Service development project to pilot a digital technology innovation for video direct observation of therapy in adult patients with asthma.

BACKGROUND: Adherence to pharmacotherapy and use of the correct inhaler technique are important basic principles of asthma management. Video- or remote-direct observation of therapy (v-DOT) could be a feasible approach to facilitate monitoring and supervising therapy, supporting the delivery of standard care. OBJECTIVE: To explore the utility and the feasibility of v-DOT to monitor inhaler technique and adherence to treatment in adults attending the asthma outpatient service in a tertiary hospital in Northern Ireland. METHOD: The project evaluated use of the technology with 10 asthma patients. Patient and clinician feedback was obtained, in addition to measures of patient engagement and disease-specific clinical markers to assess the feasibility and utility of v-DOT technology in this group of patients. RESULTS: The engagement rate with v-DOT for participating patients averaged 78% (actual video uploads vs expected video uploads) over a median 7 week usage period. Although 50% of patients reported a technical issue at some stage during the usage period, all patients and clinicians reported that the technology was easy to use and that they were satisfied with the outcomes. A range of positive impacts were observed, including optimised inhaler technique and an observed improvement in lung function. An increase in asthma control test scores aligned with clinical aims to promote adherence and alleviate symptoms. CONCLUSION: The v-DOT technology was shown to be a feasible method of assessing inhaler technique and monitoring adherence in this small group of adult asthma patients. A range of positive impacts for participating patients and clinicians were observed. Not all patients invited to join the project agreed to participate or engage with using the technology, highlighting that in this setting, digital modes of delivering care provide only one of the approaches in the necessary "tool kit" for clinicians and patients.

Vitamin D status is associated with muscle strength and quality of life in patients with COPD: a seasonal prospective observation study.

Background: Owing to hospitalization, reduced functional capacity and consequently, less sunlight exposure, suboptimal vitamin D status (25-hydroxyvitamin D [25(OH)D]⩽50 nmol/L) is prevalent among COPD patients. Objective: This study aimed to investigate seasonal changes in vitamin D status and any associated changes in fat-free mass (FFM), muscle strength and quality of life (QoL) in COPD patients. Patients and methods: COPD patients living in Northern Ireland (n=51) completed study visits at the end of winter (March/April) and at the end of summer (September/October), corresponding to the nadir and peak of vitamin D status, respectively. At both time points, serum concentration of 25(OH)D was quantified by liquid chromatography-tandem mass spectrometry, FFM (kg) was measured using bioelectrical impedance and muscle strength (kg) was measured using handgrip dynamometry. QoL was assessed using the validated St George's Respiratory Questionnaire. Results: Mean±SD 25(OH)D concentration was significantly higher at the end of summer compared to the end of winter (52.5±30.5 nmol/L vs 33.7±28.4 nmol/L, P<0.001); and house- bound patients had significantly lower 25(OH)D concentration compared to nonhousebound patients at the end of summer (42.9±4.2 vs 57.2±9.9 nmol/L; P⩽0.001). Muscle strength (at both time points) and QoL (end of summer only) were positively predicted by 25(OH)D concentration, independent of age, sex and smoking status. Conclusion: This study highlights the need for health policies to include a recommendation for year-round vitamin D supplementation in housebound COPD patients, and wintertime supplementation in nonhousebound patients, to maintain optimal 25(OH)D concentrations to protect musculoskeletal health. Furthermore, an optimal vitamin D status may have potential benefits for QoL in these patients.

Broncho-pleural fistula due to trans-diaphragmatic migration of the distal end of ventriculo-peritoneal shunt.

We report two cases of broncho-pleural fistula resulting from trans-diaphragmatic migration of the distal catheter of a ventriculo-peritoneal shunt. Relevant literature on thoracic complications of a ventriculo-peritoneal shunt is reviewed. The clinical presentation, diagnosis and management of V-P shunt-related broncho-pleural fistulae are discussed.

Bronchiectasis in secondary care: a comprehensive profile of a neglected disease.

Background: Bronchiectasis is poorly characterised in secondary care. Methods: Over 6 months, 410 bronchiectasis patients attended our clinics. One hundred randomly selected patients were characterised in detail. Results: Patients had a mean and standard error of mean (S.E.M.) age of 57 (2) years and a median and interquartile range (IQR) of three (two to four) reviews in the last 12 months. Aetiologies identified included tuberculosis (n=15), childhood pneumonia (n=7), fibrosis (n=6), connective tissue disease (n=6), whooping cough (n=5), childhood measles (n=4) and others (n=5). There was widespread use of inhaled therapy. Treatments included oral antibiotics (n=77), corticosteroid courses (n=27) and intravenous antimicrobials (n=27, 12 domicillary) in the last year. Thirty patients had hospital admissions (13 because of the inability to administer domicillary antibiotics). Haemophilus influenzae and Pseudomonas spp. were the commonest bacterial isolates. Patients culturing Pseudomonas spp. were older and had had more reviews and intravenous antibiotic courses. Conclusions: Bronchiectasis imposes a considerable burden on hospital services. Patients culturing Pseudomonas spp. impose a greater burden. Aetiology is often unknown. Therapies with unproven benefit are often used.

Comparison of sputum induction using high-output and low-output ultrasonic nebulizers in normal subjects and patients with COPD.

STUDY OBJECTIVE: s: Induced sputum is used to investigate pulmonary diseases. Low-output ultrasonic nebulizers have become available and have potential advantages over high-output nebulizers. We hypothesized that a low-output nebulizer would give comparable results to a high-output nebulizer, with an acceptable safety profile. DESIGN: Randomized, crossover study. SETTING: University teaching hospital. PARTICIPANTS: Ten normal subjects and 10 patients with COPD. INTERVENTIONS: Participants attended for sputum induction on two occasions in random order using low-output and high-output nebulizers. MEASUREMENTS AND RESULTS: Lung function and oxygen saturation were measured during sputum induction, and tolerability of the procedure was assessed. Cell counts, interleukin 8, and neutrophil elastase were measured in sputum. Use of the high-output nebulizer resulted in a greater FEV(1) (mean +/- SEM, 0.29 +/- 0.04 L vs 0.21 +/- 0.04 L; p = 0.04) and percentage drop in FEV(1) (25.8 +/- 2.6% vs 19.5 +/- 2.9%, respectively; p = 0.02) compared with the low-output nebulizer in patients with COPD. There was a shorter tolerated nebulization time with the high-output nebulizer compared with the low-output nebulizer: 12.7 +/- 2.0 min vs 16.5 +/- 1.8 min, respectively (p = 0.02). Modified Borg scores were lower with the low-output nebulizer than the high-output nebulizer in normal subjects: median, 0 (interquartile range [IQR], 0 to 1) vs median, 1.5 (IQR, 0 to 2), respectively (p = 0.05). There were no differences in cell counts and soluble markers of inflammation. CONCLUSIONS: The low-output ultrasonic nebulizer is comparable to high-output nebulizer for cellular and soluble markers of inflammation, results in a smaller reduction in FEV(1), is better tolerated, and is a suitable tool for investigating airway inflammation in patients with COPD.