Martin Balzan

Predictors of seasonal influenza vaccination in chronic asthma.

BackgroundGuidelines advise annual influenza vaccination in chronic asthma. The aim of this study was to determine uptake of the influenza vaccine in a group of patients (n = 146) with moderate to severe chronic asthma and establish the main predictors of vaccination.MethodPatients attending a hospital asthma clinic were asked to complete a questionnaire in February 2012 (n = 146). These same patients were contacted a year later via telephone (n = 109 responded), and they were asked to complete the same questionnaire.ResultsVaccination rate was 50.3% in winter 2011/12, and 57.8% in 2012/13. Using binary logistic regression, the predictors for vaccination in 2012 were patient advice (Odds ratio [OR] 15.37 p = 0.001), female gender (OR 2.75, p = 0.028), past side effects (OR 0.21, p = 0.001) and comorbidity (OR 0.39, p = 0.013). Stepwise regression resulted in age as predictor (T value = 3.99, p = 0.001). On analyzing the responses from the second questionnaire at one year after attendance to asthma clinic, predictors changed to compliance to medication (OR 9.52, p= 0.001) and previous exacerbations (OR 4.19, p = 0.026). Out of the 56 patients vaccinated in 2011/12, 33 reported asthma exacerbations before 2012, and 29 reported asthma exacerbations after receiving the influenza vaccine. Out of the 46 unvaccinated patients in 2012, 27 had asthma exacerbations before 2012 and 19 patients had exacerbations in 2013. Patients vaccinated in 2011/12 needed 0.59 courses of steroid/patient/year, and 1.23 visits for nebulizer/patient/year while non-vaccinated patients needed 0.18 courses of steroids/patient/year (p = 0.048), and 0.65 visits for nebulized/patient/year (p = 0.012). Patients’ subjective statements broadly confirmed the predictors. 16/69 (23.1%) received the vaccine in winter 2012/13 despite reporting previous side effects.ConclusionsAdvice to patient, female gender and patients’ age predicted vaccination, while past side effects to the influenza vaccine, and presence of comorbidities predicted non vaccination. Symptomatic asthma patients are more likely to be vaccinated. One year after the first contact, treatment compliance and previous asthma exacerbations gained statistical significance as predictors of vaccination.

Predictors of correct technique in patients using pressurized metered dose inhalers

BackgroundCorrect inhaler technique is recommended by guidelines for optimum asthma care. The objective of the study is to determine real life predictors of correct pressurized metered dose inhaler (pMDI) technique in Asthma and COPD patients.MethodsTwo hundred eight adult patients aged 18+ from respiratory outpatients (69.2%) and the community on regular pMDI for a diagnosis of Asthma (78.9%) or COPD, were recruited. A questionnaire containing 31 possible predictors was administered and pMDI technique with or without spacer was observed by trained researchers on 12 point steps, of which 4 were considered critical.Results23.1% of patients had no errors in inhaler technique and 32.2% had no critical errors. Patients had a median of 10 correct steps (IQR9-11), and 3(IQR2-4) correct critical steps. Using binary logistic regression the predictors of 10 correct steps were, other healthcare professional (pharmacist, nurse, physiotherapist) explained OR 3.73(1.63–8.54, p = 0.001), male gender 2.70(1.35–5.39, p = 0.004), self-score 1–10 1.21(1.05–1.39, p = 0.007), spacer use 0.38(0.19–0.79, p = 0.007), inhaled steroid 3.71(1.34–10.25, p = 0.01), heart disease 0.31(0.13–0.77, p = 0.01), pneumococcal vaccine 2.48(1.0–6.15, p = 0.043), education level 1–4 1.44(1.00–2.06, p = 0.05) and respiratory physician explained 0–7 times, 1.11(0.99–1.26, p = 0.08). Using ordinal logistic regression, predictors for correct critical steps 0–4, were: technique self-score 1–10 1.2(1.05–1.42, p = 0.006), inhaled corticosteroid use 2.78(1.1–7.31, p = 0.03) and education level 1–4 1.41(1.02–1.95, p = 0.03 Times respiratory physician explained inhaler technique 0–7 1.1(0.98–1.24, p = 0.1), married status 1.55(0.85–2.82, p = 0.15), hypercholesterolaemia 0.52(0.25–1.01, p = 0.054) and male gender 1.76(0.97–3.18, p = 0.06).ConclusionsKnown predictors of correct pMDI use, such as gender and education level were confirmed, while age and concomitant use of dry powder inhaler were not. Pneumococcal vaccination and awareness of steroid side effects were possible novel positive predictors, while the use of a spacer and co-morbidity with heart disease were found to be negative predictors. Patients’ self-assessment correlated well with actual performance. This information may be useful in defining approaches to optimize inhaler techniques which are so susceptible to human error.

Simulation training for foundation doctors on the management of the acutely ill patient

Background A study evaluating subjective trainee responses to simulation training organized by the Malta Foundation Program in particular whether this changed their clinical practice. Method Feedback using a standardized questionnaire was obtained from 120 (M=55%) participants. A 0–10 Likert scale was used to evaluate responses. Results Participants scored the simulation sessions as “useful” at 7.7 (95% confidence interval [CI] 7.4–8.0), rated “the overall experience” at 7.5 (95% CI 7.2–7.8), and thought it made a change in “daily practice” at 5.83 (95% CI 5.4–6.3). The score for the tutor “creating a satisfactory learning environment” and “quality of simulator equipment” was 7.8 (95% CI 7.6–8.1) and 7.7 (95% CI 7.4–8), respectively. Trainees rated “how close was the simulation to a real-life scenario” as 6.24 (95% CI 5.9–6.6). When asked whether the presence of colleagues hindered or helped, the majority were neutral 50 (41.7%), 36 (30%) said it hindered, while only 21 (28.3%) felt it helped. In contrast, 94 (78.33%) stated it was useful to observe colleagues while only 5 (4.2%) stated it was not. Likelihood for future participation was 7.4 (95% CI 7–7.8). Trainees recommended a median of 3 (interquartile range 2–5) simulations per year. Conclusion Trainees rated the sessions as useful and asked for more sessions possibly at an undergraduate level. Rating for equipment and tutors was positive; however, some felt that the effect on daily practice was limited. Most were comfortable observing others and uncomfortable being observed. The value of increasing sessions to 3–4 per year, timing them before clinical attachments and audiovisual prebriefing for candidates naïve to simulation needs to be evaluated in future studies.

Relationship between domestic smoking and metals and rare earth elements concentration in indoor PM2.5 - The Indoor and Outdoor Air Quality and Respiratory Health in Malta and Sicily

Abstract Cigarette smoke is the main source of indoor chemical and toxic elements. Cadmium (Cd), Thallium (Tl), Lead (Pb) and Antimony (Sb) are important contributors to smoke‐related health risks. Data on the association between Rare Earth Elements (REE) Cerium (Ce) and Lanthanum (La) and domestic smoking are scanty. To evaluate the relationship between cigarette smoke, indoor levels of PM2.5 and heavy metals, 73 children were investigated by parental questionnaire and skin prick tests. The houses of residence of 41 “cases” and 32 “controls” (children with and without respiratory symptoms, respectively) were evaluated by 48‐h PM2.5 indoor/outdoor monitoring. PM2.5 mass concentration was determined by gravimetry; the extracted and mineralized fractions of elements (As, Cd, Ce, La, Mn, Pb, Sb, Sr, Tl) were evaluated by ICP‐MS. PM2.5 and Ce, La, Cd, and Tl indoor concentrations were higher in smoker dwellings. When corrected for confounding factors, PM2.5, Ce, La, Cd, and Tl were associated with more likely presence of respiratory symptoms in adolescents. We found that: i) indoor smoking is associated with increased levels of PM2.5, Ce, La, Cd, and Tl and ii) the latter with increased presence of respiratory symptoms in children. Graphical abstract Figure. No Caption available. HighlightsTobacco smoke releases heavy metals (HM) and REE in indoor dwellings.Elemental content in indoor PM2.5 was measured in smoking and non smoking dwellings.Extracted and mineralized fractions of elements were evaluated by ICP‐MS.Indoor smoke was associated with increase of specific elemental fractions in PM2.5.Increased levels of HM and REE are associated with respiratory symptoms in children.

Sensitization to dust mite defines different phenotypes of asthma: A multicenter study

Indoor allergens are risk factors for asthma: Thus, the characterization of indoor air quality is important for studying environment–health relationships in children. In particular, Dermatophagoides pteronyssinus is the dominant allergen for asthma. We cross‐sectionally investigated the relationships among respiratory symptoms and function, airway inflammation, allergen sensitization, and indoor allergen concentration.