NPJ Primary Care Respiratory Medicine最新文献

Over 1400 patients using dry powder inhalers (DPIs) to deliver COPD maintenance therapies were recruited across Europe and Australia. Their peak inspiratory flow (PIF) was measured, inhaler technique was observed, and adherence to treatment assessed. From relating the findings with patient health status, and thereby identifying critical errors, key clinical recommendations for primary care clinicians were determined, namely - measure PIF before prescribing a DPI to ensure inhalation manoeuvre ability is well-matched with the device. Some patients could benefit from inhalation training whereas others should have their DPI changed for one better suited to their inspiratory ability or alternatively be prescribed an active device (such as a soft mist inhaler or pressurized metered dose inhaler). Observing the inhalation technique was valuable however this misses suboptimal PIF (approaching one fourth of patients with a satisfactory observed manoeuvre had a suboptimal PIF for their DPI). Assess adherence as deliberate non-adherence can point to a mismatch between a patient and their inhaler (deliberate non-adherence was significantly associated with PIFs below the minimum for the DPI). In-person observation of inhalation technique was found to be inferior to video rating based on device-specific checklists. Where video assessments are not possible, observation training for healthcare professionals would therefore be valuable particularly to improve the ability to identify the critical errors associated with health status namely 'teeth and lips sealed around mouthpiece', 'breathe in' and 'breathing out calmly after inhalation'. However, it is recommended that observation alone should not replace PIF measurement in the DPI selection process.Trial registration: https://clinicaltrials.gov/ct2/show/NCT04532853 .

The Netherlands has moved towards the forefront of tobacco control in Europe, after having implemented important tobacco control measures in 2020 and 2021, which included higher tobacco taxation, plain packaging of tobacco products, a partial point of sale tobacco display ban, smoking ban on school grounds, and other smoking restrictions. We examined the factors contributing to these successes, focussing on the network of tobacco control advocacy organisations and the process of agenda-setting. Crucial determining factors were stricter adherence to Article 5.3 FCTC, which prevents government to consult tobacco industry, and the genesis of a 'Smoke-free Generation' movement in the wider society, initiated by the three main national charities (Lung Foundation Netherlands, Dutch Heart Foundation, Dutch Cancer Society). The Smoke-free Generation concept proved to be a highly attractive unifying strategy for national en local policy makers and Dutch society. As a result, the Dutch government was able to start a process of strengthening tobacco control policy through drafting and implementing a National Prevention Agreement, which aims at a tobacco control endgame goal of less than 5% smokers in 2040. Between 2019 and 2020 smoking rates dropped from 21.7% to 20.2%. The Dutch experience can provide inspiration for countries where tobacco control is still lagging behind. It also illustrates that continued vigilance is needed, since the most recent government change was associated with a hampering of further reduction of the proportion of smokers and a temporary drop in attention to tobacco control from the central government.

Electronic monitoring devices (EMDs) have been trialled in interventions to improve inhaled corticosteroid adherence and clinical outcomes. This study sought to understand the perceptions and experiences of EMD end-users. Participants recruited into a six-month EMD study were invited to a semi-structured interview. Interviews were audio-recorded, transcribed verbatim and analysed using the framework approach. Twenty-eight participants (68% female, median age 47) were interviewed. Individuals described feeling responsible for their asthma control. Recent attacks motivated a desire to maintain control. Study participation led to increased awareness of asthma status and medication use. Several individuals were open to integrating digital monitoring data with other mHealth inputs, perceiving the potential to enhance communication with clinicians and empower self-management. Openness to data sharing was tied to expectations of transparent data use. Data supported integrating beliefs and habit formation to achieve behaviour change. There was a willingness for an integrated, platform-based approach to digital self-management.

Sex (whether one is 'male' or 'female', based on biological characteristics) and gender (defined by socially constructed roles and behaviors) influence asthma diagnosis and management. For example, women generally report more severe asthma symptoms than men; men and women are exposed to different asthma-causing triggers; men tend to be more physically active than women. Furthermore, implicit, often unintended gender bias by healthcare professionals (HCPs) is widespread, and may result in delayed asthma diagnosis, which can be greater in women than men. The sex and gender of the HCP can also impact asthma management. Pregnancy, menstruation, and menopause can all affect asthma in several ways and may be associated with poor asthma control. This review provides guidance for considering sex- and gender-associated impacts on asthma diagnosis and management and offers possible approaches to support HCPs in providing personalized asthma care for all patients, regardless of their sex or gender.

In Brazil, prevalence of diagnosed COPD among adults aged 40 years and over is 16% although over 70% of cases remain undiagnosed. Hypertension is common and well-recorded in primary care, and frequently co-exists with COPD because of common causes such as tobacco smoking, therefore we conducted a cross-sectional screening test accuracy study in nine Basic Health Units in Brazil, among hypertensive patients aged ≥40 years to identify the optimum screening test/combinations to detect undiagnosed COPD. We compared six index tests (four screening questionnaires, microspirometer and peak flow) against the reference test defined as those below the lower limit of normal (LLN-GLI) on quality diagnostic spirometry, with confirmed COPD at clinical review. Of 1162 participants, 6.8% (n = 79) had clinically confirmed COPD. Peak flow had a higher specificity but lower sensitivity than microspirometry (sensitivity 44.3% [95% CI 33.1, 55.9], specificity 95.5% [95% CI 94.1, 96.6]). SBQ performed well compared to the other questionnaires (sensitivity 75.9% [95% CI 65.0, 84.9], specificity 59.2% [95% CI 56.2, 62.1]). A strategy requiring both SBQ and peak flow to be positive yielded sensitivity of 39.2% (95% CI 28.4, 50.9) and specificity of 97.0% (95% CI 95.7, 97.9). The use of simple screening tests was feasible within the Brazilian primary care setting. The combination of SBQ and peak flow appeared most efficient, when considering performance of the test, cost and ease of use (costing £1690 (5554 R$) with 26.7 cases detected per 1,000 patients). However, the choice of screening tests depends on the clinical setting and availability of resources.ISRCTN registration number: 11377960.

Due to climate change, air temperature in the Netherlands has gradually increased. Higher temperatures lead to longer pollen seasons. Possible relations between air temperature and increased impact of seasonal allergic rhinitis (SAR) in general practice have not been investigated yet. We explored trends in timing of frequent seasonal allergic rhinitis presentation to general practitioners (GPs) over 25 years and explored associations with air temperature. We performed a retrospective exploratory longitudinal study with data from our Family Medicine Network (1995-2019), including all SAR patients and their GP-encounters per week. We determined patients' GP-consultation frequency. Every year we identified seasonal periods with substantial increase in SAR related encounters: peak-periods. We determined start date and duration of the peak-period and assessed associations with air temperature in the beginning and throughout the year, respectively. The peak-period duration increased by a mean of 1.3 days (95% CI 0.23-2.45, P = 0.02) per year throughout the study period. Air temperature between February and July showed a statistically significant association with peak-period duration. We could not observe direct effects of warmer years on the start of peak-periods within distinct years (P = 0.06). SAR patients' contact frequency slightly increased by 0.01 contacts per year (95% CI 0.002-0.017, P = 0.015). These longitudinal findings may help to facilitate further research on the impact of climate change, and raise awareness of the tangible impact of climate change in general practice.

Uptake and outcomes of pharmacist-initiated general practitioner (GP) referrals for patients with poorly controlled asthma were investigated. Pharmacists referred at-risk patients for GP assessment. Patients were categorized as action takers (consulted their GP on pharmacist's advice) or action avoiders (did not action the referral). Patient clinical data were compared to explore predictors of uptake and association with health outcomes. In total, 58% of patients (n = 148) received a GP referral, of whom 78% (n = 115) were action takers, and 44% (n = 50) reported changes to their asthma therapy. Patient rurality and more frequent pre-trial GP visits were associated with action takers. Action takers were more likely to have an asthma action plan (P = 0.001) at month 12, and had significantly more GP visits during the trial period (P = 0.034). Patient uptake of pharmacist-initiated GP referrals was high and led to GP review and therapy changes in patients with poorly controlled asthma.

There is increasing evidence that sex hormones may impact the development of obstructive lung disease (OLD). Therefore, we studied the effect of bilateral oophorectomy (oophorectomy) on the development of OLD. Women were identified from the Mayo Clinic Cohort Study of Oophorectomy and Aging-2. Data were collected using the Rochester Epidemiology Project records-linkage system. A total of 1653 women who underwent oophorectomy and 1653 referent women of similar age were assessed for OLD using diagnostic codes and medical record abstraction. Women who underwent oophorectomy had an overall higher risk of all OLD, all chronic obstructive pulmonary disease (COPD), emphysema, and chronic bronchitis but not of all asthma, confirmed asthma, or confirmed COPD. The association with all OLD was stronger in women who were age ≤45 years at oophorectomy, never smokers, non-obese, and in women with benign indications; however, the interactions were not statistically significant. There was an increased risk of all asthma in women age ≤45 years at oophorectomy who took estrogen therapy. Never smokers of all ages had a stronger association of oophorectomy with all asthma and all COPD, whereas smokers had a stronger association of oophorectomy with emphysema and chronic bronchitis. Non-obese women of all ages had a stronger association of oophorectomy with all COPD, emphysema, and chronic bronchitis. The results of this study combined with the increased risk of several chronic diseases reported in previous studies suggest that oophorectomy in premenopausal women should be avoided unless there is clear evidence of a high genetic risk of ovarian cancer.

Supporting self-management is key in improving disease control, with technology increasingly utilised. We hypothesised the addition of telehealth support following assessment in an integrated respiratory clinic could reduce unscheduled healthcare visits in patients with asthma and COPD. Following treatment optimisation, exacerbation-prone participants or those with difficulty in self-management were offered telehealth support. This comprised automated twice-weekly telephone calls, with a specialist nurse triaging alerts. We performed a matched cohort study assessing additional benefits of the telehealth service, matching by: confirmed diagnosis, age, sex, FEV₁ percent predicted, smoking status and ≥1 exacerbation in the last year. Thirty-four telehealth participants were matched to twenty-nine control participants. The telehealth cohort generated 165 alerts, with 29 participants raising at least one alert; 88 (53.5%) alerts received a call discussing self-management, of which 35 (21%) received definitive advice that may otherwise have required an unscheduled healthcare visit. There was a greater reduction in median exacerbation rate across both telehealth groups at 6 months post-intervention (1 to 0, p < 0.001) but not in control groups (0.5 to 0.0, p = 0.121). Similarly, there was a significant reduction in unscheduled GP visits across the telehealth groups (1.5 to 0.0, p < 0.001), but not the control groups (0.5 to 0.0, p = 0.115). These reductions led to cost-savings across all groups, but greater in the telehealth cohorts. The addition of telehealth support to exacerbation-prone patients with asthma or COPD, following comprehensive assessment and treatment optimisation, proved beneficial in reducing exacerbation frequency and unscheduled healthcare visits and thus leads to significant cost-savings for the NHS.Clinical Trial Registration: ClinicalTrials.gov: NCT03096509.

We explored past-year quit attempts, cessation methods used, and associations with sociodemographic, smoking, and health-related characteristics among smoking patients with chronic obstructive pulmonary disease (COPD) in Germany. Cross-sectional survey data of 509 past-year smokers (current smokers and ≤12 months abstinent) with COPD (ICD-10 code J44.x and FEV1/FVC <0.70) from 19 pulmonary primary care practices were used. Associations were explored between age, sex, educational qualification, lung function, urges to smoke, psychological distress, and (a) ≥1 past-year quit attempt (yes/no), (b) use of ≥1 evidence-based smoking cessation method (yes/no). Of all patients, 48.5% (n = 247, 95% confidence interval (CI) 44.2-52.9) reported ≥1 past-year quit attempt. Such an attempt was positively associated with the male sex (Odds Ratio (OR) = 1.50, 95% CI 1.01-2.24) and negatively associated with time spent with urges to smoke (OR = 0.69, 95% CI 0.52-0.91). During the most recent past-year quit attempt, one-third of the patients used ≥1 evidence-based smoking cessation method (31.2%, 95% CI 25.4-37.0), which was positively associated with the strength of urges to smoke (OR = 1.62, 95% CI 1.09-2.41). Combined behavioural and pharmacological treatments were used by 4.0% (n = 10, 95% CI 1.6-6.5). Electronic cigarettes were used most frequently (21.5%, 95% CI 16.3-26.6). Although a high proportion of COPD patients in German pulmonary primary care attempt to quit smoking, only a few of them use evidence-based methods as assistance for quitting.