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Pharmacists performing quality spirometry testing: an evidence based review.

The scope of pharmacist services for patients with pulmonary disease has primarily focused on drug related outcomes; however pharmacists have the ability to broaden the scope of clinical services by performing diagnostic testing including quality spirometry testing. Studies have demonstrated that pharmacists can perform quality spirometry testing based upon international guidelines.

AIM OF THE REVIEW: The primary aim of this review was to assess the published evidence of pharmacists performing quality spirometry testing based upon American Thoracic Society/European Respiratory Society (ATS/ERS) guidelines. In order to accomplish this, the description of evidence and type of outcome from these services were reviewed.

METHODS: A literature search was conducted using five databases [PubMed (1946-January 2015), International Pharmaceutical Abstracts (1970 to January 2015), Cumulative Index of Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews] with search terms including pharmacy, spirometry, pulmonary function, asthma or COPD was conducted. Searches were limited to publications in English and reported in humans. In addition, Uniform Resource Locators and Google Scholar searches were implemented to include any additional supplemental information.

RESULTS: Eight studies (six prospective multi-center trials, two retrospective single center studies) were included. Pharmacists in all studies received specialized training in performing spirometry testing. Of the eight studies meeting inclusion and exclusion criteria, 8 (100 %) demonstrated acceptable repeatability of spirometry testing based upon standards set by the ATS/ERS guidelines. Acceptable repeatability of seven studies ranged from 70 to 99 % consistent with published data.

CONCLUSION: Available evidence suggests that quality spirometry testing can be performed by pharmacists. More prospective studies are needed to add to the current evidence of quality spirometry testing performed by pharmacists and to measure health outcomes of the pulmonary patient.

Efficacy of acupuncture in children with asthma: a systematic review.

acupunctureWe performed a systematic review of the efficacy of various types of acupuncture in the treatment of asthma in children.

METHODS: We searched the MEDLINE, Embase, and Cochrane Library databases up to October 20, 2014. Randomized controlled trials (RCTs) of children and adolescents (<18 years of age) with asthma were included. Data extraction was applied, and methodologic quality was assessed.

RESULTS: A total of 32 articles were assessed for eligibility, and seven studies comprising 410 patients were included in the systematic review. Two RCTs showed significant improvement in peak expiratory flow (PEF) variability for acupuncture (traditional and laser) vs. control, with one showing significant improvement in asthma-specific anxiety level, but no significant differences in other lung function parameters or quality of life. Another RCT reported significant benefits of laser acupuncture on lung function parameters but did not describe or report statistical analyses. One crossover RCT showed significant improvements in response to both acupuncture and placebo acupuncture, with better improvements with acupuncture compared to placebo acupuncture (forced exhaled volume in 1 s [FEV1], PEF). Two additional crossover RCTs showed no significant differences between single sessions of laser acupuncture and placebo acupuncture on baseline, postacupuncture, and postinduced bronchoconstriction values (% predicted FEV1, maximum expiratory flow). A recent study showed a significant effect of acupuncture paired with acupressure on medication use and symptoms in preschool-age children. Methodologic and reporting variability remains an issue. However, the results suggest that acupuncture may have a beneficial effect on PEF or PEF variability in children with asthma.

CONCLUSIONS: The efficacy of acupuncture on other outcome measures is unclear. Large-scale RCTs are needed to further assess the efficacy of acupuncture in the treatment of asthma in children.

Intrapleural tissue plasminogen activator and deoxyribonuclease therapy for pleural infection.

Pleural infection remains a global health burden associated with significant morbidity. Drainage of the infected pleural fluid is important but can often be hindered by septations and loculations. Intrapleural fibrinolytic therapy alone, to break pleural adhesions, has shown no convincing advantages over placebo in improving clinical outcome. Deoxyribonucleoprotein from degradation of leukocytes contributes significantly to high viscosity of infected pleural fluid. Recombinant deoxyribonuclease (DNase) is effective in reducing pleural fluid viscosity in pre-clinical studies.

The combination of tissue plasminogen activator (tPA) and DNase was effective in animal model experiments of empyema. The benefits were established in a randomized clinical trial: those (n=48) treated with tPA/DNase had significantly improved radiological outcomes and reduced need of surgery and duration of hospital stay. A longitudinal observational series of 107 patients further confirmed the effectiveness and safety of tPA/DNase therapy, including its use as 'rescue therapy' when patients failed to respond to antibiotics and chest tube drainage. Overall, a short course of intrapleural tPA (10 mg) and DNase (5 mg) therapy provides a cure in over 90% of patients without requiring surgery. The treatment stimulates pleural fluid formation, enhances radiographic clearance and resolution of systemic inflammation. Serious complications are uncommon; pleural bleeding requiring transfusion occurred in ~2% of cases. Pain can occur, especially with the first dose.

Treatment is contraindicated in those with significant bleeding diathesis or a bronchopleural fistula. Future research is required to optimize dosing regimens and in refining patient selection.

Advances and controversies in pleural diseases.

Pleural effusion is a common presentation for many pulmonary and systemic diseases, particularly heart failure, pneumonia, cancer and tuberculosis (TB).

An estimated 1.5 million people develop a pleural effusion each year in the United States alone. Despite the prevalence of the disease, research in pleural medicine has attracted far less attention than that of much rarer respiratory conditions. Advances in pleural diseases are desperately lacking and far fewer than in other common pulmonary diseases. One paradigmatic example is the use of talc pleurodesis which was first reported in 1935, but remains the standard therapy for symptomatic malignant pleural effusion in most centers.

Few, if any, diseases in medicine are now managed in the same way as they were in the 1930’s.

Developments in inhaled combination therapies: patent activity 2013 - 2014.


Since the 1970s, the treatment options for asthma and chronic obstructive pulmonary disease have increasingly relied upon the use of inhaled drug formulations, generally from handheld inhaler devices. The introduction of combinations of a corticosteroid with a long-acting β2 agonist has dramatically transformed the accepted treatment paradigm. This has led to a dramatic increase in the development of novel combinations of inhaled drugs, including long-acting muscarinic antagonists with long-acting β2 agonists, as well as triple combinations, and of devices for their delivery. Areas covered: This review considers recent patent filings claiming inhaled drug combinations, or devices delivering them, that are useful in the treatment of asthma and/or chronic obstructive pulmonary disease. Expert opinion: The modest level of activity in patent filings relating to inhaled combinations is surprising. Many of the patents are from the major players in the respiratory market segment, with only one inhalation technology specialist showing significant activity. The limited activity from generics companies is explained by the limited range of active ingredients whose use they can usefully claim.

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