National Asthma Education Research Articles

Asthma in Pregnancy

Asthma is an increasingly common problem during pregnancy. Mild and moderate asthma can be associated with excellent maternal and perinatal pregnancy outcomes, especially if patients are managed according to contemporary recommendations of National Asthma Education and Prevention Program. Severe and poorly controlled asthma may be associated with increased prematurity, need for cesarean delivery, preeclampsia, and growth restriction. Severe asthma exacerbations can result in maternal morbidity and mortality, and can have commensurate adverse pregnancy outcomes. The management of asthma during pregnancy should be based upon objective assessment, trigger avoidance, patient education, and step therapy. Asthma medications should be continued during pregnancy and while breast-feeding.

Assessment of high-sensitivity C-reactive protein as a marker of airway inflammation in asthma

Limited data are available on the presence of a systemic measure of inflammation in asthma. One marker that has been reported is C-reactive protein (CRP). To examine the correlation between high-sensitivity CRP (hsCRP) and asthma activity. Fifty-four patients with physician-diagnosed asthma, ages 6 to 58 years, were enrolled in the study. In addition to medical history and physical examination, asthma was assessed according to the National Asthma Education and Prevention Program (NAEPP) control score, fractional exhaled nitric oxide (FeNO), and spirometry. The relationships between hsCRP and each of the asthma control measures (ie, NAEPP control scores, presence of wheeze, FeNO, and forced expiratory volume in 1 second [FEV1]) were calculated. The hsCRP levels in all patients ranged from less than 0.5 to 14.1 mg/L, with a mean (SD) of 2.1 (2.9 mg/L), compared with less than 0.5 mg/L expected in healthy individuals. The FEV1 percentage predicted ranged from 48% to 130%, with a mean (SD) of 96.5% (17.5%). Correlation coefficients for hsCRP vs FEV1 and FeNO were 0.07 and -0.03, respectively. Neither of these values reached statistical significance. The chi2 analysis values for hsCRP vs the NAEPP scores, wheeze, FEV1, and FeNO were 0.00, 2.16, 1.32, and 2.08, respectively, with none being statistically significant. Our study of patients with asthma, mostly of a mild severity, did not reveal any significant correlation between hsCRP and wheeze, NAEPP control score, FEV1, or FeNO. Larger studies with a more diverse level of asthma control are warranted in examining the utility of hsCRP in the evaluation of asthma.

Asthma Assessment Tips

obstruction, airway hyperresponsiveness, and lung inflammation. Recurrent episodes of cough, wheezing, dyspnea, and chest tightness result from complex cellular interactions, rich in eosinophils. While its disease progression is incompletely understood, exercising control over the inflammatory nature of asthma may prevent airway remodeling and permanent airflow limitations. Approximately 34.1 million Americans have been diagnosed with asthma by a health care provider.1 As the incidence of asthma is increasing in the United States, nurse practitioners (NPs) must be cognizant of both classic asthma symptoms and covert clinical findings suggestive of asthma. In addition to history and physical examination, spirometry is the gold standard for measuring airflow obstruction and reversibility. National asthma guidelines recommend spirometry to be performed in those 5 years of age.2

Adding salmeterol to fluticasone propionate or increasing the dose of fluticasone propionate in patients with asthma

The National Asthma Education and Prevention Program guidelines recommend two options for patients uncontrolled on inhaled corticosteroid (ICS) alone: add a long-acting bronchodilator or increase the dose of the ICS. The purpose of this study was to compare asthma-related exacerbations and asthma control in asthma patients receiving fluticasone propionate (FP) monotherapy with an increased dose of FP compared with maintaining the dose and adding salmeterol (SAL) via a single device (FP/SAL combination [FSC]). A retrospective observational study was performed using health insurance claims spanning from January 2001 to August 2006 ("study period"). Subjects were > or =12 years of age, with asthma (International Classification of Diseases [ICD] 493.xx), and were stepped up from FP 44 microg to either FP 110 microg (FP110) or FP 100 microg/SAL 50 microg (FSC), or from FP110 to either FP 220 microg or FP 250 microg/SAL 50 microg (FSC). There were 1744 subjects identified, 557 (32%) increased FP and 1187 (68%) added SAL. The cohorts were relatively similar, and after adjusting for baseline characteristics, patients who added SAL to their same dose of FP had 41% lower odds of an asthma exacerbation (odds ratio = 0.59; 95% confidence interval [CI] = 0.46-0.76; p < 0.001), 36% fewer prescriptions for a short-acting beta-agonist (rate ratio = 0.64; 95% CI = 0.58-0.70; p < 0.001), and a 32% increase in ICS refill persistence compared with increasing the dose of FP. In asthma patients who are not adequately controlled with ICS (FP), adding SAL as FSC is associated with lower risk of an asthma-related exacerbation and better asthma control compared with increasing the dose of ICS (FP).

Electronic Health Record–Based Decision Support to Improve Asthma Care: A Cluster-Randomized Trial

Asthma continues to be 1 of the most common chronic diseases of childhood and affects approximately 6 million US children. Although National Asthma Education Prevention Program guidelines exist and are widely accepted, previous studies have demonstrated poor clinician adherence across a variety of populations. We sought to determine if clinical decision support (CDS) embedded in an electronic health record (EHR) would improve clinician adherence to national asthma guidelines in the primary care setting. We conducted a prospective cluster-randomized trial in 12 primary care sites over a 1-year period. Practices were stratified for analysis according to whether the site was urban or suburban. Children aged 0 to 18 years with persistent asthma were identified by International Classification of Diseases, Ninth Revision codes for asthma. The 6 intervention-practice sites had CDS alerts imbedded in the EHR. Outcomes of interest were the proportion of children with at least 1 prescription for controller medication, an up-to-date asthma care plan, and the performance of office-based spirometry. Increases in the number of prescriptions for controller medications, over time, was 6% greater (P = .006) and 3% greater for spirometry (P = .04) in the intervention urban practices. Filing an up-to-date asthma care plan improved 14% (P = .03) and spirometry improved 6% (P = .003) in the suburban practices with the intervention. In our study, using a cluster-randomized trial design, CDS in the EHR, at the point of care, improved clinician compliance with National Asthma Education Prevention Program guidelines.

Levels of soluble human leukocyte antigen-G are increased in asthmatic airways

To the Editors: Human leukocyte antigen-G (HLA-G) is a non-classical, class Ib, major histocompatibility complex antigen, encoded by a gene on chromosome 6p21 within the HLA complex 1. HLA-G is constitutively expressed during pregnancy where it has a critical role in maintaining immune tolerance toward the allogenic fetus and placenta 2, 3, but has also been associated with inflammatory diseases such as psoriasis, multiple sclerosis, and ulcerative colitis, and with solid-organ transplantation 3, 4. We recently reported associations between variation in HLA-G and risk for asthma in Chicago-area asthma families, in multigenerational Dutch asthma families and in a birth cohort at high risk for developing asthma 1, 5. A role for HLA-G in asthma pathogenesis was further suggested by the demonstration of expression of a soluble isoform of HLA-G, sHLA-G5, in airway epithelial cells 1 and of increased circulating plasma levels of sHLA-G in children with atopic asthma 6. Because airway inflammation in asthma involves a T-helper cell (Th) type 2-skewing of lymphocytes similar to pregnancy, HLA-G is an attractive candidate molecule for promoting the immune profile characteristic of asthma. Localisation of HLA-G to airway epithelium suggests that its dysregulation could contribute to airway inflammation in chronic asthma. To evaluate this further, we hypothesised that HLA-G abundance would be increased in asthmatic airways. To test this hypothesis, we measured concentrations of sHLA-G in bronchoalveolar lavage (BAL) fluid obtained from 12 non-asthmatic control subjects and 15 subjects with mild persistent asthma. The use of human subjects was approved by the University of Chicago Institutional Review Board (Chicago, IL, USA). Asthma was diagnosed using National Asthma Education and Prevention Program guidelines. …

Influence of Maternal Asthma and Asthma Severity on Newborn Morphometry

Objective. To determine if maternal asthma or asthma severity affects newborn morphometry. Study Design. A secondary analysis was performed on data collected in a multicenter prospective observational cohort study of asthma in pregnancy. Patients enrolled included women with asthma stratified by severity of disease and controls. Asthma severity was defined according to the classification proposed by the National Asthma Education Program (NAEP) Report of the Working Group on Asthma and Pregnancy, modified to include medication requirements. Newborn morphometry measurements included birth weight (BW) and multiples of the median birth weight (BW-MOM), head circumference (HC), length (L), HC:BW ratio, and ponderal index (PI). Results. Of 2480 patients there were 828 nonasthmatic controls, 828 with mild, 775 with moderate, and 49 with severe disease. Comparing all groups, there were statistically significant differences in maternal age (p < .001), race (p = .005), parity (p = .006), prepregnancy weight (p = .028), and medical care source (p = .001), with the severe asthma group having the highest mean maternal age (25.7 years), and proportion of African Americans (71.4%), proportion of multiparous patients (63.3%), and proportion of patients receiving government assistance (85.7%). When the control group was excluded from the comparisons, differences in prepregnancy weight and medical care source were no longer significant. BW-MOM and L did not differ between groups. The HC:BW ratio increased with asthma severity (p = .029) and was increased compared to controls (p = .010). This remained significant after controlling for confounding variables (both p <.001). HC was statistically significantly different between all groups (p = .032), as well as among women with varying degrees of asthma severity (p = .013), which was not clinically significant. After covariates adjustment, HC was not significantly different among all groups (p = .228), nor the asthma groups (p = .144). Conclusion. Asthma severity is associated with an increased HC:BW ratio. Severity was not found to impact HC, BW-MOM, L, or PI independently. However, the magnitudes of the effects were too small to suggest a clinically significant effect of asthma on neonatal morphometry in this large prospectively studied sample.

The role of Th2 immune pathway modulation in the treatment of severe asthma and its phenotypes: Are we getting closer?

New therapeutic approaches are needed for severe asthmatics who are refractory to standard therapy with high doses of inhaled corticosteroids plus long-acting β2-agonists. Current treatment guidelines for severe asthmatics from the National Asthma Education and Prevention Program recommend the addition of oral corticosteroids, which are associated with significant morbidity, and for those with allergic asthma, anti-IgE. Genetic and translational studies, as well as clinical trials, suggest that in a sub-group of patients the pathobiology of severe asthma is mediated by immune pathways driven by Th2-type CD4+ T cells which produce a characteristic repertoire of interleukins, including IL-4, IL-5 and IL-13. Therefore, biological modifiers of Th2-type interleukins, such as monoclonal antibodies, soluble receptors and receptor antagonists, represent a rational strategy for developing new treatment approaches, but will need to be targeted to selected individuals in whom the appropriate Th2 immune pathway is “active.” The benefits of immune modifier therapies targeting Th2-type cytokines, however, will need to be weighed against the toxicities associated with inhibition of key biological pathways, as well as the expense of future medications. Therefore, future clinical trials will need to clearly establish the efficacy and safety of biological modifiers of Th2 immune pathways before these approaches can enter routine clinical practice for the treatment of severe asthma.

Narrative Review: The Role of Th2 Immune Pathway Modulation in the Treatment of Severe Asthma and Its Phenotypes

New therapeutic approaches are needed for patients with severe asthma who are refractory to standard therapy comprising high doses of inhaled corticosteroids plus long-acting beta(2)-agonists. Current treatment guidelines for patients with severe asthma from the National Asthma Education and Prevention Program recommend the addition of oral corticosteroids, which are associated with substantial morbidity, and, for those with allergic asthma, anti-IgE. Genetic and translational studies, as well as clinical trials, suggest that in a subgroup of patients, the pathobiology of severe asthma is mediated by immune pathways driven by T-helper 2 (Th2)-type CD4(+) T cells, which produce a characteristic repertoire of interleukins (ILs), including IL-4, IL-5, and IL-13. Therefore, biological modifiers of Th2-type ILs, such as monoclonal antibodies, soluble receptors, and receptor antagonists, are a rational strategy for developing new treatment approaches but will need to be targeted to selected patients in whom the appropriate Th2 immune pathway is "active." The benefits of immune-modifier therapies targeting Th2-type cytokines, however, need to be weighed against the toxicities associated with inhibition of key biological pathways, as well as the expense of future medications. Therefore, future clinical trials need to clearly establish the efficacy and safety of biological modifiers of Th2 immune pathways before these approaches can enter routine clinical practice for the treatment of severe asthma.

Advances in pediatric asthma in 2009: Gaining control of childhood asthma

This year's summary will focus on recent advances in pediatric asthma as reported in Journal of Allergy and Clinical Immunology publications in 2009. New National Asthma Education and Prevention Program asthma guidelines were released in 2007, with a particular emphasis on asthma control. Now that we have worked with the principals of the guidelines for 2 years, new insights are reported on how to implement the guidelines into clinical practice. This year's report will focus on gaps in management that need to be addressed, including health disparities, methods to improve asthma management through opportunities available in school-based asthma programs, and more information on the development of asthma in childhood. This information brings us closer to the point of managing children with controllable asthma and understanding reasons why asthma is not controlled in the remaining children. If we can close these gaps through better communication, improvements in the health care system, and new insights into treatment, we will move closer to better methods to intervene early in the course of the disease and induce clinical remission as quickly as possible in most children.

Section 1. EPR-3 versus GINA 2008 Guidelines - Asthma Control and Step 3 Care: Highlights of the Asthma Summit 2009: Beyond the Guidelines

Recent updates to asthma guidelines from the Global Initiative for Asthma (GINA) and the National Asthma Education and Prevention Program (Expert Panel Report 3, EPR-3) share many similarities, reflecting a focus on asthma control based on clinical manifestations of disease and responsiveness to therapy. Both documents build upon the recommendations of former guidelines utilizing evidence-based review of the published literature to revise algorithms for practice. A major difference between the 2 reports is the preferred treatment at Step 3. The GINA guidelines recommend a combination of low-dose inhaled corticosteroid (ICS) plus long-acting β-agonist (LABA), whereas the EPR-3 advises either monotherapy with medium-dose ICS or the low-dose ICS + LABA combination. Both approaches are supported by clinical experience and Level A evidence. The option of personalized therapy is a point of discussion for future guidelines.

Uncontrolled asthma: assessing quality of life and productivity of children and their caregivers using a cross-sectional Internet-based survey.

BackgroundResults of a national survey of asthmatic children that evaluated management goals established in 2004 by the National Asthma Education and Prevention Program (NAEPP) indicated that asthma symptom control fell short on nearly every goal.MethodsAn Internet-based survey was administered to adult caregivers of children aged 6-12 years with moderate to severe asthma. Asthma was categorized as uncontrolled when the caregiver reported pre-specified criteria for daytime symptoms, nighttime awakening, activity limitation, or rescue medication based on the NAEPP guidelines. Children's health-related quality of life (HRQOL) and caregivers' quality of life (QOL) were assessed using the Child Health Questionnaire Parent Form 28 (CHQ-PF28) and caregiver's work productivity using a modified Work Productivity and Activity Impairment Questionnaire. Children with uncontrolled vs. controlled asthma were compared.Results360 caregivers of children with uncontrolled asthma and 113 of children with controlled asthma completed the survey. Children with uncontrolled asthma had significantly lower CHQ-PF28 physical (mean 38.1 vs 49.8, uncontrolled vs controlled, respectively) and psychosocial (48.2 vs 53.8) summary measure scores. They were more likely to miss school (5.5 vs 2.2 days), arrive late or leave early (26.7 vs 7.1%), miss school-related activities (40.6 vs 6.2%), use a rescue inhaler at school (64.2 vs 31.0%), and visit the health office or school nurse (22.5 vs 8.8%). Caregivers of children with uncontrolled asthma reported significantly greater work and activity impairment and lower QOL for emotional, time-related and family activities.ConclusionsPoorly controlled asthma symptoms impair HRQOL of children, QOL of their caregivers, and productivity of both. Proper treatment and management to improve symptom control may reduce humanistic and economic burdens on asthmatic children and their caregivers.

Loss of Asthma Control in Inner City Children with Asthma after Withdraw of Asthma Controller Medication

To determine what percentage of inner-city children with asthma would lose asthma control when taken off asthma controllers, a retrospective analysis was performed on inner-city asthmatic children who achieved asthma control in an asthma specific disease management program. Once disease control was achieved patients had stepwise reduction of asthma controllers based on the National Asthma Education and Prevention Program (NAEPP) Expert Review Panel (EPR) 2 guidelines. In patients who were taken off all controllers, probability of maintaining asthma control at the first visit after cessation of these medications was significantly lower compared to patients kept on inhaled corticosteroids. We conclude that cessation of asthma controllers in previously well controlled inner-city asthmatic children results in loss of asthma control in a significant number of these patients. Data support recommendations from national asthma guidelines to step down controller therapy, but clinical monitoring is important to reduce impairment due to loss of control.

Guideline for the management of chronic asthma in children--2009 update.

To revise the guideline for the diagnosis and management of chronic asthma in children in view of the following considerations: the existing South African Childhood Asthma Working Group (SACAWG) guideline was produced 10 years ago; diagnosis of asthma in young children remains a challenge; evidence-based treatment is the new paradigm; new treatment approaches to achieving and maintaining control; therapeutic roles of several medications have evolved; more studies and data on treatment in young children; new medications and formulations; a change of emphasis in assessing asthma control to guide treatment changes. The main aim of the guideline is to promote a better standard of treatment based on understanding of the pathophysiology and pharmacotherapy of asthma, and encouraging uniformity in asthma management. A detailed literature review by a working group of clinicians from relevant disciplines. The strategies recommended are classified according to the evidence category in Appendix B, and denoted as Evidence A, B, C and D. These include an appropriate diagnostic approach, environmental control measures, treatment options, definition of asthma control, and strategies to achieve control. The guideline document was endorsed by the South African Thoracic Society (SATS), the National Asthma Education Programme (NAEP), the South African Paediatric Association (SAPA) and the South African Academy of Family Practice.

Management of Pediatric Asthma: Focus on the Expert Panel Report 3

DEFINITION AND IMPACT OF ASTHMA Asthma is a chronic inflammatory disorder of the airways involving numerous cell types and mediators. Patients with asthma exhibit variable and recurring symptoms, including recurrent episodes of cough or wheeze, breathlessness, and chest tightness (National Asthma Education and Prevention Program [NAEPP], 2007). The airflow obstruction responsible for the symptoms is largely reversible and related to bronchial smooth muscle contraction (bronchoconstriction), inflammation of the airway mucosal surface leading to edema and increased mucus production, and hyperresponsiveness or increased bronchial reactivity. Asthma is unique because it has a significant direct impact on people across the continuum of life, from the young to the very old. It is a leading diagnosis among children and is associated with significant morbidity as measured in exacerbations, missed days of school, and decreased quality of life. According to national statistics, more than 20 million people in the United States have asthma, including 9 million children and adolescents (American Lung Association, 2005; Dey, Schiller, & Tai, 2004). In other surveys, nearly 12% of children report an asthma diagnosis, and the prevalence is disproportionately higher among lower socioeconomic groups (Bloom & Dey, 2006; Cloutier, Hall, Wakefield, & Bailit, 2005). Children experience 4 million asthma attacks annually, and 44% of hospitalizations for this disease occur in children (Hall & Owings, 2002). In 2002, 14.7 million days were missed from school reportedly due to asthma. Diagnosis is challenging in young children who often present with transient

Mometasone furoate vs fluticasone propionate with salmeterol: multivariate analysis of resource use and asthma-related charges

Objective:Although current National Asthma Education and Prevention Program (NAEPP) guidelines indicate low-dose inhaled corticosteroid (ICS) monotherapy as the preferred treatment for patients with mild persistent asthma, many patients receive ICS and long-acting β2-agonist (LABA) combinations. The objective of the current study was to evaluate asthma-related charges in patients with mild asthma who began treatment with mometasone furoate (MF) versus those who began treatment with a fluticasone propionate/salmeterol (FPS) combination.Research design and methods:This retrospective administrative claims database analysis collected data from the 365-day periods before (preindex period) and after (postindex period) the study index date from patients with mild asthma aged 12 to 65 years who began treatment with MF or FPS. Asthma-related inpatient, outpatient, pharmaceutical, and total charges; exacerbations; short-acting β2-agonist (SABA) canister claims; and adherence to therapy were assessed. Matched cohorts of MF and FPS patients were compared using multivariate generalized linear regression models.Results:Among matched MF (n = 4094) and FPS (n = 4094) cohorts, MF patients had significantly lower postindex asthma-related total charges ($2136 vs $2315, respectively; P = 0.0003), lower pharmaceutical charges ($727 vs $925, respectively; P < 0.0001), fewer exacerbations (0.14 vs 0.16, respectively; P = 0.0306), fewer SABA canister claims (0.9 vs 1.0, respectively; P < 0.0001), and greater adherence measured by prescription fills (3.0 vs 2.8, respectively; P < 0.0001). Asthma-related inpatient charges, outpatient charges, and adherence measured by percent of days covered were not significantly different between treatment cohorts. Limitations included a lack of additional ICS and ICS/LABA therapies, a lack of pediatric patients, and the general limitations associated with retrospective database analyses (e.g., no patient records).Conclusions:These data suggest that MF may be more cost-effective than FPS for the treatment of mild asthma. To effectively and efficiently manage asthma, it is important for clinicians to follow current NAEPP guidelines, which indicate ICS monotherapy as preferred treatment for mild persistent asthma.

Adherence to National Asthma Education and Prevention Program’s “How Asthma-Friendly Is Your School?” Recommendations

School health policies and programs provide the framework for a safe and supportive environment for students with asthma. School Health Policies and Programs Study 2006 data were examined to assess whether schools nationwide have policies and programs consistent with the "How Asthma-Friendly Is Your School?" checklist from the National Asthma Education and Prevention Program. Adherence to some of the recommendations on the checklist was high. For example, 80% or more of schools allowed students to carry and self-administer asthma medications, and obtained and kept asthma action plans. For other recommendations, however, far fewer schools had the recommended polices or programs; most notably, less than one third of schools had a full-time Registered Nurse. Improvements in many school policies and programs are needed so that students have a safe and supportive school environment to help them control their asthma while away from home.

The differential diagnosis and management of asthma in the preschool‐aged child

To discuss the diagnosis and management of asthma in preschool-aged children by nurse practitioners in primary care. Selected research and clinical articles; 2007 National Asthma Education and Prevention Program Guidelines for the Diagnosis and Management of Asthma. Proper diagnosis leads to appropriate treatment of asthma in preschool-aged children, which facilitates asthma control. Well-controlled asthma results in fewer asthma exacerbations, fewer nighttime awakenings, and an increased ability to engage in normal childhood activities. Advanced practice nurses are in the position to aid in the initial diagnosis of asthma in preschool-aged children through taking detailed medical histories, providing thorough physical examinations, and, if needed, initiating a therapeutic trial with an inhaled corticosteroid. Proper diagnosis and management of asthma is essential to reduce asthma complications, such as exacerbations leading to emergency department visits and hospitalizations.

Managing Asthma Exacerbations in the Emergency Department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 Guidelines for the Management of Asthma Exacerbations

This article summarizes the recommendations regarding the management of asthma exacerbations presented in the Expert Panel Report 3 (EPR3). The evidence supporting these recommendations can be found in the report itself. All of the recommendations in this article are strong recommendations, unless indicated by the term conditional. Asthma exacerbations consist of acute or subacute episodes of progressively worsening shortness of breath, coughing, wheezing, and chest tightness or any combination thereof. These episodes differ from poor asthma control in that diurnal variability in airflow, a key marker of poor asthma control, might not change during an exacerbation. An important advance in the new National Asthma Education and Prevention Program (NAEPP) EPR3 guidelines is the creation of a chapter devoted to the management of asthma exacerbations. Moreover, the new EPR3 guidelines present different spirometry cut points for assessing the severity of acute asthma (exacerbations) versus chronic asthma. These and other changes underscore the distinction between acute and chronic asthma management. Two patient populations at particular risk during an asthma exacerbation include patients with 1 or more risk factors for asthma-related death (Table I) and infants, who are at greater risk

Managing asthma in primary care: putting new guideline recommendations into context.

Many patients with asthma are treated in the primary care setting. The primary care physician is therefore in a key position to recognize poorly controlled asthma and to improve asthma management for these patients. However, current evidence continues to show that, for a substantial number of patients, asthma control is inadequate for a wide variety of reasons, both physician-related and patient-related. The most recently updated treatment guidelines from the National Asthma Education and Prevention Program were designed to help clinicians, including primary care physicians, manage asthma more effectively with an increased focus on achieving and maintaining good asthma control over time. The current review is intended to assist primary care physicians in improving asthma control among their patients; this review clarifies the new guidelines and provides a specialist's perspective on diagnosis, appropriate therapy, disease control surveillance, and appropriate referral when necessary. This discussion is based primarily on the new guidelines and the references cited therein, supplemented by the author's own clinical experience.