Meyer Balter

University of Toronto, Toronto, Ontario, Canada

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Publications (45)206.04 Total impact

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    ABSTRACT: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality in the United States as well as the rest of the world. An exacerbation of COPD, periodic escalations of symptoms of cough, dyspnea and sputum production, is a major contributor to the worsening lung function, impairment in quality of life, need for urgent care or hospitalization, and costs of care in COPD. Research conducted over the past decade has contributed much to our current understanding of the pathogenesis and treatment of COPD. Additionally, an evolving literature has recently accumulated about the prevention of acute exacerbations.
    Chest 10/2014; 147(4). DOI:10.1378/chest.14-1676
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    ABSTRACT: Chronic obstructive pulmonary disease (COPD) is a common disease with substantial associated morbidity and mortality. Patients with COPD usually have a progression of airflow obstruction that is not fully reversible and can lead to a history of progressive worsening breathlessness that can impact daily activities and health-related quality of life. COPD is the fourth leading cause of death in Canadian men and women and the third in the U.S., it claimed 133,965 U.S. lives in 2009. In 2011, 12.7 million U.S. adults were estimated to have COPD. However, approximately 24 million U.S. adults have evidence of impaired lung function, indicating an under diagnosis of COPD. While 4% of Canadians aged 35 to 79 self-reported being diagnosed with COPD, direct measurements of lung function from the Canadian Health Measures Survey (CHMS) indicate that 13% of Canadians had a lung function score indicative of COPD.
    Chest 10/2014; 147(4). DOI:10.1378/chest.14-1677
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    ABSTRACT: Alpha-1 antitrypsin (A1AT) functions primarily to inhibit neutrophil elastase, and deficiency predisposes individuals to the development of chronic obstructive pulmonary disease (COPD). Severe A1AT deficiency occurs in one in 5000 to one in 5500 of the North American population. While the exact prevalence of A1AT deficiency in patients with diagnosed COPD is not known, results from small studies provide estimates of 1% to 5%. The present document updates a previous Canadian Thoracic Society position statement from 2001, and was initiated because of lack of consensus and understanding of appropriate patients suitable for targeted testing for A1AT deficiency, and for the use of A1AT augmentation therapy. Using revised guideline development methodology, the present clinical practice guideline document systematically reviews the published literature and provides an evidence-based update. The evidence supports the practice that targeted testing for A1AT deficiency be considered in individuals with COPD diagnosed before 65 years of age or with a smoking history of <20 pack years. The evidence also supports consideration of A1AT augmentation therapy in nonsmoking or exsmoking patients with COPD (forced expiratory volume in 1 s of 25% to 80% predicted) attributable to emphysema and documented A1AT deficiency (level ≤11 µmol⁄L) who are receiving optimal pharmacological and nonpharmacological therapies (including comprehensive case management and pulmonary rehabilitation) because of benefits in computed tomography scan lung density and mortality.
    Canadian respiratory journal: journal of the Canadian Thoracic Society 03/2012; 19(2):109-16.
  • Chest 10/2011; 140(4 Meeting Abstracts):567A-567A. DOI:10.1378/chest.1119376
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    ABSTRACT: Chronic beryllium disease (CBD) is clinically similar to other granulomatous diseases such as sarcoidosis. It is often misdiagnosed if a thorough occupational history is not taken. When appropriate, a beryllium lymphocyte proliferation tests (BeLPT) need to be performed. We aimed to search for CBD among currently diagnosed pulmonary sarcoidosis patients and to identify the occupations and exposures in Ontario leading to CBD. Questionnaire items included work history and details of possible exposure to beryllium. Participants who provided a history of previous work with metals underwent BeLPTs and an ELISPOT on the basis of having a higher pretest probability of CBD. Among 121 sarcoid patients enrolled, 87 (72%) reported no known previous metal dust or fume exposure, while 34 (28%) had metal exposure, including 17 (14%) with beryllium exposure at work or home. However, none of these 34 who underwent testing had positive test results. Self-reported exposure to beryllium or metals was relatively common in these patients with clinical sarcoidosis, but CBD was not confirmed using blood assays in this population.
    Beiträge zur Klinik der Tuberkulose 03/2011; 189(3):233-41. DOI:10.1007/s00408-011-9285-4
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    ABSTRACT: Symptomatic disease due to nontuberculous mycobacteria (NTM) is known to occur commonly in the presence of structural lung disease, but is not described in association with asthma. This was a case-control study nested in a cohort. We identified 22 patients with difficult asthma referred to a tertiary academic referral center and subsequently found to have infection with NTM. We matched each case with two control subjects (next two consecutive patients referred for asthma management). It took on average 2.1 years from the onset of new or worsening symptoms to NTM diagnosis. The most common symptoms were worsening cough (77%), sputum production (40.9%), and frequent exacerbations (31.8%). Mycobacterium avium complex accounted for 63.6% of the infections, Mycobacterium xenopi the balance. Case subjects were older (59.8 ± 8.9 vs 42.6 ± 18 years; P < .001) and had more severe airflow obstruction (FEV(1), 57% [40%-74%] vs 89.5% [80%-98%]; P < .001). There was no difference between case and control subjects in the proportion using inhaled corticosteroids (ICS) or the average daily dose at the time of presentation, but case subjects had used ICS for a longer period (17 [6.2-20] vs 4 [0.75-6.0] years; P=.002). Six subjects with NTM were being treated with daily oral steroids, whereas none of the control subjects was. Of the 22 cases, 10 were treated with antibiotics for NTM, seven demonstrating clinical improvement or resolution of the presenting symptoms. NTM infection can be associated with asthma and should be considered in difficult-to-treat disease, especially in older individuals with more severe airflow obstruction and greater exposure to inhaled or systemic corticosteroids.
    Chest 01/2011; 139(1):23-7. DOI:10.1378/chest.10-0186
  • American Thoracic Society 2010 International Conference, May 14-19, 2010 • New Orleans; 05/2010
  • New England Journal of Medicine 02/2010; 362(5):449-54. DOI:10.1056/NEJMcps0807342
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    ABSTRACT: Pulmonary rehabilitation (PR) participation is the standard of care for patients with chronic obstructive pulmonary disease (COPD) who remain symptomatic despite bronchodilator therapies. However, there are questions about specific aspects of PR programming including optimal site of rehabilitation delivery, components of rehabilitation programming, duration of rehabilitation, target populations and timing of rehabilitation. The present document was compiled to specifically address these important clinical issues, using an evidence-based, systematic review process led by a representative interprofessional panel of experts. The evidence reveals there are no differences in major patient-related outcomes of PR between nonhospital- (community or home sites) or hospital-based sites. There is strong support to recommend that COPD patients initiate PR within one month following an acute exacerbation due to benefits of improved dyspnea, exercise tolerance and health-related quality of life relative to usual care. Moreover, the benefits of PR are evident in both men and women, and in patients with moderate, severe and very severe COPD. The current review also suggests that longer PR programs, beyond six to eight weeks duration, be provided for COPD patients, and that while aerobic training is the foundation of PR, endurance and functional ability may be further improved with both aerobic and resistance training.
    Canadian respiratory journal: journal of the Canadian Thoracic Society 01/2010; 17(4):159-68.
  • Respiratory Medicine 12/2009; 103(12):1973-1973. DOI:10.1016/j.rmed.2009.09.009
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    Canadian Medical Association Journal 09/2009; 181(10):E210-20. DOI:10.1503/cmaj.080006
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    Canadian Medical Association Journal 09/2009; 181(12):915-22. DOI:10.1503/cmaj.080007
  • American Thoracic Society 2009 International Conference, May 15-20, 2009 • San Diego, California; 04/2009
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    ABSTRACT: Chronic obstructive pulmonary disease (COPD) is a common respiratory condition and the fourth leading cause of death in Canada. However, little is known about the impact of COPD on the lives and attitudes of individuals living with this condition. The purpose of this study was to determine whether Canadians with COPD are properly educated and supported, and to recommend solutions to any care gaps identified. A total of 389 Canadians were surveyed who were 40 years of age and older, physician diagnosed with COPD, and current or former smokers. The telephone survey contained 68 items and took 35 min to complete. COPD severity was classified according to symptom severity using the Medical Research Council (MRC) score. Respondents tended to overestimate their disease severity and reported substantial symptom burden and psychosocial impact of living with COPD. Most individuals claimed to be well informed about COPD; however, their knowledge was poor in several domains including the causes of COPD, the consequences of inadequate therapy and the management of exacerbations. Family physicians were the main health care providers. A minority of respondents had seen a lung health educator. Only 34% had ever received a written action plan and only 33% had been told how to prevent an exacerbation. The symptom burden and psychosocial impact of living with COPD is substantial. There are significant gaps in patients' knowledge about the management of COPD and little contact with lung health educators. Increased use of COPD-specific, self-management education programs may help rectify these care gaps.
    Respiratory medicine 04/2009; 103(7):1004-12. DOI:10.1016/j.rmed.2009.01.018
  • American Thoracic Society 2009 International Conference, May 15-20, 2009 • San Diego, California; 04/2009
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    ABSTRACT: Clinical trials measure exacerbations of chronic obstructive pulmonary disease (COPD) inconsistently. A study was undertaken to determine if different methods for ascertaining and analysing COPD exacerbations lead to biased estimates of treatment effects. Information on the methods used to count, analyse and report COPD exacerbation rates was abstracted from clinical trials of long-acting bronchodilators or long-acting bronchodilator/inhaled steroid combination products published between 2000 and 2006. Data from the Canadian Optimal Therapy of COPD Trial was used to illustrate how different analytical approaches can affect the estimate of exacerbation rates and their confidence intervals. 22 trials (17,156 patients) met the inclusion criteria and were reviewed. None of the trials adjudicated exacerbations or determined independence of events. 14/22 studies (64%) introduced selection bias by not analysing outcome data for subjects who prematurely stopped study medications. Only 31% of trials used time-weighted analyses to calculate the mean number of exacerbations/patient-year and only 15% accounted for between-subject variation. In the Canadian Optimal Therapy of COPD Trial the rate ratio for exacerbations/patient-year was 0.85 when all data were included in a time-weighted analysis, but was overestimated as 0.79 when data for those who prematurely stopped study medications were excluded and was further overestimated as 0.46 when a time-weighted analysis was not conducted; p values ranged from 0.03 to 0.24 depending on how exacerbations were determined and analysed. Clinical trials have used widely different methods to define and analyse COPD exacerbations and this can lead to biased estimates of treatment effects. Future trials should strive to include blinded adjudication and assessment of the independence of exacerbation events, and trials should report time-weighted intention-to-treat analyses with adjustments for between-subject variation in COPD exacerbations.
    Thorax 03/2008; 63(2):122-8. DOI:10.1136/thx.2007.082636
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    ABSTRACT: CLINICAL ASSESSMENTMost individuals with COPD are not diagnosed until the disease is well advanced. Targeted testing of symptomatic individuals with risk factors for the development of COPD followed by intensive smoking cessation counselling can change the progression of disease.Mass screening of asymptomatic individuals for COPD is not supported by the current evidence and therefore is not recommended. The following criteria are recommended to help the family physician decide who to target for spirometry in their practice so as to establish early diagnosis in individuals at risk of COPD.Patients who are older than 40 years of age and who are current or ex-smokers should undertake spirometry if they answer yes to any one of the following questions: Do you cough regularly?Do you cough up phlegm regularly?Do even simple chores make you short of breath?Do you wheeze when you exert yourself, or at night?Do you get frequent colds that persist longer than those of other people you know?Episodes of acute bronchitis in a smoker may represent the first clinical presentation of COPD – spirometry should be obtained after the acute episode has resolved and the patient is clinically stable.Tobacco consumption should be quantified: total pack years = (number of cigarettes smoked per day ÷ 20) × numberof years of smoking.Individual susceptibility for the development of COPD varies, so no minimum number of pack years is required to place an individual at risk.COPD management decisions should be made on an individual basis and should not be based exclusively on spirometry results but also on an assessment of severity of dyspnea and disability, which are assessed by using the Medical Research Council dyspnea scale (Tables 1 and and22).TABLE 1The Medical Research Council dyspnea scaleTABLE 2Canadian Thoracic Society chronic obstructive pulmonary disease (COPD) classification of severity by symptoms and disability*, and impairment of lung functionClinical assessment begins with a thorough history and physical examination. Occupational or environmental exposures to cigarette smoke and other lung irritants should be recorded. Symptoms and signs related to the COPD, complications (eg, leg edema in cor pulmonale) and comorbidities should be identified. Inquiry concerning frequency and severity of exacerbations is crucial to management decisions. Current medical treatment should be reviewed. Physical examination, although important, is not usually diagnostic except in the presence of very severe airflow limitation.Postbronchodilator spirometry is required to evaluate the presence and severity of airway obstruction (Table 2). Additional pulmonary function and exercise tests may be undertaken in selected patients for a more complete clinical characterization of the COPD phenotype. Arterial blood gas measurements should be considered in patients with forced expiratory volume in 1 s (FEV1) of less than 40% predicted (with a resting arterial oxygen saturation of less than 90%) to assess for evidence of hypoxemia or hypercapnia. Chest x-rays and other investigations are not diagnostic of COPD but are often required to assess comorbidities.COPD and asthma are fundamentally differentIn a small proportion of patients, diagnostic differentiation can be challenging and may require additional investigation or specialist referral. Clinical differences between asthma and COPD can usually help in making a correct diagnosis (Table 3). Patients with a large improvement in FEV1 (eg, greater than 0.4 L) acutely following inhaled short-acting bronchodilators or following treatment with inhaled or oral steroids likely have an asthmatic component.TABLE 3Clinical differences between asthma and chronic obstructive pulmonary disease (COPD)Other conditions included in the differential diagnosis of older patients presenting with progressive dyspnea include cardiovascular conditions, pulmonary vascular disease, severe deconditioning, obesity, anemia, interstitial lung disease and neuromuscular disease.
    Canadian respiratory journal: journal of the Canadian Thoracic Society 02/2008; 15 Suppl A(Suppl A):1A-8A.
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    ABSTRACT: Most asthma patients prescribed maintenance asthma therapies still experience periods of asthma worsenings characterized by daytime or night-time symptoms, or an increased need for rescue medication. In fact, these episodes are highly prevalent even in patients with well-controlled disease. Published literature suggests that asthma worsenings likely represent a window of opportunity during which patients could intervene early to prevent exacerbations or further deterioration of asthma symptoms. However, current evidence suggests that most patients fail to respond or to self-manage appropriately during these periods.To address the issue of asthma worsenings, an interdisciplinary committee of respirologists, allergists, family physicians, pharmacists and certified asthma educators from across Canada developed a practical definition of asthma worsenings and provided approaches to the prevention and management of these episodes based on current literature. To date, combination inhaled corticosteroid/long-acting beta-agonist therapy, particularly single inhaler maintenance and reliever therapy, appears to be an effective strategy for preventing asthma worsenings and exacerbations. Addressing the potential barriers to appropriate patient self-management of asthma worsenings, such as failure to adequately identify and respond to worsenings, low expectations for controlling asthma, low health literacy and poor patient-health care professional communication, are also critical to the successful prevention and management of these episodes. Finally, an interdisciplinary team approach involving patients and their families, certified asthma educators, primary care physicians, pharmacists and specialists is likely to have the greatest impact on the identification, prevention and management of asthma worsenings.
    Canadian respiratory journal: journal of the Canadian Thoracic Society 01/2008; 15 Suppl B:1B-19B.
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    ABSTRACT: Chronic obstructive pulmonary disease (COPD) is a major respiratory illness in Canada that is both preventable and treatable. Our understanding of the pathophysiology of this complex condition continues to grow and our ability to offer effective treatment to those who suffer from it has improved considerably. The purpose of the present educational initiative of the Canadian Thoracic Society (CTS) is to provide up to date information on new developments in the field so that patients with this condition will receive optimal care that is firmly based on scientific evidence. Since the previous CTS management recommendations were published in 2003, a wealth of new scientific information has become available. The implications of this new knowledge with respect to optimal clinical care have been carefully considered by the CTS Panel and the conclusions are presented in the current document. Highlights of this update include new epidemiological information on mortality and prevalence of COPD, which charts its emergence as a major health problem for women; a new section on common comorbidities in COPD; an increased emphasis on the meaningful benefits of combined pharmacological and nonpharmacological therapies; and a new discussion on the prevention of acute exacerbations. A revised stratification system for severity of airway obstruction is proposed, together with other suggestions on how best to clinically evaluate individual patients with this complex disease. The results of the largest randomized clinical trial ever undertaken in COPD have recently been published, enabling the Panel to make evidence-based recommendations on the role of modern pharmacotherapy. The Panel hopes that these new practice guidelines, which reflect a rigorous analysis of the recent literature, will assist caregivers in the diagnosis and management of this common condition.
    Canadian respiratory journal: journal of the Canadian Thoracic Society 10/2007; 14 Suppl B(Suppl B):5B-32B.
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    ABSTRACT: To assess the therapeutic effects of oral zileuton tablets combined with low-dose beclomethasone compared to doubling the dose of beclomethasone, in improving lung function and reducing asthma symptoms. Randomized, active-control, double-blind, parallel, multi-center study of zileuton (400 or 600 mg QID)+200 microg beclomethasone dipropionate (BDP) BID versus placebo+BDP 400 microg BID in asthmatics with baseline FEV(1) percent predicted values between 40% and 80% following a single-blind ICS (BDP 200 microg BID) 2-week run-in. During the 3-month double-blind treatment period, assessments included safety, daytime and nighttime symptoms, acute asthma exacerbations, beta(2)-agonist use, AM and PM peak expiratory flow (PEF) and FEV(1). The addition of a 5-lipoxygenase (5-LO) inhibitor added to a low-dose of BDP showed no significant difference in FEV(1) compared to doubling the dose of BDP. FEV(1) improved in all 3 treatment groups, with mean increases of 10% with zileuton 600 mg QID+BDP 200 microg BID, 12% with zileuton 400mg QID+BDP 200 microg BID, and 11% with BDP 400 microg BID by study end. Within each treatment group, there were significant improvements in asthma symptoms and AM and PM PEF compared to baseline. No significant differences were observed between groups with regards to salbutamol use, acute asthma exacerbations, the requirement for oral/parenteral corticosteroids and adverse clinical events. The addition of a 5-LO inhibitor added to low-dose beclomethasone may be an alternative to higher-doses of ICS in patients unable to achieve sufficient asthma control on low-dose ICS therapy.
    Respiratory Medicine 07/2007; 101(6):1088-96. DOI:10.1016/j.rmed.2007.01.017