Effectiveness of an educational intervention about inhalation technique in healthcare professionals in primary care: a cluster randomized trial.

Background: Incorrect inhalation technique (IT) is an important issue for chronic obstructive pulmonary disease (COPD) patients and healthcare professionals. Studies in which counseling is carried out with healthcare professionals beforehand so that they can properly educate their patients are required. The objective of the present trial is to assess the improvement in the performance of the IT in subjects with COPD and prescribed inhaled therapy after the implementation of an educational intervention conducted by their general practitioners. Methods: A cluster randomized clinical trial was conducted. A total of 286 COPD patients received scheduled inhalation therapy from 27 general practices in seven primary care centers. A teach-back educational intervention was implemented for both healthcare professionals and patients. The primary outcome of this study was the performance of the correct inhalation technique. It is considered a good technique if all steps in the inhalation data sheet are correctly performed. The secondary outcomes were assessed using forced spirometry, the basal dyspnea index, the Medical Research Council dyspnea scale, St George's Respiratory Questionnaire (SGRQ), and EuroQoL5D-5L for health-related quality of life. A one-year follow-up was conducted using an intention-to-treat analysis. Results: After the intervention, incorrect IT was observed in 92% of professionals and patients, with rates reaching 50% and 69.2%, respectively. The effectiveness in patients was significant, with a number needed to treat of 2.14 (95% CI 1.79-2.66). Factors related to correct IT in patients included the type of intervention, length of intervention (>25 min), good pulmonary function, age (youngest <=65, oldest >83), and less limitation of activity due to dyspnea. There was no relation with the cluster. Conclusion: This study shows the effectiveness of direct inhaler technique training provided by a trained professional on an appropriate timescale (for example, a specific consultation for medication reviews), aiming to help subjects improve their performance using the teach-back method. This could be an encouraging intervention to improve medication adherence and health promotion in people with COPD. Clinical Trial Registration: clinicaltrials.gov, identifier ISRCTN93725230.

A generalised approach to the study and understanding of adaptive evolution.

Evolutionary theory has made large impacts on our understanding and management of the world, in part because it has been able to incorporate new data and new insights successfully. Nonetheless, there is currently a tension between certain biological phenomena and mainstream evolutionary theory. For example, how does the inheritance of molecular epigenetic changes fit into mainstream evolutionary theory? Is niche construction an evolutionary process? Is local adaptation via habitat choice also adaptive evolution? These examples suggest there is scope (and perhaps even a need) to broaden our views on evolution. We identify three aspects whose incorporation into a single framework would enable a more generalised approach to the understanding and study of adaptive evolution: (i) a broadened view of extended phenotypes; (ii) that traits can respond to each other; and (iii) that inheritance can be non-genetic. We use causal modelling to integrate these three aspects with established views on the variables and mechanisms that drive and allow for adaptive evolution. Our causal model identifies natural selection and non-genetic inheritance of adaptive parental responses as two complementary yet distinct and independent drivers of adaptive evolution. Both drivers are compatible with the Price equation; specifically, non-genetic inheritance of parental responses is captured by an often-neglected component of the Price equation. Our causal model is general and simplified, but can be adjusted flexibly in terms of variables and causal connections, depending on the research question and/or biological system. By revisiting the three examples given above, we show how to use it as a heuristic tool to clarify conceptual issues and to help design empirical research. In contrast to a gene-centric view defining evolution only in terms of genetic change, our generalised approach allows us to see evolution as a change in the whole causal structure, consisting not just of genetic but also of phenotypic and environmental variables.

Relevancia clínica de la técnica de utilización de inhaladores en pacientes con enfermedad pulmonar obstructiva crónica / The clinical relevance of inhalation technique in chronic obstructive pulmonary disease patients

Introducción:Numerosos estudios muestran que los pacientes con Enfermedad Pulmonar Obstructiva Crónica (EPOC) realizan una técnica de inhalación (TI) incorrecta. Nuestra investigación pretende describir los errores cometidos y la Importancia Clínica de dichos Fallos (ICF), e identificar los factores relacionados con ello.Pacientes y métodos:Estudio descriptivo transversal de 995 pacientes seguidos en 20 Centros de Salud de Andalucía. Se recogieron variables sociodemográficas, calidad de vida, estado mental-cognitivo, espirometría, gravedad, número de dispositivos, realización correcta de la TI, instrucción previa e ICF.Resultados:906 pacientes (91,1%) realizaban una TI incorrecta. Los errores más frecuentes presentaban ICF2-moderada y se relacionaron con nivel cognitivo bajo, pico flujo inhalatorio bajo y menos visitas al neumólogo. Los errores críticos-ICF3 mostraron relación con mayor gravedad, uso de Turbuhaler® y peor calidad de vida.Discusión:Altísima tasa de técnica incorrecta cuyos errores más frecuentes comprometen de forma moderada la eficacia del fármaco, se relacionan con el modo de realizar la TI y no con la dificultad en el manejo del dispositivo. Esto muestra la importancia de entrenar correctamente a nuestros pacientes. (AU)

Introduction:Numerous studies show that patients with chronic obstructive pulmonary disease (COPD) perform an incorrect inhalation technique (IT). This research aims to describe inhalation errors committed and their clinical importance, and to identify factors related to them.Patients and methods:A total of 995 patients were recruited in this cross-sectional, descriptive study that was conducted across 20 Andalusian Health Care Centres. The following variables were collected: socio-demographic data, quality of life, mental and cognitive status, spirometry tests, severity, number of IT devices, IT correct performance, previous instruction and clinical importance of errors.Results:Of the 995 patients, 906 (91,1%) performed an incorrect IT. The most common errors showed moderate errors, which were related to low-cognitive level, low-peak expiratory flow and fewer medical consultations with the pulmonologist. Critical errors were correlated with greater severity, usage of Turbuhaler® and worse quality of life.Discussion:Soaring incorrect technique rate, whose most common errors sparingly compromise the drug effectiveness. These errors are related to the way the patients perform the IT, and not to the difficulty in handling the device. This information demonstrates the relevance of training patients in a proper way. (AU)

[The clinical relevance of inhalation technique in chronic obstructive pulmonary disease patients]. / Relevancia clínica de la técnica de utilización de inhaladores en pacientes con enfermedad pulmonar obstructiva crónica.

INTRODUCTION: Numerous studies show that patients with chronic obstructive pulmonary disease (COPD) perform an incorrect inhalation technique (IT). This research aims to describe inhalation errors committed and their clinical importance, and to identify factors related to them. PATIENTS AND METHODS: A total of 995 patients were recruited in this cross-sectional, descriptive study that was conducted across 20 Andalusian Health Care Centres. The following variables were collected: socio-demographic data, quality of life, mental and cognitive status, spirometry tests, severity, number of IT devices, IT correct performance, previous instruction and clinical importance of errors. RESULTS: Of the 995 patients, 906 (91,1%) performed an incorrect IT. The most common errors showed moderate errors, which were related to low-cognitive level, low-peak expiratory flow and fewer medical consultations with the pulmonologist. Critical errors were correlated with greater severity, usage of Turbuhaler® and worse quality of life. DISCUSSION: Soaring incorrect technique rate, whose most common errors sparingly compromise the drug effectiveness. These errors are related to the way the patients perform the IT, and not to the difficulty in handling the device. This information demonstrates the relevance of training patients in a proper way.

Evolutionary causes as mechanisms: a critical analysis.

In this paper, we address the question whether a mechanistic approach can account for evolutionary causes. The last decade has seen a major attempt to account for natural selection as a mechanism. Nevertheless, we stress the relevance of broadening the debate by including the other evolutionary causes inside the mechanistic approach, in order to be a legitimate conceptual framework on the same footing as other approaches to evolutionary theory. We analyse the current debate on natural selection as a mechanism, and extend it to the rest of the evolutionary causes. We focus on three approaches that we call the stochastic view, the functional view, and the minimalist view. We argue that all of them are unable to account for evolutionary causes as mechanisms. It is concluded that the current mechanistic proposals cannot be accepted as a common framework for evolutionary causes. Finally, we outline some guidelines and requirements that any mechanistic proposal should meet in order to be applied to evolutionary theory.

The Principle of Stasis: Why drift is not a Zero-Cause Law.

This paper analyses the structure of evolutionary theory as a quasi-Newtonian theory and the need to establish a Zero-Cause Law. Several authors have postulated that the special character of drift is because it is the default behaviour or Zero-Cause Law of evolutionary systems, where change and not stasis is the normal state of them. For these authors, drift would be a Zero-Cause Law, the default behaviour and therefore a constituent assumption impossible to change without changing the system. I defend that drift's causal and explanatory power prevents it from being considered as a Zero-Cause Law. Instead, I propose that the default behaviour of evolutionary systems is what I call the Principle of Stasis, which posits that an evolutionary system where there is no selection, drift, mutation, migration, etc., and therefore no difference-maker, will not undergo any change (it will remain in stasis).