Effects and acceptability of implementing improved cookstoves and heaters to reduce household air pollution: a FRESH AIR study

The objective was to evaluate the effectiveness and acceptability of locally tailored implementation of improved cookstoves/heaters in low- and middle-income countries. This interventional implementation study among 649 adults and children living in rural communities in Uganda, Vietnam and Kyrgyzstan, was performed after situational analyses and awareness programmes. Outcomes included household air pollution (PM2.5 and CO), self-reported respiratory symptoms (with CCQ and MRC-breathlessness scale), chest infections, school absence and intervention acceptability. Measurements were conducted at baseline, 2 and 6-12 months after implementing improved cookstoves/heaters. Mean PM2.5 values decrease by 31% (to 95.1 µg/m3) in Uganda (95%CI 71.5-126.6), by 32% (to 31.1 µg/m3) in Vietnam (95%CI 24.5-39.5) and by 65% (to 32.4 µg/m3) in Kyrgyzstan (95%CI 25.7-40.8), but all remain above the WHO guidelines. CO-levels remain below the WHO guidelines. After intervention, symptoms and infections diminish significantly in Uganda and Kyrgyzstan, and to a smaller extent in Vietnam. Quantitative assessment indicates high acceptance of the new cookstoves/heaters. In conclusion, locally tailored implementation of improved cookstoves/heaters is acceptable and has considerable effects on respiratory symptoms and indoor pollution, yet mean PM2.5 levels remain above WHO recommendations.European Union’s Horizon 2020 programme under grant agreement no. 680997, TRIAL ID NTR5759, http://www.trialregister.nl/trialreg/admin/rctsearch.asp?Term=23332. The devices, measuring the personal HAP, were funded by Netherlands Enterprise Agency (RVO

COPD’s early origins in low-and-middle income countries: what are the implications of a false start?

[Excerpt] The Global Initiative for chronic Obstructive Lung disease (GOLD)guideline of 2018 describes COPD as‘the result of a complexinterplay of long-term cumulative exposure to noxious gases andparticles, combined with a variety of host factors includinggenetics, airway hyper-responsiveness and poor lung growthduring childhood’.1Tobacco smoking is traditionally viewed as themain contributing factor to the development of COPD. However,COPD also occurs among non-smokers, especially in low-incomeand middle-income countries (LMICs).2,3Notably, more than 90%of COPD-related deaths occur in LMICs.4For these countries, otherrisk factors, such as ambient, occupational and household airpollution play a significant role in the development of COPD.1,2,5–7Does COPD in these settings have a different pathophysiologicaltrajectory compared to COPD in high-income countries, and if so:what does this imply?In normal lung development, airway branching is completed bythe 17th week of gestation, after which airways increase in volumeuntil young adulthood. Alveoli are present at birth and developfurther during childhood. Lung volume and airflow continue toincrease as the thorax grows, influenced by age, sex, and ethnicity,reaching a peak at young adulthood. Lung function then remainsconstant for about 10 years (the plateau phase), after which itgradually declines.8In the‘classic’COPD patient, the decline inlung function is more rapid than in healthy individuals. However,in a considerable proportion of COPD patients, lung function doesnot decline rapidly, but reaches a lower plateau phase in earlyadulthood instead. For these patients, a completely differentpathophysiological trajectory seems to lead to the diagnosis ofCOPD: the decline in lung function follows a normal pattern, yetthey seem to have a‘false start’by attaining a lower maximumlung function. [...

Burden and risk factors for Pseudomonas aeruginosa community-acquired pneumonia:a Multinational Point Prevalence Study of Hospitalised Patients

Pseudornonas aeruginosa is a challenging bacterium to treat due to its intrinsic resistance to the antibiotics used most frequently in patients with community-acquired pneumonia (CAP). Data about the global burden and risk factors associated with P. aeruginosa-CAP are limited. We assessed the multinational burden and specific risk factors associated with P. aeruginosa-CAP. We enrolled 3193 patients in 54 countries with confirmed diagnosis of CAP who underwent microbiological testing at admission. Prevalence was calculated according to the identification of P. aeruginosa. Logistic regression analysis was used to identify risk factors for antibiotic-susceptible and antibiotic-resistant P. aeruginosa-CAP. The prevalence of P. aeruginosa and antibiotic-resistant P. aeruginosa-CAP was 4.2% and 2.0%, respectively. The rate of P. aeruginosa CAP in patients with prior infection/colonisation due to P. aeruginosa and at least one of the three independently associated chronic lung diseases (i.e. tracheostomy, bronchiectasis and/or very severe chronic obstructive pulmonary disease) was 67%. In contrast, the rate of P. aeruginosa-CAP was 2% in patients without prior P. aeruginosa infection/colonisation and none of the selected chronic lung diseases. The multinational prevalence of P. aeruginosa-CAP is low. The risk factors identified in this study may guide healthcare professionals in deciding empirical antibiotic coverage for CAP patients

Electric scooters: batteries in the battle against ambient air pollution?

Public Health and primary carePrevention, Population and Disease management (PrePoD

PDB34 A PERSONALIZED SCREENING STRATEGY FOR DIABETIC RETINOPATHY:A COST-EFFECTIVENESS PERSPECTIVE

Objectives: Diabetic retinopathy (DR) is one of the leading causes of visual impairment and blindness. However, only a minority of the type 2 diabetes population is at risk of sight-threatening retinopathy (STR). Most current DR screening programs recommend that these patients should be screened annually or biennially. Recently, a prediction model for DR was developed. Combined with the appropriately chosen STR risk margin this resulted in personalized screening intervals. We examined the cost-effectiveness of using this personalized model compared with annual screening and the most recent Dutch guideline algorithm. Methods: DR screening intervals were determined for STR risk margins ranging from 0.0% to 4.0%, for each individual. Observational data (1998-2017) of the Diabetes Care System, a cohort of people with type 2 diabetes, were used (N=5,514). Missed cases were determined by comparing model based screening to observed grades of DR, then, costs were calculated based on screening and travel costs. Real time to develop STR was missing for 22 percent of STR cases, for these an optimistic and a pessimistic scenario were assumed. Finally, savings per missed case were determined, as compared with annual screening for finding the best risk margin and then this model was compared with the Dutch guideline algorithm. Results: The risk margins that maximized the savings per missed case compared to annual screening were 2.7% (€12,500) and 3.0% (€15,900) for the pessimistic and optimistic scenarios, respectively. Screening patients according to the Dutch guideline led to more missed cases (N=10) as well as higher costs compared to personalized screening (C=€2.1 per patient). Conclusions: A personalized DR screening model with a risk margin of around 3.0% is cheaper and more effective than the Dutch guideline. Assuming 800,000 diabetes patients in the Netherlands, implementing this personalized model could save 8.3 to 8.8 million euros annually

Cost-effectiveness of increasing bisphosphonates adherence for osteoporosis in community pharmacies

OBJECTIVES: Increasing real-life adherence to bisphosphonates therapy is important to achieve the clinical benefits of reducing fractures reported in randomized clinical trials (RCTs). The aim of this pharmacoeconomic analysis was to determine the cost-effectiveness of a pharmaceutical care intervention program in community pharmacies, aimed to increase bisphosphonates adherence for the prevention of osteoporotic fractures. METHODS: A decision analytical model was constructed with a time horizon of three years, discounting at 4.0% and 1.5% annually for costs and effects, respectively. A Dutch healthcare provider's perspective was adopted. Adherence and efficacy data were gathered from a Dutch pharmaceutical care program in community pharmacies (the MeMO intervention). The association between bisphosphonate adherence and osteoporotic fractures was modelled using Dutch clinical studies. Recent and upcoming reimbursement policy changes in The Netherlands were modelled with a scenario of therapeutic substitution, characterized by drastically lower drug prices. RESULTS: Adherence to bisphosphonates therapy in The Netherlands was 68.3%. The pharmaceutical care intervention program increased bisphosphonates adherence to 83.9% (

Effectiveness, usability and acceptability of a smart inhaler programme in patients with asthma: protocol of the multicentre, pragmatic, open-label, cluster randomised controlled ACCEPTANCE trial

IntroductionSuboptimal asthma control is associated with incorrect inhaler use and poor medication adherence, which could lead to unfavourable clinical and economic outcomes. Smart inhaler programmes using electronic monitoring devices (EMDs) could support self-management and increase medication adherence and asthma control. However, evidence on long-term benefits and acceptability is scarce. This study aims to investigate the effectiveness of a smart inhaler asthma self-management programme on medication adherence and clinical outcomes in adults with uncontrolled asthma, to evaluate its acceptability and to identify subgroups who would benefit most based on patient characteristics.Methods and analysisThis open-label cluster randomised controlled trial of 12 months will be conducted in primary care in the Netherlands. General practices will be randomly assigned to either intervention or control group. We aim to include 242 patients. The intervention consists of (1) an EMD attached to the patient's inhaler that measures medication use; (2) a smartphone application to set medication reminders, receive motivational messages and track asthma symptoms; and (3) a portal for healthcare professionals to view data on medication use. The control group is passively monitored by the EMD but cannot view their inhaler data or receive feedback. Eligible patients are adults with suboptimal controlled asthma (Asthma Control Questionnaire score >= 0.75) with evidence of non-adherence established by the EMD during a 6-week run-in period. Primary outcome is the difference in mean medication adherence between intervention and control group. Secondary outcomes include asthma control, asthma-related quality of life, exacerbations, acceptance, cost-effectiveness and whether the effect of the intervention on medication adherence and asthma control is modified by patient characteristics (eg, self-efficacy, medication beliefs and eHealth literacy).Prevention, Population and Disease management (PrePoD)Public Health and primary car