&#44; easy to interpret&#44; and applicable to patients with different levels of disease severity and control&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0110" class="elsevierStylePara elsevierViewall">The desired level of asthma control has not been achieved in a considerable number of regions throughout the world&#46; The lack of asthma control results from the disease process itself&#44; overestimation of disease control by patients and physicians&#44; and some social and economic factors&#46; Low control levels increase morbidity and mortality&#44; especially in developing countries&#46; Providing education to physicians&#44; especially in primary care&#44; and to patients on what constitutes good asthma control according to the guidelines is the first step to improvement&#46; The revised guidelines underline the significance of assessment&#44; achievement and maintenance of control through ongoing&#44; regular monitorisation&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Here we report that we have no potential conflicts of interest&#44; and no financial support was received for this review&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical disclosures</span><span id="sec1045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Protection of human and animal subjects</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Confidentiality of data</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Right to privacy and informed consent</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Prevalence&#44; incidence&#44; mortality&#44; and morbidity"
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          "titulo" => "What does &#8220;control&#8221; mean in asthma&#63;"
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          "titulo" => "Global control levels"
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          "titulo" => "The underlying reasons for low levels of control"
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          "identificador" => "sec0030"
          "titulo" => "Poor control&#58; is it a conviction&#63;"
        ]
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          "titulo" => "Measuring control levels"
        ]
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          "titulo" => "Conclusions"
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          "titulo" => "Ethical disclosures"
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              "identificador" => "sec1045"
              "titulo" => "Protection of human and animal subjects"
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              "identificador" => "sec0050"
              "titulo" => "Confidentiality of data"
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            2 => array:2 [
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              "titulo" => "Right to privacy and informed consent"
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    "fechaRecibido" => "2012-09-19"
    "fechaAceptado" => "2012-10-26"
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            0 => "Asthma prevalence"
            1 => "Asthma mortality"
            2 => "Asthma control"
            3 => "Global Initiative for Asthma"
            4 => "Asthma Control Test"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Asthma is a complex&#44; chronic inflammatory disease of the lower airways affecting people of all ages&#46; Approximately 300 million individuals are currently suffering from asthma worldwide&#46; The prevalence of asthma is estimated to range from 3&#37; to 38&#37; in children and from 2&#37; to 12&#37; in adults&#46; The disease causes lost school and work days&#44; limitations in daily activities&#44; and sleep disturbances&#46; Lung function impairment also occurs&#44; resulting in decreased quality of life unless disease control is achieved and a high annual financial burden is incurred&#46; Achievement and maintenance of control through assessment of clinical manifestations and future risk has become the aim of treatment over the years&#46; Unfortunately&#44; the desired level of asthma control has not been achieved in a considerable number of regions throughout the world&#44; and the level of control is overestimated by both patients and their parents&#46; This review examines the mortality and morbidity rates for asthma&#44; emphasizes the challenges inherent to control management&#44; and provides data on the tools used to measure control level&#46;</p>"
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">PEF&#58; peak expiratory flow&#59; FEV<span class="elsevierStyleInf">1</span>&#58; forced expiratory volume in 1<span class="elsevierStyleHsp" style=""></span>s&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Controlled &#40;all of the following&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Partly controlled &#40;any measure present in any week&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Uncontrolled&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Daytime symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None &#40;twice or less&#47;week&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">More than twice per week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Three or more features of &#8220;partly controlled&#8221; asthma present in any week</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Limitations of activities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Any&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nocturnal symptoms&#47;awakening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Any&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Need for reliever&#47;rescue treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None &#40;twice or less per week&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">More than twice per week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lung function PEF or FEV1<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;80&#37; predicted or personal best &#40;if known&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Exacerbations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">One or more per year<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">One in any week<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab474694.png"
              ]
            ]
          ]
          "notaPie" => array:3 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara">Not a reliable test for children aged &#8804;5 years&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara">Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara">Any week with an exacerbation is an uncontrolled asthma week&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Global Initiative for Asthma &#40;GINA&#41; definitions of asthma control&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Factors related to the guidelines</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Production of complex guidelines that are not easily implemented&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Problems with the publication and distribution of guidelines&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Complicated classification of severity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Absence of case presentations from daily clinical practice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Factors related to health care providers</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Restricted time allocated for each patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Abundance of guidelines&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Problems communicating with patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Absence of a gold standard test for measuring control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Insufficient use of spirometers&#44; PEF metres and questionnaires for measuring asthma control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Failure to get up-to-date on new data about asthma management&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Overestimation of asthma control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Factors related to the patients</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Patient denial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Underestimation of symptom severity and overestimation of disease control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Drug intake non-compliance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Related psychiatric disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Trust in alternative therapy rather than in medication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Absence of health insurance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Social&#44; economic&#44; and scientific factors</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Insufficient supply of current drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>High cost of new drug production&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Low access to drugs among health care facilities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Difficulty in determining aetiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab474696.png"
              ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Challenges in the management of asthma control&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">GINA<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Global Initiative for Asthma&#59; NIH<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>National Institutes of Health&#59; PEF<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Peak expiratory flow</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Completely- and well-controlled asthma were defined by achievement of all of the specified criteria for a given week&#46; Completely-controlled asthma was achieved if the patient recorded seven totally controlled weeks and had no exacerbations&#44; emergency room visits&#44; or medication-related adverse events during the eight consecutive assessment weeks&#46; Well-controlled asthma was similarly assessed over the eight weeks&#46; All assessments were performed over eight weeks during the double-blind treatment period&#46; Baseline control and control during the open-label phase were assessed over a four-week period&#46;</p>"
          "tablatextoimagen" => array:2 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Goals of GINA&#47;NIH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Completely controlled &#40;each week&#44; all of the following&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Well-controlled &#40;each week&#44; two or more of the following&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Daytime symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Minimal &#40;ideally none&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8804;2 days with symptom score &#62; 1&#8225;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rescue &#946;2-agonist use&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Minimal &#40;ideally none&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Use on &#8804; 2 days and &#8804; 4 occasions&#47;week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Morning PEF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Near normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;80&#37; predicted<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">b</span></a> every day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;80&#37; predicted<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">b</span></a> every day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab474697.png"
              ]
            ]
            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Goals of GINA&#47;NIH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Completely controlled &#40;each week&#44; all of the following&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Well-controlled &#40;all of the following&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Night-time sleep disturbances&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Minimal &#40;ideally none&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Exacerbations<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Minimal &#40;infrequent&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Emergency visits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab474698.png"
              ]
            ]
          ]
          "notaPie" => array:2 [
            0 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara">Exacerbation was defined as deterioration in asthma requiring treatment with an oral corticosteroid&#44; an emergency department visit or hospitalisation&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara">The predicted PEF was calculated based on the European Community for Steel and Coal standards for patients 18 years and older and based on the Polgar standards for patients 12&#8211;17 years old&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Definitions of well-controlled and completely-controlled asthma based on the Global Initiative for Asthma&#47;National Institutes of Health guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">ACQ&#58; Asthma Control Questionnaire&#59; ACSS&#58; Asthma Control Scoring System&#59; ACT&#58; Asthma Control Test&#59; ATAQ&#58; Asthma Assessment Questionnaire&#59; LASS&#58; Lara Asthma Symptom Scale&#59; GINA&#58; Global Initiative for Asthma&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">GINA characteristics of asthma control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">ACQ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">ACSS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">ACT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">ATAQ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">LASS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Daytime symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Limitation in activities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nocturnal symptoms&#47;sleep disturbances&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Need for reliever&#47;rescue treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lung Function &#40;PEF or FEV<span class="elsevierStyleInf">1</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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Article information

ISSN: 03010546
Original language: English

DOI:10.1016/j.aller.2012.10.004

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	4	0	4
2024 October	40	10	50
2024 September	45	13	58
2024 August	46	7	53
2024 July	30	3	33
2024 June	20	3	23
2024 May	23	3	26
2024 April	30	6	36
2024 March	38	3	41
2024 February	49	6	55
2024 January	38	2	40
2023 December	48	6	54
2023 November	72	10	82
2023 October	51	20	71
2023 September	23	8	31
2023 August	39	7	46
2023 July	67	3	70
2023 June	66	3	69
2023 May	104	5	109
2023 April	79	13	92
2023 March	36	6	42
2023 February	27	11	38
2023 January	18	6	24
2022 December	15	9	24
2022 November	13	14	27
2022 October	15	7	22
2022 September	14	5	19
2022 August	21	7	28
2022 July	10	13	23
2022 June	10	9	19
2022 May	29	14	43
2022 April	18	4	22
2022 March	12	11	23
2022 February	4	3	7
2022 January	16	12	28
2021 December	8	11	19
2021 November	19	23	42
2021 October	19	13	32
2021 September	9	12	21
2021 August	7	8	15
2021 July	9	7	16
2021 June	16	7	23
2021 May	13	17	30
2021 April	26	30	56
2021 March	17	10	27
2021 February	9	9	18
2021 January	10	5	15
2020 October	0	1	1
2020 September	0	3	3
2020 August	0	1	1
2020 July	0	1	1
2020 April	0	1	1
2020 February	0	1	1
2019 December	0	4	4
2019 November	0	2	2
2019 October	0	2	2
2019 July	0	1	1
2019 June	0	2	2
2019 May	0	16	16
2018 February	12	1	13
2018 January	11	5	16
2017 December	19	2	21
2017 November	10	1	11
2017 October	5	7	12
2017 September	13	3	16
2017 August	10	5	15
2017 July	11	4	15
2017 June	22	10	32
2017 May	24	5	29
2017 April	11	3	14
2017 March	11	31	42
2017 February	13	1	14
2017 January	19	3	22
2016 December	20	10	30
2016 November	27	10	37
2016 October	26	6	32
2016 September	17	6	23
2016 August	17	4	21
2016 July	12	7	19
2016 June	20	1	21
2016 May	20	5	25
2016 April	24	1	25
2016 March	15	7	22
2016 February	23	13	36
2016 January	16	9	25
2015 December	13	9	22
2015 November	10	6	16
2015 October	21	4	25
2015 September	7	5	12
2015 August	13	8	21
2015 July	6	2	8
2015 June	7	0	7
2015 May	7	3	10
2015 April	12	12	24
2015 March	17	8	25
2015 February	1	6	7
2015 January	0	3	3
2014 December	0	1	1
2014 November	0	1	1
2014 October	1	4	5
2014 September	2	3	5
2014 August	0	2	2
2014 July	0	1	1
2014 June	0	4	4
2014 May	1	0	1
2014 April	1	7	8

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Allergologia et Immunopathologia is no longer published on Elsevier since the 2021 year.Transferred to Codon Publications

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Allergologia et Immunopathologia is no longer published on Elsevier since the 2021 year.Transferred to Codon Publications

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