Monitoring Adherence to Asthma Inhalers Using the InspirerMundi App: Analysis of Real-World, Medium-Term Feasibility Studies

Background: Poor medication adherence is a major challenge in asthma and objective assessment of inhaler adherence is needed. InspirerMundi app aims to monitor inhaler adherence while turning it into a positive experience through gamification and social support. Objective: We assessed the medium-term feasibility of the InspirerMundi app to monitor inhaler adherence in real-world patients with persistent asthma (treated with daily inhaled medication). In addition, we attempted to identify the characteristics of the patients related to higher app use. Methods: Two real-world multicenter observational studies, with one initial face-to-face visit and a 4-month telephone interview, were conducted in 29 secondary care centers from Portugal. During an initial face-to-face visit, patients were invited to use the app daily to register their asthma medication intakes. A scheduled intake was considered taken when patients took a photo of the medication (inhaler, blister, or others) using the image-based medication detection tool. Medication adherence was calculated as the number of doses taken as a percentage of the number scheduled. Interacting with the app ≥30 days was used as the cut-off for higher app use. Results: A total of 114 patients {median 20 [percentile 25 to percentile 75 (P25-P75) 16-36] years, 62% adults} were invited, 107 (94%) installed the app and 83 (73%) completed the 4-month interview. Patients interacted with the app for a median of 18 [3-45] days, translated on a median use rate of 15 [3-38]%. Median inhaler adherence assessed through the app was 34 [4-73]% when considering all scheduled inhalations for the study period. Inhaler adherence assessed was not significantly correlated with self-reported estimates. Median adherence for oral and other medication was 41 [6-83]% and 43 [3-73]%, respectively. Patients with higher app use were slightly older (p = 0.012), more frequently taking medication for other health conditions (p = 0.040), and more frequently prescribed long-acting muscarinic antagonists (LAMA, p = 0.024). After 4 months, Control of Allergic Rhinitis and Asthma Test (CARAT) scores improved (p < 0.001), but no differences between patients interacting with the app for 30 days or less were seen. Conclusions: The InspirerMundi app was feasible to monitor inhaler adherence in patients with persistent asthma. The persistent use of this mHealth technology varies widely. A better understanding of characteristics related to higher app use is still needed before effectiveness studies are undertaken.info:eu-repo/semantics/publishedVersio

Safety and Revisit Related to Discharge the Sixty-one Spanish Emergency Department Medical Centers Without Hospitalization in Patients with COVID-19 Pneumonia. A Prospective Cohort Study UMC-Pneumonia COVID-19

Background: Information is needed on the safety and efficacy of direct discharge from the emergency department (ED) of patients with COVID-19 pneumonia. Objectives: The objectives of the study were to study the variables associated with discharge from the ED in patients presenting with COVID-19 pneumonia, and study ED revisits related to COVID-19 at 30 days (EDR30d). Methods: Multicenter study of the SIESTA cohort including 1198 randomly selected COVID patients in 61 EDs of Spanish medical centers from March 1, 2020, to April 30, 2020. We collected baseline and related characteristics of the acute episode and calculated the adjusted odds ratios (aOR) for ED discharge. In addition, we analyzed the variables related to EDR30d in discharged patients. Results: We analyzed 859 patients presenting with COVID-19 pneumonia, 84 (9.8%) of whom were discharged from the ED. The variables independently associated with discharge were being a woman (aOR 1.890; 95%CI 1.176-3.037), age 1200/mm(3) (aOR 4.667; 95%CI 1.045-20.839). The EDR30d of the ED discharged group was 40.0%, being lower in women (aOR 0.368; 95%CI 0.142-0.953). A total of 130 hospitalized patients died (16.8%) as did two in the group discharged from the ED (2.4%) (OR 0.121; 95%CI 0.029-0.498). Conclusion: Discharge from the ED in patients with COVID-19 pneumonia was infrequent and was associated with few variables of the episode. The EDR30d was high, albeit with a low mortality

A miniature world in decline: European Red List of Mosses, Liverworts and Hornworts

AimThis Red List is a summary of the conservation status of the European species of mosses, liverworts and hornworts, collectively known as bryophytes, evaluated according to IUCN’s Guidelines for Application of IUCN Red List Criteria at Regional Level. It provides the first comprehensive, region-wide assessment of bryophytes and it identifies those species that are threatened with extinction at a European level, so that appropriate policy measures and conservation actions, based on the best available evidence, can be taken to improve their status.ScopeAll bryophytes native to or naturalised in Europe (a total of 1,817 species), have been included in this Red List. In Europe, 1,796 species were assessed, with the remaining 21 species considered Not Applicable (NA). For the EU 28, 1,728 species were assessed, with a remaining 20 species considered NA and 69 species considered Not Evaluated (NE). The geographical scope is continentwide, extending from Iceland in the west to the Urals in the east, and from Franz Josef Land in the north to theCanary Islands in the south. The Caucasus region is not included. Red List assessments were made at two regional levels: for geographical Europe and for the 28 Member States of the European Union.ResultsOverall, 22.5% of European bryophyte species assessed in this study are considered threatened in Europe, with two species classified as Extinct and six assessed as Regionally Extinct (RE). A further 9.6% (173 species) are considered Near Threatened and 63.5% (1,140 species) are assessed as Least Concern. For 93 species (5.3%), there was insufficient information available to be able to evaluate their risk of extinction and thus they were classified as Data Deficient (DD). The main threats identified were natural system modifications (i.e., dam construction, increases in fire frequency/intensity, and water management/use), climate change (mainly increasing frequency of droughts and temperature extremes), agriculture (including pollution from agricultural effluents) and aquaculture.RecommendationsPolicy measures• Use the European Red List as the scientific basis to inform regional/national lists of rare and threatened species and to identify priorities for conservation action in addition to the requirements of the Habitats Directive, thereby highlighting the conservation status of bryophytes at the regional/local level.• Use the European Red List to support the integration of conservation policy with the Common Agricultural Policy (CAP) and other national and international policies. For example, CAP Strategic Plans should include biodiversity recovery commitments that could anticipate, among others, the creation of Important Bryophyte Areas. An increased involvement of national environmental agencies in the preparation of these strategic plans, and more broadly in ongoing discussions on the Future CAP Green Architecture, would likely also ensure the design of conservation measures better tailored to conserve bryophytes in agricultural landscapes.• Update the European Red List every decade to ensure that the data remains current and relevant.• Develop Key Biodiversity Areas for bryophytes in Europe with a view to ensuring adequate site-based protection for bryophytes.Research and monitoring• Use the European Red List as a basis for future targeted fieldwork on possibly extinct and understudied species.• Establish a monitoring programme for targeted species (for example, threatened species and/or arable bryophytes).• Use the European Red List to obtain funding for research into the biology and ecology of key targeted species.Action on the ground• Use the European Red List as evidence to support multi-scale conservation initiatives, including designation of protected areas, reform of agricultural practices and land management, habitat restoration and rewilding, and pollution reduction measures.• Use the European Red List as a tool to target species that would benefit the most from the widespread implementation of the solutions offered by the 1991 Nitrates Directive (Council Directive 91/676/EEC), including the application of correct amounts of nutrients for each crop, only in periods of crop growth under suitable climatic conditions and never during periods of heavy rainfall or on frozen ground, and the creation of buffer zones to protect waters from run-off from the application of fertilizers.Ex situ conservation• Undertake ex situ conservation of species of conservation concern in botanic gardens and spore and gene banks, with a view to reintroduction where appropriate.</p

What Do We Know about Growth Patterns in Pakistan?

This paper explores stylized facts of Pakistan's growth patterns. It identifies the short-lived predominant character of its increasingly scarce growth accelerations, the average volatility of the growth rate by international standards, the high but decreasing correlation between overall growth and agricultural growth, the long term decline of its growth (potential) rate to around 4.5 percent, well below the 6 percent rate of the 1960s or from the 7 percent rate required for absorbing the young labor force. It also explores the dramatically steady fall in productivity during the 2000s (measured by Total Factor Productivity) and, to a lesser extent, capital accumulation as main reasons of such decline. The paper analyzes the role factor accumulation plays in long-term labor reallocation across sectors, with industry stalling, agriculture still playing a major role that goes beyond its own contribution to GDP, and services playing an increasing role in creating employment, but on low productivity jobs. Growth acceleration is not assured and Pakistan will need to create more jobs moving from agriculture to industry and services in activities where productivity is higher, but to do this, curbing the factors that constraint growth overall and sectoral and Total Factor Productivity in particular will be essential

Hemoperfusion with activated charcoal in the treatment of severe poisoning by carbamazepine

RESUMO Caso clínico: Os autores apresentam o caso de uma adolescente admitida no Serviço de Urgência por alterações neurológicas de início agudo e progressivas, existindo na residência um familiar medicado com um antiepiléptico. A avaliação inicial revelou sonolência, discurso adequado, disartria, nistagmo, dismetria bilateral e ataxia da marcha. Foi efectuado doseamento sérico de carbamazepina, que revelou valores muito elevados, confirmando intoxicação aguda por este fármaco. Não houve resposta à administração com carvão activado por via gastrointestinal, havendo mesmo agravamento do estado de consciência. Por esta razão, iniciou hemoperfusão com carvão activado, com recuperação completa do quadro neurológico ao fim de três horas de tratamento. Conclusão: Os autores sublinham as dificuldades na abordagem de intoxicações graves provocadas por fármacos com forte ligação às proteínas, realçando a eficácia da hemoperfusão com carvão activado.ABSTRACT Case report: The authors present a case of a teenage girl admitted to the emergency room with a sudden progressive neurologic disorder. A family member was on antiepileptic drug treatment. The initial assessment revealed a drowsy adolescent with appropriate speech, though dysarthric, presenting nystagmus and bilateral dysmetria and gait ataxia. Serum assay was performed and revealed high levels of carbamazepine thus confirming acute poisoning with this drug. Activated charcoal therapy was done with no reponse, even with deterioration of the level of consciousness. Hemoperfusion with activated charcoal was then performed with complete neurological recovery within three hours. Conclusion: The authors underline the difficulties in dealing with severe cases of poisoning caused by drugs with high protein binding and emphasize the effectiveness of hemoperfusion with activated charcoal

Hydrops fetalis – pathology of past, present and… future? A retrospective study

RESUMO Introdução: A hidropisia fetal define-se por uma acumulação anormal de fluído intersticial no feto. Descrita inicialmente como uma entidade patológica única, Ballantyne em 1892 levantou a hipótese de representar um estado final comum a uma variedade de processos patológicos diferentes. Potter distingue 2 tipos: imune (mais frequente na era prévia à utilização da RhoGAM) e não imune (implicada actualmente em cerca de 90% dos casos). Apesar de todos os avanços de diagnóstico, a hidropisia fetal continua a ser uma entidade desafiante na medicina perinatal. O objectivo deste estudo foi analisar os casos de hidropisia fetal numa Unidade de Cuidados Intensivos Neonatais (UCIN), para avaliação de etiologia, morbilidade e mortalidade. Pacientes e métodos: Os autores apresentam cinco casos de hidropisia fetal tratados numa Unidade de Cuidados Intensivos Neonatais entre Setembro de 2005 a Janeiro de 2009, ilustrativos de diferentes etiologias. O estudo baseou-se na análise retrospectiva dos processos das mães e recém-nascidos, com avaliação dos dados obstétricos e neonatais. Resultados: De Setembro de 2005 a Janeiro de 2009 foram internados na Unidade 1923 recém-nascidos dos quais cinco com diagnóstico de hidropisia fetal. Destes, três casos foram de causa não imune (fibromatose generalizada congénita; diabetes materna e cardiomiopatia dilatada; quilotórax congénito), um caso por iso-imunização Rh e o outro de causa idiopática. Só um dos casos tinha diagnóstico pré-natal. A mortalidade na nossa série foi de 40%. Conclusão: Apesar da melhoria no diagnóstico e abordagem terapêutica, a elevada taxa de morbilidade e mortalidade permanece, sendo de extrema importância o diagnóstico pré-natal precoce. Este permite determinar a etiologia, antecipar problemas, tomar decisões clínicas de acordo com o prognóstico esperado e também o aconselhamento genético/ DPN. Uma boa coordenação multidisciplinar, envolvendo neonatologistas, obstetras e patologistas é essencial.ABSTRACT Introduction: Hydrops fetalis is defined by an abnormal accumulation of interstitial fluid in fetuses. Initially described as a unique pathologic entity, in 1892 Ballantyne suggested it might represent a final state common to a variety of different pathologic processes. Potter distinguishes 2 types: immune (more frequent till the discovering of RhoGAM) and non immune (90% of the cases nowadays, with an estimated incidence of 1 in 1500 to 3800 births). Besides all advances in diagnosis, hydrops fetalis still remains a defying entity in perinatal medicine. The aim of this review was to analyze the cases of hydrops fetalis in a Neonatal Intensive Care Unit (NICU) to assess etiology, morbidity and mortality. Patients and methods: The authors present five cases of hydrops fetalis treated in a NICU, from September 2005 to January 2009, illustrating different aetiologies. The study was based on the retrospective analysis of mothers and newborns’ medical files evaluating obstetric and perinatal parameters, diagnosis, treatment and evolution. Results: From September 2005 to January 2009, 1923 newborns were admitted in NICU. Five had the diagnosis of hydrops fetalis. Three of these were of non immune cause (congenital generalized fibromatosis, maternal diabetes and dilated cardiomyopathy and congenital chylothorax), one of Rh iso-immunization and the last of unknown aetiology. Only one of the cases had prenatal diagnosis. The group mortality was of 2/5 cases (40%). Conclusion: Besides the improvement in diagnosis and therapeutic approach, the high mortality and morbidity rates still remain, being extremely important an early prenatal diagnosis. This allows the determination of the aetiology, anticipating problems, making clinical decision based on the expected prognosis and also the genetic counselling. An excellent multidisciplinary coordination, involving neonatologists, obstetricians and pathologists is essential

Validation of app and phone versions of the Control of Allergic Rhinitis and Asthma Test (CARAT)

Assessment of asthma control at every opportunity is recommended. Control of Allergic Rhinitis and Asthma Test (CARAT) is a patient reported outcome measure commonly used to assess asthma control in clinical practice.It includes ten questions answered in a 4 point Like rt scale that address upper and lower airway symptoms, sleep interference, limitation of activities , and the need to increase medication over a 4 week period. CARAT is frequently administered on paper during medical visits, but digital versions through website and mobile apps are available.info:eu-repo/semantics/publishedVersio