NPJ Primary Care Respiratory Medicine最新文献

Asthma, a common chronic respiratory illness is mostly managed in primary care. We aimed to determine healthcare resources, organisational support, and doctors' practice in managing asthma in a Malaysian primary care setting. A total of six public health clinics participated. We found four clinics had dedicated asthma services. There was only one clinic which had a tracing defaulter system. Long-term controller medications were available in all clinics, but not adequately provided. Resources, educational materials, and equipment for asthma management were present, though restricted in number and not placed in main locations of the clinic. To diagnose asthma, most doctors used clinical judgement and peak flow metre measurements with reversibility test. Although spirometry is recommended to diagnose asthma, it was less practiced, being inaccessible and unskilled in using as the main reasons. Most doctors reported providing asthma self-management; asthma action plan, but for only half of the patients that they encountered. In conclusion, there is still room for improvement in the provision of clinic resources and support for asthma care. Utilising peak flow metre measurement and reversibility test suggest practical alternative in low resource for spirometry. Reinforcing education on asthma action plan is vital to ensure optimal asthma care.

Poor adherence to asthma preventer medication is associated with life-threatening asthma attacks. The quality and outcomes framework mandated primary care annual asthma review does not include adherence monitoring and the effect of poor adherence on lung function in paediatric primary care patients is unknown. The aim was to investigate the link between inhaled corticosteroid (ICS) adherence and spirometry, fraction of exhaled nitric oxide (FeNO) and asthma control in asthmatic school-age children in this cross-sectional observational study involving three Leicestershire general practices. Children 5-16 years on the practice's asthma registers, were invited for a routine annual asthma review between August 2018 and August 2019. Prescription and clinical data were extracted from practice databases. Spirometry, bronchodilator reversibility (BDR) and FeNO testing were performed as part of the review. 130 of 205 eligible children (63.4%) attended their review. Mean adherence to ICS was 36.2% (SEM 2.1%) and only 14.6% of children had good adherence (≥75% prescriptions issued). We found no differences in asthma exacerbations in the preceding 12 months between the adherence quartiles. 28.6% of children in the lowest and 5.6% in the highest adherence quartile had BDR ≥ 12% but this was not statistically significant (p = 0.55). A single high FeNO value did not predict adherence to ICS. Adherence to ICS in children with asthma in primary care is poor. The link between adherence to ICS and asthma exacerbations, spirometry and FeNO is complex but knowledge of adherence to ICS is critical in the management of children with asthma.

Assessing changes in functional exercise capacity is highly relevant in the treatment of people with Chronic Obstructive Pulmonary Disease (COPD), as lung function is often static. In Denmark, most people with COPD are followed in general practice where traditional functional tests, like six-minute walk test, require too much time and space. Therefore, there is an urgent need for a quick functional exercise capacity test that can be performed in a limited setting, such as general practice. This study aimed to identify a quick test to measure functional exercise capacity in people with COPD and identify which factors could affect the implementation of such a test in general practice. A mixed method feasibility study composed of a literature review and qualitative interviews was used. Quick functional tests for people with COPD were identified and evaluated through the COSMIN methodology. For the interviews, 64 general practices were included, and 50 staff members and 14 general practitioners (GPs) participated in the interviews. Responses were categorized and thematically analyzed. The 1 min sit-to-stand-test (1 M STST) was found suitable for a general practice setting. The COSMIN methodology rated it "sufficient" in reliability (ICC 0.90-0.99), measurement error (MID 2.5-3), construct validity and responsiveness (AUC 0.72), and found a moderate to strong correlation in criterion validity (r = 0.4-0.75). Several GPs wished for a quick functional test and emphasized evidence, information, and limitations as essential when deciding on implementation. Other factors identified included time, other tests, and economy. 1 M STST is a valid test to assess functional exercise capacity in people with COPD. The test is quick and can easily be performed in a standard consultation, and several GPs wished for such a test.

Asthma is closely associated with inflammation. We evaluated the predictive and prognostic value of leptin status in asthma. We searched the electronic databases for articles that determined the leptin level in asthma cases through May 2020. We compared the differences of leptin level between asthma and non-asthma controls, as well as between severe and mild asthma cases. We also investigated the impact of age and gender on these differences by using meta-regression analysis. 59 studies were included in our pooled analysis. Asthma cases demonstrated significantly higher leptin level than that in non-asthma controls among overall populations (SMD:1.061, 95% CI: 0.784-1.338, p < 10^-4), Caucasians (SMD:0.287, 95% CI: 0.125-0.448, p = 0.001), Asians (SMD:1.500, 95% CI: 1.064-1.936, p < 10^-4) and Africans (SMD: 8.386, 95% CI: 6.519-10.253, p < 10^-4). Severe asthma cases showed markedly higher leptin level than that in mild asthma cases among overall populations (SMD:1.638, 95% CI: 0.952-2.323, p < 10^-4) and Asians (SMD:2.600, 95% CI: 1.854-3.345, p < 10^-4). No significant difference of leptin level between severe and mild asthma was observed in Caucasians (SMD:-0.819, 95% CI: -1.998-0.360, p = 0.173). Cumulative analyses yielded similar results regarding the difference of leptin status between asthma and non-asthma controls, as well as between severe and mild asthma cases among overall populations. Age and male/ female ratio were not associated with the difference of leptin status between asthma and non-asthma controls (coefficient:-0.031, 95% CI: -0.123-0.061, p = 0.495; coefficient:0.172, 95% CI: -2.445-2.789, p = 0.895), as well as between severe and mild asthma cases among overall populations (coefficient:-0.072, 95% CI: -0.208-0.063, p = 0.279; coefficient: 2.373, 95% CI: -0.414-5.161, p = 0.090). Asthma demonstrated significantly higher level of leptin than that in non-asthma controls among overall populations, Caucasians, Asians and Africans. Severe asthma cases showed markedly higher leptin level than that in mild cases among overall populations and Asians. Leptin may be a risk predictor and prognostic marker of asthma. Early monitoring and intervention of leptin may be needed for asthma.

An algorithm to describe patterns of intermittent oral corticosteroid use in the UK (n = 476,167) found that one-third of patients receiving intermittent oral corticosteroids for asthma only had short gaps (<90 days) between oral corticosteroid prescriptions sometime during follow-up. The increasing frequency pattern was more likely in patients with greater asthma severity and with more short-acting β₂-agonist use at baseline. Our approach may provide a clinically relevant representation of intermittent oral corticosteroid use in asthma.

Heated tobacco products have a rapid uptake, especially among young people, mostly where advertising is unregulated, as is the case in Romania. This qualitative study explores the influence of direct marketing methods of heated tobacco products on young people, their perception and behaviour towards smoking. We have carried out 19 interviews with smokers of heated tobacco products (HTPs) or/and combustible cigarettes (CCs) or non-smokers (NS), aged 18-26. Using the thematic analysis, we have identified three overarching themes: (1) people, places, and subjects of marketing, (2) engagement with risk narratives and (3) social body, family bonds, and autonomous self. Even if most of the participants have been exposed to a mix of marketing methods, they did not acknowledge the influence that marketing has on their decision to experience smoking. Young adults' decision to use heated tobacco products seems to be influenced by a cluster of reasons: overcoming the legislation gap which prohibits indoor use of combustible cigarettes but not heated tobacco products; the attractivity of the product (novelty, inviting appearance, technological appeal and price) and presumed less damaging effects on health.

The Global Initiative for Asthma (GINA) was established in 1993 by the World Health Organization and the US National Heart Lung and Blood Institute to improve asthma awareness, prevention and management worldwide. GINA develops and publishes evidence-based, annually updated resources for clinicians. GINA guidance is adopted by national asthma guidelines in many countries, adapted to fit local healthcare systems, practices, and resource availability. GINA is independent of industry, funded by the sale and licensing of its materials. This review summarizes key practical guidance for primary care from the 2022 GINA strategy report. It provides guidance on confirming the diagnosis of asthma using spirometry or peak expiratory flow. GINA recommends that all adults, adolescents and most children with asthma should receive inhaled corticosteroid (ICS)-containing therapy to reduce the risk of severe exacerbations, either taken regularly, or (for adults and adolescents with "mild" asthma) as combination ICS-formoterol taken as needed for symptom relief. For patients with moderate-severe asthma, the preferred regimen is maintenance-and-reliever therapy (MART) with ICS-formoterol. Asthma treatment is not "one size fits all"; GINA recommends individualized assessment, adjustment, and review of treatment. As many patients with difficult-to-treat or severe asthma are not referred early for specialist review, we provide updated guidance for primary care on diagnosis, further investigation, optimization and treatment of severe asthma across secondary and tertiary care. While the GINA strategy has global relevance, we recognize that there are special considerations for its adoption in low- and middle-income countries, particularly the current poor access to inhaled medications.

Greater Manchester has a greater prevalence and worse asthma outcomes than the national average. This study aims to evaluate a digital approach to primary care asthma management and in particular the initial impact of implementing Clinical Decision Support System software in the form of a computer-guided consultation (CGC) in the setting of primary care asthma reviews in deprived areas of Greater Manchester. The CGC (LungHealth Ltd) is an intelligent decision support system ensuring accurate guideline-based staging of asthma and assessment of asthma control with the software subsequently prompting guideline-standard management. Patients on asthma registers in Greater Manchester Primary Care Networks were identified and underwent remote review by nursing staff using the CGC linked directly to the GP clinical system. Three-hundred thirty-eight patients (mean age 59 (SD 17) years; 60% Female) were reviewed. The CGC reported the patient's asthma control to be "Good" in 22%, "Partial" in 6% and "Poor" in 72%. ACT scores were significantly higher in those patients exhibiting "Good" and "Partial" control when compared to those with "Poor" control. The number of steroid courses and hospital admissions in the previous 12 months was significantly lower in those patients exhibiting "Good" and "Partial" control when compared to those with "Poor" control. Nineteen percent were found not to have a personalised asthma management plan during CGC review, which was alerted by the CGC and subsequently, all but 3 patients had this created on review completion (McNemar's test; p < 0.001). 5% were found not to have been prescribed regular inhaled steroid therapy resulting in the operator being alerted by the CGC in all cases. Overall, 44% underwent alteration in asthma therapy following the CGC review with 82% of these representing treatment escalation. An end-to-end digital service solution is feasible for Asthma within primary care and the utilisation of a CGC when conducting primary care asthma reviews increases implementation of guideline-level management thus addressing healthcare inequality while enabling identification of "high risk" asthma patients and guiding appropriate therapy escalation and de-escalation.

All inhalers have an environmental impact; the majority are not recycled, with many disposed of inappropriately through domestic waste. To assess the feasibility of a method for recovering and recycling inhalers, Chiesi Limited (Chiesi) set up and funded 'Take AIR (Action for Inhaler Recycling)', a 12-month pilot postal scheme facilitated by community pharmacies across Leicester, Leicestershire, and Rutland, and hospitals in Leicestershire. All inhalers were accepted in the scheme. The recovered pressurised metered-dose inhalers (pMDIs) were dismantled and component parts recycled where possible; the remaining propellant gas was extracted for reuse in refrigeration and air conditioning industries. Other inhaler types were incinerated in an 'energy-from-waste' facility. From February 2021 to February 2022, 20,049 inhalers were returned; most (77%) were pMDIs. So far, Take AIR has saved the equivalent of an estimated 119.3 tonnes of carbon dioxide emissions from entering the atmosphere. Our experience demonstrates the feasibility and effectiveness of a postal inhaler recovery and recycling scheme, which could be used as a foundation to build future initiatives.

The Extended Salford Lung Study (Ext-SLS) is an extension of the Salford Lung Studies (SLS) in asthma and chronic obstructive pulmonary disease (COPD) through retrospective and prospective collection of patient-level electronic health record (EHR) data. We compared the Ext-SLS cohort with the SLS intention-to-treat populations using descriptive analyses to determine if the strengths (e.g. randomization) of the clinical trial were maintained in the new cohort. Historical and patient-reported outcome data were captured from asthma-/COPD-specific questionnaires (e.g., Asthma Control Test [ACT]/COPD Assessment Test [CAT]). The Ext-SLS included 1147 participants (n = 798, SLS asthma; n = 349, SLS COPD). Of participants answering the ACT, 39% scored <20, suggesting poorly controlled asthma. For COPD, 61% of participants answering the CAT scored ≥21, demonstrating a high disease burden. Demographic/clinical characteristics of the cohorts were similar at SLS baseline. EHR data provided a long-term view of participants' disease, and questionnaires provided information not typically captured. The Ext-SLS cohort is a valuable resource for respiratory research, and ongoing prospective data collection will add further value and ensure the Ext-SLS is an important source of patient-level information on obstructive airways disease.