NPJ Primary Care Respiratory Medicine最新文献

The asthma diagnosis jigsaw puzzle is a clinical practice and teaching concept conceived in clinical practice and refined through an expert multidisciplinary consensus process by academics and clinicians with an interest in primary respiratory care. The concept incorporates guidance to facilitate the effective diagnosis of adults or children with asthma in primary care where misdiagnosis is common. The jigsaw puzzle metaphor teaches a problem-solving approach to diagnosis, introducing the concept of diagnosis over time and in no particular sequence. Puzzle pieces can be collected from the domains of presentation, history, symptoms and physical examination, as well as objective tests. The clinician's challenge is to complete the diagnostic jigsaw puzzle testing the likelihood of a picture which can be recognised as asthma. This approach aligns with symptom-based pattern-recognition approaches taught to primary care clinicians which gets easier and more reliable with experience. Relational continuity, or informational continuity through the patient record, is integral to the process of puzzle completion. Where non-fitting puzzle pieces are encountered, alternative or additional diagnoses should be considered and/or referral to secondary care pursued. As a metaphor, 'puzzle completion' may be used within clinical communication encounters, addressing the importance of partnership working ('completing the puzzle together'), uncertainty (deciding 'which pieces fit') and changes in symptoms over time (enabling the 'puzzle picture to become clearer'). Adaptation of this teaching concept has started through translation of educational resources, including puzzle pieces. Supporting case vignettes developed locally will contextualise the jigsaw puzzle teaching concept. The Asthma Diagnosis Jigsaw Puzzle teaching concept has been piloted in North Macedonia and is also developed for educational workshops by primary care health educators in Malaysia, India and Uganda.

Breathlessness is highly prevalent in low and middle-income countries (LMICs). Low-cost, non-drug, breathlessness self-management interventions are effective in high-income countries. However, health beliefs influence acceptability and have not been explored in LMIC settings. Review with stakeholder engagement to co-develop explanatory programme theories for whom, if, and how breathlessness self-management might work in community settings in India. Iterative and systematic searches identified peer-reviewed articles, policy and media, and expert-identified sources. Data were extracted in terms of contribution to theory (high, medium, low), and theories developed with stakeholder groups (doctors, nurses and allied professionals, people with lived experiences, lay health workers) and an International Steering Group (RAMESES guidelines (PROSPERO42022375768)). One hundred and four data sources and 11 stakeholder workshops produced 8 initial programme theories and 3 consolidated programme theories. (1) Context: breathlessness is common due to illness, environment, and lifestyle. Cultural beliefs shape misunderstandings about breathlessness; hereditary, part of aging, linked to asthma. It is stigmatised and poorly understood as a treatable issue. People often use rest, incense, or tea, while avoiding physical activity due to fear of worsening breathlessness. Trusted voices, such as healthcare workers and community members, can help address misconceptions with clear, simple messages. (2) Breathlessness intervention applicability: nonpharmacological interventions can work across different contexts when they address unhelpful beliefs and behaviours. Introducing concepts like "too much rest leads to deconditioning" aligns with cultural norms while promoting beneficial behavioural changes, such as gradual physical activity. Acknowledging breathlessness as a medical issue is key to improving patient and family well-being. (3) Implementation: community-based healthcare workers are trusted but need simple, low-cost resources/skills integrated into existing training. Education should focus on managing acute episodes and daily breathlessness, reducing fear, and encouraging behavioural change. Evidence-based tools are vital to gain support from policymakers and expand implementation. Breathlessness management in India must integrate symptom management alongside public health and disease treatment strategies. Self-management interventions can be implemented in an LMIC setting. However, our novel methods indicate that understanding the context for implementation is essential so that unhelpful health beliefs can be addressed at the point of intervention delivery.

This study evaluates the impact of using a Clinical Decision Support System software in the form of a computer-guided consultation (CGC) when conducting Chronic Obstructive Pulmonary Disease (COPD) reviews in primary care. 5221 patients on the COPD register underwent CGC review with 21.1% found not to have COPD. Previously unrecognised cardiac disease was highlighted by the CGC in 7% of confirmed COPD cases. CGC review resulted in the number of patients possessing a self-management plan rising from 62-85%. 13% were found to have sub-optimal inhaler technique during CGC review with the CGC prompting correction in all cases. Only 26% of patients identified by the CGC as appropriate for Pulmonary Rehabilitation (PR) referral had previously attended a PR program. The integration of technology in the form of clinical decision support system software results in greater implementation of guideline-level care representing a scalable solution when performing COPD reviews.

Management of long-term conditions is a significant challenge in contemporary health care as people often require support for both physical and psychological symptoms. Assessing the competence of healthcare professionals delivering psychologically informed interventions informs decisions about future implementation. This is a comprehensive intervention fidelity assessment nested within a randomised controlled trial. We developed a bespoke intervention fidelity assessment framework to assess the competence of primary care respiratory nurses, physiotherapists and occupational therapists delivering a cognitive behavioural intervention for people with COPD. A total of 180 (representing 15% of trial cases) intervention audio files, from 36 intervention arm participants, were coded. The intervention was delivered with acceptable adherence for most components. Therapeutic competency was achieved and comparable with previous research studies. Interpersonal skills and focus had higher competency whilst guided discovery and application of appropriate change techniques was lower but still adequate. Skills improved over time and with an increased number of clients. With proper training and supervision, primary care respiratory nurses, physiotherapists and occupational therapists can deliver cognitive behavioural interventions with acceptable therapeutic competency but questioning and change techniques may need particular focus in training and greater practice.

Inhaled corticosteroids (ICS) plus long-acting β₂-agonists (LABA) are recommended for maintenance-only or maintenance and reliever therapy (MART) in patients with asthma. However, real-world data on ICS/LABA as maintenance-only or MART are limited. This study characterized clinical, economic, and humanistic burdens of asthma in Canada, China, Europe, Japan, and the US, using data collected from patients and physicians via a cross-sectional survey (Asthma Disease Specific Programme). Patients were ≥18 years of age with physician-confirmed asthma and receiving fixed-dose ICS/LABA for ≥3 months. Mean physician-reported symptom-free days over the past 30 days ranged from 10.1-20.6 days, and 31.5-34.6% of ICS/LABA users self-reported not well-controlled asthma. SABA co-prescription was reported in 8.8-67.8% of patients. These findings highlight the continued disease burden among ICS/LABA users, with the high level of SABA co-prescription indicating potentially inappropriate prescribing of ICS/LABA as MART or detrimental reliance on SABA medication in addition to MART.

We performed a retrospective cohort analysis comparing trends in low global warming potential (GWP) inhaler prescribing in primary care in England, Scotland, Wales and Northern Ireland between 2018 and 2024 using national prescribing data. There was little change in England, a reduction from 36.6-31.0% in Scotland, a reduction from 36.7-33.2% in Northern Ireland, and an increase from 30.8-41.1% in Wales. Only in Wales was there a simultaneous reduction in high GWP inhalers and an increase in low GWP inhalers. Over the time period of the study there has been a saving of 20,303 tonnes of carbon dioxide equivalent in Wales.

The coronavirus disease 2019 (COVID-19) epidemic has brought major challenges to the global health system, and influenza is also a problem that cannot be ignored. We aimed to explore and compare the clinical characteristics of COVID-19 and influenza to deepen the understanding of these two diseases and provide some guidance for clinicians to make differential diagnoses. We searched PubMed, Embase and Web of Science for articles and performed a meta-analysis using Stata 14.0 with a random-effects model. This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. One hundred articles involving 226,913 COVID-19 patients and 201,617 influenza patients were included, and all the articles included patients with these two diseases as experimental and control groups. Compared to influenza, COVID-19 was more common among men (OR = 1.46, 95% CI: 1.23-1.74) and people with a higher body mass index (MD = 1.43, 95% CI: 1.09-1.77). The proportion of current smokers among COVID-19 patients was lower than that among influenza patients (OR = 0.25, 95% CI: 0.18-0.33). Patients with COVID-19 had longer stays in the hospital (MD = 3.20, 95% CI: 2.58-3.82) and ICU (MD = 3.10, 95% CI: 1.44-4.76), required mechanical ventilation more frequently (OR = 2.30, 95% CI: 1.77-3.00), and had higher mortality (OR = 2.22, 95% CI: 1.93-2.55). We also found significant differences in some blood parameters between the two groups of patients. Upper respiratory symptoms were more obvious in influenza patients, and the proportion of comorbidities was higher than that among COVID-19 patients. There are some differences in the major characteristics, symptoms, laboratory findings and comorbidities between COVID-19 patients and influenza patients. COVID-19 patients often require more medical resources and have worse clinical outcomes.

Evidence relating to peer support and community-based psychological and social (psychosocial) interventions to reduce stigma and depression among people with tuberculosis (TB) and their households is limited. This study aimed to engage with multisectoral stakeholders in Indonesia to co-develop a peer-led, community-based psychosocial intervention that is replicable, acceptable, and sustainable. We used a participatory action design and engaged key national, multisectoral stakeholders to ensure that the intervention co-design was relevant and appropriate to the TB health system and the sociocultural context of Indonesia. The co-design of the intervention evolved through four phases: (1) a scoping review to identify a long list of potential TB stigma reduction interventions; (2) a modified Delphi survey to define a shortlist of the potential interventions; (3) a national multisectoral participatory workshop to identify and pre-finalize the most viable elements of psychosocial support to distill into a single multi-faceted intervention; and (4) finalization of the intervention activities. The scoping review identified 12 potential intervention activities. These were then reduced to a shortlist of six potential intervention activities through a modified Delphi Survey completed by 22 multisectoral stakeholder representatives. At the national participatory workshop, the suitability, acceptability, and feasibility of the six potential intervention activities were discussed by the key stakeholders, and consensus reached on the final four activities to be integrated into the psychosocial support intervention. These activities consisted of: individual psychological assessment and counselling; monthly peer-led group counselling; peer-led individual support; and community-based TB Talks. In Indonesia, meaningful participation of multisectoral stakeholders facilitated co-design of a community-based, peer-led intervention to reduce TB stigma and depression amongst people with TB and their households. The intervention was considered to be locally appropriate and viable, and is being implemented and evaluated as part of the TB-CAPS intervention study.

This survey aimed to investigate the availability of drugs for stable chronic obstructive pulmonary disease (COPD) treatment in Chinese hospitals and to determine whether drug availability significantly varied among hospitals with different characteristics. A well-constructed questionnaire was designed according to the Chinese Guidelines for the Diagnosis and Management of COPD (revised version 2021). Both inhaled drugs (monotherapy, double therapy and triple therapy) and oral drugs (expectorants, theophylline, antibiotics, and bacterial lysates) were included in this survey. Doctors from different hospitals completed the survey via WeChat. The availability of each category and kind of drug was analyzed based on final valid responses. Subgroup analyses were also conducted to reveal drug availability in hospitals with different characteristics. A total of 1018 hospitals with different characteristics were enrolled in this survey, with 53.73% of which establishing independent respiratory departments. Insufficient supply of COPD-related drugs was observed, with only short-acting β2 agonists (80.6%), expectorants (88.2%) and antibiotics (84.3%) reaching 80%. Results of subgroup analyses suggested that primary hospitals were associated with poorer availability of all kinds of drugs than secondary and tertiary hospitals (all p < 0.001). Most inhaled drugs did not reach an availability of 20% in primary hospitals, except for salbutamol (59.7%), tiotropium bromide (20.0%) and beclometasone/formoterol (23.1%). Results of this survey suggested that the availability of drugs for COPD treatment in China is still an ongoing challenge for healthcare institutions. Insufficient drug supply and imbalanced drug availability among different hospitals are major barriers that warrant further improvements.

Chronic breathlessness is a debilitating symptom with detrimental impact on individuals and carers. However, little is known about the experiences of community-dwelling, frail, older adults living with chronic breathlessness. To explore, (i) the psychological impact of living with chronic breathlessness, (older frail adult patients, carers) and (ii) how patients, carers, and clinicians experience identification and assessment of chronic breathlessness in the primary care setting. In-depth semi-structured interviews with eligible older adults (≥65 years; moderate to severe frailty [electronic Frailty Index >0.36]), and carers recruited from a community-based Integrated Care Centre in England. Clinicians were recruited from the Centre and affiliated GP practices. Recorded in-person interviews were transcribed and subjected to reflexive thematic analysis using Total Dyspnoea and Breathing Space conceptual frameworks. 20 patients (9 females), carers (4 spouses, 1 daughter), and clinicians (5 GPs, 3 advanced clinical practitioners, 2 nurses) were interviewed. Four themes were identified: (1) Widespread negative impact of chronic breathlessness. Breathlessness adversely impacts physical and psychological wellbeing. (2) Barriers to optimal health-seeking and identification of chronic breathlessness. Breathlessness is 'one of many' symptoms, and not prioritised in 'one appointment, one problem' consultations. Clinicians do not routinely ask about breathlessness. Patients are unaware of breathlessness-specific therapies. (3) Variations in chronic breathlessness management. Management is limited; few are offered evidence-based treatments (e.g., handheld fan) and patients find their own strategies. (4) Need for education and information. Clinicians felt helpless about breathlessness management, and patients lacked understanding and had low expectations of receiving help for this symptom. Breathlessness adversely impacts the psychological wellbeing of older frail adults. Chronic breathlessness in older, frail adults is invisible, unidentified and unmanaged in primary care. Evidence-based breathlessness interventions are available, but not routinely implemented with few patients accessing them. Proactive identification, assessment and management of breathlessness in primary care is needed to support adults living with chronic breathlessness.