Patient Characteristics to Consider When Selecting an Inhaler for the Treatment of Chronic Obstructive Pulmonary Disease and Available Assessment Methods: A Narrative Review.

Inhaler misuse is common among patients with chronic obstructive pulmonary disease and associated with poor disease control. Many patient characteristics are reported to impact inhaler use, but there are no studies in the literature on the best way to evaluate them. This narrative review aims to identify patient characteristics that influence the correct use of an inhaler and describe the tools available for their assessment. First, we searched four different databases to identify reviews describing patient characteristics reported to impact inhaler use. In a second step, ways to characterize these aspects were searched using the same databases. Fifteen patient characteristics impacting on the use of inhalers were identified. Peak inspiratory flow, dexterity, and cognitive impairment were the most studied characteristics and appeared to have the highest impact on the correct use of inhalers. Notably, peak inspiratory flow can be reliably assessed in clinical practice using the In-Check Dial®. Triggering coordination, breath retention, collaboration/consciousness, and muscle strength in the fingers were important characteristics, but insufficient data exist to recommend the use of a specific tool for their assessment in daily practice. Other identified characteristics have a more uncertain impact. A demonstration of inhalation technique by the patient, combined with the measurement of peak inspiratory flow using the In-Check Dial®, appears to be an effective strategy to assess the characteristics with the highest impact on the correct use of an inhaler. In the future, "smart" inhalers could also play a decisive role in this area.

[Adherence to inhaled therapy in adult patients affected by asthma or COPD]. / Adhérence aux traitements inhalés chez les patients adultes atteints d'un asthme ou d'une BPCO.

Inhaled treatment is the cornerstone of drug treatment for the two most common chronic obstructive respiratory diseases: asthma and chronic obstructive pulmonary disease (COPD). Therapeutic adherence is essential in the management of any chronic disease. In real life, only one-third of adult patients with chronic obstructive pulmonary disease have "good adherence". In this article, we will define therapeutic adherence before describing ways to assess and improve it in patients receiving inhaled therapies.

Le traitement inhalé est la pierre angulaire de la prise en charge médicamenteuse des deux maladies pulmonaires chroniques obstructives (MPCO) les plus fréquentes : l'asthme et la bronchopneumopathie chronique obstructive (BPCO). Comme dans toute maladie chronique, l'adhérence thérapeutique est primordiale. Dans la vie réelle, seul un tiers des patients adultes souffrant d'une MPCO présente une « bonne adhérence ¼. Dans cet article, nous définirons l'adhérence thérapeutique avant de décrire les moyens de l'évaluer et de l'améliorer chez les patients bénéficiant de traitements par inhalation.

[Aerosol therapy: help in selecting an adapted inhaler for COPD patients]. / Aérosolthérapie : aide à la sélection d'un inhalateur adapté chez les patients souffrant de BPCO.

Inhaled medication is the cornerstone of medical treatment of COPD. The efficacy of these treatments depends on the optimal use of inhalation devices. This requires not only an impeccable inhalation technique, but above all the selection of an inhaler adapted to the patient. In this article, we describe the specificities of the different inhalation devices and some of the patient's characteristics to be taken into account when selecting an inhaler, in particular the presence of cognitive disorders, impaired dexterity or insufficient inspiratory force.

La thérapie par aérosols est la pierre angulaire du traitement médicamenteux de la BPCO. L'efficacité de ces traitements repose sur une utilisation optimale du dispositif d'inhalation. Cela nécessite non seulement une technique d'inhalation irréprochable mais surtout la sélection d'un inhalateur adapté au patient. Dans cet article, nous décrivons les spécificités des différents dispositifs d'inhalation et certaines caractéristiques du patient à prendre en compte lors de la sélection d'un inhalateur, notamment la présence de troubles cognitifs, d'atteinte de la dextérité ou de force inspiratoire insuffisante.

Identification of Francisella tularensis in ascites in the context of typhoidal tularaemia.

Tularaemia is a highly infectious, zoonotic disease caused by Francisella tularensis, which has become increasingly prevalent over the past decade. Depending on the route of infection, different clinical manifestations can be observed. We report a case of typhoidal tularaemia presenting as a febrile illness with gastrointestinal symptoms in a patient in her mid-80s. During the acute illness phase and in the context of alcohol-related liver cirrhosis, the patient developed progressive ascites. During paracentesis, spontaneous bacterial peritonitis was consistently reported. Blood culture revealed Gram-negative bacilli identified as F. tularensis upon microscopic examination. Immediate clinical improvement was observed after adaptation to a pathogen-specific antibiotic regime. Typhoidal tularaemia presents general, non-specific symptoms without the local manifestations seen in other forms of the disease, thus representing a diagnostic challenge. In the case of protracted fever and if the epidemiological context as well as possible exposure are compatible, tularaemia should be considered in the differential diagnosis.

An in-hospital intervention to reduce the proportion of misused inhalers at hospital discharge among patients with COPD: a non-randomised intervention study.

AIMS OF THE STUDY: Misuse of inhalers during chronic obstructive pulmonary disease (COPD) treatment is common and may result from errors in inhalation technique or insufficient peak inspiratory flow (PIF). We aimed to evaluate the impact of an in-hospital intervention to reduce inhaler misuse at hospital discharge among patients with COPD. METHODS: We conducted a monocentric, non-randomised intervention study to compare the proportion of misused inhalers at hospital discharge by patients with COPD between a group with standard care and a group receiving an in-hospital intervention. The control group successively included all patients hospitalised between March and June 2022, and the intervention group included patients hospitalised between August and December 2022. The intervention consisted of (a) an evaluation of inhalation technique and PIF at admission, (b) the provision of a written guide to assist in the selection of an inhaler, and (c) therapeutic education. The primary outcome was the proportion of misused inhalers, defined as an inhaler used with a critical error and/or insufficient PIF, at hospital discharge. The primary outcome was assessed by observing inhalation technique and measuring PIF using the In-Check DIAL G16® . RESULTS: The study included 93 patients: 46 in the control group and 47 in the intervention group. Mean age was 70.5 years (SD 10.9 years), 56 patients (60.2%) were men, and 57 patients (62%) were hospitalised for a COPD exacerbation. Patients used an average of 1.9 inhalers at hospital discharge; 98 inhalers were assessed in the control group and 81 in the intervention group. The proportion of misused inhalers at discharge was 61.2% in the control group and 21.0% in the intervention group (absolute risk reduction 40.2% [95% CI 25.5-55.0]; p <0.01). In the intervention group, the proportion of inhalers used with at least one critical error was reduced by 38.6% (95% CI 24.3-52.3%) and that of inhalers used with insufficient PIF by 13.9% (95% CI 4.2-23.6%). CONCLUSIONS: An in-hospital intervention was associated with a reduction in the proportion of misused inhalers at hospital discharge. This intervention should be considered for hospitalised patients with COPD. The trial was registered with ClinicalTrials.gov (NCT05207631).

Prevalence of Critical Errors and Insufficient Peak Inspiratory Flow in Patients Hospitalized with COPD in a Department of General Internal Medicine: A Cross-Sectional Study.

Background: The suboptimal use of inhalers in the treatment of patients with chronic obstructive pulmonary disease (COPD) is probably a major but poorly documented problem in hospitalized patients. We aimed to describe the prevalence of misused inhalers among patients hospitalized with COPD in a department of general internal medicine. Methods: We conducted a monocentric cross-sectional study in consecutive patients with a diagnosis of COPD and hospitalized between August 2022 and April 2023 in the internal medicine division of Fribourg Hospital, Switzerland. Patients underwent an assessment of their inhaler technique and peak inspiratory flow (PIF) using the In-Check Dial G16®. The primary outcome was the prevalence of misused inhalers, defined as an inhaler used with a critical error and/or insufficient PIF. Secondary outcomes included the prevalence of inhalers unsuitable to patients' characteristics and of patients using at least one misused inhaler. Results: The study included 96 patients and 160 inhalers were assessed at admission. Among these inhalers, 111 (69.4%; 95% confidence interval [CI] 61.6-76.4) were misused; 105 (65.6%; 95% CI 57.7-72.9) due to the presence of a critical error in the inhalation technique and 22 (13.8%; 95% CI 8.8-20.1) due to insufficient PIF. Concerning the secondary outcome, 27 inhalers (16.9%) were unsuitable, and 79 patients (82.3%) used at least one misused inhaler. Conclusion: Among patients hospitalized with a diagnosis of COPD, two-thirds of inhalers were misused. Suboptimal use was mainly due to the presence of critical errors, but also to the presence of an insufficient PIF and unsuitable inhalers.

Transient central hypoxemia due to intermittent high-degree atrioventricular block in a heart-transplanted patient diagnosed during routine electroencephalography: a case report.

BACKGROUND: Bradycardia frequently occurs in heart-transplanted patients, mainly as a temporally restricted manifestation early after transplantation and often without symptoms. A high-degree atrioventricular block is mostly symptomatic through cerebral hypoxia induced through cerebral hypoperfusion. Only a few published cases show this specific electroencephalography result in this context. The purpose of this case is to bring attention to atypical manifestations of typical cardiac complications after heart transplantation and the importance of perseverance in the diagnostic. CASE PRESENTATION: A Central European man in his 50s with history of heart transplantation 31 years previously was admitted to the internal medicine ward for short-lived recurrent episodes of generalized weakness with multiple falls but without loss of consciousness. During routine electroencephalography, the patient perceived this recurrent sensation. This episode coincided with a transient third-degree atrioventricular block followed 8-10 seconds later by a generalized slowing of the electroencephalography, reflecting cerebral hypoxia due to cerebral hypoperfusion. Holter monitoring confirmed the diagnosis. A pacemaker was implanted, consequently resolving the episodes. CONCLUSION: This case report illustrates the pathophysiological central hypoxemic origin of episodes of generalized weakness caused by a high-degree atrioventricular block in a patient surviving 29 years after heart transplant. It highlights the benefit of electroencephalography as a diagnostic tool in well-selected patients.

Temporary atrial overdrive pacing during a drug-refractory electrical storm in acute myocardial infarction.

A 64-year-old man with diabetes mellitus was diagnosed with a non-ST-segment elevation myocardial infarction and was treated with stent implantation. Four days later, he developed an electrical storm (ES) that persisted despite antiarrhythmic drugs and sedation. External defibrillation was performed more than 100 times over 2 hours. After ruling out the common causes of polymorphic ventricular tachycardia, an ES was considered because of brady-dependent R-on-T phenomenon, presumably precipitated by antiarrhythmic drugs. Temporary transvenous atrial overdrive pacing allowed complete suppression of premature ventricular complexes and ventricular fibrillation.

Rapidly progressive heart failure after dual-chamber pacemaker implantation.

Pacing-induced cardiomyopathy (PICM) consists of heart failure (HF) associated with a drop in the left ventricular ejection fraction (LVEF) in the setting of high-burden right ventricular pacing, with presentation that may range from subclinical to severe. Time to manifestation can go from weeks to years after device implantation. Treatment typically consists in an upgrade to a cardiac resynchronisation therapy (CRT) or His bundle pacing (HisP). Several risk factors for PICM have been described and should be considered before pacemaker (PM) implantation, as thorough patient selection for de novo CRT or HisP, may preclude its manifestation. We present the case of an 82-year-old patient presenting with acute congestive HF and new severely reduced LVEF, 30 days following dual chamber PM implantation for high-grade atrioventricular block. Treatment with HF medication and upgrade to a CRT permitted rapid resolution of the symptoms and normalisation of the LVEF at 1-month follow-up.

Elderly woman presenting with multivessel coronary artery disease and Takotsubo syndrome.

Takotsubo syndrome is an acute and often reversible condition, with initial presentation mimicking acute coronary syndrome. Typically, patients present with left ventricular regional wall motion abnormalities, without a corresponding coronary artery obstruction on angiography. Coexistence of a coronary artery disease is possible and may render the distinction between the two entities particularly challenging. We report the case of a 94-year-old woman with chest pain after an emotional upset and acute myocardial injury. Transthoracic echocardiogram (TTE) revealed a severely reduced left ventricular ejection fraction (LVEF) with apical ballooning. Coronary angiogram showed significant stenosis of the distal left main coronary artery and of the mid-left anterior descending artery, as well as a 30%-50% stenosis of the mid-distal right coronary artery. Revascularisation was deferred and antiplatelet as well as heart failure therapy begun. A repeat TTE 6 days later revealed a quasi-normalised LVEF. Ultimately, percutaneous coronary revascularisation of the left main and left anterior descending artery was performed, with favourable outcome at 6-month follow-up.

Erythema nodosum as a cutaneous manifestation of COVID-19 infection.

Erythema nodosum (EN) is a common dermatological manifestation with many different aetiologies. Often however, the aetiology remains unidentified. We present here a 42-year-old male patient with an EN that is due to an acute COVID-19 infection. Most of the usual aetiologies were excluded by laboratory testing and imaging studies. This case is, to our knowledge, the first report of this cutaneous manifestation in the context of a COVID-19 infection. The EN was successfully treated with the disappearance of the COVID-19 infection and topical corticosteroids.

Manipulation of single cells inside nanoliter water droplets using acoustic forces.

Droplet microfluidics enables high-throughput screening of single cells and is particularly valuable for applications, where the secreted compounds are analyzed. Typically, optical methods are employed for analysis, which are limited in their applicability as labeling protocols are required. Alternative label-free methods such as mass spectrometry would broaden the range of assays but are harmful to the cells, which is detrimental for some applications such as directed evolution. In this context, separation of cells from supernatant is beneficial prior to the analysis to retain viable cells. In this work, we propose an in-droplet separation method based on contactless and label-free acoustic particle manipulation. In a microfluidic chip, nanoliter droplets containing particles are produced at a T-junction. The particles are trapped in the tip of the droplet by the interplay of acoustic forces in two dimensions and internal flow fields. The droplets are subsequently split at a second T-junction into two daughter droplets-one containing the supernatant and the other containing the corresponding particles. The separation efficiency is measured in detail for polystyrene (PS) beads as a function of droplet speed, size, split ratio, and particle concentration. Further, single-bead (PS) and single-cell (yeast) experiments were carried out. At a throughput of 114 droplets/min, a separation efficiency of 100% ± 0% was achieved for more than 150 droplets. Finally, mammalian cells and bacteria were introduced into the system to test its versatility. This work demonstrates a robust, non-invasive strategy to perform single yeast cell-supernatant sampling in nanoliter volumes.

Preventive and protective measures reducing influenza transmission in general practice: a systematic review.

BACKGROUND: Seasonal influenza and influenza-like illnesses are widespread, with an impact on GP consultations. GPs apply many preventive and protective measures to prevent seasonal influenza transmission, with no clear evidence of their effectiveness in this setting. AIM: To review the effectiveness of preventive and protective measures to reduce the transmission of seasonal influenza and influenza-like illnesses in GP practices. DESIGN & SETTING: A systematic review was conducted of the literature in Medline, Embase, and the Cochrane Central Register databases published between January 1960 and April 2014, later extended to January 2018. METHOD: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria were used. Controlled trials and experimental studies were included. Study quality was assessed according to the Cochrane risk of bias tool. RESULTS: Out of 5727 articles screened, only two studies were finally retained: one study about the seasonal influenza vaccination of GPs to prevent transmission from patients or staff, and one about surface disinfection. The first study was a controlled trial, which showed limited evidence for seasonal influenza infection reduction among GPs through vaccination. The second, an experimental study, performed a virus screening on toys in the waiting area before and after disinfection. No study on protection measures was found that assessed the impact on influenza transmission in general practices. CONCLUSION: The evidence is scarce on interventions that reduce influenza transmission in GP practices.