The excessive carbon footprint of inhalers used in airway disease and its remedies

Abstract : The carbon footprint of human activities is a conversation topic worldwide. Many fields, including healthcare, have attempted to reduce their carbon footprint. For example, in Canada, 4.6% of greenhouse gases are manufactured by healthcare institutions. When it comes to the accountable parties in healthcare, the current treatments for asthma and chronic obstructive pulmonary disease are the main contributors. These highly prevalent diseases affect 11% and 10% of the Western populations, respectively. This editorial aims to discuss the impact of pressurized metered dose inhalers on the environment, alternatives and changes to current diagnostic and therapeutic practices, public awareness, potential changes to regulations and paths forward

Tackling "people remodelling" in corticosteroid-dependent asthma with type-2 targeting biologics and a formal corticosteroid weaning protocol

Abstract : People with severe corticosteroid-dependent asthma have greater morbidity, mortality and corticosteroid side effects than any other people with asthma. Just as type-2 inflammation and recurrent asthma attacks remodel airways, we propose the concept of ‘people remodelling’ to represent the utter disruption of people’s lives by the consequences of severe asthma and its associated corticosteroid treatments. To tackle this important problem, three biologics targeting type-2 inflammation – mepolizumab, benralizumab and dupilumab – have shown efficacy in tapering corticosteroids in dedicated phase III trials. We herein review the literature and propose an evidence-based, dose- and agent-specific corticosteroid weaning protocol for busy clinicians looking to achieve the best outcomes possible for their patients: independence from corticosteroids and reversal of people remodelling

Prédiction des courbes photosynthèse-lumière à l'aide de traits foliaires l'influence environnementale

Les modèles de foresterie et d'écologie végétale utilisent la lumière comme facteur central à la détermination de la photosynthèse.Les courbes mettant en relation le taux de photosynthèse nette et la quantité de lumière atteignant la feuille (courbes photosynthèse-lumière) utilisées par ces modèles sont cependant peu précises puisque les modèles actuels utilisent une courbe générale pour prévoir la photosynthèse de plusieurs espèces. On sait que ces courbes sont différentes pour chacune des feuilles existantes en nature, et qu'elles varient en fonction de l'environnement et de l'espèce de la feuille. Récemment, une association internationale de chercheurs a construit une base de données regroupant des traits foliaires pour des espèces provenant de la plupart des biomes terrestres et ont analysé ces données afin de dégager les relations unissant ces traits foliaires morphologiques et chimiques. D'après ces relations, il semble que les traits foliaires covarient entre eux selon un spectre unique qui est peu affecté par l'espèce ou l'environnement. En se basant sur ces résultats, des chercheurs ont tenté de déterminer s'il était possible de prévoir les courbes photosynthèse-lumière d'herbacées en prédisant les paramètres des fonctions mathématiques décrivant les courbes photosynthèse-lumière à l'aide de traits foliaires. Il s'est avéré possible de prévoir ces paramètres à l'aide des traits foliaires et, conséquemment, de prévoir les courbes photosynthèse-lumière des feuilles, pour des feuilles provenant du même environnement de croissance. On ne sait cependant pas si les courbes photosynthèse-lumière des feuilles issues d'un milieu de croissance différent pourront être prédites avec les mêmes relations allométriques reliant les traits foliaires aux paramètres.Les objectifs de cette étude sont donc de déterminer si l'environnement de croissance de la feuille aura un impact sur la généralité des prédictions des courbes photosynthèse-lumière à l'aide des relations allométriques entre les traits foliaires et les paramètres des fonctions décrivant ces courbes. Pour ce faire, nous avons fait pousser des herbacées dans des milieux contrastés de luminosité et de disponibilité en nutriments, dans des chambres de croissance. Nous avons ensuite mesuré les traits foliaires et les courbes photosynthèse-lumière de ces plantes pour vérifier si les relations allométriques unissant les traits aux paramètres des courbes différaient selon l'environnement. Il apparaît que les relations allométriques reliant les traits foliaires aux paramètres des courbes varient entre les environnements de croissance. Cependant, ces variations sont négligeables et n'empêchent pas une bonne prédiction des courbes photosynthèse-lumière à l'aide de relations générales qui ne sont pas spécifiques à l'environnement de croissance. Ces résultats sont intéressants puisqu'ils ouvrent la porte à l'obtention d'une plus grande précision des modèles de foresterie et d'écologie végétale qui utilisent la photosynthèse dans leurs calculs. Il serait en effet intéressant d'affiner la précision de l'estimation de la photosynthèse en substituant les équations limitées de ces modèles par de nouvelles relations mathématiques englobant plus d'espèces et permettant une précision supérieure

Cross-border mobility and therapeutic itinerary of Haitians in the Ouanaminthe region

Background On 16 September 2017, 40 Haitian, including 15 pregnant Haitian women, were arrested at the Dominican border and repatriated. This information relayed by the Haitian press echoes those published by some Dominican newspapers, which repeatedly denounce the care provided by Dominican public hospitals to Haitian patients and its impact on the health care system. Nevertheless, very few studies in Haiti or the Dominican Republic have addressed this issue even though s..

Mobilité transfrontalière et itinéraire thérapeutique des Haïtiennes et des Haïtiens de la région de Ouanaminthe

Cette étude aborde la mobilité thérapeutique transfrontalière entre deux pays à faibles revenus, Haïti et la République dominicaine. L’objectif est d’explorer les logiques qui sous-tendent la recherche de soins des Haïtiens et Haïtiennes résidant dans la ville frontalière de Ouanaminthe. En plus de cerner les motivations du recours transfrontalier aux soins de santé, l’étude qualitative propose de le situer dans l’itinéraire thérapeutique. Vingt et un entretiens semi-dirigés auprès de patientes et patients ont été menés dans deux cliniques privées et un hôpital public à Dajabón (République dominicaine). Sept entretiens ont aussi été menés avec des cliniciens et gestionnaires. Ces récits révèlent que la recherche d’efficacité et de qualité, la relation patient/médecin et le temps d’attente interviennent dans la décision de se faire soigner en République dominicaine. Le cheminement thérapeutique des patientes et patients n’est pas linéaire, mais fait de va-et-vient, selon les besoins, entre deux systèmes de santé originellement disjoints.Background On 16 September 2017, 40 Haitian, including 15 pregnant Haitian women, were arrested at the Dominican border and repatriated. This information relayed by the Haitian press echoes those published by some Dominican newspapers, which repeatedly denounce the care provided by Dominican public hospitals to Haitian patients and its impact on the health care system. Nevertheless, very few studies in Haiti or the Dominican Republic have addressed this issue even though several authors have pointed out the existence of health care related cross-border mobility. Moreover, the reasons for such mobility are rarely analyzed. For some, the lack of services in Haiti and free access to health care in the Dominican Republic are identified as the main drivers for such behavior. Yet crossing the border (even at official entry points) is not always easy for Haitians. Our paper asks: what then are the driving factors that lead to cross-border health care seeking? At what point in the therapeutic itinerary is such a decision made? Evidence from studies on transnational health related mobility indicates that availability, affordability, accessibility, familiarity and perception of service quality play a role in the decision-making. Furthermore, in a context of proximity with the border, attractiveness of care can polarize the flows in a push/pull dynamics. Several studies also highlight the importance of social networks and ethnolinguistic factors in the decision to travel or return to their country of origin after care has been sought. Dissatisfaction with local services and hope for better care are also among the identified driving factors. This lead to complex and sinuous therapeutic paths within and outside one’s country. The main purpose of this paper is to explore the rationale behind the health-related cross-border mobility of Haitians living in or near the border town of Ouanaminthe, Haiti. The driving factors will also be identified and cross-border health utilization will be contextualized within the overall therapeutic itinerary. Methods This descriptive qualitative study used several combined methods, namely observation and semi-directive interviews. Overall, 28 interviews were carried out (21 patients, 7 Dominican and Haitian clinicians or decision makers). The interviews with cross-border patients focused mainly on their therapeutic itinerary, the motives behind this decision, obstacles encountered and their perceptions of the quality of care received both in Haiti and the Dominican Republic. Interviews with the clinicians and decision makers helped gathered information on health care facilities, their attendance by Haitian clients and the existing collaboration or system of medical referral between Haiti and the Dominican Republic. An iterative thematic analysis process was conducted. First, a pre-coding based and initial thematic categories inspired from the literature was used. From this process, other thematic categories have emerged, pointing to context specific issues. Findings Patients’ cross-border health seeking is not linear, but rather a back and forth process between two separate health care systems. For some participants, it lasts several years, while for others, it leads to a first visit. The results show that visiting different health care facilities for the same health problem (or evolving symptoms over time) is usual. Having a second opinion is a frequently reported reason (for both patients and clinicians). The study also shows that cross-border health seeking requires participants to mobilize various skills such as familiarity with the health care system, border crossing experience and abilities, and knowledge of the Dominican language. Respondents also emphasized three main issues related to the Haitian health system that led them to cross-border for health care in the Dominican Republic: 1) the search for efficiency and service quality; 2) the poor patient/clinician relationship; 3) excessive waiting times. Furthermore, the importance of social networks and the strategies used to overcome language barrier is striking. Both clinicians and patients implement different strategies to enable appropriate care. Participants also underlined the important financial burden required to seek treatment abroad. Conclusion The cross-border health-related mobility practices observed in Ouanaminthe have many similarities with those analyzed in other contexts. Some aspects have been highlighted but need to be deepened to gain a better understanding of the health-seeking behavior as well as the strategies in place to cope with the expenses. An in-depth understanding of individual behaviors and strategies can help in the definition of public health policies and the development of a framework for a bilateral cooperation that takes into account cross-border health mobility practices and the thorny issue of migration

Brane Bremsstrahlung in DBI Inflation

We consider the effect of trapped branes on the evolution of a test brane whose motion generates DBI inflation along a warped throat. The coupling between the inflationary brane and a trapped brane leads to the radiation of non-thermal particles on the trapped brane. We calculate the Gaussian spectrum of the radiated particles and their backreaction on the DBI motion of the inflationary brane. Radiation occurs for momenta lower than the speed of the test brane when crossing the trapped brane. The slowing down effect is either due to a parametric resonance when the interaction time is small compared to the Hubble time or a tachyonic resonance when the interaction time is large. In both cases the motion of the inflationary brane after the interaction is governed by a chameleonic potential,which tends to slow it down. We find that a single trapped brane can hardly slow down a DBI inflaton whose fluctuations lead to the Cosmic Microwave Background spectrum. A more drastic effect is obtained when the DBI brane encounters a tightly spaced stack of trapped branes.Comment: 20 pages, 1 figur

A value-based comparison of the management of ambulatory respiratory diseases in walk-in clinics, primary care practices, and emergency departments : protocol for a multicenter prospective cohort study

Background: In Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal. Objective: The aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. Methods: A multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness. Results: Phase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025. Conclusions: The end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative

A collaborative model to implement flexible, accessible and efficient oncogenetic services for hereditary breast and ovarian cancer : the C-MOnGene study

Medical genetic services are facing an unprecedented demand for counseling and testing for hereditary breast and ovarian cancer (HBOC) in a context of limited resources. To help resolve this issue, a collaborative oncogenetic model was recently developed and implemented at the CHU de Québec-Université Laval; Quebec; Canada. Here, we present the protocol of the C-MOnGene (Collaborative Model in OncoGenetics) study, funded to examine the context in which the model was implemented and document the lessons that can be learned to optimize the delivery of oncogenetic services. Within three years of implementation, the model allowed researchers to double the annual number of patients seen in genetic counseling. The average number of days between genetic counseling and disclosure of test results significantly decreased. Group counseling sessions improved participants' understanding of breast cancer risk and increased knowledge of breast cancer and genetics and a large majority of them reported to be overwhelmingly satisfied with the process. These quality and performance indicators suggest this oncogenetic model offers a flexible, patient-centered and efficient genetic counseling and testing for HBOC. By identifying the critical facilitating factors and barriers, our study will provide an evidence base for organizations interested in transitioning to an oncogenetic model integrated into oncology care; including teams that are not specialized but are trained in genetics