World Allergy Organization. Updated: July 2. 01.

Updated: December 2. Originally Posted: September 2. Updated by: Jennifer E.

Fergeson, D. O. Division of Allergy and Immunology,University of South Florida Morsani College of Medicine. James A. Haley Veterans' Hospital. Tampa, FL 3. 36. 12. Email: Jfergeso@health.

Richard F. Lockey, M. D. Distinguished University Health Professor.

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Professor of Medicine, Pediatrics and Public Health. Director, Division of Allergy and Immunology. Joy Mc. Cann Culverhouse Chair in Allergy and Immunology. University of South Florida Morsani College of Medicine. James A. Haley Veterans' Hospital.

Email: rlockey@health. Original Authors: Michael A. Kaliner, MD FAAAAIMedical Director, Institute for Asthma and Allergy. Chevy Chase and Wheaton, Maryland. Professor of Medicine, George Washington University School of Medicine. Washington, DC Richard F. Lockey, MDProfessor of Medicine, Pediatrics and Public Health.

Director of the Division of Allergy and Immunology. Joy Mc. Cann Culverhouse Chair of Allergy and Immunology. University of South Florida College of Medicine and the James A. Haley Veterans' Hospital. Tampa, FLIntroduction.

Asthma exacerbations are avoidable with appropriate, regular therapy and patient education. In contrast, poor asthma control typically presents with a diurnal variability in airflow and is a characteristic that is usually not seen during an acute exacerbation. Recognition of patients who are at a greater risk for near- fatal or fatal asthma. Education of the patient to recognize a deterioration in their disease.

Provision of an individual action plan for the patient to manage the exacerbation and to know when to seek professional help. Management of co- morbidities such as rhinitis, sinusitis, obesity, gastroesophageal reflux disease (GERD), obstructive sleep apnea (OSA), chronic obstructive respiratory disease (COPD), vocal cord dysfunction (VCD) and atopic dermatitis . Physical Examination. Clinical estimates of severity based on an interview and a physical examination can result in an inaccurate estimation of disease severity; audible wheezing is usually a sign of moderate asthma, whereas no wheezing can be a sign of severe airflow obstruction.

Symptoms of severe asthma include severe chest tightness, cough (with or without sputum), sensation of air hunger, inability to lie flat, insomnia and severe fatigue. Altered mental status, with or without cyanosis, is an ominous sign and immediate emergency care and hospitalization are required. A detailed examination should include examining for signs and symptoms of pneumonia, pneumothorax or a pneumomediastinum, the latter of which can be investigated by palpation for subcutaneous crepitations, particularly in the supraclavicular areas of the chest wall.

Special attention should be paid to the patient's blood pressure, pulse and respiratory rate . The patient interview should include questions about recent events including . The history should include a review of previous episodes of near- fatal asthma and whether the patient has experienced multiple emergency room visits or hospitalizations, particularly those requiring admission to an intensive care unit, involving respiratory failure, intubation and mechanical ventilation. A history of allergic asthma and other known or suspected allergic symptoms should be obtained.

Inadequate therapy may include excessive use of . Recent withdrawal of oral corticosteroids (OCS) suggests that the patient is at greater risk for a severe exacerbation. Limited access of the patient to appropriate health care and lack of education about appropriate management strategies are additional risk factors. Certain ethnic groups within a population may have a higher incidence of severe asthma . A peak expiratory flow (PEF) rate provides a simple, quick, and cost effective assessment of the severity of airflow obstruction.

While standing, the patient takes a deep breath to maximum inspiration, briefly holds the breath, and with lips sealed around a mouthpiece blows out as hard and fast as possible. The best of three recordings is logged as the PEF and compared to predicted normal values based on gender, age and height or to previous determinations. An individual management plan will be based upon the personal best PEF value, and pre- determined PEF values can be set at which time the patient is alerted to the degree of severity of symptoms and can institute appropriate therapy and/or consult their physician (Figure 2). PEF values of 5. 0- 7. SABA), PEF values below 5.

PEF values below 3. FEV1 is less variable than PEF and is independent of effort once a moderate effort has been made by the patient. While sitting, the patient is asked to forcibly exhale from the point of maximal inhalation into the spirometer, ideally over 6 seconds. Three determinations should be obtained, if possible, with the best being recorded, and severity of assessment is made by comparison to predicted normal values for the gender, height and age of the patient or to a previous value. If a complication is suspected, such as pneumonia, pneumothorax, pneumomediastinum, or atelectasis secondary to mucous plugging, a chest X- ray should be obtained .

Acute asthma severity: clinical signs and symptoms. A seasonal exacerbation of asthma in a pollen- sensitive patient is more easily treatable than an exacerbation triggered by a viral infection. Allergic asthma is more likely to respond immediately to inhaled .

A patient who is over- using short- acting . Physician knowledge of an individual patient will suggest whether a systemic corticosteroid is required or whether an exacerbation can be managed on very high doses of inhaled corticosteroids . Acute Asthma Management: Emergency Department and Hospital- Based Care. Initial treatment should begin with albuterol, either administered by MDI with a spacer device or mask (children < 4 years of age) or nebulizer. In children, albuterol by MDI is given at a dose of 9. At this time, there is no proven advantage of use of systemic therapy over aerosol treatment.

It provides competitive inhibition of acetylcholine at the muscarinic cholinergic receptor, thus relaxing smooth muscle in large central airways. It is not a first line therapy, but can be added in severe asthma particularly when albuterol is not optimally beneficial. It can be given with albuterol or levalbuterol and may be used for up to 3 hours in the initial management of acute asthma.

Administration via MDI (spacer and mask in children < 4 years of age) can be given at a dose of 1. However, oral corticosteroids (OCS) are the best medications available to reduce airway inflammation and should be used immediately and until the attack has abated as evidenced by the PEF and FEV1 returning to near baseline levels and the patient becoming asymptomatic . Current guidelines recommend at least quadrupling the recommended dose of ICS.

Inhaled therapy reduces the risk of unwanted effects associated with oral corticosteroid treatment, e. ICS are less likely to be effective in patients with upper respiratory tract infections exacerbating their asthma or those who are over- using . When an ICS is not utilized, a systemic glucocorticoid with instructions for its use should be prescribed as a back up treatment regimen and the patient and/or family should understand when to start it and also have immediate access to a physician and/or other healthcare professional until the asthma exacerbation is resolved .

Improvement may be seen between 5 to 1. It is not necessary to taper OCS after a course of less than three weeks, but after use for longer than 3 weeks, it is advisable to taper the medication over one to two weeks to decrease withdrawal side effects such as adrenal insufficiency, fatigue, myalgias and joint pain . The recommended dose for IV methylprednisolone is 1 to 2 mg/kg for 2.

Origins of 1. 0X – How Valid is the Underlying Research?- 1. Software Development. Posted on January 9, 2. PM by Steve Mc. Connell to 1. Software Development.

Methods & Processes, Testing & QA, Technique, Agile, estimation, requirements, productivity, Management, Design, Maintenance, 1. Articles, Books, Construction. I recently contributed a chapter to Making Software (Oram and Wilson, eds., O'Reilly, 2. The purpose of this edited collection of essays is to pull together research- based writing on software engineering.

In essence, the purpose is to say, . That critique was translated into English on a different website. The critique (or its English translation, anyway) is quite critical of the claim that programmer productivity varies by 1. The specific nature of the criticism gives me an opportunity to talk about the state of research in software development, my approach to writing about software development, and to revisit the 1. The State of Software Engineering Research. Bossavit's criticism of my writing is notable for the fact that it cites my work, comments on some of the citations that my work cites, but doesn't cite any other software- specific research of its own.

In marked contrast, while I was working on the early stages of Code Complete, 1st Ed., I read a paper by B. Sheil titled . 1, March 1. Sheil reviewed dozens of papers on programming issues with a specific eye toward the research methodologies used. The conclusion of Sheil's paper was sobering. The programming studies he reviewed failed to control for variables carefully enough to meet research standards that would be needed for publication in other more established fields like psychology.

The papers didn't achieve levels of statistical significance good enough for publication in other fields either. In other words, the research foundation for software engineering (circa 1. One of the biggest issues identified was that studies didn't control for differences in individual capabilities. Suppose you have a new methodology you believe increases productivity and quality by 5. If there are potential differences as large as 1.

See Figure 1. Figure 1. This is a very big deal because almost none of the research at the time I was working on Code Complete. For example, a study would have Programmer Group A read a sample of code formatted using Technique X and Programmer Group B read a sample of code formatted using Technique Y. If Group A was found to be 2. Group B, you don't really know whether it's because Technique X is better than Technique Y and is helping productivity, or whether it's because Group A started out being way more productive than Group B and Technique X actually hurt Group A's productivity.

Since Sheil's paper in 1. For example, in the early 2. Numerous claims were made for XP's effectiveness based on the productivity of that project. I personally never accepted the claims for the effectiveness of the XP methodology based on the C3 project because that project included rock star programmers Kent Beck, Martin Fowler, and Ron Jeffries, all working on the same project.

The productivity of any project those guys work on would be at the top end of the bar shown on the left of Figure 1. Those guys could do a project using batch mode processing and punch cards and still be more productive than 9.

Any methodological variations of 1x or 2x due to XP (or - 1x or - 2x) would be drowned out by the variation arising from C3's exceptional personnel. In other words, considering the exceptional talent on the C3 project, it was impossible to tell whether the C3 project's results were because of XP's practices or in spite of XP's practices. My Decision About How to Write Code Complete. Bringing this all back to Code Complete 1, I hit a point early in the writing of Code Complete 1 where I was aware of Sheil's research, aware of the limitations of many of the studies I was using, and trying to decide what kind of book I wanted to write. The first argument I had with myself was how much weight to put on all the studies I had read. I read about 6. 00 books and articles as background for Code Complete.

Was I going to discard them altogether? I decided, No. The studies might not be conclusive, but many of them were surely suggestive. The book was being written by me and ultimately reflected my judgment, so whether the studies were conclusive or suggestive, my role as author was the same- -separate the wheat from the chaff and present my personal conclusions.

Of the 6. 00 books and articles I read, only about half made it into the bibliography. Code Complete's bibliography includes only those 3. The second argument I had with myself was how much detail to provide about the studies I cited. The academic side of me argued that every time I cited a study I should explain the limitations of the study. The pragmatic side of me argued that Code Complete wasn't supposed to be an academic book; it was supposed to be a practical book. If I went into detail about every study I cited, the book would be 3x as long without adding any practical value for its readers.

In the end I felt that detailed citations and elaborate explanations of each study would detract from the main focus of the book. So I settled on a citation style in which I cited (Author, Year) keyed to fuller bibliographic citations in the bibliography. I figured readers who wanted more academic detail could follow up on the citations themselves.

A Deeper Dive Into the Research Supporting . That appears to have been the case with Laurent Bossavit's critique of my .

Let's follow the same path and fill in the blanks. Sackman, Erickson, and Grant, 1. Here is my summary of the first research to find 1. Detailed examination of Sackman, Erickson, and Grant's findings shows some flaws in their methodology (including combining results from programmers working in low level programming languages with those working in high level programming languages). However, even after accounting for the flaws, their data still shows more than a 1. In years since the original study, the general finding that .

Card 1. 98. 7, Boehm and Papaccio 1. Valett and Mc. Garry 1. Boehm et al 2. 00. The research on variations among individual programmers began with Sackman, Erickson, and Grant's study published in 1. Bossavit states that the 1.

As I stated in my blog article, the ratio of initial coding time between the best and worst programmers was about 2. The difference in program sizes was about 5: 1. The difference in debugging was the most dramatic difference, at about 2.

Differences found in coding time, debugging time, and program size all support a general claim of . The purpose of their research was to determine whether programming online offered any real productivity advantage compared to programming offline. What they discovered, to their surprise, was that, ala Figure 1, any difference in online vs. The factor they set out to study would be irrelevant today. The conclusion they stumbled onto by accident is one that we're still talking about. Curtis 1. 98. 1. Bossavit criticizes my (Curtis 1. The 1. 98. 1 Curtis study included 6.

I do not know why he thinks this statement is a criticism of the Curtis study. In my corner of the world debugging is not the only programming task, but it certainly is an essential programming task, and everyone knows that. The Curtis article concludes that, . Moving to the next citation, Bossavit states that, . Bossavit says the paper . The specific numbers cited are 2.

Clearly that again offers direct support for the 1. Mills 1. 98. 3. As Bossavit points out, the Mills book contains . Red Faction Guerrilla Crack Pc Background more. Apparently Bossavit doesn't consider an .

Bossavit misreads my citation of De. Marco and Lister 1.

Peopleware. That is a natural assumption, but as I stated clearly in the article's bibliography, the reference was to their paper titled, . Their 1. 98. 5 study had some of the methodological limitations Sheil's discussed in 1. Having said that, their study supports the 1. De. Marco and Lister reported results from 1.