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POPH8552 Clinical Epidemiology Questions: Asthma is a common medical condition caused by narrowing of the small air passages (breathing tubes) in the lungs. The narrowing happens because the air passages become swollen and inflamed. This makes it difficult for air to get through and causes wheezing, coughing and problems with breathing. Approximately one in four children in Australia will have some symptoms of asthma during childhood, but with the right medicine and interventions, nearly all children with asthma will be able to join in sport and lead active lives. There are many different things that can trigger or start an asthma attack, including infection, exercise, changes in the weather, cigarette smoking, housedust mite, pollens and pets. The Director of Paediatric Medicine department in an urban hospital in Melbourne notices that many children with asthma admitted to the Emergency Department (ED) for acute asthmatic attack re-represent to the hospital in weeks following the initial admission to the ED. He wants to reduce re-admission rates of acute asthmatic attack at the hospital, and wonders if a short community intervention in the form of a follow-up telephone call (to assess how the patients were feeling, and provide advice for community support such as avoidance of known allergies) might lead to reductions in the number of re-admission due to acute asthmatic attack in children with asthma. 1.Write a focused clinical question for this particular problem that will help you organise a search of the clinical literature for an answer.  2.If you were to search Medline/PubMed/Web of science for original research on this question. (i) Describe what your search strategy would be. Be as specific with your response, and consider specific keywords, MeSH terms, and delimiters. (ii) Explain your rationale for taking this approach and explain your reasoning. (iii) Cite the best article from among those you find, using any referencing style of your choice. 3.What type of study design would best be able to address this question? Discuss why.  4.What information sources would you use to find an answer to questions such as the above? (i) Name at least four (4) possible types or categories of information sources as you can that could be used to find relevant evidence. (ii) Discuss at least three (3) types of information sources to demonstrate your awareness of the convenience, relevance and quality of common information sources in clinical practice. 5.a. Construct a 2×2 table using figures shown in the abstract, and answer the following questions: (i) What is the risk of losing at least 5% of body weight in all patients included in the study?  (ii) What is the risk of losing at least 5% of body weight in patients who were treated with liraglutide? (iii) What is the risk of losing at least 5% of body weight in patients who were treated with placebo? (iv) What is the relative risk of treatment with liraglutide versus placebo with regard to weight management? How would you interpret this relative risk estimate?  b. If equal numbers of patients in the population were treated with liraglutide vs placebo treatment, what would be the expected population relative risk reduction (RRR) for liraglutide treatment? How would you interpret this measure? c. How many patients need to be treated with liraglutide for one more patient to benefit compared with the placebo? What is this measure called? How would you interpret this measure  d. How does the measure in question 5b differ from question 5c? 6. What characteristics of the study would you consider in order to determine if its findings are valid? Include wider considerations of study quality/validity and give examples. (Q8 will address relevance, and the next question will ask how to determine the importance of the findings…for this question, focus on the internal validity of the study)  7. What characteristics of the findings would you consider, in order, to determine if they are clinically meaningful and statistically significant? Include examples. (You’ve already addressed validity…for this question, focus on how to determine the clinical significance and statistical significance of an effect reported in the study)  8. What characteristics of the study would you consider, in order, to determine if it is generalizable to your context? Explain your answers and provide examples. (Questions 6 and 7 have asked how to determine if the study is valid, and how important the findings are….for this question, focus on how to determine if it is really relevant or generalizable to your practice.)  Answers: 1.The focused clinical question based on this case study is, ‘What are the main causes and the risk factors that involve in the growing rate of asthma in the children in Australia?’ 2.The main search strategy for the problem in this study is to search in the official website of National Library of Medicine. By searching, the key terms like the prevalence rate of the disease and the risk factors associated with the disease in the official website can give good information. The variation in geographical conditions in the childhood of Australian children increases the prevalence rate of asthma. The prevalence rate of asthma in children is increasing from 2% to 37%. One of the major reasons for the increase in the prevalence rate of asthma may be the several labels attached to it. It has been reported by the health experts that new data reveals the huge increasing in the death rates in children in Australia suffering from asthma. According to the National Asthma Council Australia Chair, this phenomenon is new in Australia, which is observed from the past few years. Therefore, the risk factors related to asthma in children is increasing day by day and there has to be preventing measures to be found out for the control of the increasing rate of asthma in the country However, the main focus should be given to the causes of the growing asthma mainly in children of  the country. The influence of childhood traffic?related air pollution exposure on asthma, allergy and sensitization: a systematic review and a meta?analysis of birth cohort studies.Allergy, 70(3), 245-256. (Bowatte et al. 2015) 3.The type of study design used in this case is cross sectional design. This is because, to know about the risk factors and prevalence rate of asthma in the children of Australia the only design that can be used is the cross sectional design. The parents of the children were asked to fill a complete questionnaire that included questions on the several facets of asthma, the respiratory symptoms that confirmed asthma and the risk factors attached with asthma. The skin pricking tests conducted the measurement of atopy n the children. The parents were asked to complete the questionnaire before the administration of skin prick tests. 4.The four possible ways through which the information can be used to find a relevant evidences are through official website of the national council of Australia, official websites of Australian National Medical Library, the journals based on the asthma related issues in Australia and daily newspaper sights of Australia that  gives information about the asthma prevalence rates in Australia The journals gives information about the several results related to the prevalence rates of asthma in the country. The growing rate of asthma is causing a severe problem within the country. The several causes about this disease are found out from the journals and the articles that are published in the country. The official medical websites of the country provides current rates of asthmatic attacked children in the country. The newspapers also aware the concordance rates of the disease within the country. 5.a.The losing at least 5% of body weight in all the patients have shown reduction in the complications related to chronic obesity. This has also improved the quality of life of the patients. The risk factor for losing 5% body weight in patients who are treated with litraglutide, there was a increase in the reduction rate of glycated hemoglobin, fasting insulin levels and fasting glucose levels. The exposure to liraglutide also lowered down the plasma glucose levels of participants who were randomly selected from the population to undergo the process of trial. The risk factors of losing 5% of body weight of the patients, who were treated with placebo, decreased the cardio metabolic variables and increased the high sensitivity to the C reactive proteins and plasimogen activator inhibitor one. b.For any randomized group there has to be two groups that should be equally distributed. To see an effective report of the effect of any drug on the population the equal distribution of the drug exposed group and placebo exposed group should be equal. The relative risk reduction will be less for the drug-exposed group. This is because of the fact that the effectiveness of the drugs will be higher than the effect of placebo. c.The patients who are treated with liraglutide are more n number than the patients who were treated with placebo. The equal numbers of patients are to be taken for the experiment. d.The measures taken in case of 5b and 5c are randomization of the patients and equal distribution of the participants in each group are needed. 6.The validity and reliability of any test is generally the key properties that points out the effectiveness and quality of a test. They are generally two major facets of a test. An experimenter should examine these two factors to evaluate the suitability and the usability of the test. For the assessment of the items of the test, the first criteria the test needs to be satisfied is the suitability of the test and whether the test is a good test or not. The test measures the consistency of the test items and their reliability. The test always measures that claims to be measured by the test. The test should be relevant and there should measure more than one characteristics of the test that are of high importance. The using a reliable test more effective results are obtained. The reliability of the test increases the effectiveness and generalization of the test. Reliability of a test measures the consistency and dependability of the test. This means, that if a person takes the test again then they will get similar test results in the test. Many factors can influence the psychological and physical state of the participants. Firstly, the test performance of the participants can be influenced by the psychological and physical state they are in while giving the test responses. Secondly, the environmental factors that can influence test performance are the illumination of the room, noise and the administrator of the test can influence the individual performance of the test. Thirdly, the test can have more than one versions of the test. There are two forms namely the parallel form and the alternate form. Fourthly, the there are multiple raters that can be used for rating the test scores. The difference in the procedures of training can also influence the type of measurement used to get the reliability of the test. However, if there are no random errors in the measurement of the test, there are high indications of the reliability of any test. The tools of reliability produce dependent, repeated and consistent information from the test scores. For the meaningful interpretation of test scores and for making the most use  of the generating tests for getting several rep[orts for patients the reliability of the tool is very important. There are several types of testing the reliability of the test, namely, test retest reliability, alternate of parallel form reliability, inter rater reliability and internal consistency reliability. On the other hand, validity is the most important facet for selecting a test. It refers to the characteristics of the measurement of the test. Validity indicates the characteristics that can be measured by the test that is related for the test requirements of the reports of the patients. It also gives proper meaning to the test. Validity is a link between the test and the report that is inferred from the test. It also predicts the test scores. It also provides the predictions and specific conclusion of the test. Internal validity is the imprecise truth about the inferences that are drawn on the causal relationship. Therefore, internal validity is useful for the studies that are based on cause and effect relationship. Internal validity is useful for the analysis of the tests that are based on the social programs, intervention programs and validity of primary considerations. They are not used for the descriptive and observational studies. In other words, internal validity indicates the effectiveness of the procedures used for the test. It also checks that whether the test is avoiding the effect of confounding or not. Confounding is a term that is generally used when the more than one independent variable is used in the test. Therefore, the internal validity is the analysis of the effectiveness of the research and allows choosing between alternate explanations of the study. A research study shows high internal validity that gives options in its explanations of the study because the study is free from confounding. The essay discusses the about the weight loss of obese people. There were two groups were taken for the test, in the first group the participants are given to liraglutide dose and in the second group, the participants are given placebo effect. The tests that are used for this study are reliable because they can be tested on same patients with familiar symptoms and the results that are obtained will be similar to the previous finding. The internal consistency is high in this study because there is no confounding effect being found in the study. Therefore, it can be said that the study is of good quality and is valid. 7.For conducting the study, 2400 patients were assigned to take litraglutide and 1200 were assigned to take placebo. The analysis was done on a pre specified data that included participants who were divided into two groups. The main objective of the study is to see the effect of the drug litraglutide and its exposure to the diabetic patients. The results of the trial group showed that overall percentage of weight loss in the liraglutide group is 92% and in the placebo group is 65%. The exposure of the drug in the patient’s body has shown significant reduction in the body weight. The sensitivity analyses confirmed that the superiority of litraglutide over placebo with respect to the co primary towards the ends. It was also observed that the prevalence rate of the pre diabetic patients was lower for the liraglutide-exposed group than the placebo group by the end of the fifty sixth weeks. The systolic and diastolic pressure had significant decrease in the liraglutide-exposed group has decreased more than the group who are exposed to the effect of placebo. The liraglutide exposed groups showed higher quality of life due to the effect of drug because of the drugs increases the mental and physical domains of the participants. Due to the exposure of drugs, some gastrointestinal events were observed in the participants. The liraglutide exposed group showed symptoms like nausea and vomiting indicating severe gastric problems. However, the study is highly beneficial for selecting a proper drug for chronic obesity. Although, the participants were given proper counseling on lifestyle modification, but it is very difficult to adapt to vast lifestyle changes in a practical approach. Therefore, a drug that has low levels of risk needs to be introduced for the people in the country. The quality of life was also shown in the higher domain as with the exposure to the drug. The statistical analysis also shows the significant difference between the two groups that are exposed to discrete condition. Therefore, it can be analyzed that the study is clinically proved and statistically significant. 8.From the study, it was found that liraglutide treatment involved the high reductions in the risks factors associated with cardio metabolic rates that includes, circumference of the waist, blood pressure and the inflammations in the areas of the marker. The modest increasing rates of fasting lipid profile levels were also observed. However, the weight loss percentage is observed more in the participants who were exposed to the liraglutide group than the placebo exposed group. The safety profile of the liraglutide drug was found to be consistent with respect to the findings of the previous reports. However, gallbladder related events were found more common in the participants who were exposed to the liraglutide drug. The current trial shows that the participants who were under the influence of liraglutide drug had greater association to gallstones and pancreatic enzymes. The negligence of this condition can cause calcitonin concentration and C cell hyperplasia. Medullar thyroid carcinoma events are consistent with a prior observation that liraglutide exposure is not associated with medullar thyroid carcinoma in humans. The clinical analysis also showed rapid heart rates of the participants who were exposed to the liraglutide drug. However, the test reports showed beneficial effects on blood pressure and cardio metabolic variables of the participants who were exposed to the liraglutide drugs. The two groups that are taken in the experiments are the placebo and drug exposed group. For any drug to be finalized as a clear medicine for the chronic obesity problems, the side effects of the drugs are needed to be highlighted. The patient exposed to the drug has suffered from gastric problems and reductions in cardio metabolic rates. Therefore, the drug has a good amount of risk factors associated with it. Nevertheless, the drug has certain risk factors but its merits cannot be avoided. The exposure of drugs has lead to the reduction in body weight with respect to body fat. The quality of life has also improved of the drug-exposed patients. Therefore, the drug can be generalized and can be used by the patients who are suffering from chronic obesity but for the risk factors associated with it can be controlled by other medicines that are already used for controlling the risk factors. References Bowatte, G., Lodge, C., Lowe, A. J., Erbas, B., Perret, J., Abramson, M. J., … & Dharmage, S. C. (2015). The influence of childhood traffic?related air pollution exposure on asthma, allergy and sensitization: a systematic review and a meta?analysis of birth cohort studies. Allergy, 70(3), 245-256. Buchmueller, T. C., & Johar, M. (2015). Obesity and health expenditures: evidence from Australia. Economics & Human Biology, 17, 42-58. Chang, A. B., Bell, S. C., Torzillo, P. J., King, P. T., Maguire, G. P., Byrnes, C. A., … & Grimwood, K. (2015). Chronic suppurative lung disease and bronchiectasis in children and adults in Australia and New Zealand Thoracic Society of Australia and New Zealand guidelines. Med J Aust, 202(1), 21-23. Egger, G., & Dixon, J. (2014). Beyond obesity and lifestyle: a review of 21st century chronic disease determinants. BioMed research international, 2014. Hollams, E. M., De Klerk, N. H., Holt, P. G., & Sly, P. D. (2014). Persistent effects of maternal smoking during pregnancy on lung function and asthma in adolescents. American journal of respiratory and critical care medicine, 189(4), 401-407. Lyall, K., Van de Water, J., Ashwood, P., & Hertz?Picciotto, I. (2015). Asthma and allergies in children with autism spectrum disorders: results from the CHARGE study. Autism Research, 8(5), 567-574. Mahajan, R., Lau, D. H., Brooks, A. G., Shipp, N. J., Manavis, J., Wood, J. P., … & Thanigaimani, S. (2015). Electrophysiological, electroanatomical, and structural remodeling of the atria as consequences of sustained obesity. Journal of the American College of Cardiology, 66(1), 1-11. Murphy, V. E., Mattes, J., Powell, H., Baines, K. J., & Gibson, P. G. (2014). Respiratory viral infections in pregnant women with asthma are associated with wheezing in the first 12 months of life. Pediatric Allergy and Immunology, 25(2), 151-158. Petsky, H. L., Li, A. M., Au, C. T., Kynaston, J. A., Turner, C., & Chang, A. B. (2015). Management based on exhaled nitric oxide levels adjusted for atopy reduces asthma exacerbations in children: A dual centre randomized controlled trial. Pediatric pulmonology, 50(6), 535-543. Tai, A., Tran, H., Roberts, M., Clarke, N., Gibson, A. M., Vidmar, S., … & Robertson, C. F. (2014). Outcomes of childhood asthma to the age of 50 years. Journal of Allergy and Clinical Immunology, 133(6), 1572-1578.

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