[The ears on the vessel of medicine: Jan van Beverwijck's collection of opinions on medicine in antiquity]. / De oren aan het vat van de medische kennis.

Johan van Beverwijck (1595-1647) is known as the author of two Dutch books in which he made medical knowledge accessible to laymen who did not have command of the Latin language. The Dordrecht doctor was open to the many new insights that arose in his time and shook the foundations of the ancient humoural stronghold of Aristotle, Hippocrates and Galen. A nearly forgotten book, Idea veterum medicinae (Opinions on medicine in antiquity), was recently translated into Dutch by the author of this article. It shows that Van Beverwijck remained a true humanist, who loved the ancient world and its culture. The book consists of an extensive compilation of comments by ancient philosophers, poets and historians on health and health care. Van Beverwijck believed his book would provide the tired practitioner with some distraction and might help the medical student to memorise his subject material. Moreover, he believed that some knowledge of the ancient world would deepen medical thinking.

Undernotification and underreporting of tuberculosis in Zambia: a national data quality assessment.

BACKGROUND: Despite national implementation of several high impact interventions and innovations to bolster tuberculosis (TB) detection and improve quality of TB services in Zambia, notifications have been declining since 2004. A countrywide data quality assessment (DQA) of Zambia's National TB and Leprosy Programme (NTLP) was undertaken to quantify the degree to which undernotification and underreporting of TB notifications may be occurring. METHODS: The NTLP conducted a retrospective DQA of health facilities in high burden districts in all ten Zambian provinces. Multiple routine programmatic data sources were triangulated through a multi-step verification process to enumerate the total number of unique TB patients diagnosed between 1st January and 31st August 2019; both bacteriologically confirmed and clinically diagnosed TB patients were included. Undernotification was defined as the number of TB patients identified through the DQA that were not documented in facility treatment registers, while underreporting was defined as the number of notified TB cases not reported to the NTLP. RESULTS: Overall, 265 health facilities across 55 districts were assessed from which 28,402 TB patients were identified; 94.5% of TB patients were ≥ 15 years old, 65.1% were male, 52.0% were HIV-positive, and 89.6% were a new/relapse case. Among all TB cases, 32.8% (95%CI: 32.2-33.3) were unnotified. Undernotification was associated with age ≥ 15 years old (adjusted prevalence odds ratio [aPOR] = 2.4 [95%CI: 2.0-2.9]), HIV-positive status (aPOR = 1.6 [95%CI: 1.5-1.8]), being a new/relapse TB case (aPOR = 17.5 [95%CI: 13.4-22.8]), being a clinically diagnosed TB case (aPOR = 4.2 [95%CI:3.8-4.6]), and being diagnosed at a hospital (range, aPOR = 1.5 [95%CI: 1.3-1.6] to 2.6 [95%CI: 2.3-2.9]). There was substantial heterogeneity in the proportion of unnotified TB cases by province (range, 18.2% to 43.6%). In a sub-analysis among 22,199 TB patients with further data available, 55.9% (95%CI: 55.2-56.6) were notified and reported to the NTLP, 32.8% (95%CI: 32.2-33.4) were unnotified, and 11.3% (95%CI: 10.9-11.7) went unreported to the NTLP. CONCLUSIONS: The findings from Zambia's first countrywide TB programme DQA demonstrate substantial undernotification and underreporting of TB cases across all provinces. This underscores the urgent need to implement a robust and integrated data management system to facilitate timely registration and reporting of all TB patients who are diagnosed and treated.

Prevalence and interpretation of Xpert® Ultra trace results among presumptive TB patients.

BACKGROUND: The "trace call" results on Xpert® Ultra indicates extremely low TB levels and may be difficult to interpret. The prevalence of trace results among presumptive TB patients in high TB-HIV infection settings is unknown, as is the significance of divergent "trace call" result interpretations. METHODS: Presumptive TB patients attending a public health facility in Lusaka, Zambia, were prospectively enrolled. Participants underwent several TB investigations, including sputum smear microscopy, Ultra testing, and culture. The diagnostic accuracy of Ultra (culture-based reference) and the number of patients recommended for TB treatment was assessed according to several different interpretation criteria for "trace call" results. RESULTS: Among the 740 participants, 78 (10.5%) were Ultra-positive and an additional 37 (5.0%) had a "trace call" result. The prevalence of trace results did not differ according to HIV status (5.3% vs. 4.8%) or prior TB status (5.6% vs. 4.9%). Differing interpretations of trace results had modest effects on Ultra's sensitivity (range 79.3-82.6%) and specificity (range 94.3-99.2%), but increased the number of patients recommended for treatment by up to 44.9%. CONCLUSIONS: Ultra trace results were common in this setting. The interpretation of trace results may substantially impact TB case yield.

CONTEXTE: La catégorie de résultats « traces ¼ du test Xpert Ultra indique des taux de TB très faibles et peut être difficile à interpréter. La prévalence de résultats traces parmi des patients suspects de TB dans des zones à forte prévalence de TB-VIH est inconnue, tout comme la signification d'interprétations divergentes des résultats traces. MÉTHODES: Les patients suspects de TB consultant dans un centre de soins public de Lusaka, Zambie, ont été inclus de manière prospective. Les participants ont fait l'objet de plusieurs examens de détection de la TB, dont microscopie des frottis d'expectorations, test Xpert® Ultra et culture. La précision diagnostique du test Ultra (par rapport à la culture) et le nombre de patients recommandés pour traitement antituberculeux ont été évalués selon plusieurs critères d'interprétation des résultats traces. RÉSULTATS: Parmi les 740 participants, 78 (10,5%) étaient positifs au test Ultra et 37 autres participants (5.0%) avaient un résultat trace. La prévalence des résultats traces ne différait pas en fonction du statut VIH (5,3% vs. 4,8%) ou du statut tuberculeux antérieur (5,6% vs. 4,9%). Les interprétations divergentes des résultats traces avaient un effet modéré sur la sensibilité du test Ultra (écart 79,3­82,6%) et sur sa spécificité (écart 94,3­99,2%), mais elles augmentaient le nombre de patients à qui un traitement était recommandé de 44,9% maximum. CONCLUSIONS: Les résultats traces au test Ultra étaient fréquents. L'interprétation de ces résultats peut impacter considérablement la détection des cas de TB.

The challenge of comparing digitally captured signatures registered with different software and hardware.

Along with the growing popularity of electronic documents authorised with digitally captured signatures, such evidence has appeared in the work of forensic practitioners. Many different vendors offer signature pads with varying specifications. It is therefore expected that forensic handwriting experts will be called upon to compare questioned and known samples captured with completely or partially different hardware and software combinations. Such cases may be challenging as numerical handwriting data produced by various equipment may differ not only in the type of information captured and its quality, but also in its structure and coding. In this research, numerical data of handwriting - i.e. spatial coordinates, force, and time values - were acquired with 26 different combinations of hardware and software to study characteristics of their coding. The analysis of samples revealed that scaling of numerical data is not only hardware but also software dependent. Therefore, their compliance with the ISO/IEC 19794-7 standard is recommended to improve the data interoperability. This standard emphasizes the importance of supplementing numerical signature data with scaling ratios of the used signing solution. The paper also includes descriptions of several phenomena observed in the acquired data to highlight possible pitfalls in performing inter-solution comparisons in casework.

Features of digitally captured signatures vs. pen and paper signatures: Similar or completely different?

The question of whether digitally captured signatures and conventional signatures executed with a pen on paper differ in their characteristics is of practical relevance for forensic handwriting examiners. Due to gaps in the current literature, the present research is dedicated to this issue. Eighty persons signed in three conditions: a) with a stylus on a pad, b) with an inking pen on a sticky note attached to a signature pad allowing to obtain a digital and an analogue version on paper of one and the same writing simultaneously, and c) with a pen on paper. The first step was to investigate to what extent the character shape and number of pen lifts differ between the digital and analogue representation of one and the same signature. This revealed minor differences which are due to technical characteristics of the devices used. The observed distortions are of minor practical relevance according to ratings by eight participating forensic handwriting examiners. Subsequently, signature characteristics were compared between the three different writing conditions in a casework-oriented way. Statistical multi-level models indicate significant differences between the three signature types, but minor effect sizes in most of the examined characteristics. From the point of view of the participating handwriting examiners, these factors do not fundamentally restrict the comparability between digitally captured and conventional signatures in practice. However, caution should be exercised when generalising the results, as several factors, such as the usage of different signature pads as well as signatures made with the finger instead of a stylus, could result in more important differences compared to pen and paper signatures.

Diagnosed with TB in the era of COVID-19: patient perspectives in Zambia.

INTRODUCTION: Delayed TB diagnosis and treatment perpetuate the high burden of TB-related morbidity and mortality in resource-constrained settings. We explored the potential of COVID-19 to further compromise TB care engagement in Zambia. METHODS: From April to May 2020, we purposefully selected 17 adults newly diagnosed with TB from three public health facilities in Lusaka, Zambia, for in-depth phone interviews. We conducted thematic analyses using a hybrid approach. RESULTS: The majority of participants were highly concerned about the impact of lockdowns on their financial security. Most were not worried about being diagnosed with COVID-19 when seeking care for their illness because they felt unwell prior to the outbreak; however, they were very worried about contracting COVID-19 during clinic visits. COVID-19 was perceived as a greater threat than TB as it is highly transmittable and there is no treatment for it, which provoked fear of social isolation and of death among participants in case they contracted it. Nonetheless, participants reported willingness to continue with TB medication and the clinic visits required to improve their health. CONCLUSION: The COVID-19 pandemic did not appear to deter care-seeking for TB by patients. However, messaging on TB in the era of COVID-19 must encourage timely care-seeking by informing people of infection control measures taken at health facilities.

[How can gentlemen of standing grow old healthily? Plemp and his De togatorum valetudine tuenda commentatio (1670)]. / Hoe worden heren van stand gezond oud?

In 1670, the Professor of Medicine V.F. Plemp from the Belgian University of Leuven published a book explaining in an entertaining fashion how elderly gentlemen in positions of authority could live for a long time in good health but still have enjoyable lives. In writing this book the author manifested himself as a 17th century forerunner of the modern fitness and wellness movement. Plemp was a humanist who believed in the renaissance of Antiquity, and his medical revelations originate largely from ancient Roman sources. He also skilfully intertwined his health advice with descriptions of Greek and Roman customs and mores.

Gemcitabine combined with the monoclonal antibody nimotuzumab is an active first-line regimen in KRAS wildtype patients with locally advanced or metastatic pancreatic cancer: a multicenter, randomized phase IIb study.

BACKGROUND: This randomized study was designed to investigate the superiority of gemcitabine (gem) plus nimotuzumab (nimo), an anti-epidermal growth factor receptor monoclonal antibody, compared with gem plus placebo as first-line therapy in patients with advanced pancreatic cancer. PATIENTS AND METHODS: Patients with previously untreated, unresectable, locally advanced or metastatic pancreatic cancer were randomly assigned to receive gem: 1000 mg/m2, 30-min i.v. once weekly (d1, 8, 15; q29) and nimo: fixed dose of 400 mg once weekly as a 30-min infusion, or gem plus placebo, until progression or unacceptable toxicity. The primary end point was overall survival (OS), secondary end points included time to progression, overall response rate, safety and quality of life. RESULTS: A total of 192 patients were randomized, with 186 of them being assessable for efficacy and safety (average age 63.6 years). One-year OS/progression-free survival (PFS) was 34%/22% for gem plus nimo compared with 19%/10% for gem plus placebo (HR = 0.69; P = 0.03/HR = 0.68; P = 0.02). Median OS/PFS was 8.6/5.1 months for gem plus nimo versus 6.0/3.4 mo in the gem plus placebo group (HR = 0.69; P = 0.0341/HR = 0.68; P = 0.0163), with very few grade 3/4 toxicities. KRAS wildtype patients experienced a significantly better OS than those with KRAS mutations (11.6 versus 5.6 months, P = 0.03). CONCLUSION: This randomized study showed that nimo in combination with gem is safe and well tolerated. The 1-year OS and PFS rates for the entire population were significantly improved. Especially, those patients with KRAS wildtype seem to benefit. The study was registered as protocol ID OSAG101-PCS07, NCT00561990 and EudraCT 2007-000338-38.

Anaemia in patients with HIV-associated TB: relative contributions of anaemia of chronic disease and iron deficiency.

BACKGROUND: Anaemia commonly complicates both human immunodeficiency virus (HIV) infection and tuberculosis (TB), contributing substantially to morbidity and mortality. The mechanisms underlying anaemia and corresponding treatments in co-infected patients are poorly defined. OBJECTIVE: To determine the relative contributions of anaemia of chronic disease (ACD) and iron deficiency to anaemia in patients with HIV-associated TB. DESIGN: Consecutively recruited hospitalised (n = 102) and matched ambulatory patients (n = 51) with microbiologically confirmed HIV-associated TB in Cape Town, South Africa, were included. Haemoglobin levels, iron status markers, hepcidin and pro-inflammatory cytokines in blood were measured. We determined the prevalence of ACD and iron-deficiency anaemia (IDA) using seven different published definitions of IDA. RESULTS: More than 80% of enrolled HIV-associated TB patients were anaemic, and anaemia was more severe among in-patients. Over 95% of anaemic HIV-associated TB patients had ACD, whereas the proportion with IDA using a range of seven different definitions was low overall (median <3%, range 0-32.6) in both patient groups. The proportion with IDA and hepcidin concentration â©¿ 20.0 ng/ml (predictive of responsiveness to oral iron supplementation) was also very low (median <3%, range 0-15.1). CONCLUSIONS: ACD was the predominant cause underlying anaemia in HIV-associated TB patients, and IDA was very uncommon in this setting. The majority of anaemic HIV-associated TB patients were unlikely to benefit from oral iron supplementation.

Diagnostic and prognostic value of serum C-reactive protein for screening for HIV-associated tuberculosis.

BACKGROUND: Rapid means of ruling in or ruling out tuberculosis (TB) would permit more efficient management of patients starting antiretroviral treatment (ART). OBJECTIVE: To assess the diagnostic and prognostic utility of C-reactive protein (CRP) among patients being screened for TB before ART in a South African ART clinic. DESIGN: Patients were microbiologically screened for TB regardless of symptoms; serum CRP was measured, and mortality at 3 months was assessed. RESULTS: Among 496 patients (median CD4 count 171 cells/l), culture-positive TB was diagnosed in 81 (16.3%). CRP concentrations were much higher among TB cases (median 57.8 mg/l, IQR 20.0202.7) than in those without TB (6.4 mg/l, IQR 2.121.8, P < 0.001). Very low (<1.5 mg/l) CRP concentrations excluded TB (100% negative predictive value), whereas very high concentrations (>400 mg/l) were strongly predictive of TB (100% positive predictive value). However, these thresholds encompassed only 14.3% and 2.0%, respectively, of all patients screened and identified only 12.3% of TB cases. CRP concentrations ≥50 mg/l were associated with poor prognostic characteristics, higher mycobacterial load, disseminated disease and greater mortality risk. CONCLUSION: CRP concentrations identified groups of patients with very high or very low TB risk, but only in an unacceptably small minority of patients screened. However, in those with confirmed TB, CRP concentrations had useful prognostic value.

Diagnostic yield of tuberculosis using sputum induction in HIV-positive patients before antiretroviral therapy.

Adults (n = 602) enrolling in a South African antiretroviral treatment clinic underwent culture-based screening for tuberculosis (TB), regardless of symptoms. For those unable to spontaneously expectorate a 'spot' sample (n = 124), sputum induction with nebulised hypertonic saline was used to obtain a first sample and also to rapidly obtain a second sample from all patients. Collection of both samples typically took 10-15 min. The prevalence of culture-positive TB was 15.6% (95%CI 12.8-18.8). Spontaneously expectorated spot samples yielded 79.8% of all culture-positive TB diagnoses. The incremental yield from those needing an induced first sample was 5.3% and the yield from induced second samples was 14.9%.

['Advanced triage' improves patient flow in the emergency department without affecting the quality of care]. / 'Advanced triage' geeft snellere patiëntdoorstroming SEH, zonder verlies aan kwaliteit van zorg.

OBJECTIVE: To investigate whether 'advanced triage' improved patient flow among self-referred patients in the emergency department of a level 1 trauma centre and, most importantly, whether the quality of medical care was maintained. In advanced triage, the triage nurse initiates additional diagnostic investigations independently. DESIGN: Interventional study. METHODS: After a baseline measurement had been carried out for eleven days (n = 506), the advanced triage protocol was tested during ten day or evening shifts (n = 198). The length of stay in the emergency department was measured. The attending emergency physician assessed the correctness and completeness of the additional diagnostics initiated by the triage nurse. Two traumatologists and two radiologists assessed the quality of x-ray imaging requests independently of each other. RESULTS: Average patient length of stay (LOS) was reduced by fourteen minutes (14%). The improvement was achieved primarily in patients who required additional diagnostic investigations. Their average LOS decreased by 27 minutes (18%). There was an 8% increase in the total number of diagnostic investigations requested. The triage nurse initiated the investigations correctly and fully in 93% of cases. The quality of x-ray imaging requests remained the same as before the introduction of advanced triage. CONCLUSION: The implementation of advanced triage improved patient flow for self-referred patients in the emergency department without affecting the quality of medical care. Advanced triage was successful in the Dutch system, too.

Biological stoichiometry of plant production: metabolism, scaling and ecological response to global change.

Biological stoichiometry theory considers the balance of multiple chemical elements in living systems, whereas metabolic scaling theory considers how size affects metabolic properties from cells to ecosystems. We review recent developments integrating biological stoichiometry and metabolic scaling theories in the context of plant ecology and global change. Although vascular plants exhibit wide variation in foliar carbon:nitrogen:phosphorus ratios, they exhibit a higher degree of 'stoichiometric homeostasis' than previously appreciated. Thus, terrestrial carbon:nitrogen:phosphorus stoichiometry will reflect the effects of adjustment to local growth conditions as well as species' replacements. Plant stoichiometry exhibits size scaling, as foliar nutrient concentration decreases with increasing plant size, especially for phosphorus. Thus, small plants have lower nitrogen:phosphorus ratios. Furthermore, foliar nutrient concentration is reflected in other tissues (root, reproductive, support), permitting the development of empirical models of production that scale from tissue to whole-plant levels. Plant stoichiometry exhibits large-scale macroecological patterns, including stronger latitudinal trends and environmental correlations for phosphorus concentration (relative to nitrogen) and a positive correlation between nutrient concentrations and geographic range size. Given this emerging knowledge of how plant nutrients respond to environmental variables and are connected to size, the effects of global change factors (such as carbon dioxide, temperature, nitrogen deposition) can be better understood.

Ultrasonographic screening for developmental dysplasia of the hip in infants. Reproducibility of assessments made by radiographers.

We studied the reproducibility of ultrasonographic screening examination of the hip when read by diagnostic radiographers. In order to determine interobserver variability, 200 ultrasonograms were classified according to Graf's method by five observers (four radiographers and one radiologist). The kappa values for interobserver variability indicated moderate agreement (kappa 0.47) for the exact Graf classification and substantial agreement (kappa 0.65) for the classification of normal (type I) versus abnormal (type IIa-IV). Agreement was significantly different for normal, immature and abnormal hips. Comparison of the findings in our interobserver study with existing information based on other examinations and treatment revealed that only a small number of infants with mildly dysplastic hips would have been typed as normal by some observers as a result of observer variability. In conclusion, the interobserver agreement on the ultrasound assessment of the hip was good enough for screening purposes. Observer variability did not result in any severe cases being missed.

Inhalation technique of 166 adult asthmatics prior to and following a self-management program.

Self-management of asthma and self-treatment of exacerbations are considered important in the treatment of asthma. For successful self-treatment, medication has to be inhaled correctly, but the percentage of patients inhaling effectively varies widely. As part of a self-management program we checked and corrected inhalation technique. This paper addresses differences among inhalers in relation to patient characteristics and the effect of instruction, 1 year after enrollment. Maneuvers that are essential for adequate inhalation were identified. When errors in inhalation technique were observed, patients were instructed in the correct use of their devices. One year later, inhalation technique was checked again. Only patients who used the same inhaler throughout the entire study period were analyzed. Of the 245 adult asthmatic patients who were enrolled in the self-management program, 166 used the same inhaler throughout the study period. One hundred twenty patients (72%) performed all key items correctly at baseline and this increased to 80% after 1 year. At follow-up, older patients were less likely to demonstrate a perfect inhalation. Patients with a Diskhaler made fewest errors. Adjustment for differences in patient characteristics did not significantly change the results. Because many patients with asthma use their inhaler ineffectively, there is a need to know which inhaler leads to fewest errors. Diskhaler was nominated by this study. When patients are not able to demonstrate adequate inhalation technique in a "tranquil" setting, it is doubtful that they can do so when they experience an exacerbation. Therefore, inhalation instruction should be considered an essential ingredient, not only of self-management programs, but also of asthma patient care in general.

Granulocyte colony-stimulating factor shortens duration of critical neutropenia and prolongs disease-free survival after sequential high-dose cytosine arabinoside and mitoxantrone (S-HAM) salvage therapy for refractory and relapsed acute myeloid leukemia. German AML Cooperative Group.

Patients with primary refractory or relapsed acute myeloid leukemia (AML) who undergo intensive salvage chemotherapy carry a high risk of treatment failure due to infectious complications and early relapses. The study presented here assessed the effect of granulocyte colony-stimulating factor (G-CSF) on the duration of post-treatment neutropenia, the incidence of infection-related deaths, and the disease-free and overall survival. Sixty-eight evaluable patients with relapsed and refractory AML received G-CSF 5 microg/kg per day subcutaneously starting 2 days after the completion of salvage treatment with the S-HAM regimen, consisting of high-dose cytosine arabinoside twice daily on days 1, 2, 8, and 9 and mitoxantrone on days 3, 4, 10, and 11. Ninety-one patients who were treated with the identical S-HAM regimen but without G-CSF support during a preceding study served as controls. The application of G-CSF resulted in a significant shortening of critical neutropenia of less than 500 microl (36 vs. 40 days; p = 0.008), which translated into a trend towards a lower early death rate (21% vs. 30%) and an increase of complete remissions (56% vs. 47%, p=0.11). In patients younger than 60 years a significant prolongation of time to treatment failure (159 vs. 93 days, p=0.038) and of duration of disease-free survival (203 vs. 97 days, p=0.003) was observed. These results indicate a beneficial effect of G-CSF on early mortality as well as on long-term outcome when administered after S-HAM salvage therapy for advanced AML.

Failure of fluconazole prophylaxis to reduce mortality or the requirement of systemic amphotericin B therapy during treatment for refractory acute myeloid leukemia: results of a prospective randomized phase III study. German AML Cooperative Group.

BACKGROUND: Invasive fungal infections have increasingly become a matter of concern with regard to patients receiving intensive myelosuppressive therapy for hematologic malignancies. Such infections, especially prolonged neutropenia systemic fungal infections, may contribute substantially to infectious complications and early death. Measures for early detection and effective prophylactic strategies using active and nontoxic antifungal agents are therefore urgently needed. METHODS: The current randomized study was initiated to assess the efficacy of oral fluconazole as systemic antifungal prophylaxis for high risk patients with recurrent acute myeloid leukemia undergoing intensive salvage therapy. RESULTS: Of 68 fully evaluable patients, 36 were randomized to fluconazole in addition to standard prophylaxis with oral co-trimoxazol, colistin sulphate, and amphotericin B suspension, and 32 were randomized to standard prophylaxis only. No major differences between the two groups were observed in the number of episodes of fever of unknown origin (61% vs. 50%) or clinically defined infections (56% vs. 50%). Microbiologically defined infections were more frequent in the fluconazole group (50% vs. 31%), mainly due to a higher incidence of bacteremias (42% vs. 22%). There were two cases of proven invasive fungal infections in each group. Systemic amphotericin B was administered more frequently to patients receiving fluconazole prophylaxis (56% vs. 28%). Fluconazole prophylaxis had no impact on the rate of early death or overall survival. CONCLUSIONS: For patients with high risk recurrent acute myeloid leukemia undergoing intensive salvage therapy, antifungal prophylaxis with fluconazole was not superior to standard prophylaxis only.

[Knowledge about drugs used by adult patients with asthma for self-treatment]. / Medicijnkennis van volwassenen met astma onvoldoende voor zelfbehandeling.

OBJECTIVE: To assess the knowledge of adult asthmatics about medication for self-treatment. DESIGN: Descriptive. SETTING: Department of Pulmonary Diseases, Medisch Spectrum Twente, Enschede, the Netherlands. METHODS: As a part of a larger project aimed at improvement of self-management and self-treatment, all adults aged 18-65 years in Enschede (population 146,000) reported by the city pharmacists as using medication for asthma or chronic obstructive pulmonary disease, in 1994 were sent a questionnaire including 7 items pertaining to knowledge about lung medication. From among those who failed to respond after a written reminder and an appeal in local papers, a random group of 9% were interviewed by telephone. Of the responders who reported that according to their GPs they had asthma and who had answered the questions on medication, the number of questions answered correctly was counted; in addition, the question was investigated whether their level of knowledge was related to sex, education, use of (inhalation) corticosteroids and the form of explanation received. RESULTS: A total of 4563 questionnaires were sent out: 2259 (50%) usable forms were returned. The responders were better educated than the 192 non-responders interviewed, but did not differ as to age or sex. Of the responders, 1262 (56%) reported that their GPs had told them they had asthma. On average they had answered 2.4 (range: 0-7) out of 7 questions correctly. Previous instruction, number of sources of information, duration of taking medication, use of inhaled steroids, female sex and better education were all positively related with a higher knowledge score in this group. CONCLUSION: Adult asthmatics did not have sufficient knowledge about their medication. Improving such knowledge should therefore be an important element in the development of a self-management programme.

Evaluation of the long-term effectiveness of three instruction modes for inhaling medicines.

Inhaled medication is important in the treatment of chronic obstructive pulmonary disease (COPD). In this paper a comparison of the long-term efficacy of three instruction-models is presented. A total of 152 COPD-patients were randomized into one of four groups: Personal-, video-, group-instruction and a control group. Inhalation technique was assessed by means of checklists, on which essential inhalation manoeuvres were identified. Up to 9 months later, 148 patients returned for follow-up assessment. Prior to instruction 61% of patients in the control group had a perfect score on essential actions, compared to 62, 65 and 53% for those receiving group-, personal- and video-instruction respectively. At follow-up these percentages were 49, 97, 75 and 76%. For group-(35%) and video-instruction (24%) the increase from baseline was significant. Examining the different inhalers under investigation, it is striking, that only 24% of all patients with a Metered Dose Inhaler (MDI) performed all essential checklist items correctly, versus 96% for those using a Diskhaler. The fact that for the MDI this percentage improved to 90% post-instruction, shows that time spent on instruction, is time well spent. We conclude that group instruction seems superior to personal counselling, and equally effective or even better than video instruction. Personal instruction should not be dismissed and a combination with video instruction might prove to be effective as well.

Evaluation of the effectiveness of four different inhalers in patients with chronic obstructive pulmonary disease.

BACKGROUND: The percentage of patients inhaling their medication effectively varies widely, according to methods of assessment and inhalers used. This study was carried out to assess differences among four types of inhalers using inhaler-specific checklists. METHODS: Inhalation technique was evaluated in adult patients with chronic obstructive pulmonary disease (COPD). Inhalers investigated were either metered dose inhalers (MDIs) or the dry powder inhalers Turbohaler (Turbuhaler), Diskhaler, and Rotahaler. Errors were recorded against inhaler-specific checklists. From these, scores were derived by dividing the number of items correctly completed by the total number of items on the checklist and the result was expressed as a percentage. For every inhaler "essential actions" were identified and scores on these key manoeuvres were calculated. The percentage of patients performing all these essential actions correctly was also calculated. Scores were also compared with adjustment for differences in relevant patient characteristics. RESULTS: Important differences among inhalers were found. Of 152 patients with COPD (mean (SD) age 55.1 (8.7) years), those with MDIs performed worst, especially when only essential items were considered. Patients with a Diskhaler did best, although after correction for patient characteristics the differences tended to diminish. Only 60% of patients were able to perform all essential inhaler actions satisfactorily. Of those using the Diskhaler, 96% did so correctly, while the corresponding figure for those using the MDI was only 24%. CONCLUSIONS: Many patients with COPD use their inhaler ineffectively. After adjusting for patient characteristics, differences among inhalers, although less pronounced, persist. Patients using a Diskhaler made fewest errors, while most patients using MDIs made crucial mistakes.