Inhalant Research Articles

Effectiveness of an educational intervention on different types of errors -occurring during inhaler therapy use in COPD patients during a -Pulmonary Rehabilitation Program.

Inhaled drug therapy is an essential treatment in Chronic Obstructive Pulmonary Disease (COPD) patients as it reduces symptoms, exacerbation rate and mortality risk. Errors in inhaler use can affect drug delivery to the lungs and minimize treatment benefits. The aim of the study was to evaluate the effect of a nurse-lead educational intervention on inhaler use in a group of patients with COPD during a Respiratory Rehabilitation Program. COPD patients attending a Respiratory Rehabilitation Unit for a pulmonary rehabilitation program participated in the educational training program. The nurse-lead educational intervention included a specific checklist used to evaluate each patient's inhalation technique. Errors were scored and classified as device- dependent, device-independent and critical one. Patients completed a pre and post-intervention survey to compare pre and post nurse-lead educational intervention results. One-hundred twenty-three COPD patients attending a Respiratory Rehabilitation Unit participated in the training program. A high frequency of total errors has been found at baseline (72.1%) whose critical errors represented 35%, irrespective of the severity of airway obstruction, the length of disease history and the educational level. The structured educational intervention resulted in changes on patients' attitudes and skills on inhaler use with a significant reduction in the frequency of all types of errors (P-value < 0.01), particularly total and critical errors (35% and 12.9%, respectively), but not completely eliminated them. Patient training in the use of the inhaler and regular review of the patient's competence in using the devices by health care professionals remains a crucial aspect of effective inhalation therapy regardless of the disease trajectory. These interventions are feasible and may impact the ability to engage patients in the chronic care journey.

A randomized crossover study assessing critical errors, preferences, and ease of use of two multidose powder inhalers

ABSTRACT Background The effectiveness of inhaled medications in asthma and COPD is significantly impacted by inhalation errors. Feedback mechanisms, built into the design of the inhaler might reduce the number of critical errors. This study compares critical errors, preferences, and ease of use of two dry powder inhalers, the Nexthaler and the Turbuhaler. Research design and methods In this multi-center, prospective, randomized, open-label, cross-over study, the proportions of asthma and COPD patients making critical errors were compared between the Nexthaler and Turbuhaler after 4 weeks of clinical use, after having been trained in the correct use of both inhalers. Results 90 and 49 patients with asthma and COPD, respectively were assessed. No significant difference was found in the number of critical errors between the two inhalers (3 with Nexthaler and 5 with Turbuhaler). However, more patients preferred the Nexthaler (57.6%) over the Turbuhaler (34.5%) (p = 0.006), while 7.9% stated no preference. Conclusions The study found no significant differences in critical error rate between the Nexthaler and Turbuhaler but the Nexthaler was preferred over the Turbuhaler. This study highlights the importance of dedicating sufficient time to instructing patients in correct inhalation technique, which can lead to long-term retention of the inhalation technique. Trial Registration The trial is registered at International Clinical Trials Registry Platform. Trial number NL-OMON55778.

Diferencias de género en el consumo de sustancias psicoactivas en estudiantes mexicanos de bachillerato

Introduction: research into the psychoactive substances use is very broad and diverse; however, in Mexico there is still a lack of specific information that highlights the possible differences in the use of these substances considering a gender perspective beyond the male/female dichotomy. Objective: explore the psychoactive substances use in high school degree students according to their gender and compare possible differences. Method: a non-experimental, cross-sectional, ex post facto study was designed with three comparison groups: cisgender-women, cisgender-men and other gender identity (non-binary, fluid, transgender-man, transgender-woman, among others). 4,136 students in the Gulf of Mexico area participated in a non-probabilistic sampling (2,120 cisgender-women, 1,964 cisgender-men, and 52 to be other gender identity). Results: the alcohol use was substantially higher in cisgender-women, while the tobacco use in cisgender-men. Illegal drug use was significantly higher in people to be other gender, especially the use of inhalants, methamphetamines, ecstasy, and hallucinogens. The marijuana, cocaine, amphetamines and heroin use was greater in cisgender-men, while that of tranquilizers was greater in cisgender-women. Discussion and conclusions: the results allowed an approach to a population group little addressed in studies of drug consumption, that of people who assume a gender different from the dichotomy (man/woman), making visible that they are a group with high consumption that it can place them in certain conditions of vulnerability.

Evidencias de validez y precisión de la Escala Breve de Autocontrol en adolescentes mexicanos y asociación con el consumo de sustancias

Introduction: the Self-control has been understood as the ability to override or modify internal responses, interrupt unwanted internal responses, interrupting unwanted behavioral tendencies, and refraining and tendencies and to refrain from acting accordingly. Its study has been approached clinical and non-experimental research through the use of self-report scales self-report scales. Objective: assess the validity and precision evidence of the Brief Self-Control Scale (EBA-AM), the creation of a scale score and the association between Self-Control with substance use in 1,004 Mexican adolescents (59.4% female) aged 11 - 19 years from a public middle school and high school in the Metropolitan Area of Guadalajara. Method: a self-administered questionnaire was administered using Google Forms that included the assessment of sociodemographic variables, substance use and the 13-item Brief Self-Control Scale. An exploratory factor analysis was carried out in which a structure with 10 items grouped into two factors was identified. Subsequently, a second-order confirmatory factor analysis was performed, the internal consistency of the scale was estimated using McDonald’s Omega, the EBA-AM was scored using percentiles and the association of the scale with substance use was assessed. Results: different structural, single and multidimensional models were tested, and the exploratory and confirmatory factor analysis presented better goodness of fit with ten items grouped into two factors: Impulse Control, with six items, and Self-discipline, with four items. Internal consistency was ω = .82. It was identified that the overall self-control score showed a high correlation with the use of tobacco, alcohol, marijuana, inhalants and illicit drugs. The linear correlation was significant and explained 56% of substance use with self-control. Discussion and conclusions: validity and precision evidence support the use of the Brief Self-Control Scale in Mexican Adolescents.

Ethyl chloride poisoning from inhalational misuse: clinical features and outcomes

Introduction Ethyl chloride misuse remains a prevailing concern due to its accessibility, but detailed descriptions of the features of toxicity are limited to sporadic reports, resulting in knowledge gaps in their clinical features and diagnosis. Objective To describe the clinical features, treatment, and outcomes of patients reported in the literature who developed toxicity from inhalational use of ethyl chloride. Methods We reviewed relevant literature over the past 50 years and analyzed the characteristics and outcomes of patients with toxicity from the inhalational use of ethyl chloride. Results A total of 21 studies from 1979 to 2024 were identified, making available 22 patients for analysis. Their median age was 40 years (range 16–62 years), and there were more than four times as many males as females. Ethyl chloride-containing cleaning solvents (8/22, 36%) were most commonly used. Regular inhalation of ethyl chloride was documented in approximately two-thirds of the patients (14/22, 66%), with a median duration of five months of misuse (range 2–360 months). A large proportion of patients (15/22, 68%) inhaled ethyl chloride again within a week from the onset of toxicity. Although features of cerebellar dysfunction were very common at presentation (13/16, 81%), abnormalities on neuroimaging studies were rare. Death occurred in more than a quarter of cases (6/22, 27%), with patients either already deceased or dying shortly after. Half (3/6) of these deaths were directly attributable to the development of lethal cardiac dysrhythmias. Conversely, most survivors either improved or fully recovered within a few days to weeks (14/16, 88%), independent of their presenting symptoms, clinical signs, and the treatments they received. Discussion Ethyl chloride users are likely young or middle-aged males, and clinical features of toxicity can range from transient neurological symptoms to cardiac dysrhythmias and death. The prominence of neurotoxicity may be attributed to the lipophilic nature of ethyl chloride and its tendency to accumulate in neural tissue, while cardiac dysrhythmias have been attributed to cardiac sensitization to catecholamines through ethyl chloride-induced inhibition of potassium, calcium, and sodium channels. Conclusions Toxicity from the inhalational misuse of ethyl chloride should be considered in young or middle-aged males presenting with acute cerebellar dysfunction. We recommend that suspected cases undergo telemetric monitoring for 24 h, especially when tachycardia and/or palpitations are present, as deaths from lethal cardiac dysrhythmias are not uncommon.

Correct use of inhalers for asthma.

Correct use of inhalers for asthma.

Parental practices as mediators of the effect of a family-based program on the prevention of substance use among Brazilian adolescentes

BackgroundEvidence-based family prevention programs aims at strengthening family relationships and for reducing substance use. Thus, this study aims to evaluate the mediating effect of parental practices in reducing the prevalence of lifetime alcohol, cigarette, and inhalant use among adolescents enrolled in a family-based program. Material and methodsA cluster-randomized controlled trial was conducted in Social Assistance Reference Centers of 12 Brazilian municipalities to verify the effectiveness of the Famílias Fortes program. The sample included 1610 participants from 805 families, with each family nucleus consisting of one adolescent aged 10 to 14 years and one of their parents or guardians. The intervention group participated in seven meetings led by previously trained facilitators. The control group did not receive any interventions to prevent substance use. Data were collected at baseline, 6 and 12 months. Four mediation models were conducted, assessing the effect of the program according to the combined influence of parental practices on each outcome: adolescents’ lifetime use of alcohol, cigarettes, inhalants, and the practice of binge drinking. ResultsThe combination of all parental behaviors tested was found to act as a mediator of the effect of Famíilias Fortes in reducing lifetime alcohol use and binge drinking. The mediation model also showed that the program had an indirect effect in the reduction of cigarette and inhalant use by increasing parental responsiveness and demandingness. ConclusionsAlthough the program did not directly influence adolescents, it effectively prevented substance use by positively influencing parental actions, which indirectly influenced substance use behaviors in adolescents.

Case Report: Dust Remover Inhalant Use Disorder in an Individual in Early Remission from Alcohol Use Disorder Treated with Naltrexone.

Inhalants are a very diverse class of substances with a highly prevalent recreational use. Difluroethane (DFE) is a psychoactive ingredient present in several propellants and dust remover products. Past reports have described the toxicological effects of this compound, but its addictive potential is poorly described in the literature. We present a case report (N = 1) of an adult man who very rapidly developed a severe inhalant use disorder (IUD), in the context of an early remission of an alcohol use disorder (AUD). He received treatment with naltrexone in a residential treatment program. He provided verbal and written consent for the publication of this case report. This is the first follow-up case of dust remover-IUD treated with naltrexone described in the literature. This case is clinically important for several reasons, including its atypical age of presentation, rapid progression, medical consequences, and positive response to multimodal treatment. The easy availability and lack of regulation of many inhalants, such as DFE, combined with the inability to be detected in regular screening tests, make this phenomenon a potential public health threat. We hypothesize that, consistent with previous reports, there might be a common neurobiological signature between AUD and IUD.

Sustainability and choice of inhaled treatment for obstructive pulmonary diseases

Inhaled treatments are essential for obstructive lung diseases such as asthma and chronic obstructive pulmonary disease (COPD). However, pressurized metered-dose inhalers (pMDI) use propellant gases, contributing to greenhouse gas (GHG) emissions and thereby to climate change. The use of dry powder inhalers (DPI) or soft mist inhalers (SMI) when clinically appropriate is a way to reduce these emissions. It is essential to confirm the diagnosis, promote adherence and therapeutic education, and support effective recycling policies and the development of less polluting treatments. In any case, the right inhaler is the one that suits the patient, is used correctly, and stabilizes of the respiratory condition.

Abstract 4123563: High Prevalence of Unrecognized Actionable Cardiac Arrhythmias in Patients with Moderate to Severe Chronic Obstructive Pulmonary Disease

Background: Patients with chronic obstructive pulmonary disease (COPD) are at high risk for developing arrhythmias due to hypoxemia, right heart failure and use of beta-agonists inhalers. Symptoms related to arrhythmias can often be masked or confounded by symptoms related to COPD exacerbation and remain undiagnosed. Objective: To identify the incidence of actionable arrhythmias in patients with no prior cardiology follow-up and moderate–severe COPD with continuous monitoring. Methods: An automatic referral for electrophysiology (EP) consult was generated in patients with moderate-severe COPD if they answered yes to one of the following: palpitations, dizziness, abnormal ECG, near syncope. Upon consultation with EP specialist, implantation of loop reorder was discussed (ILR) with the patient. Patients were then monitored for 12 months via remote monitoring. Actionable arrhythmia was defined the arrhythmia that correlated with symptoms triggered by the patient, necessitated adjustment of medications (including initiation of anticoagulation), catheter ablation and implantation of implantable cardiac defibrillator (ICD) or permanent pacemaker (PPM). Results: Out of 62 patients referred 22 (35.5%) agreed to undergo ILR implantation. Of the 22 (50.0% female, 62 ± 9.5 years) patients implanted with an ILR, 15 (68.2%) had an actionable arrhythmia after a mean follow-up of 2.7± .3 months. These included 14 symptomatic events requiring medication adjustment (10 atrial tachycardias, 4 ventricular events), 7 cases of atrial fibrillation (requiring initiation of anticoagulation in all cases and catheter ablation in 1), 1 case of sinus node dysfunction requiring pacemaker implantation, and 1 episodes of sustained ventricular tachycardia requiring ICD implantation. Conclusion: Continuous monitoring had high yield in diagnosing significant arrhythmic events in patients with moderate-severe COPD. Awareness should be raised about the high arrhythmic risk of this population and the role of continuous monitoring should be sought in larger studies.

Systematic Review of Obstetric and Child Outcomes of Prenatal Exposure to Inhalants in the Context of a Use Disorder.

Inhalants are often used for their psychoactive effects, producing feelings of euphoria. Inhalant and solvent use is a serious public health concern, yet little is known about their effects on perinatal, fetal, and child outcomes. The aim of our review is to evaluate the impact of inhalant use by pregnant people on maternal, fetal, neonatal, and early childhood outcomes. A systematic review was conducted on March 1, 2023, in 6 databases using relevant keywords. Bias assessment was performed using JBI Critical Appraisal Tools. Studies were included if they described a prenatal exposure to an inhalant; focused on maternal, fetal, neonatal, or early childhood outcomes; and were published as peer-reviewed reports in English. The search yielded 1101 unique references with 22 studies meeting eligibility criteria and representing 205 pregnancies and 171 infants.The most common symptom of inhalant use reported in pregnant people was altered mentation, followed by renal tubular acidosis (RTA) reported with toluene use. Most common fetal outcomes included fetal growth restriction and preterm delivery (<37 weeks), while neonatal outcomes were withdrawal symptoms, such as jitteriness, trouble feeding, and dystonia. Child outcomes included developmental delays, including cognitive and speech impairments, and postnatal growth restriction, including microcephaly. Perinatal, fetal, and child outcomes associated with inhalant use among pregnant individuals are largely based on case reports and series. Prospective studies are needed to better characterize these outcomes, reduce stigma, increase equitable access to treatment, and identify potential interventions to reduce use and potential harm.

Pharmaceutical, Clinical, and Regulatory Challenges of Reformulating Pressurized Metered-Dose Inhalers to Reduce Their Environmental Impact.

The chlorofluorocarbons (CFCs) that were used as propellants in early pressurized metered-dose inhalers (pMDIs) had substantial ozone-depleting potential. Following the Montreal Protocol in 1987, the manufacture of a range of ozone-depleting substances, including CFCs, was gradually phased out, which required the propellants used in pMDIs to be replaced. Current pMDIs use hydrofluoroalkanes (HFAs) as propellants, such as 1,1,1,2-tetrafluoroethane (HFA-134a). Although these HFAs have no ozone-depleting potential, they have a high global warming potential (GWP), and consequently, their use is being phased down. One option for the discontinuation of HFA use in inhalers would be to discontinue all pMDIs, switching patients to dry powder inhalers (DPIs). However, a switch from pMDIs to DPIs may not be a clinically appropriate option for some patients; furthermore, the full lifecycle carbon footprint and the overall environmental impact of different inhalers should be considered. An alternative is therefore to reformulate the current HFA pMDIs to use low-GWP propellants, such as 1,1-difluoroethane (HFA-152a). This article summarizes the various steps and challenges associated with this change, illustrated using data from the inhaled triple combination of beclomethasone dipropionate, formoterol fumarate, and glycopyrronium bromide, a complex formulation of three molecules in a solution that contains liquid-phase propellant.

Clinical profile, inhaler technique, and predictors of inhaler adherence among asthma and COPD patients who attended the outpatient emergency department for acute exacerbation.

Understanding the patients' clinical profile, barriers to optimal inhaler use, and adherence are crucial in achieving the treatment goal for asthma and chronic obstructive pulmonary disease (COPD). This study aimed to assess the inhaler technique and identify the predictors of inhaler adherence among asthma and COPD patients who presented to the Emergency Department (ED). This prospective cross-sectional study recruited patients who presented to the outpatient ED of a tertiary hospital for mild-to-moderate exacerbation from March 2022 to February 2023. Convenience sampling was used in this study. The inhaler techniques and adherence of all subjects were evaluated. Regression analysis was used to identify predictors of inhaler adherence. We recruited 120 subjects with a mean age of 47.8 ± 16.0 and were predominantly asthma patients (n = 85, 70.8%). Most were on regular follow-up (n = 72, 60.0%) and adhered to their inhaler(s) (n = 86, 71.7%). Less than half of the subjects use their inhaler(s) correctly (n = 45, 37.5%). Three predictors of inhaler adherence were identified: regular follow-up (aOR 2.072, p = 0.041), correct inhaler technique (aOR 3.071, p = 0.039), and ability to explain inhalers' mode of action (aOR 10.906, p = 0.031). The high rate of wrong inhaler techniques among asthma and COPD patients is worrisome. Identified predictors of inhaler adherence should be targeted when managing this group of patients. In addition to the exacerbation treatment in the ED, referrals to public primary health clinics for regular follow-ups, evaluation of inhaler techniques, and counseling to enhance patient knowledge are crucial.

Improving inhaler technique and adherence in children

How to improve the use of inhalers to manage asthma in children and young people. By Debbie Duncan

Pharmacist Interventions for Inhaled Medication Use in Chronic Obstructive Pulmonary Disease (COPD).

Pharmacists are ideally situated and trained to educate and advocate for the proper use of inhaled medications among patients in the community. Proper inhaler technique is an important way to prevent exacerbations and manage the symptoms associated with chronic pulmonary diseases. The American Lung Association estimates almost 6 million people 65 years of age or older had a diagnosis of chronic obstructive pulmonary disease (COPD) in 2020 in the United States. However, published reports have found that less than 20% of older people with COPD use inhalers correctly. As inhalers are the primary route of administration for medications used to treat chronic airway diseases such as COPD, pharmacist-led education can help overcome the widespread lack of knowledge regarding proper inhaler use.

MISCONCEPTIONS ABOUT ASTHMA AMONG PATIENTS VISITING THE TERTIARY CARE HOSPITAL OF KARACHI

Asthma is a common respiratory condition that significantly impacts patient quality of life, with many individuals lacking adequate knowledge about triggers and proper inhalation therapy. Understanding patient awareness of asthma management is crucial in designing interventions that enhance their ability to prevent and manage symptoms effectively. Objective: This study aimed to assess the awareness of asthma triggers, perceptions of inhalation therapy, and the effect of a teaching intervention among patients visiting a tertiary healthcare facility in Karachi, Pakistan. Methods: A cross-sectional descriptive survey was conducted in the Department of Pulmonary Medicine at Aga Khan University Hospital, Karachi, from January to June 2024. A total of 200 asthma patients were included through convenience sampling. Data were collected using a standardized questionnaire that assessed participants' knowledge of primary asthma triggers, correct inhaler usage, and relevant socio-demographic factors. The statistical analysis was performed using SPSS Version 25, and frequencies, percentages, and chi-square tests were used to examine associations between patient knowledge and other variables. Results: The study revealed that asthma awareness among participants was limited. Only 45% of respondents could identify common asthma triggers accurately, while 30% believed that asthma was solely caused by smoking or pollution. Additionally, 35% of patients expressed concerns about frequent reliance on inhalers, and 40% indicated that they were unsure of the correct way to use their inhalers. The teaching intervention demonstrated an improvement in inhaler usage knowledge and reduced anxiety related to inhalation therapy. Conclusion: This study highlights a significant gap in patient awareness regarding asthma triggers and the proper use of inhalers. These findings emphasize the importance of developing targeted educational interventions to improve asthma management, particularly in low-resource settings. Future efforts should focus on enhancing patient education to prevent asthma-related complications and improve overall disease control.

Association of volatile substance, nitrous oxide and alkyl nitrate use with mental health in UK adolescents.

'Inhalants' have been associated with poorer mental health in adolescence, but little is known of associations with specific types of inhalants. We aimed to investigate associations of using volatile substances, nitrous oxide and alkyl nitrates with mental health problems in adolescence. We conducted a cross-sectional analysis using data from 13- to 14-year-old adolescents across England and Wales collected between September 2019 and March 2020. Multilevel logistic regression examined associations between lifetime use of volatile substances, nitrous oxide and alkyl nitrates with self-reported symptoms of probable depression, anxiety, conduct disorder and auditory hallucinations. Of the 6672 adolescents in the study, 5.1% reported use of nitrous oxide, 4.9% volatile solvents and 0.1% alkyl nitrates. After accounting for multiple testing, adolescents who had used volatile solvents were significantly more likely to report probable depressive (odds ratio = 4.59, 95% CI 3.58, 5.88), anxiety (odds ratio = 3.47, 95% CI 2.72, 4.43) or conduct disorder (odds ratio = 7.52, 95% CI 5.80, 9.76) and auditory hallucinations (odds ratio = 5.35, 95% CI 4.00, 7.17) than those who had not. Nitrous oxide use was significantly associated with probable depression and conduct disorder but not anxiety disorder or auditory hallucinations. Alkyl nitrate use was rare and not associated with mental health outcomes. Adjustment for use of other inhalants, tobacco and alcohol resulted in marked attenuation but socioeconomic disadvantage had little effect. To our knowledge, this study provides the first general population evidence that volatile solvents and nitrous oxide are associated with probable mental health disorders in adolescence. These findings require replication, ideally with prospective designs.

Impact of pharmacist-led intervention in medication adherence and inhaler usage on asthma and chronic obstructive pulmonary disease control: a quasi-experimental study.

Despite recent advances in the management of asthma and chronic obstructive pulmonary disease (COPD), patients still experience suboptimal disease control largely due to medication non-adherence and inappropriate use of inhaler. This study evaluates the impact of pharmacist-led intervention in medication adherence and inhaler usage on asthma and COPD control among out-patients attending the premier tertiary hospital in Nigeria. A quasi-experimental study carried-out among eligible out-patients attending pulmonology clinic of University College Hospital, Ibadan. Baseline questionnaire explored medication adherence using a comprehensive-medication-adherence-assessment-scale (CMAAS-12) developed by the study co-investigators, use of pressurized-metered-dose (pMDI) and Diskus inhalers, as well as asthma/COPD control using validated asthma control test (ACT) and COPD assessment test (CAT). Subsequently, patients were allocated into control (n = 65) or intervention group (n = 65) using odd or even number. Intervention group received 2-month follow-up educational and/or cognitive-behavioural interventions to resolve identified adherence barriers, while control group continued with traditional care. Descriptive statistics, Chi-square and Wilcoxon-signed-ranked tests were used for analysis at p < 0.05. Overall, patients with optimal adherence were 11(18.6%) and 16(27.1%), p = 0.132 (control), but 20(33.3%) and 38(63.3%), p < 0.001 (intervention) at baseline and post-baseline, respectively. Specifically, in the intervention group, the identified adherence barriers at baseline were summarized into knowledge (120;40.4%), practical (115;38.7%) and attitudinal (62;20.9%). Patients with correct use of pMDI were 11(21.6%) baseline and 19(36.5%) post-baseline, p = 0.011 (control), but 13(22.8%) and 46(80.7%) respectively, p < 0.001 (intervention). Correct use of Diskus inhaler were 5(50.0%) and 4(40.0%), p = 0.157 (control), but 7(35.0%) and 14(70.0%), p = 0.025 (intervention) at baseline and post-baseline, respectively. Patients with 'well-controlled asthma' were 25(44.6%) and 26 (47.3%), p = 0.025 (control), but 18(35.3%) and 32(60.4%), p < 0.001 (intervention) at baseline and post-baseline, respectively. The COPD-specific health status indicated that 0(0.0%) and 1(14.3%), p = 0.059 (control), but 0(0.0%) and 7(50.0%), p < 0.001 (intervention) at baseline and post-baseline, respectively, belonged to 'low COPD impact'. Pharmacist-led intervention significantly enhanced medication adherence and appropriate use of inhaler among the intervention cohort, with subsequent significant improvement in asthma control and reduced COPD impact compared with the control group. This underscores the need for active involvement of pharmacists in collaborative management of patients with chronic respiratory diseases in clinical practice. ClinicalTrials.gov identifier: NCT06417931. Retrospectively-registered.

7002 Building Poor Bone, A Rare Presentation Of Skeletal Fluorosis

Abstract Disclosure: C. Pham: None. J.S. Lopresti: None. Skeletal fluorosis is a rare disease associated with osteosclerosis and fractures. Case: 26 year old male presented with a history of multiple traumatic fractures but no childhood or family history of fractures. Initial labs revealed a corrected calcium of 8.1 mg/dL (8.5-10.3), ALP 1,504 U/L (40-129), PTH 131 pg/ml (15-65), 25-OH D 14 ng/ml (30-100), PO4 3.7 mg/dl (2.5-4.5) and normal creatinine. X-Rays demonstrated osteosclerosis and cortical expansion of bone and nuclear bone scan demonstrated diffuse increased uptake. Further history revealed huffing of computer inhalants (10 cans daily) for years. Due to these findings, urine fluoride 16.88 mg/L (0.20-3.20 mg/L) and serum fluoride 0.40 mg/L (&amp;lt;0.05 mg/L) were obtained and vitamin D was started. 4 months later, his vitamin D level improved to 21 while calcium levels normalized despite ongoing inhalant use. ALP (878) and PTH (92) continued to be elevated albeit at improved levels. Conclusion: Exposure to fluoride leads to a rare condition called skeletal fluorosis causing accelerated osteogenesis and bone turnover leading to weak bone. Symptoms include bony pain, fractures, and osteosclerosis on radiographs. Differential diagnosis includes other conditions associated with osteosclerosis such as Paget’s disease and myelofibrosis. However, diffuse osteosclerosis and vertebral osteophytosis are noted only in skeletal fluorosis compared to other potential causes, though our patient did not have a CT spine done to assess for osteophytes. Biochemical studies can include hypocalcemia and hyperparathyroidism. It is thought that low calcium intake contributes to the hyperparathyroidism. Elevated serum and urine fluoride levels are also diagnostic and can persist for months after cessation of fluoride intake. Sodium fluoride has been posited as a treatment for osteoporosis due to its tremendous ability to build bone; however, the quality of bone made is poor leading to unacceptable fracture rates. Skeletal fluorosis should be suspected in any patient with history of diffuse osteosclerosis and hyperparathyroidism; and vitamin D supplementation should be initiated. In our case, hypocalcemia and PTH levels were improved despite active inhalant use after vitamin D supplementation. This suggests that Vitamin D deficiency and fluoride may be two independent driving factors in hyperparathyroidism in patients with fluorosis. Increased calcium absorption with vitamin D provides therapeutic benefit in both cases. Presentation: 6/1/2024

Understanding the Drivers of Inhaler Non-Adherence in Asthma and its Influence on Asthma Control

Background Asthma remains a significant global health concern, with adherence to inhaler therapy playing a crucial role in its management. Understanding demographic characteristics and adherence behaviours among asthma patients is essential for optimizing treatment outcomes. This study delves into the multifaceted factors associated with non-adherence to inhaler therapy among asthma patients in India, to enhance adherence and improve asthma management outcomes. MethodsA cross-sectional study was conducted among 195 asthma patients at Shaikh-UI-Hind Maulana Mahmood Hasan Medical College in Saharanpur, India. Asthma control was assessed using standardized criteria, and adherence to inhaler therapy was evaluated through self-reported questionnaires. Demographic variables including smoking habit, possession of health insurance, comorbidities, duration of asthma, and duration of inhaler use were also recorded.ResultsAnalysis of demographic characteristics revealed a higher prevalence of asthma among females, aged 18-45, and individuals from low-income rural families. Additionally, a substantial proportion of patients had comorbidities and had been diagnosed with asthma for more than five years. Asthma control levels indicated a concerning proportion of patients with poorly controlled asthma, highlighting challenges in achieving optimal management outcomes. Furthermore, significant challenges in adherence to inhaler medication regimens were observed, including medication dosage modification without medical guidance and barriers to proper device use.Conclusions This study reveals significant challenges in asthma control and inhaler adherence, particularly among females and low-income rural patients in India. The patient’s education are essential to address these issues and improve asthma management outcomes.