Checklists for Powder Inhaler Technique: A Review and Recommendations

Selection of Municipal Drinking Water Treatment Approach using Multiple Criteria

The pallet-loading problem, in which a number of identical boxes are to be packed orthogonally onto a rectangular pallet, has been the subject of several algorithms in recent years. These algorithms are concerned with maximizing the number of boxes fitted. In this paper, consideration is given to the development of loading patterns into pallet stacks, and criteria which might be applied to determine the suitability of these stacks for storage and transportation. A technique is developed which allows the stability and clampability of stacks to be tested, and this is applied to layouts produced by the recent algorithm of Bischoff and Dowsland. The relative importance of different criteria is illustrated and shown to have implications for the structure of algorithms that are to provide acceptable pallet stacks.

Batteries have been the predominant energy storage system used in electric vehicles. Battery packs have a large number of cells that develop charge, thermal, and capacity imbalances over time, limiting the power, range, and lifetime. Electronic battery management and state of charge (SoC) equalization methods are necessary to mitigate such imbalances. Today, it is possible to find a wide range of battery equalization methods in the literature, but how to decide which of these methods should be applied in practice? This paper compares 24 SoC equalization circuits that are typically found in automotive applications. We employ an analytic hierarchy process (AHP) approach to rank these equalization circuits according to multiple decision criteria (energy efficiency, equalization speed, implementation and control simplicity, hardware size, and total price). We also prepared a survey to collect design preferences from multiple battery balancing experts from around the world in order to better understand the relative importance of different criteria. The obtained results confirm that automotive engineers continue to favor passive balancing methods because of their low price, small PCB size, and implementation simplicity—despite the energy efficiency benefits of active balancing.

Basketball arenas are crucial spaces that must meet specific standards to ensure the sustainability of the sport and the quality of play. While Post-Occupancy Evaluation (POE) assesses these standards, it often assumes that all performance indicators are equally important, potentially leading to a gap between design intent and actual user experience. This study aims to bridge this gap by using the Analytic Hierarchy Process (AHP) to prioritize evaluation criteria for Turkish professional basketball arenas designed for national and international matches, regional/local competitions, and training programs. Existing studies and reports indicate that basketball arenas in Turkey often fall short in meeting necessary physical requirements and exhibit performance deficiencies. To address this gap, this study identifies factors determining arena performance, categorized as technical, functional, and behavioral based on Preiser's framework. These criteria were further categorized according to different spaces within the arena, including general use areas, administrative spaces, and athlete-specific areas. A panel of expert sports facility design professionals provided judgments about the relative importance of these criteria using pairwise comparisons. The AHP method was then employed to calculate priority weights for each criterion. The results reveal the relative importance of different criteria for each space. For example, in general use areas, "furniture suitability/sufficiency" and "provision of ergonomic conditions for the disabled" ranked highest. In administrative spaces, "fire protection" and "accessibility" were deemed most important, while in athlete-specific areas, "visual and auditory privacy" and "security" took precedence. This study demonstrates the potential of AHP for developing a systematic and reliable framework for qualitative evaluations that measure user satisfaction. AHP-based evaluation models offer a valuable tool for architects, facility managers, and decision-makers to assess architectural design quality, prioritize design criteria, and support user-centered design processes.

The impact of cumulative stress on asthma outcomes among urban adolescents

Real-world comparison of T2-biologics effectiveness in severe allergic asthma with nasal polyps.

The authors demonstrate that a Centers for Medicare and Medicaid Services (CMS) funded Community Asthma Initiative transition from a mixed nurse-community health worker model to a nurse supervised community health worker model could engender enhanced outcomes for hospitalizations and missed school and parent and/or guardian missed workdays.In the study, researchers included 389 patients were enrolled under the CMS grant from 2013–2015 at Boston Children’s Hospital and 733 Medicaid patients enrolled from 2005–2012 (comparison group).The 2 groups were compared at baseline, 6 months, and 12 months post enrollment for 5 asthma outcome measures: emergency department visits, hospitalizations, physical activity limitations, missed school days, and parent and/or guardian missed workdays. These measures were analyzed as dichotomous variables by using logistic regression, with the numbers of occurrences as continuous variables. A 13 question survey composed of activity and emotional health subscales was used to assess quality of life changes.The CMS group demonstrated more improvement in asthma outcomes, compared with the comparison group. They had a greater odds of decreased hospitalization (odds ratio: 3.13 [95% confidence interval: 1.49 to 6.59]), missed school days (odds ratio: 1.91 [95% confidence interval: 1.09 to 3.36]), and parent and/or guardian missed workdays (odds ratio: 2.72 [95% confidence interval: 1.15 to 6.41]). One year post enrollment, the CMS group experienced enhancement in all measured QoL parameters (all P values were <.01)The transition of the Community Asthma Initiative to a nurse supervised community health worker model for home visits resulted in positive impacts on asthma outcomes and quality of life.In the study, the authors highlight that home visits by nurse supervised community health workers can benefit pediatric asthma control and quality of life. The study is limited by fact that patient data were from 2 different time frames and the lack of spirometry testing to provide a more precise assessment of asthma control. The data supports that community engagement and home visits can be effective strategies to contain health care use and costs.

Ample evidence suggests a dose-response relationship between increasing weight and level of asthma risk or reduced asthma control. To establish reversibility, several randomized controlled trials (RCTs) have recently been published to investigate the impact of weight management on asthma. This systematic review synthesizes evidence from these RCTs on the effects of weight management (weight loss, weight maintenance, maintenance of lost weight, or weight gain prevention) interventions on asthma outcomes in both adult and pediatric populations. We searched Medline, CINAHL, PsychInfo, and Cochrane for studies published between 1950 and November 2014. Two researchers independently rated the included studies using the quality assessment tool for RCTs as outlined in the 2013 Obesity Treatment Guideline. Discrepancies were resolved by consensus after discussion between the raters and, if needed, with the senior author. Four RCTs in adults and 3 in children and adolescents were included. The adult studies seem to consistently support the benefit of substantial weight loss, but a threshold effect may exist such that only weight loss beyond a minimal amount will likely lead to clinically important improvement in asthma outcomes. Three of them suggest that the threshold may lie between 5-10% of weight loss. RCTs in youth suggest that modest calorie reductions alone or combined with increased physical activity, or even a healthy normocaloric diet, may lead to improved asthma outcomes. However, most RCTs reviewed were limited by small sample size, short intervention durations, and short follow-up periods. Trial evidence shows the promise of weight loss interventions for asthma control in adults and youth. More adequately-powered, long-term RCTs are needed to elucidate the role of weight loss and other weight management interventions in asthma control and prevention. Definitive data are needed to guide clinical and public health practice to effectively address the dual epidemic of obesity and asthma.

Background Suboptimal inhaler technique is an important reason of poor health outcomes in asthma & COPD patients. Various educational interventions to improve inhaler technique have been developed, yet the key characteristics of successful interventions have not been identified. Aims We aimed to systematically review RCTs of educational inhalation technique interventions to assess overall effectiveness and key success factors. Methods The MEDLINE, EMBASE and CINAHL databases were searched for RCTs on educational interventions to improve inhaler technique in asthma and COPD patients. Inclusion eligibility and quality appraisal (Cochrane Collaboration's risk of bias tool) were performed by two independent reviewers. Characteristics of the education (e.g. setting, provider, group size and time), study population, inhaler type, and outcomes were systematically extracted. Regression analyses were performed to identify key characteristics contributing to inhaler technique improvement. Results Thirty-seven of the 39 included studies showed statistically significant improvement of inhaler technique for educational intervention groups compared to control. Poor initial technique, setting, and time elapsed since intervention (all, p<0.05), were shown to have a significant impact on effectiveness of the intervention, explaining up to 91% of the effectiveness variation. Other factors, such as disease, group size, and inhaler type did not play a statistically significant role. Conclusion This study suggests that educational interventions to improve inhaler technique are generally effective, especially in patients with poor initial technique. However, they should be reinforced over time.

BackgroundChronic obstructive pulmonary disease (COPD) accounts for 10–12 % of primary care consultations, 7 % of hospital admissions and 35 % of chronic incapacity related to productivity. The misuse of inhalers is a significant problem in COPD because it is associated with reduced therapeutic drug effects leading to lack of control of both symptoms and disease. Despite all advice, health care professionals’ practice management of inhalation treatments is usually deficient. Interventions to improve inhaler technique by health care professionals are limited, especially among primary care professionals, who provide the most care to patients with COPD. The aim of this study is to evaluate the efficacy of an educational intervention to train general practitioners (GPs) in the right inhalation technique for the most commonly used inhalers.Methods/designWe are conducting a pragmatic cluster randomised controlled trial. The sample population is composed of 267 patients diagnosed with COPD using inhalation therapy selected from among those in 20 general practices, divided into two groups (control and intervention) by block randomisation at 8 primary care centres. The sample has two levels. The first level is patients with COPD who agree to participate in the trial and receive the educational intervention from their GPs. The second level is GPs who are primary health care professionals and receive the educational intervention. The intervention is one session of the educational intervention with a monitor given to GPs for training in the right inhalation technique. The primary outcome is correct inhalation technique in patients. Secondary outcomes are functional status (spirometry) and quality of life. The follow-up period will be 1 year. GPs will have two visits (baseline and at the 1-year follow-up visit. Patients will have four visits (at baseline and 3, 6 and 12 months). Analysis will be done on an intention-to-treat basis.DiscussionWe carried out three previous clinical trials in patients with COPD, which showed the efficacy of an educational intervention based on monitor training to improve the inhalation technique in patients. This intervention is suitable and feasible in the context of clinical practice. Now we are seeking to know if we can improve it when the monitor is the GP (the real care provider in daily practise).Trial registrationISRCTN Registry identifier ISRCTN93725230. Registered on 18 August 2014.

Background:Inhaled drug delivery has been hailed as a major advancement in respiratory therapeutics. However, a major limitation to use the inhaled medications effectively is the inability of patients and nurses to use and demonstrate the proper use of these devices correctly. Being the drug experts, pharmacists are in a pivotal position to delivered tailored education to their peers, the nurses.Aim:This study aims to examine nurses’ knowledge of asthma management, their ability to demonstrate proper inhaler technique, and the impact of a specialized workshop training program delivered by skilled pharmacists on improving their performance.Methods:This is a pre- and post-cross-sectional study design in hospital setting where nurses were recruited from the respiratory and emergency departments within a healthcare facility in the United Arab Emirates (UAE). The nurses attended a training workshop prepared and delivered by skilled pharmacists on inhaler technique demonstration skills. Nurses’ inhaler technique demonstration skills for Diskus, Turbuhaler, and pMDI were assessed at baseline, immediately after the workshop, and after four weeks. The nurses completed the demographic and Asthma Knowledge Questionnaire (AKQ).Results:A random convenience sample of registered nurses (n=20) from the respiratory and emergency departments was recruited from a tertiary hospital in Sharjah, UAE, with a mean age of 35.25 (SD=6.96) years, of whom 90% were females. The mean number of years of experience was 12.00 years (SD=5.81). Inhaler technique assessment revealed low inhaler technique scores for all the three study inhalers at baseline (mean score for Diskus=3.85 (SD=2.87); Turbuhaler=3.70 (SD=3.20); pMDI=4.50 (SD=2.65)) Significant improvements in inhaler technique scores were noted after the workshop (Diskus=8.9 (SD=0.31); Turbuhaler=8.9 (SD=0.31); pMDI=8.0 (SD=0.00), P<0.001). A significant difference in AKQ scores was found before (mean=4.85 (SD=1.27)) and after (mean=7.50 (SD=0.95)) the workshop training session (P<0.001), and four weeks after the workshop training session (mean=7.55 (SD=0.76), P<0.001).Conclusion:The UAE nurses’ inhaler technique and AKQ scores were suboptimal at baseline. The specialized training program prepared and delivered by the skilled pharmacists improved nurses’ inhaler technique demonstration skills and AKQ scores. Such improvements would reflect positively on patients’ asthma management outcomes as nurses are the health care professionals who interact the most with the patients during hospitalization.

RATIONALE: Poor inhaler technique is a pervasive problem among patients with chronic respiratory conditions. It has been associated with inadequate drug delivery and poor respiratory outcomes.OBJECTIVES: This pilot study assessed the feasibility of having registered Pharmacy Technicians (PT) in community pharmacies assess and correct inhaler technique at inhaler refill pick-ups.METHODS: Assessment and correction of inhaler technique was conducted by PTs in three community pharmacies during a 30-day period. For each patient interaction, the following data was collected: estimated patient age and sex, type of issue detected (if any), perceived patient response, and length of interaction. Semi-structured interviews were conducted with the PTs and pharmacy managers at the end of the 30-day period to assess perceptions and feasibility of expanding the service.MEASUREMENTS AND MAIN RESULTS: Eighty-five percent (40/47) of patients that were offered the assessment accepted and demonstrated their inhaler technique; the median interaction time was 3 minutes. More than half of patients (52.5%) demonstrated at least one technical error, all of which the PTs were able to correct. Almost all patients (39/40) were perceived to be either satisfied or very satisfied with the assessment. Five primary themes emerged from the interviews, including: feasibility, patient benefit, potential to reduce pharmacist workload, professional development/job satisfaction, and barriers.CONCLUSIONS: PTs helped to identify inhaler misuse in community pharmacies, and this study identified barriers and potential solutions for expanding the service. Future studies should investigate the benefit of the PT expanded role on clinical outcomes in asthma and chronic obstructive pulmonary disease (COPD).

Long-term effects of a peer-led asthma self-management program on asthma outcomes in adolescent peer leaders

<h3>Context</h3> Significant disparities in asthma outcomes occur by gender, race, ethnicity, and socioeconomic status. Many of these are from individual and system-level factors that contribute to poor asthma outcomes, which persist due to the lack of a comprehensive approach to asthma care. Improved asthma outcomes are associated with effective communication strategies between patients and providers. Coach McLungs is a shared decision-making IT intervention that engages patients, caregivers, and providers. <h3>Objective</h3> Descriptive statistics of asthma patient demographics from study associated primary care practices (practice cohort) indicated a diverse patient population (45% African American and 61% male), populations considered most at risk for asthma exacerbations. We compared the demographics of Coach McLung’s asthma patient utilizers (Coach McLung’s cohort) with those of the practice cohort, with the hypothesis that similar demographics would exist between the two cohorts, indicating representative demographic adoption of the intervention. <h3>Study Design and Analysis</h3> T-tests comparing gender and race between practice and Coach McLungs cohorts. <h3>Setting or Dataset</h3> patients with asthma diagnosis from 21 primary practices within Atrium Health, a large healthcare system, across Charlotte NC. <h3>Population Studied</h3> 5,241 patients with asthma diagnosis in the 18 months prior to the implementation of the project in January 2022 (practice cohort). 358 unique patients utilizing Coach McLungs between January 2022 to January 2024 (Coach McLungs cohort). <h3>Intervention/Instrument</h3> T-test statistical analysis. Patients who utilized Coach McLungs before a scheduled appointment with their primary care physician. <h3>Outcome Measures</h3> Proportions of gender and race of patients in both cohorts. <h3>Results</h3> T-test analysis showed a difference between males (60.9% practice vs. 52.2% Coach McLungs, P=0.005). For race, there was no difference for White/Caucasian (practice 44.5% vs Coach McLungs 45.5%, P=0.704) or Black/African American (practice 44.3% vs. Coach McLungs 45.3%, P=0.701). <h3>Conclusions</h3> Analysis of patients within the practice cohort shows a diverse population utilizing Coach McLungs. Although the patients who utilized Coach McLungs matched the overall patient population by race but not gender, patients from demographics at the highest risk for poor asthma outcomes are being proportionally reached by the intervention.

Asthma remains poorly controlled for many due to poor inhaler technique. This study evaluated the effectiveness of pharmacist-led inhaler technique education for 116 asthma inpatients in Jordan. Patients were divided into three groups: active 1 received education with a checklist label attached to their inhaler, active 2 received education with initial incorrect steps highlighted on the checklist label, and a control group received standard care. Asthma symptom control (assessed via the asthma control test questionnaire (ACT)), quality of life (assessed via the mini asthma quality of life questionnaire (mini AQLQ)), and adherence (assessed via the adult asthma adherence assessment questionnaire (AAAQ)) were assessed at baseline, pre-discharge, and three months later. Significant improvements were observed in inhaler techniques, with mean follow-up scores for ACT and mini AQLQ increasing notably. After three months, the mean difference in inhaler technique score between the groups was significant (0.711, p &amp;lt; 0.001). This study demonstrates that a simple, pharmacist-led intervention is feasible and can significantly improve inhaler technique and asthma outcomes in hospitalized patients.