Earlier palliative home care is associated with patient-centred medical resource utilisation and lower costs in the last 30†days before death in COPD: a population-level decedent cohort study.

COPD patients often use many medical resources, such as hospital admissions and medical imaging, inappropriately close to death. Palliative home care (PHC) could beneficially affect this. The aim was to study the effect of use and timing of PHC on medical resource use and costs in the last 30 days before death (DBD) for COPD.We performed a retrospective study of all Belgian decedents in 2010-2015 with COPD and a primary cause of death being COPD or cardiovascular diseases. Odds ratios for medical resources were calculated between using and four PHC timing categories (>360, 360-181, 180-91 and 90-31 DBD) versus not using. Confounders were socio-demographic, care intensity and disease severity variables.Of the 58 527 decedents with COPD, 644 (1.1%) patients received PHC earlier than 30 DBD. Using PHC (versus not using) decreased the odds ratio for hospitalisation (0.35), intensive care unit admission (0.16), specialist contacts (0.58), invasive ventilation (0.13), medical imaging including chest radiograph (0.34), sedatives (0.48) and hospital death (0.14). It increased the odds ratio for home care (3.27), general practitioner contact (4.65), palliative care unit admission (2.61), noninvasive ventilation (2.65), gastric tube (2.15), oxygen (2.22) and opioids (4.04) (p<0.001). Mean total healthcare costs were €1569 lower for using PHC. All PHC timing categories showed a benefit in medical resource use and costs. However, we observed the largest benefit in the category PHC 90-31 DBD.Health policy and services should focus on increasing PHC access, while research should further explore early PHC initiation for COPD.

The effect of intravenous corticotropin-releasing hormone administration on esophageal sensitivity and motility in health.

Esophageal hypersensitivity is important in gastroesophageal reflux disease (GERD) patients who are refractory to acid-suppressive therapy. Stress affects visceral sensitivity and exacerbates heartburn in GERD. Peripheral CRH is a key mediator of the gut stress response. We hypothesize that CRH increases esophageal sensitivity and alters esophageal motility in health. Esophageal sensitivity to thermal, mechanical, electrical, and chemical stimuli was assessed in 14 healthy subjects after administration of placebo or CRH (100 µg iv). Perception scores were assessed for first perception, pain perception threshold (PPT), and pain tolerance threshold (PTT). Esophageal motility was investigated by high-resolution impedance manometry, before and after CRH and evaluated by distal contractile integral (DCI) and intrabolus pressure (IBP). Pressure flow analysis assessed bolus clearance (impedance ratio), degree of pressurization needed to propel bolus onward (IBP slope), and pressure flow (pressure flow index, PFI). Stress and mood were assessed during the study. Sensitivity to mechanical distention was increased after CRH compared with placebo (PPT: P = 0.0023; PTT: P = 0.0253). CRH had no influence on the other stimulations. DCI was increased for all boluses (liquid, P = 0.0012; semisolid, P = 0.0017; solid, P = 0.0107). Impedance ratio for liquid (P < 0.0001) and semisolid swallows (P = 0.0327) decreased after CRH. IBP slope increased after CRH for semisolid (P = 0.0041) and solid (P = 0.0003) swallows. PFI increased for semisolid (P = 0.0017) and solid swallows (P = 0.0031). CRH increased esophageal sensitivity to mechanical distention, not to the other stimulation modalities. CRH increased esophageal contractility and tone, decreased LES relaxation, increased esophageal bolus pressurization, improved esophageal bolus clearance, and increased pressure flow.NEW & NOTEWORTHY This is the first study to address the effect of corticotropin-releasing hormone (CRH) on esophageal sensitivity and alterations in motility in health. CRH administration increased esophageal sensitivity to mechanical distention. This effect is accompanied by an increase in esophageal contractility and tone and a decrease in lower esophageal sphincter relaxation. CRH increased esophageal bolus pressurization, improved esophageal bolus clearance, and increased pressure flow. The changes in esophageal contractile properties may underlie the increased sensitivity to mechanical distention after CRH.

Pan-Colonic Pressurizations Associated With Relaxation of the Anal Sphincter in Health and Disease: A New Colonic Motor Pattern Identified Using High-Resolution Manometry.

OBJECTIVES: Only a few studies have applied high-resolution manometry (HRM) to the study of colonic motility in adults and none of them have concurrently evaluated colonic and anal motor activity. The aim of the study was to evaluate colonic and anal motor activity by means of HRM in healthy subjects. As the present study revealed the presence of a new colonic motor pattern (pan-colonic pressurizations) in healthy subjects, three additional studies were conducted: the first and the second to exclude that this motor event results from an artifact due to abdominal wall contraction and to confirm its modulation by cholinergic stimulation, and the third, as pilot study, to test the hypothesis that this colonic pattern is defective in patients with chronic constipation refractory to current pharmacological treatments. METHODS: In both volunteers and patients the HRM catheter was advanced proximally during colonoscopy. RESULTS: In all subjects, pressure increases of 15±3 mm Hg and 24±4 s simultaneously occurring in all colonic sensors (pan-colonic pressurizations) and associated with anal sphincter relaxation were identified. Subjects had 85±38 pan-colonic pressurizations, which increased significantly during meal (P=0.007) and decreased afterward (P=0.01), and were correlated with feelings of and desire to evacuate gas. The mean number of propagating sequences was 47±39, and only retrograde increased significantly postprandially (P=0.01). Pan-colonic pressurizations differed from strain artifacts and significantly increased after prostigmine. In patients pan-colonic pressurizations were significantly reduced as compared with volunteers. CONCLUSIONS: Pan-colonic pressurizations associated with relaxations of the anal sphincter represent a new colonic motor pattern that seems to be defective in patients with treatment-refractory chronic constipation and may have a role in the transport of colonic gas and in the facilitation of the propagating sequence-induced colonic transport.

Action plans increase advance care planning documentation and engagement among English and Spanish-speaking older adults.

BACKGROUND: Advance care planning (ACP) has been reconceptualized as a health behavior. Action plans (APs), or patient-directed mini contracts, improve behavior change. However, no prior studies have assessed whether APs can increase ACP documentation and engagement. METHODS: We included English and Spanish-speaking primary care patients from San Francisco, ≥55 years of age, with ≥2 serious or chronic illnesses. Participants were in the intervention arm of the PREPAREforYOURcare.org trial and asked at baseline to choose 1 of 5 actions (e.g., choose a surrogate). At 6 months, we assessed whether participants completed their AP and if completion was associated with demographics, electronic health record (EHR) ACP documentation, and five-point ACP Engagement Survey scores. We used t-tests, chi-squared, multivariate analysis adjusted for baseline ACP and clustering by physician, and qualitative thematic analysis to explore reasons for non-completion. RESULTS: The mean age of 586 participants was 65 ± 10 years; 44.0% women, 45.9% Spanish-speaking, 31.4% had limited health literacy, and 43% completed an AP at 6 months; surrogate-related (47.4%), tell others about medical wishes (33.7%), ask clinicians questions (13.7%), and decide what matters most in life (5.2%). Participants with limited versus adequate health literacy were less likely to complete an AP (25.4% vs 35.9%, p = 0.01). Completing an AP was associated with greater ACP EMR documentation 49.8% vs 35.6%, p < 0.001 (adjusted odds ratio: 2.06; 95% CI [1.43-2.97]) and engagement (adjusted five-point scores [3.69; 95% CI 3.57-3.81 vs 3.10; 95% CI: 2.98-3.21], p < 0.001). Themes for non-completion included not being ready and logistical issues (e.g., surrogate deceased). CONCLUSIONS: Among English and Spanish-speaking older adults, creating an ACP AP resulted in greater documentation and engagement. APs may help facilitate ACP behavior change as part of effective ACP interventions. Additional support may be needed for patients with limited health literacy and those facing logistical barriers.

Planetary health and environmental sustainability in African health professions education.

CliMigHealth and the Education for Sustainable Healthcare (ESH) Special Interest Group of the Southern African Association of Health Educationalists (SAAHE) call for the urgent integration of planetary health (PH) and environmental sustainability into health professions curricula in Africa. Education on PH and sustainable healthcare develops much-needed health worker agency to address the connections between healthcare and PH. Faculties are urged to develop their own 'net zero' plans and to advocate for national and sub-national policies and practices that promote the Sustainable Development Goals (SDGs) and PH. National education bodies and health professional societies are urged to incentivise innovation in ESH and to provide discussion forums and resources to support the integration of PH into curricula.Contribution: This article provides a position statement for integrating planetary health and environmental sustainability into African health professions education curricula.

Gaps and opportunities in the climate change, migration and health nexus: Insights from a questionnaire based study of practitioners and researchers.

Background: : While climate change and migration are separately recognised as public health challenges, the combination of the two - climate change-induced migration which is predicted to increase through this century - requires further research to ensure population health needs are met. As such, this paper aims to identify initial gaps and opportunities in the nexus of climate change, migration and health research. Methods: : We conducted a questionnaire based study of academics and practitioners working in the fields of climate change, migration and health. Open-ended responses were thematically analysed. Results: : Responses from 72 practitioners collected in October 2021 were categorised into a thematic framework encompassing i) gaps and opportunities: across health care and outcomes, impact pathways between climate change and migration, most at risk groups (specific actors) and regions, and longitudinal perspectives on migrant journeys; alongside ii) methodological challenges; iii) ethical challenges, and iv) advancing research with better funding and collaboration. Broadly, findings suggested that research must clarify the interlinkages and drivers between climate change, migration, health (systems), and intersecting factors including the broader determinants of health. Study of the dynamics of migration needs to extend beyond the current focus of rural-urban migration and international migration into high income countries, to include internal displacement and immobile/ trapped populations. Research could better include considerations of vulnerable groups currently underrepresented, people with specific health needs, and focus more on most at-risk regions. Research methodology could be strengthened through better data and definitions, clear ethical guidelines, and increased funding and collaboration. Conclusion: : This study describes gaps, challenges and needs within research on the nexus of climate change, migration and health, in acknowledgement of the complexity of studying across multiple intersecting factors. Working with complexity can be supported by using the framework and findings to support researchers grappling with these intersecting themes.

Unmet health-related needs of community-dwelling older adults during COVID-19 lockdown in a diverse urban cohort.

BACKGROUND: Shelter-in-place orders during the COVID-19 pandemic created unmet health-related and access-related needs among older adults. We sought to understand the prevalence of these needs among community-dwelling older adults. METHODS: We performed a retrospective chart review of pandemic-related outreach calls to older adults between March and July 2020 at four urban, primary care clinics: a home-based practice, a safety net adult medicine clinic, an academic geriatrics practice, and a safety net clinic for adults living with HIV. Participants included those 60 or older at three sites, and those 65 or older with a chronic health condition at the fourth. We describe unmet health-related needs (the need for medication refills, medical supplies, or food) and access-related needs (ability to perform a telehealth visit, need for a call back from the primary care provider). We performed bivariate and multivariate analyses to examine the association between unmet needs and demographics, medical conditions, and healthcare utilization. RESULTS: Sixty-two percent of people had at least one unmet need. Twenty-six percent had at least one unmet health-related need; 14.0% needed medication refills, 12.5% needed medical supplies, and 3.0% had food insecurity. Among access-related needs, 33% were not ready for video visits, and 36.4% asked for a return call from their provider. Prevalence of any unmet health-related need was the highest among Asian versus White (36.4% vs. 19.1%) and in the highest versus lowest poverty zip codes (30.8% vs. 18.2%). Those with diabetes and COPD had higher unmet health-related needs than those without, and there was no change in healthcare utilization. CONCLUSIONS: During COVID, we found that disruptions in access to services created unmet needs among older adults, particularly for those who self-identified as Asian. We must foreground the needs of this older population group in the response to future public health crises.

Personal and community-level exposure to air pollution and daily changes in respiratory symptoms and oxygen saturation among adults with COPD.

Background: Air pollution exposure is associated with hospital admissions for Chronic Obstructive Pulmonary Disease (COPD). Few studies have investigated whether daily personal exposure to air pollutants affects respiratory symptoms and oxygenation among COPD patients. Methodology: We followed 30 former smokers with COPD for up to 4 non-consecutive 30-day periods in different seasons. Participants recorded worsening of respiratory symptoms (sub-categorized as breathing or bronchitis symptoms) by daily questionnaire, and oxygen saturation by pulse oximeter. Personal and community-level exposure to fine particulate matter (PM2.5), nitrogen dioxide (NO2), and ozone (O3) were measured by portable air quality monitors and stationary monitors in the Boston area. We used generalized and multi-level linear mixed-effects models to estimate associations of the 24-hour average of each pollutant in the previous day with changes in respiratory symptoms and oxygen saturation. Results: Higher community-level exposure to air pollutants was associated with worsening respiratory symptoms. An interquartile range (IQR) higher community-level O3 was associated with a 1.35 (95%CI: 1.07-1.70) higher odds of worsening respiratory symptoms. The corresponding ORs for community-level PM2.5 and NO2 were 1.18 (95%CI: 1.02-1.37) and 1.06 (95%CI: 0.90-1.25), respectively. Community-level NO2 was associated with worsening bronchitis symptoms (OR=1.25, 95%CI: 1.00-1.56), but not breathing symptoms. Personal PM2.5 exposure was associated with lower odds of worsening respiratory symptoms (OR=0.91; 95%CI: 0.81-1.01). Personal exposure to NO2 was associated with 0.11% lower oxygen saturation (95%CI: -0.22, 0.00) per IQR. Conclusions: In this COPD population, there was a pattern of worsening respiratory symptoms associated with community-level exposure to O3 and PM2.5, and worsening oxygenation associated with personal exposure to NO2.

How did primary health care in Beira experience Cyclone Idai?

Beira, the biggest city of Mozambique's Sofala province, was struck by Cyclone Idai on 14 March 2019, with devastating impacts. The floods along with the cyclone destroyed road infrastructure and health facilities and disrupted primary health care (PHC) service delivery. In addition, destruction of farmland and food stocks resulted in malnutrition; the abundance of water fostered the reproduction of mosquitos, exacerbating the burden of malaria; and problems with water and sanitation led to epidemics of cholera. The exact role and contribution of human-induced climate change is very difficult to quantify, but there is little doubt that climate change is driving more frequent and severe cyclones, such as Idai. Considering the current climatic changes, it is expected that climate hotspots such as Beira will only experience more frequent extreme weather events. In these settings, with high risks but low adaptive capacity, dedicated efforts are required to strengthen PHC with a focus on preparedness for disasters. This should entail community awareness and education, strengthening infrastructure and service provision, as well as collaboration with important stakeholders across other sectors.Contribution: Using a case study approach, this article contributes climate resilient PHC for better preparedness to service continuity.

The impact of personal and outdoor temperature exposure during cold and warm seasons on lung function and respiratory symptoms in COPD.

Rationale: Chronic obstructive pulmonary disease (COPD) patients often report aggravated symptoms due to heat and cold, but few studies have formally evaluated this. Methodology: We followed 30 Boston-based former smokers with COPD for four non-consecutive 30-day periods over 12 months. Personal and outdoor temperature exposure were measured using portable and Boston-area outdoor stationary monitors. Participants recorded daily morning lung function measurements as well as any worsening breathing (breathlessness, chest tightness, wheeze) and bronchitis symptoms (cough, sputum colour and amount) compared to baseline. Using linear and generalised linear mixed-effects models, we assessed associations between personal and outdoor temperature exposure (1-3-day moving averages) and lung function and symptoms, adjusting for humidity, smoking pack-years and demographics. We also stratified by warm and cold season. Results: Participants were on average 71.1±8.4 years old, with 54.4±30.7 pack-years of smoking. Each 5°C increase in personal temperature exposure was associated with 1.85 (95% CI 0.99-3.48) higher odds of worsening breathing symptoms. In the warm season, each 5°C increase in personal and outdoor temperature exposure was associated with 3.20 (95% CI 1.05-9.72) and 2.22 (95% CI 1.41-3.48) higher odds of worsening breathing symptoms, respectively. Each 5°C decrease in outdoor temperature was associated with 1.25 (95% CI 1.04-1.51) higher odds of worsening bronchitis symptoms. There were no associations between temperature and lung function. Conclusions: Our findings suggest that higher temperature, including outdoor exposure during the warm season and personal temperature exposure year-round, may worsen dyspnoea, while colder outdoor temperature may trigger cough and phlegm symptoms among COPD patients.

Climate change, migration, and health(care) in primary care training.

No abstract available.

Developing eHealth tools for diverse older adults: Lessons learned from the PREPARE for Your Care Program.

BACKGROUND/OBJECTIVES: Electronic Health (eHealth) tools offer opportunities for people to access health information online; yet, most tools are not designed to meet the unique needs of diverse older adults, leading to health disparities. Our goal was to provide guidance for the development of eHealth tools for diverse older populations for use in geriatric care models. DESIGN: Guidance for eHealth tools was compiled from user design resources and eHealth design literature. Pragmatic examples were provided from an evidenced-based eHealth tool called PREPAREforYourCare.org (PREPARE). We used quantitative feasibility data from PREPARE research studies and qualitative analysis of PREPARE focus groups, cognitive interviews, and feedback from randomized trials to further inform our recommendations. RESULTS: Guidance and lessons learned include: (1) define clear objectives and a conceptual framework; (2) co-create with the target population; (3) optimize the design and layout for accessibility and ease of use, such as text at the 5th grade reading level, closed captioning, etc.; (4) use simple, standardized navigation design; (5) use actionable information to enhance behavior change, such as modeling of behaviors; (6) align accompanying written materials with the eHealth tool; and (7) create tracking mechanisms for ongoing user feedback. PREPARE is used as a case example to provide pragmatic illustrations for how the guidance may be operationalized. CONCLUSION: eHealth tools can be tailored to the unique characteristics, preferences, and needs of diverse older populations. Following the "lessons learned" may help decrease health disparities among diverse older adults and ensure eHealth tools are readily accessible and culturally appropriate.

Family Physician Perceptions of Climate Change, Migration, Health, and Healthcare in Sub-Saharan Africa: An Exploratory Study.

Although family physicians (FPs) are community-oriented primary care generalists and should be the entry point for the population's interaction with the health system, they are underrepresented in research on the climate change, migration, and health(care) nexus (hereafter referred to as the nexus). Similarly, FPs can provide valuable insights into building capacity through integrating health-determining sectors for climate-resilient and migration-inclusive health systems, especially in Sub-Saharan Africa (SSA). Here, we explore FPs' perceptions on the nexus in SSA and on intersectoral capacity building. Three focus groups conducted during the 2019 WONCA-Africa conference in Uganda were transcribed verbatim and analyzed using an inductive thematic approach. Participants' perceived interactions related to (1) migration and climate change, (2) migration for better health and healthcare, (3) health impacts of climate change and the role of healthcare, and (4) health impacts of migration and the role of healthcare were studied. We coined these complex and reinforcing interactions as continuous feedback loops intertwined with socio-economic, institutional, and demographic context. Participants identified five intersectoral capacity-building opportunities on micro, meso, macro, and supra (international) levels: multi-dimensional and multi-layered governance structures; improving FP training and primary healthcare working conditions; health advocacy in primary healthcare; collaboration between the health sector and civil society; and more responsibilities for high-income countries. This exploratory study presents a unique and novel perspective on the nexus in SSA which contributes to interdisciplinary research agendas and FP policy responses on national, regional, and global levels.

Early Integrated Palliative Home Care and Standard Care for End-Stage COPD (EPIC): A Phase II Pilot RCT Testing Feasibility, Acceptability, and Effectiveness.

CONTEXT: Although early integrated palliative home care (PHC) is believed to be beneficial for patients with chronic obstructive pulmonary disease (COPD), trials testing this hypothesis are rare and show inconclusive results. OBJECTIVES: To test feasibility, acceptability, and preliminary effectiveness of early integrated PHC for end-stage COPD. METHODS: Testing a six-month early integrated PHC pilot randomized controlled trial given by palliative home care nurses (PHCNs) for end-stage COPD with five components: 1) preinclusion COPD support training for PHCNs; 2) monthly PHC visits; 3) leaflets on coping mechanisms; 4) a protocol on symptom management and support, a care plan and an action plan; and 5) integration of PHC and usual care through reporting and communication mechanisms. Patient-reported outcomes were assessed six times weekly. Participants and health care professionals involved were interviewed. RESULTS: Of 70 eligible patients, 39 (56%) participated (20:19 intervention vs control group) and 64% completed the trial. A patient received on average 3.4 PHC visits, mainly for disease insight, symptom management, and care planning. Nurses distributed all reports but hardly connected with health professionals except general practitioners (GPs); eight of 10 interviewed patients referred to the psychosocial support, breathing exercises, and care decisions as helpful. Some GPs criticized PHC being given too early, but pulmonologists and PHCNs did not. Effectiveness analysis showed no overall intervention effect for the outcomes, but between baseline and week 24, fewer hospitalizations in the control group (P = 0.03) and a trend of higher perceived quality of care in the intervention group (P = 0.06) were found. A clinically relevant difference was observed at week 24 for health-related quality of life in favor of the control group. CONCLUSION: Our intervention on early integrated PHC for end-stage COPD is feasible and accepted but did not yield the anticipated preliminary effectiveness. Before moving to a Phase III trial, enhanced coordination of care, more GP involvement, more intensive training for PHCNs in COPD support, and revision of the trial design, for example, of targeted outcomes in line with individual patient goals and care preferences should be done.

High-resolution impedance manometry parameters in the evaluation of esophageal function of non-obstructive dysphagia patients.

BACKGROUND: High-resolution impedance manometry (HRIM) allows evaluation of esophageal bolus retention, flow, and pressurization. We explored novel HRIM measures and assessed their temporal relationship to dysphagia symptoms for boluses of different volume and consistency in non-obstructive dysphagia (NOD) patients. METHODS: Thirty-three NOD patients (n = 19 minor or no disorder of peristalsis ("Normal") and n = 14 esophagogastric junction outflow obstruction ("EGJOO")) were evaluated with HRIM. Patients were administered 5 and 10 mL liquid, semisolid, and 2 and 4 cm solid boluses and indicated bolus perception during individual swallows using a 5-point Likert scale. HRIM was analyzed to assess Chicago Classification and pressure flow metrics, esophageal impedance integral (EII) ratio, and bolus flow time (BFT). KEY RESULTS: Overall, bolus perception increased with increasing bolus consistency (P < 0.001), but did not differ significantly between EGJOO and Normal patients. EGJOO patients had higher IRP4, higher levels of bolus residual (ie, EII ratio and IR), and restricted esophageal emptying. The results for linking semisolid bolus perception to semisolid-derived measures revealed more biomechanically plausible and consistent patterns when compared to those derived for liquid boluses. In Normal patients, perception of boluses of heavier viscosity was related to higher bolus flow resistance during transport, whilst in EGJOO, perception was related to restriction of esophageal emptying. CONCLUSION & INFERENCES: These novel pressure-impedance measures may aid in the evaluation of NOD patients by revealing abnormal motor patterns, which may explain symptom generation. Future studies are needed to evaluate which of these measures are worthy of calculation and to establish protocol settings that allow for their meaningful interpretation.

"A palliative end-stage COPD patient does not exist": a qualitative study of barriers to and facilitators for early integration of palliative home care for end-stage COPD.

Early integration of palliative home care (PHC) might positively affect people with chronic obstructive pulmonary disease (COPD). However, PHC as a holistic approach is not well integrated in clinical practice at the end-stage COPD. General practitioners (GPs) and community nurses (CNs) are highly involved in primary and home care and could provide valuable perspectives about barriers to and facilitators for early integrated PHC in end-stage COPD. Three focus groups were organised with GPs (n = 28) and four with CNs (n = 28), transcribed verbatim and comparatively analysed. Barriers were related to the unpredictability of COPD, a lack of disease insight and resistance towards care of the patient, lack of cooperation and experience with PHC for professional caregivers, lack of education about early integrated PHC, insufficient continuity of care from hospital to home, and lack of communication about PHC between professional caregivers and with end-stage COPD patients. Facilitators were the use of trigger moments for early integrating PHC, such as after a hospital admission or when an end-stage COPD patient becomes oxygen-dependent or housebound, positive attitudes towards PHC in informal caregivers, more focus on early integration of PHC in professional caregivers' education, implementing advance care planning in healthcare and PHC systems, and enhancing communication about care and PHC. The results provide insights for clinical practice and the development of key components for successful practice in a phase 0-2 Early Integration of PHC for end-stage COPD (EPIC) trial, such as improving care integration, patients' disease insight and training PHC nurses in care for end-stage COPD.

Development of a complex intervention for early integration of palliative home care into standard care for end-stage COPD patients: A Phase 0-I study.

BACKGROUND: Research suggests that palliative home care should be integrated early into standard care for end-stage COPD patients. Patients also express the wish to be cared for and to die at home. However, a practice model for early integration of palliative home care (PHC) into standard care for end-stage COPD has not been fully developed. AIM: To develop an intervention for early integration of PHC into standard care for end-stage COPD patients. METHODS: We conducted a Phase 0-I study according to the Medical Research Council Framework for the development of complex interventions. Phase 0 aimed to identify the inclusion criteria and key components of the intervention by way of an explorative literature search of interventions, expert consultations, and seven focus groups with general practitioners and community nurses on perceived barriers to and facilitators of early integrated PHC for COPD. In Phase 1, the intervention, its inclusion criteria and its components were developed and further refined by an expert panel and two expert opinions. RESULTS: Phase 0 resulted in identification of inclusion criteria and components from existing interventions, and barriers to and facilitators of early integration of PHC for end-stage COPD. Based on these findings, a nurse-led intervention was developed in Phase I consisting of training for PHC nurses in symptom recognition and physical therapy exercises for end-stage COPD, regular visits by PHC nurses at the patients' homes, two information leaflets on self-management, a semi-structured protocol and follow-up plan to record the outcomes of the home visits, and integration of care by enabling collaboration and communication between home and hospital-based professional caregivers. CONCLUSION: This Phase 0-I trial succeeded in developing a complex intervention for early integration of PHC for end-stage COPD. The use of three methods in Phase 0 gave reliable data on which to base inclusion criteria and components of the intervention. The preliminary effectiveness, feasibility and acceptability of the intervention will be subsequently tested in a Phase II study.

The Potential Benefits of Applying Recent Advances in Esophageal Motility Testing in Patients with Esophageal Atresia.

Infants and children with esophageal atresia commonly present with swallowing dysfunction or dysphagia. Dysphagia can lead to a range of significant consequences such as aspiration pneumonia, malnutrition, dehydration, and food impaction. To improve oral intake, the clinical diagnosis of dysphagia in patients with esophageal atresia should focus on both the pharynx and the esophagus. To characterize the complex interactions of bolus flow and motor function between mouth, pharynx, and esophagus, a detailed understanding of normal and abnormal deglutition is required through the use of adequate and objective assessment techniques. As clinical symptoms do not correlate well with conventional assessment methods of motor function such as radiology or manometry but do correlate with bolus flow, the current state-of-the-art diagnosis involves high-resolution manometry combined with impedance measurements to characterize the interplay between esophageal motor function and bolus clearance. Using a novel pressure flow analysis (PFA) method as an integrated analysis method of manometric and impedance measurements, differentiation of patients with impaired esophago-gastric junction relaxation from patients with bolus outflow disorders is clinically relevant. In this, pressure flow matrix categorizing the quantitative PFA measures may be used to make rational therapeutic decisions in patients with esophageal atresia. Through more advanced diagnostics, improved understanding of pathophysiology may improve our patient care by directly targeting the failed biomechanics of both the pharynx and the esophagus.

Buspirone, a new drug for the management of patients with ineffective esophageal motility?

Ineffective esophageal motility (IEM) is the most frequently encountered esophageal motility disorder. Patients may present with a variety of symptoms, such as dysphagia, heartburn, odynophagia, and regurgitation. Over the past years, the landscape of esophageal motility testing has been revolutionized; however, our current treatment options for IEM still remain limited. Previous studies have suggested that buspirone, a serotonin receptor agonist, enhances esophageal peristalsis and lower esophageal sphincter (LES) function. Recent work provides the first evidence that buspirone may influence LES resting pressure in patients with systemic sclerosis. Future research should evaluate whether the beneficial effects of buspirone also apply to the broad clinical entity of esophageal dysphagia patients with IEM.